Douglas A. Ducey, Governor Jami Snyder, Director

August 28, 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 2020 Appropriation Status Report for the Period Ended July 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 July 31, 2019.

Status Summary – AHCCCS is in the process of finalizing its Fiscal Year 2021 budget request, including an update of Fiscal Year 2020 for submission to the Governor’s Office of Strategic Planning and Budgeting pursuant to A.R.S. § 35-113. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

Enrollment Update – July 2019 enrollment is 1,880,641 members, a 8,472 member increase over the prior month. Enrollment for August 2019 increased to 1,891,455 members, a 10,814 member change.

Major August 2019 changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 4,255; Supplemental Security Income – increase of 483; Prop 204 Restoration - increase of 3,886; Adult Expansion – increase of 787; Medicare Cost Sharing – increase of 378; KidsCare – increase of 362; and Federal Emergency Services – increase of 461.

Tobacco Funds Revenue Update - Tobacco tax collections through July 2019 are $4.7 million more than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2020 appropriations.

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

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 August 28, 2019
Page 2

Sincerely,
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 2020
Through July 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 2020…	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 2020 APPROPRIATION STATUS REPORT
For the Period Ending July 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	$	88,542,300	$	10,462,645	$	10,462,645	$	-	$	88,542,300	$	-	
AHCCCS Prop 204 Administration	14,182,800	1,950,692	1,950,692	-	14,182,800	-	
Information Technology	9,878,000	-	-	-	9,878,000	-	
DES Eligibility	91,874,500	9,372,133	9,372,133	-	91,874,500	-	
DES Prop 204 Eligibility	44,358,700	2,978,349	2,978,349	-	44,358,700	-	
ADOA Data Center	19,325,800	-	-	-	19,325,800	-	
School District Suicide Prevention Coordinator	100,000	12,639	12,639	-	100,000	-	

TOTAL ADMINISTRATION	 	268,262,100	 	24,776,458	 	24,776,458	 	-		 	268,262,100	 	-	

Traditional Medicaid Services	5,178,162,100	552,996,807	552,996,807	-	5,178,162,100	-	
Proposition 204 Services	4,168,410,500	346,570,791	346,570,791	-	4,168,410,500	-	
ACA Adult Expansion	527,018,800	43,668,908	43,668,908	-	527,018,800	-	
KidsCare Services	106,516,300	6,505,746	6,505,746	-	106,516,300	-	
ALTCS Services	1,796,913,800	136,370,015	136,370,015	-	1,796,913,800	-	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	28,612,400	-	-	-	28,612,400	-	
Voluntary Political Subdivision Programs	345,281,700	12,602,424	12,602,424	-	345,281,700	-	
CMDP	180,729,500	15,434,609	15,434,609	-	180,729,500	-	
Behavioral Health Services - in Schools	9,990,000	-	-	-	9,990,000	-	
Targeted Investment Program	90,000,000	-	-	-	90,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	5,965,309	5,965,309	-	77,646,900	-	
Supported Housing	5,324,800	393,733	393,733	-	5,324,800	-	
Crisis Services	16,391,300	1,354,692	1,354,692	-	16,391,300	-	

TOTAL PROGRAMMATIC	 	12,536,085,200	 	1,121,863,034	 	1,121,863,034	 	-		 	12,536,085,200	 	-	

TOTAL EXPENDITURES

  $	12,804,347,300

-

$	1,146,639,492

$	1,146,639,492	$

-	$   12,804,347,300	$	-

2

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		
Administrative Expenditures	$	60,044,200	$	5,876,589	$	5,876,589	-	$	60,044,200	$	-	
Proposition 204 - Administrative Expenditures	21,538,900	1,809,928	1,809,928	-	21,538,900	-	

Programmatic Expenditures				
Traditional Medicaid Services	1,170,113,300	95,264,979	95,264,979	-	1,170,113,300	-	
Proposition 204 Services	95,088,500	-	-	-	95,088,500	-	
ACA Adult Expansion	5,393,400	-	-	-	5,393,400	-	
KidsCare Services	7,523,800	24,080	24,080	-	7,523,800	-	
ALTCS Services	234,042,300	19,503,525	19,503,525	-	234,042,300	-	
DSH and Rural Hospitals	8,843,300	-	-	-	8,843,300	-	
CMDP	54,297,600	4,715,306	4,715,306	-	54,297,600	-	
Behavior Health Services - in Schools	3,000,000	-	-	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	5,965,309	5,965,309	-	77,646,900	-	
Supported Housing	5,324,800	393,733	393,733	-	5,324,800	-	
Crisis Services	14,141,100	1,167,175	1,167,175	-	14,141,100	-	
Voluntary Political Subdivision Programs	 	3,750,000	 	-	 	-	 	-	 	3,750,000	 	- 	
TOTAL GF EXPENDITURES	1,760,748,100	134,720,625	134,720,625	-	1,760,748,100	-	

FEDERAL		
Administrative Expenditures	146,947,600	13,967,544	13,967,544	-	146,947,600	-	
Proposition 204 - Administrative Expenditures	33,035,300	3,119,112	3,119,112	-	33,035,300	-	
Programmatic Expenditures				
Traditional Medicaid Services	3,176,462,800	316,973,030	316,973,030	-	3,176,462,800	-	
Proposition 204 Services	3,615,003,800	305,374,214	305,374,214	-	3,615,003,800	-	
ACA Adult Expansion	484,056,500	40,645,888	40,645,888	-	484,056,500	-	
KidsCare Services	86,764,900	5,764,760	5,764,760	-	86,764,900	-	
ALTCS Services and Nursing Facility Assessment	1,144,403,700	91,143,787	91,143,787	-	1,144,403,700	-	
DSH and Rural Hospitals	24,856,200	-	-	-	24,856,200	-	
CMDP	126,431,900	10,719,303	10,719,303	-	126,431,900	-	
Behavior Health Services - in Schools	6,990,000	-	-	-	6,990,000	-	
Targeted Investment Program	61,937,600	-	-	-	61,937,600	-	
Voluntary Political Subdivision Programs	 	240,664,300	 	8,807,834	 	8,807,834	 	-	 	240,664,300	 	- 	
TOTAL FEDERAL EXPENDITURES	9,147,554,600	796,515,471	796,515,471	-	9,147,554,600	-	

Administrative Expenditures Proposition 204 - BNCF	

COUNTY

3,906,400	

-	-	-	3,906,400	-	
Programmatic Expenditures						
Traditional Medicaid Services Acute Care	46,512,900	3,846,808	3,846,808	-	46,512,900	-	
ALTCS Services	 	268,554,800	 	19,267,449	 	19,267,449	 	-	 	268,554,800	 	- 	
TOTAL COUNTY EXPENDITURES	318,974,100	23,114,257	23,114,257	-	318,974,100	-	

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	61,752,600	7,153,430	7,153,430	-	61,752,600	-	
Proposition 204 Services - Emergency Health Services	16,216,300	1,964,116	1,964,116	-	16,216,300	-	
Proposition 204 Services - Proposition 204 Protection	34,054,300	4,124,644	4,124,644	-	34,054,300	-	
Proposition 204 Services - ATLSF	 	102,000,000	 	- 	 	- 	 	-	 	102,000,000	 	- 	
TOTAL TOBACCO EXPENDITURES	214,023,200	13,242,191	13,242,191	-	214,023,200	-	

OTHER		
Administrative Expenditures						
Prescription Drug Rebate Program	2,789,700	3,284	3,284	-	2,789,700	-	
Programmatic Expenditures						
Traditional Medicaid Services - IGA Fund	10,297,700	2,574,425	2,574,425	-	10,297,700	-	
Acute Care - Prescription Drug Rebate Program State Match	140,158,600	11,679,883	11,679,883	-	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	115,377,560	115,377,560	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	631,533	631,533	-	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	5,743,662	5,743,662	-	36,422,000	-	
Proposition 204 Services - Hospital Assessment	303,482,900	34,466,642	34,466,642	-	303,482,900	-	
Proposition 204 Services - IGA Fund	2,564,700	641,175	641,175	-	2,564,700	-	
ACA Adult Expansion - Hospital Assessment	37,389,000	2,978,045	2,978,045	-	37,389,000	-	
ACA Adult Expansion - IGA Fund	179,900	44,975	44,975	-	179,900	-	
Traditional Medicaid Services - TPL	194,700	117,620	117,620	-	194,700	-	
ALTCS Services - TPL	-	80,060	80,060	-	-	-	
ALTCS Services - Nursing Facility Assessment	105,912,600	-	-	-	105,912,600	-	
Targeted Investment Program	28,062,400	-	-	-	28,062,400	-	
KidsCare Services - IGA Fund	76,300	-	-	-	76,300	-	
KidsCare Services Premiums	12,151,300	716,906	716,906	-	12,151,300	-	
Freedom to Work Premiums	31,200	9,071	9,071	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	187,517	187,517	-	2,250,200	-	
Voluntary Political Subdivision Programs	 	100,867,400	 	3,794,590	 	3,794,590	 	-	 	100,867,400	 	- 	
TOTAL OTHER EXPENDITURES	1,363,047,300	179,046,948	179,046,948	-	1,363,047,300	-	

TOTAL		
Administrative Expenditures	268,262,100	24,776,458	24,776,458	-	268,262,100	-	
Acute Care	10,739,171,400	985,493,019	985,493,019	-	10,739,171,400	-	
Long Term Care	 	1,796,913,800	 	136,370,015	 	136,370,015	 	-	 	1,796,913,800	 	- 	
TOTAL EXPENDITURES	  $	12,804,347,300	  $	1,146,639,492	  $	1,146,639,492	  $	-	 $	12,804,347,300	  $	- 	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending July 31, 2019

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,251,144,200	$	101,141,568	$	101,141,568	
Proposition 204 Services & Administrative	116,627,400	1,809,928	2,451,103	
KidsCare Services	7,523,800.00	24,079.97	24,080	
ALTCS Services	234,042,300	19,503,525	19,503,525	
Behavioral Health Traditional Medicaid Services	 	151,410,400	 	12,241,524	 	12,241,524	
TOTAL	1,760,748,100	134,720,625	135,361,800	

FEDERAL:
Acute & Administrative	7,789,954,100	688,887,622	682,341,308	
KidsCare Services	86,764,900	5,764,760	6,668,294	
ALTCS Services	1,144,403,700	91,143,787	91,143,787	
Behavioral Health Traditional Medicaid Services	 	126,431,900	 	10,719,303	 	10,773,984	
TOTAL	9,147,554,600	796,515,471	790,927,374	

COUNTY:				
Acute & Administrative	50,419,300		3,846,808		2,767,185	
ALTCS Services	 	268,554,800		 	19,267,449		 	24,189,676	
TOTAL	318,974,100		23,114,257		26,956,861	

TOBACCO FUNDS:						
Traditional Medicaid Services	61,752,600		7,153,430		7,153,430	
Proposition 204 Services	 	152,270,600		 	6,088,761		 	6,088,761	
TOTAL	214,023,200		13,242,191		13,242,191	

OTHER:

Administrative	2,789,700	3,284	3,284	
Traditional Medicaid Services - IGA Fund	10,297,700	2,574,425	2,574,425	
Acute Care - Prescription Drug Rebate Program	712,796,900	127,057,443	127,057,443	
Long Term Care - Prescription Drug Rebate Program	44,000,400	6,375,195	6,375,195	
Hospital Assessment	343,616,500	38,130,837	1,081,629	
ALTCS - Nursing Facility Assessment	105,912,600	-	-	
Acute TPL - Note 1	194,700	117,620	117,620	
LTC TPL - Note 1	-	80,060	80,060	
KidsCare Services - IGA Fund	76,300	-	-	
KidsCare TPL - Note 1	-	-	(44.00)	
Member Premiums - CHIP	12,151,300	716,906	716,906	
Member Premiums - Freedom to Work	31,200	9,071	9,071	
Targeted Investment Program	28,062,400	-	-	
Behavioral Health Traditional Medicaid Services	2,250,200	187,517	-	
Voluntary Political Subdivision - State Match	 	100,867,400	 	3,794,590	 	5,960,875	
TOTAL	1,363,047,300	179,046,948	143,976,464	

TOTAL REVENUE

$	12,804,347,300

$	1,146,639,492

$	1,110,464,689

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending July 31, 2019	
Note 1:	Third Party Liability Collections:	July 2019		July 2018		July 1, 2019		July 1, 2018	
	Gross Collections:					July 31, 2019		July 31, 2018	
	Acute	$	1,008,189		$	511,802		$	1,008,189		$	511,802	
	LTC	403,408		255,878		403,408		255,878	
	KidsCare	1,003		-		1,003		-	
	Total TPL Collections	  $	1,412,600		$	767,680		$	1,412,600		$	767,680	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	117,620		$	42,072		$	117,620		$	42,072		
LTC	80,060		54,018		80,060		54,018		
KidsCare	(44)		-		(44)		-		
Total Expenditure Offsets	  $	197,636		$	96,090		$	197,636		$	96,090		

FY 20 Total		
Note 2:	Authorized Positions	1,188.0		
	Actual Positions as of July 31, 2019	1,102.0		

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending July 31, 2019

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2019	$ 5,258,991	
	Revenues	929,805	
	Transfers-In	 	45,090	
	Total Revenues	 	974,895	
	Expenditures	1,028,021	
	Transfers-out	 	924,350	
	Total Expenditures	 	1,952,371	
	Ending Balance July 31, 2019	  $ 4,281,516	

Of the $4,281,516 ending balance, $2,221,689 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through August 2019.

Note 4:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of July 31, 2019 Expenditures
Appropriation	State Match	Federal	Total

DSH Voluntary	$	40,980,200	$	3,794,590	$ 8,807,834	$	12,602,424	
GME Voluntary	304,301,500	-	-	-	

Total Voluntary Political Subdivision Program Expenditures

$	345,281,700	$

3,794,590

$ 8,807,834	$

12,602,424

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	325,136,671	0	0	0	0	0	0	0	0	0	0	0	325,136,671	
CAPITATION - AIMHS	292,639	0	0	0	0	0	0	0	0	0	0	0	292,639	
CAPITATION - LTC	250,917,794	0	0	0	0	0	0	0	0	0	0	0	250,917,794	
MENTAL HEALTH - CHILD	865	0	0	0	0	0	0	0	0	0	0	0	865	
MENTAL HEALTH - ADULT	340,947	0	0	0	0	0	0	0	0	0	0	0	340,947	
MENTAL HEALTH - GENERAL	755	0	0	0	0	0	0	0	0	0	0	0	755	
MENTAL HEALTH - CMDP	11,210,666	0	0	0	0	0	0	0	0	0	0	0	11,210,666	
MENTAL HEALTH - DD	7,458,766	0	0	0	0	0	0	0	0	0	0	0	7,458,766	
MENTAL HEALTH - RBHA CRISIS	3,210,728	0	0	0	0	0	0	0	0	0	0	0	3,210,728	
FEE FOR SERVICE - ACUTE	48,820,855	0	0	0	0	0	0	0	0	0	0	0	48,820,855	
FFS - PRIOR QUARTER COVERAGE	953,544	0	0	0	0	0	0	0	0	0	0	0	953,544	
EMERGENCY SERVICES - FEDERAL	4,491,141	0	0	0	0	0	0	0	0	0	0	0	4,491,141	
FEDERAL ESP CHRONIC SERVICES	4,719	0	0	0	0	0	0	0	0	0	0	0	4,719	
FFS MEDICAID IN PUBLIC SCHOOLS	949,770	0	0	0	0	0	0	0	0	0	0	0	949,770	
STATE ONLY TRBHA FFS	158,244	0	0	0	0	0	0	0	0	0	0	0	158,244	
INPATIENT INMATES FFS	244,004	0	0	0	0	0	0	0	0	0	0	0	244,004	
FFS TRBHA FEE FOR SERVICE	12,287,430	0	0	0	0	0	0	0	0	0	0	0	12,287,430	
QMB - FEE FOR SERVICE	660,278	0	0	0	0	0	0	0	0	0	0	0	660,278	
MARICOPA CTY INMATES FFS	19,819	0	0	0	0	0	0	0	0	0	0	0	19,819	
COCONINO COUNTY INMATES FFS	3,561	0	0	0	0	0	0	0	0	0	0	0	3,561	
PIMA COUNTY INMATES FFS	4,917	0	0	0	0	0	0	0	0	0	0	0	4,917	
PINAL COUNTY INMATES FFS	2,190	0	0	0	0	0	0	0	0	0	0	0	2,190	
FEE FOR SERVICE - LTC	14,641,720	0	0	0	0	0	0	0	0	0	0	0	14,641,720	
LFFS - PRIOR QUARTER COVERAGE	72,181	0	0	0	0	0	0	0	0	0	0	0	72,181	
COCONINO COUNTY INMATES LTC F	415	0	0	0	0	0	0	0	0	0	0	0	415	
INPATIENT INMATES LTC FFS	27,260	0	0	0	0	0	0	0	0	0	0	0	27,260	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,557,681	0	0	0	0	0	0	0	0	0	0	0	1,557,681	
REINSURANCE - ACC	13,954,921	0	0	0	0	0	0	0	0	0	0	0	13,954,921	
REINSURANCE - LTC	6,843,752	0	0	0	0	0	0	0	0	0	0	0	6,843,752	
SMIB - ACC	15,867,509	0	0	0	0	0	0	0	0	0	0	0	15,867,509	
HIB - ACC	775,609	0	0	0	0	0	0	0	0	0	0	0	775,609	
Q1	2,951,192	0	0	0	0	0	0	0	0	0	0	0	2,951,192	
SMIB - LTC	4,094,296	0	0	0	0	0	0	0	0	0	0	0	4,094,296	
HIB - LTC	381,353	0	0	0	0	0	0	0	0	0	0	0	381,353	
SUBTOTAL	728,338,191	0	0	0	0	0	0	0	0	0	0	0	728,338,191	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL
TITLE XIX PROP 204
CAPITATION - ACC	278,294,618	0	0	0	0	0	0	0	0	0	0	0	278,294,618	
CAPITATION - AIMHS	134,306	0	0	0	0	0	0	0	0	0	0	0	134,306	
MENTAL HEALTH - ADULT	414,838	0	0	0	0	0	0	0	0	0	0	0	414,838	
MENTAL HEALTH - GENERAL	-2,350	0	0	0	0	0	0	0	0	0	0	0	-2,350	
MENTAL HEALTH - RBHA CRISIS	3,634,857	0	0	0	0	0	0	0	0	0	0	0	3,634,857	
FEE FOR SERVICE - ACUTE	37,859,959	0	0	0	0	0	0	0	0	0	0	0	37,859,959	
FFS - PRIOR QUARTER COVERAGE	1,204,975	0	0	0	0	0	0	0	0	0	0	0	1,204,975	
EMERGENCY SERVICES - FEDERAL	3,246,745	0	0	0	0	0	0	0	0	0	0	0	3,246,745	
FFS MEDICAID IN PUBLIC SCHOOLS	723	0	0	0	0	0	0	0	0	0	0	0	723	
FFS TRBHA FEE FOR SERVICE	7,885,916	0	0	0	0	0	0	0	0	0	0	0	7,885,916	
INPATIENT INMATES FFS	889,101	0	0	0	0	0	0	0	0	0	0	0	889,101	
STATE ONLY TRBHA FFS	399,387	0	0	0	0	0	0	0	0	0	0	0	399,387	
PINAL COUNTY INMATES FFS	415	0	0	0	0	0	0	0	0	0	0	0	415	
PIMA COUNTY INMATES FFS	44,460	0	0	0	0	0	0	0	0	0	0	0	44,460	
MOHAVE COUNTY INMATES FFS	3,409	0	0	0	0	0	0	0	0	0	0	0	3,409	
MARICOPA CTY INMATES FFS	214,579	0	0	0	0	0	0	0	0	0	0	0	214,579	
COCONINO COUNTY INMATES FFS	302	0	0	0	0	0	0	0	0	0	0	0	302	
REINSURANCE - ACC	6,253,343	0	0	0	0	0	0	0	0	0	0	0	6,253,343	
SMIB - ACC	7,097,119	0	0	0	0	0	0	0	0	0	0	0	7,097,119	
HIB - ACC	6,248	0	0	0	0	0	0	0	0	0	0	0	6,248	
SUBTOTAL	347,582,951	0	0	0	0	0	0	0	0	0	0	0	347,582,951	

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

CAPITATION - ACC	33,607,896	0	0	0	0	0	0	0	0	0	0	0	33,607,896	
CAPITATION - AIMHS	12,254	0	0	0	0	0	0	0	0	0	0	0	12,254	
MENTAL HEALTH - ADULT	12,078	0	0	0	0	0	0	0	0	0	0	0	12,078	
MENTAL HEALTH - GENERAL	399	0	0	0	0	0	0	0	0	0	0	0	399	
MENTAL HEALTH - RBHA CRISIS	575,493	0	0	0	0	0	0	0	0	0	0	0	575,493	
FEE FOR SERVICE - ACUTE	2,872,751	0	0	0	0	0	0	0	0	0	0	0	2,872,751	
FFS - PRIOR QUARTER COVERAGE	200,446	0	0	0	0	0	0	0	0	0	0	0	200,446	
EMERGENCY SERVICES - FEDERAL	5,151,773	0	0	0	0	0	0	0	0	0	0	0	5,151,773	
FFS MEDICAID IN PUBLIC SCHOOLS	66	0	0	0	0	0	0	0	0	0	0	0	66	
FFS TRBHA FEE FOR SERVICE	279,336	0	0	0	0	0	0	0	0	0	0	0	279,336	
STATE ONLY TRBHA FFS	39,350	0	0	0	0	0	0	0	0	0	0	0	39,350	
INPATIENT INMATES FFS	61,395	0	0	0	0	0	0	0	0	0	0	0	61,395	
MARICOPA CTY INMATES FFS	8,779	0	0	0	0	0	0	0	0	0	0	0	8,779	
PIMA COUNTY INMATES FFS	11	0	0	0	0	0	0	0	0	0	0	0	11	
REINSURANCE - ACC	726,411	0	0	0	0	0	0	0	0	0	0	0	726,411	
SMIB - ACC	271	0	0	0	0	0	0	0	0	0	0	0	271	
	43,548,708	0	0	0	0	0	0	0	0	0	0	0	43,548,708	
	1,119,469,850	0	0	0	0	0	0	0	0	0	0	0	1,119,469,850	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - RBHA CRISIS	19	0	0	0	0	0	0	0	0	0	0	0	19	
KidsCare - CAPITATION	6,102,844	0	0	0	0	0	0	0	0	0	0	0	6,102,844	
KidsCare - FEE FOR SERVICE	124,559	0	0	0	0	0	0	0	0	0	0	0	124,559	
KidsCare - MENTAL HEALTH	59,368	0	0	0	0	0	0	0	0	0	0	0	59,368	
KidsCare - REINSURANCE	200,701	0	0	0	0	0	0	0	0	0	0	0	200,701	

6,487,491	0	0	0	0	0	0	0	0	0	0	0	6,487,491	

TOTAL TITLE XXI

1,125,957,341	0	0	0	0	0	0	0	0	0	0	0	1,125,957,341	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	42,054.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,054.34		
1007	TANF 21-44 FEMALE WI	45,256.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,256.87		
1008	TANF 45-64 M & F WIT	58,324.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,324.80		
1009	TANF 65+ M & F WITH	16,091.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,091.48		
100F	TANF 21-44 MALE WITH	40.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.03		
100G	TANF 21-44 FEMALE WI	2,488.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,488.06		
100H	TANF 45-64 M & F WIT	4,175.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,175.05		
100J	TANF 65+ M & F WITH	212.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		212.66		
1011	TANF <1 M & F NON-ME	5,612,601.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,612,601.91		
1012	TANF 01-05 M & F NON	3,457,250.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,457,250.59		
1013	TANF 06-13 M & F NON	6,124,074.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,124,074.11		
1014	TANF 14-20 MALE NON-	1,914,202.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,914,202.78		
1015	TANF 14-20 FEMALE N O	2,353,294.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,353,294.72		
1016	TANF 21-44 MALE NON-	9,364,324.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,364,324.51		
1017	TANF 21-44 FEMALE N O	32,620,357.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,620,357.05		
1018	TANF 45-64 M & F NON	7,767,766.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,767,766.58		
1019	TANF 65+ M & F NON-M	31,052.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,052.28		
101A	TANF < 1 M & F NON-M	352,937.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		352,937.84		
101B	TANF 01-05 M & F NON	31,695.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,695.97		
101C	TANF 06-13 M & F NON	16,670.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,670.28		
101D	TANF 14-20 MALE NON-	9,808.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,808.43		
101E	TANF 14-20 FEMALE N O	18,630.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,630.37		
101F	TANF 21-44 MALE NON-	246,596.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246,596.25		
101G	TANF 21-44 FEMALE N O	615,659.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		615,659.33		
101H	TANF 44-64 M & F NON	131,317.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,317.46		
101J	TANF 65+ N & F NON-M	198.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198.84		
1024	TANF 14-20 MALE WITH	1,991.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,991.65		
1026	TANF 21-44 MALE WITH	30,833.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,833.82		
1027	TANF 21-44 FEMALE WI	33,845.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,845.08		
1028	TANF 45-64 M & F WIT	32,482.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,482.04		
1029	TANF 65+ M & F WITH	9,312.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,312.30		
2100	SSI AGED WITH MEDIC A	712,678.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		712,678.64		
210Z	SSI AGED WITH MEDIC
A	52,660.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,660.57		
2110	SSI AGED NON-MEDICA R	8,462,181.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,462,181.12		
211Z	SSI AGED NON-MEDICA
R	216,958.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		216,958.62		
2120	SSI AGED WITH QMB	5,479,950.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,479,950.99		

ACC CAPITATION - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
212Z	SSI AGED WITH QMB P P	4,799.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,799.26		
2200	SSI DISABLED WITH M
E	1,774,556.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,774,556.51		
220Z	SSI DISABLED WITH M E	96,386.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,386.79		
2210	SSI DISABLED NON-ME
D	70,901,267.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,901,267.74		
221Z	SSI DISABLED NON-ME D	942,051.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		942,051.13		
2220	SSI DISABLED WITH Q
M	14,966,350.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,966,350.81		
222Z	SSI DISABLED WITH Q M	31,562.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,562.80		
2300	SSI BLIND WITH MEDIC	7,894.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,894.62		
2310	SSI BLIND NON-MEDIC A	633,695.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		633,695.19		
231Z	SSI BLIND NON-MEDIC
A	5,251.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,251.90		
2320	SSI BLIND WITH QMB	47,291.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,291.74		
4302	SOBRA CHILD 01-05 M	384.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.93		
4303	SOBRA CHILD 06-13 M	671.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		671.85		
4305	SOBRA CHILD 14-20 FE	598.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		598.98		
4311	SOBRA CHILD <1 M & F	20,305,933.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,305,933.37		
4312	SOBRA CHILD 01-05 M	30,346,403.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,346,403.53		
4313	SOBRA CHILD 06-13 M	39,139,381.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,139,381.16		
4314	SOBRA CHILD 14-20 MA	10,797,911.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,797,911.21		
4315	SOBRA CHILD 14-20 FE	10,814,438.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,814,438.27		
431A	SOBRA CHILD < 1 M &	255,349.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,349.52		
431B	SOBRA CHILD 01-05 M	734,288.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		734,288.72		
431C	SOBRA CHILD 6-13 M&F	698,553.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		698,553.25		
431D	SOBRA CHILD 14-20 MA	203,649.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,649.34		
431E	SOBRA CHILD 14-20 FE	210,973.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210,973.01		
4322	SOBRA CHILD 01-05 M	191.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191.11		
4325	SOBRA CHILD 14-20 FE	194.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194.52		
432E	SOBRA CHILD 14-20 FE	80.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80.05		
5007	SOBRA PREG 21-44 FE M	21,876.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,876.18		
5008	SOBRA PREG 45-64 FE
M	253.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253.60		
500G	SOBRA PREG 21-44 FE M	3,420.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,420.46		
5013	SOBRA PREG 09-13 FE
M	370.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		370.17		
5015	SOBRA PREG 14-20 FE M	530,163.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		530,163.48		
5017	SOBRA PREG 21-44 FE
M	5,865,449.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,865,449.13		
5018	SOBRA PREG 45-64 FE M	17,581.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,581.17		
501C	SOBRA PREG 09-13 FE
M	167.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167.73		
501E	SOBRA PREG 14-20 FE M	46,644.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,644.18		

ACC CAPITATION - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
501G	SOBRA PREG 21-44 FE M	403,573.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403,573.06		
501H	SOBRA PREG 45-64 FE
M	54.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.35		
5027	SOBRA PREG 21-44 FE M	14,542.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,542.79		
5028	SOBRA PREG 45-64 FE
M	2,368.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,368.16		
SUBTOTAL:	295,696,553.1	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295,696,553.19		

3100	TRANSPLANT OPTION 1	66.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	66.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

66.00

66.00

9910	TANF & SOBRA CHILDR E	1,876,376.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	29,939.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	110,362.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	13,035,099.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,051,779.2	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,876,376.98	
29,939.56	
110,362.96	
13,035,099.79	
15,051,779.29	

1104	TANF EXPANDED 14-20	145.06	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	67,859.05	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	178,443.22	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	395,922.11	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
&	98,841.89	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	3,591.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	9,576.37	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	9,815.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	6,731.65	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	186.83	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	1,252.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	38,415.06	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	275,091.63	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	9,859,718.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	26,992,566.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	9,163,569.86	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
&	30,255.92	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	2,490.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	7,437.73	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	267,373.80	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	525,020.23	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	178,932.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+ M
&	592.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
145.06	
67,859.05	
178,443.22	
395,922.11	
98,841.89	
3,591.96	
9,576.37	
9,815.87	
6,731.65	
186.83	
1,252.85	
38,415.06	
275,091.63	
9,859,718.71	
26,992,566.22	
9,163,569.86	
30,255.92	
2,490.39	
7,437.73	
267,373.80	
525,020.23	
178,932.04	
592.01	

ACC CAPITATION - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	297,942.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		297,942.68		
1127	TANF EXPANDED 21-44	790,701.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		790,701.02		
1128	TANF EXPANDED 45-64	900,768.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		900,768.88		
1129	TANF EXPANDED 65+ M
&	256,772.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256,772.30		
112G	TANF EXPANDED 21-44	2,213.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,213.20		
112H	TANF EXPANDED 45-64	6,227.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,227.67		
112J	TANF EXPANDED 65+ M
&	3,111.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,111.80		
2400	SSI AGED EXPANDED WI	40,745.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,745.64		
240Z	SSI AGED EXPANDED
WI	26,984.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,984.10		
2410	SSI AGED EXPANDED N O	116,302.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116,302.77		
241Z	SSI AGED EXPANDED N
O	15,686.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,686.56		
2420	SSI AGED EXPANDED WI	5,409,424.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,409,424.18		
242Z	SSI AGED EXPANDED
WI	10,566.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,566.52		
2520	SSI BLIND EXPANDED W	191.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191.11		
2600	SSI DISABLED EXPAND
E	95,669.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,669.32		
260Z	SSI DISABLED EXPAND E	60,164.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,164.41		
2610	SSI DISABLED EXPAND
E	1,902,019.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,902,019.15		
261Z	SSI DISABLED EXPAND E	41,560.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,560.30		
2620	SSI DISABLED EXPAND
E	10,627,342.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,627,342.37		
262Z	SSI DISABLED EXPAND E	24,786.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,786.63		
SUBTOTAL:	68,743,011.0	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,743,011.07		

3506	ADULT 40-100% MALE 2	5,764.11	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	2,241.00	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	52,917.78	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	4,596.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	4,201.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	8,724.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	3,584,131.94	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	3,935,913.21	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	12,328,492.47	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	10,396,684.34	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	24,233,844.77	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	4,796.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,764.11	
2,241.00	
52,917.78	
4,596.56	
4,201.57	
8,724.34	
3,584,131.94	
3,935,913.21	
12,328,492.47	
10,396,684.34	
24,233,844.77	
4,796.70	

9911	SB PAYMENT FOR TAN F	1,192,225.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,192,225.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

1,192,225.73

1,192,225.73

ACC CAPITATION - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351D	ADULT 40-100% MALE 1	69,871.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,871.09		
351E	ADULT 40-100% FEMAL E	96,620.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,620.75		
351F	ADULT 40-100% MALE 2	378,306.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		378,306.71		
351G	ADULT 40-100% FEMAL E	314,532.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,532.51		
351H	ADULT 40-100% M&F 45	571,004.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		571,004.41		
351J	ADULT 40-100% M&F 65	1,126.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,126.81		
3526	ADULT 40-100% MALE 2	512.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		512.80		
3528	ADULT 40-100% M&F 45	1,367.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,367.52		
352F	ADULT 40-100% MALE 2	2,314.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,314.23		
352H	ADULT 40-100% M&F 45	2,899.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,899.38		
3706	ADULT <40% EXP MALE	27,591.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,591.56		
3707	ADULT <40% EXP FEMA L	3,910.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,910.19		
3708	ADULT <40% EXP M&F
4	57,244.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,244.70		
3709	ADULT <40% EXP M&F 6	3,342.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,342.45		
370F	ADULT <40% EXP MALE	10,732.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,732.30		
370G	ADULT <40% EXP FEMA L	497.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		497.19		
370H	ADULT <40% EXP M&F
4	9,493.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,493.54		
3714	ADULT <40% EXP MALE	6,531,198.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,531,198.24		
3715	ADULT <40% EXP FEMA L	5,936,403.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,936,403.04		
3716	ADULT <40% EXP MALE	48,789,421.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,789,421.85		
3717	ADULT <40% EXP FEMA L	29,124,659.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,124,659.29		
3718	ADULT <40% EXP M&F
4	56,709,300.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,709,300.26		
3719	ADULT <40% EXP M&F 6	4,322.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,322.81		
371D	ADULT <40% EXP MALE	173,398.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173,398.88		
371E	ADULT <40% EXP FEMA L	170,863.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,863.21		
371F	ADULT <40% EXP MALE	1,729,093.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,729,093.63		
371G	ADULT <40% EXP FEMA L	1,025,917.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,025,917.09		
371H	ADULT <40% EXP M&F
4	1,427,011.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,427,011.49		
3726	ADULT <40% EXP MALE	1,897.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,897.66		
3727	ADULT <40% EXP FEMA L	1,521.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,521.58		
372F	ADULT <40% EXP MALE	1,485.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,485.99		
372G	ADULT <40% EXP FEMA L	327.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327.59		
SUBTOTAL:	207,740,499.5	4	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,740,499.54		

151,291.91

9935	BIRTH SUPP PAYMENT A	151,291.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	467,589.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

467,589.31

ACC CAPITATION - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	618,881.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		618,881.22		

287,755.48

3906	NEWLY ELIGIBLE MALE	9,297.77	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	1,217.16	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	33,923.88	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	7,185.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	291.08	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	3,238.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,284,259.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	1,465,580.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	7,364,904.93	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	10,869,239.04	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	11,162,990.77	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	475.27	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	35,162.36	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	45,902.91	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	276,730.87	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	424,973.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	330,872.11	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	530.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	2,368.16	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	764.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392F	NEWLY ELIGIBLE MALE	231.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	33,320,140.2	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,297.77	
1,217.16	
33,923.88	
7,185.51	
291.08	
3,238.66	
1,284,259.95	
1,465,580.91	
7,364,904.93	
10,869,239.04	
11,162,990.77	
475.27	
35,162.36	
45,902.91	
276,730.87	
424,973.22	
330,872.11	
530.47	
2,368.16	
764.22	
231.01	
33,320,140.26	

9939	BIRTH SUPP PAYMENT N	287,755.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	287,755.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
287,755.48

4413	SOBRA 100-133% M&F
6	7,453,485.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,125,710.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2,040,252.05	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	203,140.56	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	57,197.67	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	49,539.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,929,326.2	8	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,453,485.41	
2,125,710.78	
2,040,252.05	
203,140.56	
57,197.67	
49,539.81	
11,929,326.28	

11,882.90

9944	BIRTH SUPP PAYMENT S	11,882.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,882.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,882.90

ACC CAPITATION - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4517	BC PATIENT FEMALE 2 1	10,376.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,376.74		
4518	BC PATIENT FEMALE 4
5	47,200.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,200.02		
451G	BC PATIENT FEMALE 2 1	142.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.44		
451H	BC PATIENT FEMALE 4
5	6,761.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,761.14		
4617	CC PATIENT FEMALE 2 1	4,771.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,771.12		
4618	CC PATIENT FEMALE 4
5	2,661.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,661.05		
SUBTOTAL:	71,912.51	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,912.51		

8600	SSI BLIND FREEDOM/W O	2,514.53	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	136.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,558,410.72	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	39,870.23	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	503,485.23	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	29,729.13	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	234,348.44	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	6,655.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,375,150.96	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,514.53	
136.70	
1,558,410.72	
39,870.23	
503,485.23	
29,729.13	
234,348.44	
6,655.98	
2,375,150.96	

637,039,184.43

637,039,184.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	89.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89.69		
1007	TANF 21-44 FEMALE WI	106.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.74		
1008	TANF 45-64 M & F WIT	178.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178.61		
1009	TANF 65+ M & F WITH	99.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.53		
100F	TANF 21-44 MALE WITH	0.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.29		
100G	TANF 21-44 FEMALE WI	2.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.91		
100H	TANF 45-64 M & F WIT	14.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.60		
100J	TANF 65+ M & F WITH	1.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.43		
1011	TANF <1 M & F NON-ME	9,979.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,979.28		
1012	TANF 01-05 M & F NON	18,993.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,993.92		
1013	TANF 06-13 M & F NON	34,139.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,139.11		
1014	TANF 14-20 MALE NON-	9,849.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,849.08		
1015	TANF 14-20 FEMALE N O	12,309.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,309.27		
1016	TANF 21-44 MALE NON-	24,304.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,304.85		
1017	TANF 21-44 FEMALE N O	83,159.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,159.05		
1018	TANF 45-64 M & F NON	19,720.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,720.09		
1019	TANF 65+ M & F NON-M	78.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.99		
101A	TANF < 1 M & F NON-M	622.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		622.00		
101B	TANF 01-05 M & F NON	200.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200.41		
101C	TANF 06-13 M & F NON	91.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.26		
101D	TANF 14-20 MALE NON-	54.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.36		
101E	TANF 14-20 FEMALE N O	99.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.54		
101F	TANF 21-44 MALE NON-	653.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		653.45		
101G	TANF 21-44 FEMALE N O	1,627.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,627.34		
101H	TANF 44-64 M & F NON	355.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355.51		
101J	TANF 65+ N & F NON-M	0.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.64		
1024	TANF 14-20 MALE WITH	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1026	TANF 21-44 MALE WITH	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.00		
1027	TANF 21-44 FEMALE WI	95.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.99		
1028	TANF 45-64 M & F WIT	108.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108.90		
1029	TANF 65+ M & F WITH	47.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.70		
2100	SSI AGED WITH MEDIC A	4,122.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,122.71		
210Z	SSI AGED WITH MEDIC
A	283.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283.43		
2110	SSI AGED NON-MEDICA R	6,783.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,783.06		
211Z	SSI AGED NON-MEDICA
R	187.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		187.29		
2120	SSI AGED WITH QMB	31,783.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,783.16		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
212Z	SSI AGED WITH QMB P P	32.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.92		
2200	SSI DISABLED WITH M
E	3,555.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,555.63		
220Z	SSI DISABLED WITH M E	164.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.92		
2210	SSI DISABLED NON-ME
D	51,491.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,491.33		
221Z	SSI DISABLED NON-ME D	759.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		759.58		
2220	SSI DISABLED WITH Q
M	26,441.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,441.87		
222Z	SSI DISABLED WITH Q M	37.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.02		
2300	SSI BLIND WITH MEDIC	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.00		
2310	SSI BLIND NON-MEDIC A	499.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		499.60		
231Z	SSI BLIND NON-MEDIC
A	4.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.50		
2320	SSI BLIND WITH QMB	225.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.80		
4302	SOBRA CHILD 01-05 M	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4303	SOBRA CHILD 06-13 M	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4305	SOBRA CHILD 14-20 FE	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4311	SOBRA CHILD <1 M & F	35,979.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,979.41		
4312	SOBRA CHILD 01-05 M	166,797.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,797.05		
4313	SOBRA CHILD 06-13 M	215,941.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,941.09		
4314	SOBRA CHILD 14-20 MA	58,666.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,666.27		
4315	SOBRA CHILD 14-20 FE	58,655.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,655.28		
431A	SOBRA CHILD < 1 M &	446.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		446.25		
431B	SOBRA CHILD 01-05 M	4,091.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,091.48		
431C	SOBRA CHILD 6-13 M&F	3,855.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,855.59		
431D	SOBRA CHILD 14-20 MA	1,094.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,094.86		
431E	SOBRA CHILD 14-20 FE	1,138.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,138.00		
4322	SOBRA CHILD 01-05 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		
4325	SOBRA CHILD 14-20 FE	1.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.41		
432E	SOBRA CHILD 14-20 FE	0.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.58		
5007	SOBRA PREG 21-44 FE M	28.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.29		
5008	SOBRA PREG 45-64 FE
M	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
500G	SOBRA PREG 21-44 FE M	3.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.59		
5013	SOBRA PREG 09-13 FE
M	2.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.06		
5015	SOBRA PREG 14-20 FE M	2,792.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,792.94		
5017	SOBRA PREG 21-44 FE
M	15,577.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,577.98		
5018	SOBRA PREG 45-64 FE M	38.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.47		
501C	SOBRA PREG 09-13 FE
M	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.93		
501E	SOBRA PREG 14-20 FE M	242.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242.99		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
501G	SOBRA PREG 21-44 FE M	1,105.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,105.01		
501H	SOBRA PREG 45-64 FE
M	0.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.16		
5027	SOBRA PREG 21-44 FE M	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.00		
5028	SOBRA PREG 45-64 FE
M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	909,956.0	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		909,956.05		

3100	TRANSPLANT OPTION 1	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00

4.00

9910	TANF & SOBRA CHILDR E	320.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	2,224.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,568.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
320.00	
5.00	
19.00	
2,224.00	
2,568.00	

1104	TANF EXPANDED 14-20	1.00	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	223.00	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	434.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,221.73	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
&	641.26	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	20.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	30.61	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	41.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	37.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	1.00	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	7.00	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	211.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	1,488.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	26,425.77	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	70,866.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	24,281.16	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
&	83.32	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	13.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	41.42	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	718.90	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	1,419.51	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	496.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+ M
&	1.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
223.00	
434.56	
1,221.73	
641.26	
20.37	
30.61	
41.01	
37.89	
1.00	
7.00	
211.02	
1,488.06	
26,425.77	
70,866.22	
24,281.16	
83.32	
13.79	
41.42	
718.90	
1,419.51	
496.90	
1.67	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	763.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		763.98		
1127	TANF EXPANDED 21-44	1,658.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,658.56		
1128	TANF EXPANDED 45-64	2,534.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,534.08		
1129	TANF EXPANDED 65+ M
&	1,524.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,524.12		
112G	TANF EXPANDED 21-44	4.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.97		
112H	TANF EXPANDED 45-64	16.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.91		
112J	TANF EXPANDED 65+ M
&	4.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.82		
2400	SSI AGED EXPANDED WI	227.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227.17		
240Z	SSI AGED EXPANDED
WI	188.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188.57		
2410	SSI AGED EXPANDED N O	95.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.13		
241Z	SSI AGED EXPANDED N
O	12.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.57		
2420	SSI AGED EXPANDED WI	26,237.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,237.74		
242Z	SSI AGED EXPANDED
WI	50.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.54		
2520	SSI BLIND EXPANDED W	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		
2600	SSI DISABLED EXPAND
E	203.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203.51		
260Z	SSI DISABLED EXPAND E	139.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.05		
2610	SSI DISABLED EXPAND
E	1,467.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,467.82		
261Z	SSI DISABLED EXPAND E	33.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.02		
2620	SSI DISABLED EXPAND
E	16,996.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,996.27		
262Z	SSI DISABLED EXPAND E	41.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.28		
SUBTOTAL:	180,908.2	8	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,908.28		

3506	ADULT 40-100% MALE 2	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	1.22	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	72.34	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	7.00	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	1.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	4.62	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	5,628.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	6,154.09	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	18,543.88	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	15,666.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	37,448.72	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	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6.00	
1.22	
72.34	
7.00	
1.77	
4.62	
5,628.35	
6,154.09	
18,543.88	
15,666.52	
37,448.72	
8.00	

9911	SB PAYMENT FOR TAN F	203.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	203.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

203.00

203.00

ACC CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351D	ADULT 40-100% MALE 1	107.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107.37		
351E	ADULT 40-100% FEMAL E	151.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151.90		
351F	ADULT 40-100% MALE 2	592.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		592.51		
351G	ADULT 40-100% FEMAL E	497.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		497.72		
351H	ADULT 40-100% M&F 45	894.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		894.72		
351J	ADULT 40-100% M&F 65	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
3526	ADULT 40-100% MALE 2	0.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.90		
3528	ADULT 40-100% M&F 45	1.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.80		
352F	ADULT 40-100% MALE 2	4.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.09		
352H	ADULT 40-100% M&F 45	2.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.18		
3706	ADULT <40% EXP MALE	24.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.30		
3707	ADULT <40% EXP FEMA L	3.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.22		
3708	ADULT <40% EXP M&F
4	69.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.28		
3709	ADULT <40% EXP M&F 6	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
370F	ADULT <40% EXP MALE	6.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.31		
370G	ADULT <40% EXP FEMA L	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.77		
370H	ADULT <40% EXP M&F
4	10.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.17		
3714	ADULT <40% EXP MALE	10,088.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,088.70		
3715	ADULT <40% EXP FEMA L	9,173.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,173.98		
3716	ADULT <40% EXP MALE	69,372.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,372.63		
3717	ADULT <40% EXP FEMA L	40,598.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,598.88		
3718	ADULT <40% EXP M&F
4	82,032.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,032.08		
3719	ADULT <40% EXP M&F 6	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
371D	ADULT <40% EXP MALE	267.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267.37		
371E	ADULT <40% EXP FEMA L	271.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271.22		
371F	ADULT <40% EXP MALE	2,522.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,522.08		
371G	ADULT <40% EXP FEMA L	1,522.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,522.51		
371H	ADULT <40% EXP M&F
4	2,167.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,167.78		
3726	ADULT <40% EXP MALE	3.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.18		
3727	ADULT <40% EXP FEMA L	2.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.48		
372F	ADULT <40% EXP MALE	2.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.46		
372G	ADULT <40% EXP FEMA L	0.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.51		
SUBTOTAL:	303,949.6	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		303,949.61		

26.00

9935	BIRTH SUPP PAYMENT A	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	80.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

80.00

ACC CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	106.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.00		

49.00

3906	NEWLY ELIGIBLE MALE	13.21	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	3.00	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	67.86	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	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.77	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	6.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	3,064.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,540.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	16,984.12	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	25,383.25	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	25,738.62	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	1.00	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	83.05	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	112.21	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	668.38	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	1,005.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	791.17	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	1.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	1.00	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
392F	NEWLY ELIGIBLE MALE	0.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	77,486.10	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13.21	
3.00	
67.86	
18.00	
0.77	
6.11	
3,064.23	
3,540.91	
16,984.12	
25,383.25	
25,738.62	
1.00	
83.05	
112.21	
668.38	
1,005.22	
791.17	
1.38	
1.00	
2.00	
0.61	
77,486.10	

9939	BIRTH SUPP PAYMENT N	49.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
49.00

4413	SOBRA 100-133% M&F
6	41,633.68	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	11,801.28	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	11,349.99	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	1,128.83	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	316.73	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	270.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	66,501.36	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
41,633.68	
11,801.28	
11,349.99	
1,128.83	
316.73	
270.85	
66,501.36	

2.00

9944	BIRTH SUPP PAYMENT S	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00

ACC CAPITATION - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4517	BC PATIENT FEMALE 2 1	22.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.89		
4518	BC PATIENT FEMALE 4
5	127.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.00		
451G	BC PATIENT FEMALE 2 1	0.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.38		
451H	BC PATIENT FEMALE 4
5	19.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.22		
4617	CC PATIENT FEMALE 2 1	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
4618	CC PATIENT FEMALE 4
5	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
SUBTOTAL:	184.49	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		184.49		

8600	SSI BLIND FREEDOM/W O	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W
O	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	2,089.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	67.99	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	376.44	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	21.21	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	342.00	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	4.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,904.59	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
1.00	
2,089.42	
67.99	
376.44	
21.21	
342.00	
4.53	
2,904.59	

TOTAL:	1,544,822.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,544,822.48		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	33.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.40		
1011	TANF <1 M & F NON-ME	1,753.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,753.50		
1012	TANF 01-05 M & F NON	1,402.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,402.80		
1013	TANF 06-13 M & F NON	1,285.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,285.90		
1014	TANF 14-20 MALE NON-	334.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334.00		
1015	TANF 14-20 FEMALE N O	484.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		484.30		
1016	TANF 21-44 MALE NON-	1,419.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,419.50		
1017	TANF 21-44 FEMALE N O	5,761.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,761.50		
1018	TANF 45-64 M & F NON	2,638.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,638.60		
2100	SSI AGED WITH MEDIC A	83.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.50		
2110	SSI AGED NON-MEDICA
R	116.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.90		
2120	SSI AGED WITH QMB	1,035.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,035.40		
2200	SSI DISABLED WITH M E	400.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		400.80		
2210	SSI DISABLED NON-ME
D	6,379.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,379.40		
2220	SSI DISABLED WITH Q M	2,271.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,271.20		
2310	SSI BLIND NON-MEDIC
A	66.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
2320	SSI BLIND WITH QMB	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.70		
4311	SOBRA CHILD <1 M & F	4,876.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,876.40		
4312	SOBRA CHILD 01-05 M	14,762.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,762.80		
4313	SOBRA CHILD 06-13 M	14,094.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,094.80		
4314	SOBRA CHILD 14-20 MA	2,822.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,822.30		
4315	SOBRA CHILD 14-20 FE	2,922.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,922.50		
5015	SOBRA PREG 14-20 FE M	116.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.90		
5017	SOBRA PREG 21-44 FE
M	751.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		751.50		
5018	SOBRA PREG 45-64 FE M	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.70		
SUBTOTAL:	65,848.10	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,848.10		

1108	TANF EXPANDED 45-64	33.40	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
&	116.90	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	33.40	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	83.50	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	885.10	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	3,306.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,987.30	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
&	16.70	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	50.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
33.40	
116.90	
33.40	
83.50	
885.10	
3,306.60	
1,987.30	
16.70	
50.10	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1127	TANF EXPANDED 21-44	66.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
1128	TANF EXPANDED 45-64	350.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350.70		
1129	TANF EXPANDED 65+ M
&	250.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250.50		
2420	SSI AGED EXPANDED WI	1,452.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,452.90		
2610	SSI DISABLED EXPAND
E	133.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133.60		
2620	SSI DISABLED EXPAND E	751.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		751.50		
SUBTOTAL:	9,519.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,519.00		

3908	NEWLY ELIGIBLE M&F 4	16.70	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	33.40	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	66.80	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	450.90	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	801.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,586.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,955.90	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.70	
33.40	
66.80	
450.90	
801.60	
1,586.50	
2,955.90	

4413	SOBRA 100-133% M&F
6	1,786.90	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	317.30	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	334.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,438.20	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,786.90	
317.30	
334.00	
2,438.20	

8700	SSI DISABLED FREEDO M	50.10	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	16.70	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	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	83.50	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

50.10	
16.70	
16.70	
83.50	

3514	ADULT 40-100% MALE 1	83.50	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	133.60	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	651.30	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	668.00	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	2,605.20	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	16.70	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	300.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	367.40	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	5,093.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	3,122.90	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	8,149.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	21,192.30	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
83.50	
133.60	
651.30	
668.00	
2,605.20	
16.70	
300.60	
367.40	
5,093.50	
3,122.90	
8,149.60	
21,192.30	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	102,037.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,037.00		

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1011	TANF <1 M & F NON-ME	105.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105.00		
1012	TANF 01-05 M & F NON	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84.00		
1013	TANF 06-13 M & F NON	77.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.00		
1014	TANF 14-20 MALE NON-	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
1015	TANF 14-20 FEMALE N O	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
1016	TANF 21-44 MALE NON-	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.00		
1017	TANF 21-44 FEMALE N O	345.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345.00		
1018	TANF 45-64 M & F NON	158.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.00		
2100	SSI AGED WITH MEDIC A	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2110	SSI AGED NON-MEDICA
R	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2120	SSI AGED WITH QMB	62.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.00		
2200	SSI DISABLED WITH M E	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
2210	SSI DISABLED NON-ME
D	382.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382.00		
2220	SSI DISABLED WITH Q M	136.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.00		
2310	SSI BLIND NON-MEDIC
A	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2320	SSI BLIND WITH QMB	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4311	SOBRA CHILD <1 M & F	292.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292.00		
4312	SOBRA CHILD 01-05 M	884.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		884.00		
4313	SOBRA CHILD 06-13 M	844.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		844.00		
4314	SOBRA CHILD 14-20 MA	169.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169.00		
4315	SOBRA CHILD 14-20 FE	175.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.00		
5015	SOBRA PREG 14-20 FE M	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
5017	SOBRA PREG 21-44 FE
M	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		
5018	SOBRA PREG 45-64 FE M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	3,943.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,943.00		

1108	TANF EXPANDED 45-64	2.00	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
&	7.00	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	2.00	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	5.00	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	53.00	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	198.00	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	119.00	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
&	1.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
7.00	
2.00	
5.00	
53.00	
198.00	
119.00	
1.00	
3.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1127	TANF EXPANDED 21-44	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1128	TANF EXPANDED 45-64	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
1129	TANF EXPANDED 65+ M
&	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
2420	SSI AGED EXPANDED WI	87.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.00		
2610	SSI DISABLED EXPAND
E	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2620	SSI DISABLED EXPAND E	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		
SUBTOTAL:	570.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		570.00		

3908	NEWLY ELIGIBLE M&F 4	1.00	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	2.00	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	4.00	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	27.00	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	48.00	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	95.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	177.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
2.00	
4.00	
27.00	
48.00	
95.00	
177.00	

4413	SOBRA 100-133% M&F
6	107.00	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	19.00	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	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	146.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

107.00	
19.00	
20.00	
146.00	

8700	SSI DISABLED FREEDO M	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
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	
8720	SSI DISABLED FREEDO 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	
SUBTOTAL:	5.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
1.00	
1.00	
5.00	

3514	ADULT 40-100% MALE 1	5.00	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	8.00	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	39.00	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	40.00	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	156.00	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	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	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	22.00	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	305.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	187.00	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	488.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,269.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5.00	
8.00	
39.00	
40.00	
156.00	
1.00	
18.00	
22.00	
305.00	
187.00	
488.00	
1,269.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	6,110.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,110.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.71		
1008	TANF 45-64 M & F WIT	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.71		
1009	TANF 65+ M & F WITH	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.71		
1011	TANF <1 M & F NON-ME	204.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204.39		
1012	TANF 01-05 M & F NON	431.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		431.49		
1013	TANF 06-13 M & F NON	408.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408.78		
1014	TANF 14-20 MALE NON-	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.71		
1015	TANF 14-20 FEMALE N O	181.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.68		
1016	TANF 21-44 MALE NON-	567.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567.75		
1017	TANF 21-44 FEMALE N O	4,428.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,428.45		
1018	TANF 45-64 M & F NON	1,544.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,544.28		
2100	SSI AGED WITH MEDIC A	181.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.68		
2110	SSI AGED NON-MEDICA
R	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.42		
2120	SSI AGED WITH QMB	1,975.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,975.77		
2200	SSI DISABLED WITH M E	681.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		681.30		
2210	SSI DISABLED NON-ME
D	4,110.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,110.51		
2220	SSI DISABLED WITH Q M	2,861.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,861.46		
2310	SSI BLIND NON-MEDIC
A	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.71		
2320	SSI BLIND WITH QMB	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.42		
4311	SOBRA CHILD <1 M & F	908.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		908.40		
4312	SOBRA CHILD 01-05 M	5,473.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,473.11		
4313	SOBRA CHILD 06-13 M	4,678.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,678.26		
4314	SOBRA CHILD 14-20 MA	976.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		976.53		
4315	SOBRA CHILD 14-20 FE	1,657.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,657.83		
5015	SOBRA PREG 14-20 FE M	113.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.55		
5017	SOBRA PREG 21-44 FE
M	1,021.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,021.95		
SUBTOTAL:	32,611.56	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,611.56		

1108	TANF EXPANDED 45-64	45.42	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
&	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	22.71	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	272.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	2,884.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,476.15	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	22.71	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	90.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
45.42	
22.71	
22.71	
272.52	
2,884.17	
1,476.15	
22.71	
90.84	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1129	TANF EXPANDED 65+ M
&	249.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249.81		
2410	SSI AGED EXPANDED N O	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.71		
2420	SSI AGED EXPANDED
WI	1,703.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,703.25		
2610	SSI DISABLED EXPAND E	68.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.13		
2620	SSI DISABLED EXPAND
E	567.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567.75		
SUBTOTAL:	7,448.88	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,448.88		

3908	NEWLY ELIGIBLE M&F 4	22.71	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	22.71	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	22.71	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	158.97	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	590.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,953.06	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.71	
22.71	
22.71	
158.97	
590.46	
1,135.50	
1,953.06	

4413	SOBRA 100-133% M&F
6	386.07	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	113.55	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	136.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	635.88	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

386.07	
113.55	
136.26	
635.88	

4518	BC PATIENT FEMALE 4 5	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.71

22.71

3514	ADULT 40-100% MALE 1	136.26	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	227.10	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	363.36	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	340.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	1,453.44	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	22.71	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	158.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	317.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1,794.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,657.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	5,586.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,059.01	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
136.26	
227.10	
363.36	
340.65	
1,453.44	
22.71	
158.97	
317.94	
1,794.09	
1,657.83	
5,586.66	
12,059.01	

8700	SSI DISABLED FREEDO M	45.42	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	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

45.42

45.42

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	90.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.84		

54,821.94

54,821.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	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		
1008	TANF 45-64 M & F WIT	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1009	TANF 65+ M & F WITH	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1011	TANF <1 M & F NON-ME	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1012	TANF 01-05 M & F NON	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
1013	TANF 06-13 M & F NON	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
1014	TANF 14-20 MALE NON-	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		
1015	TANF 14-20 FEMALE N O	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1016	TANF 21-44 MALE NON-	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
1017	TANF 21-44 FEMALE N O	195.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195.00		
1018	TANF 45-64 M & F NON	68.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.00		
2100	SSI AGED WITH MEDIC A	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2110	SSI AGED NON-MEDICA
R	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2120	SSI AGED WITH QMB	87.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.00		
2200	SSI DISABLED WITH M E	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
2210	SSI DISABLED NON-ME
D	181.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.00		
2220	SSI DISABLED WITH Q M	126.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126.00		
2310	SSI BLIND NON-MEDIC
A	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		
2320	SSI BLIND WITH QMB	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4311	SOBRA CHILD <1 M & F	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.00		
4312	SOBRA CHILD 01-05 M	241.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241.00		
4313	SOBRA CHILD 06-13 M	206.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206.00		
4314	SOBRA CHILD 14-20 MA	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.00		
4315	SOBRA CHILD 14-20 FE	73.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.00		
5015	SOBRA PREG 14-20 FE M	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
5017	SOBRA PREG 21-44 FE
M	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		
SUBTOTAL:	1,436.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,436.00		

1108	TANF EXPANDED 45-64	2.00	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
&	1.00	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	1.00	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	12.00	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	127.00	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	65.00	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	1.00	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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
1.00	
1.00	
12.00	
127.00	
65.00	
1.00	
4.00	

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1129	TANF EXPANDED 65+ M
&	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
2410	SSI AGED EXPANDED N O	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2420	SSI AGED EXPANDED
WI	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.00		
2610	SSI DISABLED EXPAND E	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2620	SSI DISABLED EXPAND
E	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
SUBTOTAL:	328.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		328.00		

3908	NEWLY ELIGIBLE M&F 4	1.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	26.00	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	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	86.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
1.00	
1.00	
7.00	
26.00	
50.00	
86.00	

4413	SOBRA 100-133% M&F
6	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

17.00	
5.00	
6.00	
28.00	

4518	BC PATIENT FEMALE 4 5	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	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

1.00

3514	ADULT 40-100% MALE 1	6.00	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	10.00	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	16.00	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	15.00	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	64.00	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	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	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	14.00	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	79.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	73.00	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	246.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	531.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
10.00	
16.00	
15.00	
64.00	
1.00	
7.00	
14.00	
79.00	
73.00	
246.00	
531.00	

8700	SSI DISABLED FREEDO M	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

2.00

2.00

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		

TOTAL:	2,414.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,414.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending July 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	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
1009	TANF 65+ M & F WITH	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
1011	TANF <1 M & F NON-ME	1,045.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,045.80		
1012	TANF 01-05 M & F NON	2,191.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,191.20		
1013	TANF 06-13 M & F NON	2,340.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,340.60		
1014	TANF 14-20 MALE NON-	423.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		423.30		
1015	TANF 14-20 FEMALE N O	1,767.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,767.90		
1016	TANF 21-44 MALE NON-	6,474.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,474.00		
1017	TANF 21-44 FEMALE N O	23,904.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,904.00		
1018	TANF 45-64 M & F NON	7,519.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,519.80		
1019	TANF 65+ M & F NON-M	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
1026	TANF 21-44 MALE WITH	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
1028	TANF 45-64 M & F WIT	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
1029	TANF 65+ M & F WITH	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
2100	SSI AGED WITH MEDIC A	1,444.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,444.20		
2110	SSI AGED NON-MEDICA
R	199.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.20		
2120	SSI AGED WITH QMB	5,229.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,229.00		
2200	SSI DISABLED WITH M E	3,336.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,336.60		
2210	SSI DISABLED NON-ME
D	18,077.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,077.40		
2220	SSI DISABLED WITH Q M	8,341.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,341.50		
2300	SSI BLIND WITH MEDIC	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
2310	SSI BLIND NON-MEDIC A	273.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		273.90		
2320	SSI BLIND WITH QMB	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
4311	SOBRA CHILD <1 M & F	3,884.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,884.40		
4312	SOBRA CHILD 01-05 M	31,847.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,847.10		
4313	SOBRA CHILD 06-13 M	42,330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,330.00		
4314	SOBRA CHILD 14-20 MA	10,034.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,034.70		
4315	SOBRA CHILD 14-20 FE	11,727.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,727.90		
5013	SOBRA PREG 09-13 FE M	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
5015	SOBRA PREG 14-20 FE
M	473.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		473.10		
5017	SOBRA PREG 21-44 FE M	2,838.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,838.60		
5018	SOBRA PREG 45-64 FE
M	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
SUBTOTAL:	186,102.6	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186,102.60		

24.90

1106	TANF EXPANDED 21-44	24.90	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	249.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

249.00

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+ M
&	174.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.30		
1115	TANF EXPANDED 14-20	249.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249.00		
1116	TANF EXPANDED 21-44	3,237.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,237.00		
1117	TANF EXPANDED 21-44	9,935.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,935.10		
1118	TANF EXPANDED 45-64	5,004.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,004.90		
1119	TANF EXPANDED 65+ M
&	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
1126	TANF EXPANDED 21-44	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
1127	TANF EXPANDED 21-44	249.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249.00		
1128	TANF EXPANDED 45-64	498.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.00		
1129	TANF EXPANDED 65+ M
&	498.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.00		
2410	SSI AGED EXPANDED N O	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
2420	SSI AGED EXPANDED
WI	3,311.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,311.70		
2610	SSI DISABLED EXPAND E	124.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.50		
2620	SSI DISABLED EXPAND
E	1,593.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,593.60		
SUBTOTAL:	25,373.10	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,373.10		

3906	NEWLY ELIGIBLE MALE	24.90	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	24.90	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	224.10	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	298.80	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	1,269.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	2,589.60	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	2,913.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,345.50	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

24.90	
24.90	
224.10	
298.80	
1,269.90	
2,589.60	
2,913.30	
7,345.50	

3514	ADULT 40-100% MALE 1	398.40	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	597.60	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	1,344.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	1,269.90	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	3,834.60	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	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	2,365.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	2,664.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	18,102.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	9,163.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	18,948.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	58,714.20	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
398.40	
597.60	
1,344.60	
1,269.90	
3,834.60	
24.90	
2,365.50	
2,664.30	
18,102.30	
9,163.20	
18,948.90	
58,714.20	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	2,813.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,813.70		
4414	SOBRA 100-133% MALE	946.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		946.20		
4415	SOBRA 100-133% FEMA L	996.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		996.00		
SUBTOTAL:	4,755.90	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,755.90		

49.80

282,341.10

49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8710	SSI DISABLED FREEDO	0
M
SUBTOTAL:

282,341.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

49.80

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending July 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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1009	TANF 65+ M & F WITH	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1011	TANF <1 M & F NON-ME	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.00		
1012	TANF 01-05 M & F NON	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.00		
1013	TANF 06-13 M & F NON	94.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94.00		
1014	TANF 14-20 MALE NON-	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
1015	TANF 14-20 FEMALE N O	71.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.00		
1016	TANF 21-44 MALE NON-	260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		260.00		
1017	TANF 21-44 FEMALE N O	960.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		960.00		
1018	TANF 45-64 M & F NON	302.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302.00		
1019	TANF 65+ M & F NON-M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1026	TANF 21-44 MALE WITH	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1028	TANF 45-64 M & F WIT	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1029	TANF 65+ M & F WITH	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2100	SSI AGED WITH MEDIC A	58.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.00		
2110	SSI AGED NON-MEDICA
R	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2120	SSI AGED WITH QMB	210.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210.00		
2200	SSI DISABLED WITH M E	134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134.00		
2210	SSI DISABLED NON-ME
D	726.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		726.00		
2220	SSI DISABLED WITH Q M	335.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		335.00		
2300	SSI BLIND WITH MEDIC	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2310	SSI BLIND NON-MEDIC A	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
2320	SSI BLIND WITH QMB	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4311	SOBRA CHILD <1 M & F	156.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156.00		
4312	SOBRA CHILD 01-05 M	1,279.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,279.00		
4313	SOBRA CHILD 06-13 M	1,700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,700.00		
4314	SOBRA CHILD 14-20 MA	403.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403.00		
4315	SOBRA CHILD 14-20 FE	471.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471.00		
5013	SOBRA PREG 09-13 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		
5015	SOBRA PREG 14-20 FE
M	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
5017	SOBRA PREG 21-44 FE M	114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.00		
5018	SOBRA PREG 45-64 FE
M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	7,474.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,474.00		

1.00

1106	TANF EXPANDED 21-44	1.00	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	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+ M
&	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1115	TANF EXPANDED 14-20	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1116	TANF EXPANDED 21-44	130.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.00		
1117	TANF EXPANDED 21-44	399.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		399.00		
1118	TANF EXPANDED 45-64	201.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201.00		
1119	TANF EXPANDED 65+ 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		
1126	TANF EXPANDED 21-44	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1127	TANF EXPANDED 21-44	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1128	TANF EXPANDED 45-64	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
1129	TANF EXPANDED 65+ M
&	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
2410	SSI AGED EXPANDED N O	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2420	SSI AGED EXPANDED
WI	133.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133.00		
2610	SSI DISABLED EXPAND E	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2620	SSI DISABLED EXPAND
E	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.00		
SUBTOTAL:	1,019.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,019.00		

3906	NEWLY ELIGIBLE MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	1.00	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	9.00	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	12.00	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	51.00	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	104.00	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	117.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	295.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
1.00	
9.00	
12.00	
51.00	
104.00	
117.00	
295.00	

3514	ADULT 40-100% MALE 1	16.00	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	24.00	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	54.00	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	51.00	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	154.00	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	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	95.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	107.00	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	727.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	368.00	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	761.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,358.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16.00	
24.00	
54.00	
51.00	
154.00	
1.00	
95.00	
107.00	
727.00	
368.00	
761.00	
2,358.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	113.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.00		
4414	SOBRA 100-133% MALE	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.00		
4415	SOBRA 100-133% FEMA L	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.00		
SUBTOTAL:	191.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191.00		

2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.0	
2.00	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
SUBTOTAL:

0	2.00

2.00

TOTAL:	11,339.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,339.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	8,388.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,388.64		
1010	TANF NON-MEDICARE	1,661,849.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,661,849.71		
1020	TANF WITH QMB	20,971.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,971.60		
2100	SSI AGED WITH MEDIC A	35,053,635.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,053,635.97		
210Z	SSI AGED WITH MEDIC
A	1,732,093.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,732,093.67		
2110	SSI AGED NON-MEDICA R	3,603,820.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,603,820.94		
211Z	SSI AGED NON-MEDICA
R	101,176.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,176.43		
2120	SSI AGED WITH QMB	26,288,894.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,288,894.99		
212Z	SSI AGED WITH QMB P P	53,559.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,559.58		
2200	SSI DISABLED WITH M
E	15,658,939.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,658,939.46		
220Z	SSI DISABLED WITH M E	241,491.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241,491.30		
2210	SSI DISABLED NON-ME
D	136,360,868.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,360,868.15		
221Z	SSI DISABLED NON-ME D	220,330.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,330.68		
2220	SSI DISABLED WITH Q
M	29,326,623.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,326,623.98		
222Z	SSI DISABLED WITH Q M	36,101.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,101.66		
2300	SSI BLIND WITH MEDIC	2,719.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,719.44		
2310	SSI BLIND NON-MEDIC A	108,525.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,525.41		
2320	SSI BLIND WITH QMB	20,374.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,374.22		
SUBTOTAL:	250,500,365.8	3	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250,500,365.83		

8700	SSI DISABLED FREEDO M	155,943.28	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	193,336.11	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	6,470.18	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	61,678.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	417,428.1	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
155,943.28	
0.00	
193,336.11	
6,470.18	
61,678.62	
417,428.19	

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

250,917,794.02

TOTAL:

250,917,794.02

0.00

LONG TERM CARE MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1010	TANF NON-MEDICARE	393.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		393.91		
1020	TANF WITH QMB	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2100	SSI AGED WITH MEDIC A	11,901.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,901.36		
210Z	SSI AGED WITH MEDIC
A	562.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		562.03		
2110	SSI AGED NON-MEDICA R	611.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611.47		
211Z	SSI AGED NON-MEDICA
R	16.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.60		
2120	SSI AGED WITH QMB	9,350.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,350.65		
212Z	SSI AGED WITH QMB P P	17.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.29		
2200	SSI DISABLED WITH M
E	4,466.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,466.83		
220Z	SSI DISABLED WITH M E	78.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.72		
2210	SSI DISABLED NON-ME
D	30,896.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,896.55		
221Z	SSI DISABLED NON-ME D	35.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.96		
2220	SSI DISABLED WITH Q
M	7,937.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,937.60		
222Z	SSI DISABLED WITH Q M	11.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.96		
2300	SSI BLIND WITH MEDIC	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2310	SSI BLIND NON-MEDIC A	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
2320	SSI BLIND WITH QMB	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
SUBTOTAL:	66,319.93	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,319.93		

8700	SSI DISABLED FREEDO M	42.00	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	31.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	1.00	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	16.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	91.98	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
42.00	
0.00	
31.99	
1.00	
16.99	
91.98	

TOTAL:	66,411.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,411.91		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	360.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		360.61		
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-	675.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		675.61		
1015	TANF 14-20 FEMALE N O	236.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236.81		
4311	SOBRA CHILD <1 M & F	-365.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-365.58		
4312	SOBRA CHILD 01-05 M	-100.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-100.40		
4313	SOBRA CHILD 06-13 M	292.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292.16		
4314	SOBRA CHILD 14-20 MA	-0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.83		
4315	SOBRA CHILD 14-20 FE	-301.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-301.20		
431C	SOBRA CHILD 6-13 M&F	67.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.66		
SUBTOTAL:	864.84	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		864.84		

864.84

864.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		
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		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	27,128.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,128.70		
1014	TANF 14-20 MALE NON-	993.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		993.49		
1017	TANF 21-44 FEMALE N O	8,755.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,755.69		
101D	TANF 14-20 MALE NON-	47.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.31		
101F	TANF 21-44 MALE NON-	3,972.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,972.40		
101H	TANF 44-64 M & F NON	611.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611.14		
1020	TANF WITH QMB	1,466.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,466.58		
2100	SSI AGED WITH MEDIC A	399.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		399.06		
2120	SSI AGED WITH QMB	9,121.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,121.46		
2200	SSI DISABLED WITH M E	6,705.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,705.80		
220Z	SSI DISABLED WITH M
E	1,230.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,230.03		
2210	SSI DISABLED NON-ME D	191,817.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,817.13		
221Z	SSI DISABLED NON-ME
D	4,176.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,176.42		
2220	SSI DISABLED WITH Q M	70,948.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,948.72		
222Z	SSI DISABLED WITH Q
M	880.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		880.65		
2310	SSI BLIND NON-MEDIC A	1,706.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,706.25		
4314	SOBRA CHILD 14-20 MA	1,680.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,680.63		
SUBTOTAL:	331,641.4	6	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		331,641.46		

3510	ADULT 40-100% FOR FI	49,075.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	1,816.33	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	2,291.77	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	208,662.74	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	534.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1,314.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

49,075.49	
1,816.33	
2,291.77	
208,662.74	
534.75	
1,314.71	

1100	TANF EXPANDED FPR FI	5,780.66	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	26,238.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,604.24	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	3,738.47	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	5,500.24	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	1,466.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	10,037.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
260Z	SSI DISABLED EXPAND E	440.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
261Z	SSI DISABLED EXPAND
E	2,520.94	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	28,947.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	86,275.20	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,780.66	
26,238.37	
1,604.24	
3,738.47	
5,500.24	
1,466.58	
10,037.64	
440.32	
2,520.94	
28,947.74	
86,275.20	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEMA L	38,663.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,663.11		
3718	ADULT <40% EXP M&F
4	2,368.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,368.16		
371F	ADULT <40% EXP MALE	10,405.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,405.58		
371G	ADULT <40% EXP FEMA L	13,048.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,048.25		
371H	ADULT <40% EXP M&F
4	381.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381.96		
SUBTOTAL:	328,562.8	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		328,562.85		

3910	NEWLY ELIGIBLE FOR F	11,840.80	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	236.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,077.62	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,840.80	
236.82	
12,077.62	

8700	SSI DISABLED FREEDO M	5,118.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,118.75	
SUBTOTAL:	5,118.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,118.75	
																
S000	STATE-ONLY BHS	4,186.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,186.30	
SUBTOTAL:	4,186.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,186.30	
																
TOTAL:		767,862.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		767,862.18	

222Z

SSI DISABLED WITH Q M
SSI BLIND NON-MEDIC
A

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

2310

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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

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

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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	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	
260Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
261Z	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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	
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	
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	
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	
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	
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	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	
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

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	
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	
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

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 - GENERAL
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	-1.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1.81		
1017	TANF 21-44 FEMALE N O	593.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		593.22		
101G	TANF 21-44 FEMALE N
O	-57.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-57.94		
2100	SSI AGED WITH MEDIC A	70.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.96		
221Z	SSI DISABLED NON-ME
D	135.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.05		
4312	SOBRA CHILD 01-05 M	59.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.49		
4314	SOBRA CHILD 14-20 MA	-1.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1.81		
5017	SOBRA PREG 21-44 FE M	-4.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4.40		
SUBTOTAL:	792.76	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		792.76		

1116	TANF EXPANDED 21-44	-182.58	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	70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-112.05	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-182.58	
70.53	
-112.05	

3618	AHC CARE/MI M&F 45-6	155.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	155.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

155.73

155.73

3514	ADULT 40-100% MALE 1	209.24	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	-3.91	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	-3.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	-1,000.44	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	634.77	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	-806.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	-1,472.07	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	-19.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	211.59	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	-100.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA L	-43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-2,393.56	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
209.24	
-3.91	
-3.41	
-1,000.44	
634.77	
-806.04	
-1,472.07	
-19.73	
211.59	
-100.56	
-43.00	
-2,393.56	

3916	NEWLY ELIGIBLE MALE	398.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	398.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
398.60

398.60

S000	STATE-ONLY BHS	-37.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-37.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-37.60

-37.60

-1,196.12

-1,196.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

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	
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	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	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
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	
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	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA 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:

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	
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

0.00

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

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	675,910.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		675,910.00		
1011	TANF <1 M & F NON-ME	248.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248.11		
1012	TANF 01-05 M & F NON	-15,379.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-15,379.82		
1013	TANF 06-13 M & F NON	-2,418.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,418.26		
1014	TANF 14-20 MALE NON-	-811.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-811.16		
1015	TANF 14-20 FEMALE N O	-368.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-368.71		
1017	TANF 21-44 FEMALE N
O	712.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		712.84		
101B	TANF 01-05 M & F NON	-261.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-261.17		
101C	TANF 06-13 M & F NON	1,300.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,300.68		
101D	TANF 14-20 MALE NON-	751.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		751.24		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	258,752.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258,752.13		
221Z	SSI DISABLED NON-ME D	232.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232.93		
2220	SSI DISABLED WITH Q
M	762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		762.00		
2310	SSI BLIND NON-MEDIC A	762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		762.00		
4310	SOBRA CHILD NON-ME
DI	10,445,633.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,445,633.40		
4311	SOBRA CHILD <1 M & F	13,625.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,625.43		
4312	SOBRA CHILD 01-05 M	-74,721.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-74,721.61		
4313	SOBRA CHILD 06-13 M	-105,628.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-105,628.37		
4314	SOBRA CHILD 14-20 MA	-43,134.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-43,134.77		
4315	SOBRA CHILD 14-20 FE	-40,754.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-40,754.75		
431A	SOBRA CHILD < 1 M &	1,940.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,940.81		
431B	SOBRA CHILD 01-05 M	12,785.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,785.94		
431C	SOBRA CHILD 6-13 M&F	25,205.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,205.14		
431D	SOBRA CHILD 14-20 MA	16,781.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,781.28		
431E	SOBRA CHILD 14-20 FE	11,745.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,745.14		
5010	SOBRA PREGNANT WO MAN	13,738.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,738.15		
SUBTOTAL:	11,197,408.6	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,197,408.60		

4410	SOBRA 100-133% FOR F	12,926.90	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	1,092.50	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	-762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,257.40	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,926.90	
1,092.50	
-762.00	
13,257.40	

11,210,666.00

11,210,666.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending July 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	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

O
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

101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

101E	TANF 14-20 FEMALE N
O
2210	SSI DISABLED NON-ME

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	
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	

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

2310	SSI BLIND NON-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

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

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

4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5010	SOBRA PREGNANT WO MAN	0.00	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	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

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 July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	204.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204.75		
1010	TANF NON-MEDICARE	88,390.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,390.05		
1020	TANF WITH QMB	796.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796.94		
2100	SSI AGED WITH MEDIC A	53,657.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,657.95		
2110	SSI AGED NON-MEDICA
R	2,380.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,380.90		
2120	SSI AGED WITH QMB	90,544.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,544.71		
2200	SSI DISABLED WITH M E	391,262.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391,262.61		
2210	SSI DISABLED NON-ME
D	5,853,769.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,853,769.90		
221Z	SSI DISABLED NON-ME D	123.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.42		
2220	SSI DISABLED WITH Q
M	968,050.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		968,050.49		
2310	SSI BLIND NON-MEDIC A	1,463.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,463.86		
2320	SSI BLIND WITH QMB	398.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		398.47		
SUBTOTAL:	7,451,044.05	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,451,044.05		

8700	SSI DISABLED FREEDO M	4,554.83	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	785.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	2,380.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,721.64	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,554.83	
785.91	
2,380.90	
7,721.64	

7,458,765.69

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

7,458,765.69

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending July 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		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
2220	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

data is

0.00

0.00

under re

0.00

0.00

visio

0.00

n.

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

SSI DISABLED FREEDO M

8720

SSI DISABLED FREEDO M

8710

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SSI DISABLED FREEDO M

8700

0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

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

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	572.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572.44		
1007	TANF 21-44 FEMALE WI	697.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		697.86		
1008	TANF 45-64 M & F WIT	1,292.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,292.20		
1009	TANF 65+ M & F WITH	784.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		784.65		
1011	TANF <1 M & F NON-ME	13,774.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,774.43		
1012	TANF 01-05 M & F NON	26,627.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,627.12		
1013	TANF 06-13 M & F NON	48,891.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,891.34		
1014	TANF 14-20 MALE NON-	29,752.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,752.48		
1015	TANF 14-20 FEMALE N O	50,257.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,257.49		
1016	TANF 21-44 MALE NON-	196,818.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196,818.83		
1017	TANF 21-44 FEMALE N O	669,123.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		669,123.39		
1018	TANF 45-64 M & F NON	161,187.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,187.72		
1019	TANF 65+ M & F NON-M	674.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		674.30		
1024	TANF 14-20 MALE WITH	10.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.41		
1026	TANF 21-44 MALE WITH	387.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		387.68		
1027	TANF 21-44 FEMALE WI	653.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		653.45		
1028	TANF 45-64 M & F WIT	835.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		835.76		
1029	TANF 65+ M & F WITH	450.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		450.07		
2100	SSI AGED WITH MEDIC A	32,980.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,980.00		
2110	SSI AGED NON-MEDICA
R	53,956.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,956.16		
2120	SSI AGED WITH QMB	256,470.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256,470.33		
2200	SSI DISABLED WITH M E	25,887.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,887.66		
2210	SSI DISABLED NON-ME
D	277,976.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277,976.12		
2220	SSI DISABLED WITH Q M	170,604.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,604.53		
2300	SSI BLIND WITH MEDIC	235.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		235.51		
2310	SSI BLIND NON-MEDIC A	3,591.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,591.59		
2320	SSI BLIND WITH QMB	1,900.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,900.92		
4302	SOBRA CHILD 01-05 M	3.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.24		
4303	SOBRA CHILD 06-13 M	9.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.76		
4305	SOBRA CHILD 14-20 FE	20.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.16		
4311	SOBRA CHILD <1 M & F	48,698.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,698.46		
4312	SOBRA CHILD 01-05 M	236,845.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236,845.73		
4313	SOBRA CHILD 06-13 M	310,882.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310,882.77		
4314	SOBRA CHILD 14-20 MA	155,400.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,400.15		
4315	SOBRA CHILD 14-20 FE	157,772.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157,772.95		
4322	SOBRA CHILD 01-05 M	1.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.08		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4325	SOBRA CHILD 14-20 FE	2.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.17		
5007	SOBRA PREG 21-44 FE M	148.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148.67		
5008	SOBRA PREG 45-64 FE
M	11.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.36		
5013	SOBRA PREG 09-13 FE M	3.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.32		
5015	SOBRA PREG 14-20 FE
M	18,252.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,252.71		
5017	SOBRA PREG 21-44 FE M	118,643.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,643.32		
5018	SOBRA PREG 45-64 FE
M	307.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		307.55		
5027	SOBRA PREG 21-44 FE M	205.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205.51		
SUBTOTAL:	3,073,603.35	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,073,603.35		

1104	TANF EXPANDED 14-20	7.58	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	1,498.50	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	2,773.08	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	8,681.03	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
&	5,243.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	2.17	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	9.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	1,728.16	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	11,819.11	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	206,769.69	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	559,426.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	193,896.05	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
&	675.07	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	5,230.29	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	10,842.84	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	18,557.98	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
&	12,988.91	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	839.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	734.20	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	200,778.15	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	7.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	762.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND
E	10,383.49	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	99,455.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.58	
1,498.50	
2,773.08	
8,681.03	
5,243.88	
2.17	
9.77	
1,728.16	
11,819.11	
206,769.69	
559,426.66	
193,896.05	
675.07	
5,230.29	
10,842.84	
18,557.98	
12,988.91	
839.74	
734.20	
200,778.15	
7.58	
762.25	
10,383.49	
99,455.39	

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

 
30.32

30.32

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1,353,111.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,353,111.57		

3906	NEWLY ELIGIBLE MALE	90.34	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	22.74	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	508.36	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	153.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	23,916.71	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	27,726.24	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	130,814.88	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	195,391.19	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	196,812.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	16.91	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	9.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

90.34	
22.74	
508.36	
153.92	
23,916.71	
27,726.24	
130,814.88	
195,391.19	
196,812.85	
16.91	
9.33	

3506	ADULT 40-100% MALE 2	39.65	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	489.12	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	52.76	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	44,503.32	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	48,337.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	143,262.93	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	120,707.93	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	284,786.15	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	60.32	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	15.16	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	131.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	15.16	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	423.53	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	39.65	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	81,881.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	74,646.71	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	546,095.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	311,573.37	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	624,590.56	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	69.67	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	7.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEMA L	15.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,281,745.11	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
39.65	
489.12	
52.76	
44,503.32	
48,337.08	
143,262.93	
120,707.93	
284,786.15	
60.32	
15.16	
131.78	
15.16	
423.53	
39.65	
81,881.88	
74,646.71	
546,095.64	
311,573.37	
624,590.56	
69.67	
7.58	
15.16	
2,281,745.11	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3928	NEWLY ELIGIBLE M&F 4	16.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.91		
3929	NEWLY ELIGIBLE M&F
6	13.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.11		
SUBTOTAL:	575,493.4	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		575,493.49		

4413	SOBRA 100-133% M&F
6	58,543.74	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	31,311.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	30,354.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	120,209.7	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
58,543.74	
31,311.71	
30,354.30	
120,209.75	

4517	BC PATIENT FEMALE 2 1	143.38	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	952.24	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	48.96	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	65.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,210.47	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
143.38	
952.24	
48.96	
65.89	
1,210.47	

8600	SSI BLIND FREEDOM/W O	7.58	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	9.33	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	11,292.61	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	2,466.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1,897.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,673.94	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7.58	
9.33	
11,292.61	
2,466.77	
1,897.65	
15,673.94	

6015	KIDS 14-19 FEMALE NO	18.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	18.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
18.76

18.76

7,421,096.76

7,421,096.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending July 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

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

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

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

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

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
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
2220	SSI DISABLED WITH Q

2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
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	

M

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
0.00	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 July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5008	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

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	
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	

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

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

0.00

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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		
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
&	

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

1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED	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	WI
SSI AGED EXPANDED N
O	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	
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	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	E													

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending July 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		

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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

3508

3509

3514

3515

3516

3517

3518

3519

3528

3706

3707

3708	ADULT 40-100% MALE 2

ADULT 40-100% M&F 45

ADULT 40-100% M&F 65

ADULT 40-100% MALE 1

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

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

ADULT 40-100% M&F 65

ADULT 40-100% M&F 45 ADULT <40% EXP MALE
ADULT <40% EXP FEMA L
ADULT <40% EXP M&F
4	
3709	ADULT <40% EXP M&F 6	
3714	ADULT <40% EXP MALE	
3715

3716

3717

3718

3719

3726

3727

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

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

ADULT <40% EXP FEMA L
:	

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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 July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		

0.00

0.00

0.00

0.00

0.00

8710

8720

SS

SSI DISABLED FREEDO M
SSI DISABLED FREEDO

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

M
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

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	O				pri0or m	onth	data	is	und0.00er r0e.00   vis0i.0o0      n. 0.00	
8700	O
I DISABLED FREEDO	0.00	0.00	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	M													

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

0.00

4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	7,179.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,179.92		
1007	TANF 21-44 FEMALE WI	5,660.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,660.13		
1008	TANF 45-64 M & F WIT	13,522.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,522.79		
1009	TANF 65+ M & F WITH	7,573.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,573.40		
1011	TANF <1 M & F NON-ME	1,704,748.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,704,748.88		
1012	TANF 01-05 M & F NON	321,855.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321,855.78		
1013	TANF 06-13 M & F NON	530,515.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		530,515.76		
1014	TANF 14-20 MALE NON-	203,236.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,236.61		
1015	TANF 14-20 FEMALE N O	393,263.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		393,263.47		
1016	TANF 21-44 MALE NON-	1,956,741.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,956,741.53		
1017	TANF 21-44 FEMALE N O	6,391,025.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,391,025.27		
1018	TANF 45-64 M & F NON	2,566,895.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,566,895.07		
1019	TANF 65+ M & F NON-M	3,082.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,082.12		
1026	TANF 21-44 MALE WITH	5,452.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,452.82		
1027	TANF 21-44 FEMALE WI	8,052.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,052.27		
1028	TANF 45-64 M & F WIT	7,027.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,027.85		
1029	TANF 65+ M & F WITH	11,881.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,881.21		
2100	SSI AGED WITH MEDIC A	231,952.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		231,952.74		
2110	SSI AGED NON-MEDICA
R	164,988.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164,988.00		
2120	SSI AGED WITH QMB	696,504.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		696,504.68		
2200	SSI DISABLED WITH M E	509,724.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		509,724.57		
2210	SSI DISABLED NON-ME
D	9,349,394.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,349,394.09		
2220	SSI DISABLED WITH Q M	1,799,464.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,799,464.98		
2300	SSI BLIND WITH MEDIC	2,786.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,786.12		
2310	SSI BLIND NON-MEDIC A	105,581.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,581.25		
2320	SSI BLIND WITH QMB	25,806.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,806.73		
4311	SOBRA CHILD <1 M & F	3,079,674.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,079,674.40		
4312	SOBRA CHILD 01-05 M	4,144,566.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,144,566.09		
4313	SOBRA CHILD 06-13 M	6,203,269.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,203,269.83		
4314	SOBRA CHILD 14-20 MA	1,874,493.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,874,493.90		
4315	SOBRA CHILD 14-20 FE	2,264,127.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,264,127.22		
5007	SOBRA PREG 21-44 FE M	1,468.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,468.11		
5015	SOBRA PREG 14-20 FE
M	462,480.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		462,480.69		
5017	SOBRA PREG 21-44 FE M	2,739,461.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,739,461.45		
5018	SOBRA PREG 45-64 FE
M	6,539.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,539.65		
5027	SOBRA PREG 21-44 FE M	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	47,800,049.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,800,049.38		

3316	AHC CARE MALE 21-44	-153.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-153.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-153.38

-153.38

1106	TANF EXPANDED 21-44	5,110.76	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	7,837.72	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	43,884.10	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
&	41,898.71	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	4,985.00	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	46,865.67	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	842,652.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	2,677,030.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,540,583.65	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
&	910.00	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	33,491.08	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	46,273.16	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	158,730.25	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
&	83,815.25	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	9,289.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	11,659.69	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	609,814.23	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	14,393.93	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	227,516.29	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	464,964.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,871,706.59	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,110.76	
7,837.72	
43,884.10	
41,898.71	
4,985.00	
46,865.67	
842,652.04	
2,677,030.30	
1,540,583.65	
910.00	
33,491.08	
46,273.16	
158,730.25	
83,815.25	
9,289.86	
11,659.69	
609,814.23	
14,393.93	
227,516.29	
464,964.90	
6,871,706.59	

3507	ADULT 40-100% FEMAL E	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	1,036.20	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	107.15	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	82,193.78	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	133,768.02	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	929,328.88	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	719,939.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	2,471,316.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	684.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	3,777.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
427.00	
1,036.20	
107.15	
82,193.78	
133,768.02	
929,328.88	
719,939.62	
2,471,316.14	
0.00	
684.21	
3,777.08	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3708	ADULT <40% EXP M&F 4	4,674.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,674.03		
3709	ADULT <40% EXP M&F
6	-266.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-266.59		
3714	ADULT <40% EXP MALE	476,542.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		476,542.78		
3715	ADULT <40% EXP FEMA L	514,957.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		514,957.44		
3716	ADULT <40% EXP MALE	9,597,893.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,597,893.16		
3717	ADULT <40% EXP FEMA L	4,679,276.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,679,276.71		
3718	ADULT <40% EXP M&F
4	11,372,750.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,372,750.63		
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		
SUBTOTAL:	30,988,406.2	4	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,988,406.24		

3906	NEWLY ELIGIBLE MALE	390.09	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	107.12	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	14,207.86	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	75,884.26	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	798,451.54	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	669,305.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,313,681.30	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	723.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,872,750.91	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
390.09	
107.12	
14,207.86	
75,884.26	
798,451.54	
669,305.12	
1,313,681.30	
723.62	
2,872,750.91	

4412	SOBRA 100-133% M&F
1	455.00	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	485,065.80	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	190,200.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	228,920.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	904,642.2	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
455.00	
485,065.80	
190,200.70	
228,920.72	
904,642.22	

4518	BC PATIENT FEMALE 4 5	38,008.91	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	910.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	38,918.91	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
38,008.91	
910.00	
38,918.91	

8700	SSI DISABLED FREEDO M	18,707.10	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	43,835.37	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	9,872.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	72,415.46	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
18,707.10	
43,835.37	
9,872.99	
72,415.46	

S000	STATE-ONLY BHS	4,829.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,829.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,829.17

4,829.17

89,553,565.50

89,553,565.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	41.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.58		
1008	TANF 45-64 M & F WIT	250.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250.37		
1011	TANF <1 M & F NON-ME	1,720.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,720.56		
1013	TANF 06-13 M & F NON	27,471.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,471.80		
1014	TANF 14-20 MALE NON-	696.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		696.15		
1015	TANF 14-20 FEMALE N O	3,945.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,945.81		
1016	TANF 21-44 MALE NON-	42,364.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,364.00		
1017	TANF 21-44 FEMALE N O	99,491.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,491.18		
1018	TANF 45-64 M & F NON	43,845.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,845.13		
1028	TANF 45-64 M & F WIT	716.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		716.59		
2100	SSI AGED WITH MEDIC A	12,444.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,444.34		
2110	SSI AGED NON-MEDICA
R	37,219.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,219.25		
2120	SSI AGED WITH QMB	19.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.50		
2200	SSI DISABLED WITH M E	-598.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-598.77		
2210	SSI DISABLED NON-ME
D	32,328.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,328.76		
2310	SSI BLIND NON-MEDIC A	1,529.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,529.33		
4311	SOBRA CHILD <1 M & F	51,776.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,776.35		
4312	SOBRA CHILD 01-05 M	171,883.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,883.85		
4313	SOBRA CHILD 06-13 M	39,579.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,579.36		
4314	SOBRA CHILD 14-20 MA	60,862.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,862.64		
4315	SOBRA CHILD 14-20 FE	39,098.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,098.46		
5015	SOBRA PREG 14-20 FE M	36,367.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,367.09		
5017	SOBRA PREG 21-44 FE
M	145,231.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,231.52		
SUBTOTAL:	848,284.8	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		848,284.85		

1106	TANF EXPANDED 21-44	543.51	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	898.03	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	3,307.90	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
&	635.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	2,605.19	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	39,789.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	72,024.94	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	23,861.92	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	52.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	1,350.36	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	10,489.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
543.51	
898.03	
3,307.90	
635.51	
2,605.19	
39,789.35	
72,024.94	
23,861.92	
52.45	
1,350.36	
10,489.58	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2420	SSI AGED EXPANDED WI	791.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		791.45		
2600	SSI DISABLED EXPAND
E	1,295.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,295.64		
2610	SSI DISABLED EXPAND E	-219.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-219.23		
2620	SSI DISABLED EXPAND
E	1,154.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,154.85		
SUBTOTAL:	158,581.4	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,581.45		

3914	NEWLY ELIGIBLE MALE	4,623.62	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	5,279.84	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	60,063.03	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	45,195.44	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	85,283.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	200,445.7	8	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,623.62	
5,279.84	
60,063.03	
45,195.44	
85,283.85	
200,445.78	

4413	SOBRA 100-133% M&F
6	97,572.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	5,506.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2,035.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	105,114.9	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

97,572.50	
5,506.95	
2,035.46	
105,114.91	

8700	SSI DISABLED FREEDO M	144.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	144.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

144.13

144.13

3514	ADULT 40-100% MALE 1	10,702.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	5,064.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	46,133.37	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	41,567.26	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	115,030.97	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	24,541.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	26,859.93	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	327,902.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	120,559.81	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	328,031.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,046,393.49	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10,702.55	
5,064.47	
46,133.37	
41,567.26	
115,030.97	
24,541.79	
26,859.93	
327,902.19	
120,559.81	
328,031.15	
1,046,393.49	

TOTAL:	2,358,964.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,358,964.61		

FEDERAL EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	2,216.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,216.23		
1012	TANF 01-05 M & F NON	77,421.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,421.94		
1013	TANF 06-13 M & F NON	67,181.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,181.43		
1014	TANF 14-20 MALE NON-	44,070.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,070.56		
1015	TANF 14-20 FEMALE N O	346,405.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		346,405.17		
1016	TANF 21-44 MALE NON-	573.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		573.09		
1017	TANF 21-44 FEMALE N O	2,136,707.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,136,707.54		
1018	TANF 45-64 M & F NON	9,102.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,102.32		
2100	SSI AGED WITH MEDIC A	22,518.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,518.78		
2110	SSI AGED NON-MEDICA
R	1,723,508.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,723,508.17		
2120	SSI AGED WITH QMB	144.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144.29		
2200	SSI DISABLED WITH M E	9,179.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,179.10		
2210	SSI DISABLED NON-ME
D	52,112.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,112.74		
SUBTOTAL:	4,491,141.36	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,491,141.36		

3906	NEWLY ELIGIBLE MALE	88.56	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	2,053.67	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	28,807.43	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	25,005.01	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	1,008,770.47	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	595,025.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	3,491,966.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	56.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,151,773.36	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

88.56	
2,053.67	
28,807.43	
25,005.01	
1,008,770.47	
595,025.55	
3,491,966.35	
56.32	
5,151,773.36	

1108	TANF EXPANDED 45-64	27,446.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	3,651.26	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	41,374.06	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	571,399.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,721,737.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	866,332.20	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
&	4,984.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	1,534.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	1,941.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	1,355.53	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	4,987.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,246,744.83	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
27,446.45	
3,651.26	
41,374.06	
571,399.29	
1,721,737.63	
866,332.20	
4,984.50	
1,534.58	
1,941.61	
1,355.53	
4,987.72	
3,246,744.83	

FEDERAL EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	12,889,659.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,889,659.55		

FEDERAL ESP CHRONIC SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1014	TANF 14-20 MALE NON-	4,719.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,719.36		
SUBTOTAL:	4,719.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,719.36		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

4,719.36

0.00

4,719.36

0.00	0.00

0.00

0.00

QMB - FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	660,202.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		660,202.07		
8040	SLMB	75.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.68		
SUBTOTAL:	660,277.75	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		660,277.75		

660,277.75

660,277.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FFS TRBHA FEE FOR SERVICE
For The Period Ending July 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	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	502.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		502.62		
1011	TANF <1 M & F NON-ME	13,327.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,327.71		
1012	TANF 01-05 M & F NON	7,865.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,865.88		
1013	TANF 06-13 M & F NON	307,867.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		307,867.77		
1014	TANF 14-20 MALE NON-	72,162.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,162.55		
1015	TANF 14-20 FEMALE N O	109,108.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,108.33		
1016	TANF 21-44 MALE NON-	482,746.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		482,746.26		
1017	TANF 21-44 FEMALE N O	1,459,385.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,459,385.50		
1018	TANF 45-64 M & F NON	285,431.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285,431.75		
1028	TANF 45-64 M & F WIT	184.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		184.73		
1029	TANF 65+ M & F WITH	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455.00		
2100	SSI AGED WITH MEDIC A	21,178.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,178.90		
2110	SSI AGED NON-MEDICA
R	3,423.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,423.10		
2120	SSI AGED WITH QMB	66,532.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,532.03		
2200	SSI DISABLED WITH M E	63,339.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,339.72		
2210	SSI DISABLED NON-ME
D	2,142,025.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,142,025.20		
2220	SSI DISABLED WITH Q M	388,879.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		388,879.11		
2310	SSI BLIND NON-MEDIC
A	36,358.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,358.35		
2320	SSI BLIND WITH QMB	5,271.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,271.02		
4311	SOBRA CHILD <1 M & F	6,460.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,460.61		
4312	SOBRA CHILD 01-05 M	239,174.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239,174.74		
4313	SOBRA CHILD 06-13 M	3,963,253.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,963,253.67		
4314	SOBRA CHILD 14-20 MA	974,878.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		974,878.74		
4315	SOBRA CHILD 14-20 FE	1,157,053.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,157,053.84		
5015	SOBRA PREG 14-20 FE M	14,079.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,079.10		
5017	SOBRA PREG 21-44 FE
M	146,024.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,024.25		
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:	11,966,970.4	8	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,966,970.48		

1107	TANF EXPANDED 21-44	176.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	2,325.67	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
&	687.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	3,045.00	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	8,599.02	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	167,952.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
176.33	
2,325.67	
687.20	
3,045.00	
8,599.02	
167,952.92	

FFS TRBHA FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	457,969.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457,969.90		
1118	TANF EXPANDED 45-64	151,584.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151,584.86		
1126	TANF EXPANDED 21-44	5,497.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,497.39		
1127	TANF EXPANDED 21-44	310.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310.16		
1128	TANF EXPANDED 45-64	12,149.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,149.05		
1129	TANF EXPANDED 65+ M
&	4,153.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,153.95		
2400	SSI AGED EXPANDED WI	12.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.41		
2410	SSI AGED EXPANDED N
O	506.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		506.92		
2420	SSI AGED EXPANDED WI	50,579.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,579.11		
2600	SSI DISABLED EXPAND
E	1,408.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,408.72		
2610	SSI DISABLED EXPAND E	11,220.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,220.70		
2620	SSI DISABLED EXPAND
E	85,511.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,511.04		
SUBTOTAL:	963,690.3	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		963,690.35		

3914	NEWLY ELIGIBLE MALE	7,754.44	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	10,046.83	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	131,397.05	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	62,391.07	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	67,746.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	279,335.5	3	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,754.44	
10,046.83	
131,397.05	
62,391.07	
67,746.14	
279,335.53	

4413	SOBRA 100-133% M&F
6	173,365.54	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	81,411.72	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	64,610.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

173,365.54	
81,411.72	
64,610.03	

3514	ADULT 40-100% MALE 1	10,776.55	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	17,060.97	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	149,781.25	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	97,619.18	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	182,864.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	1,874.72	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	160,013.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	121,984.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	2,936,328.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,686,784.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	1,557,136.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,922,225.77	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10,776.55	
17,060.97	
149,781.25	
97,619.18	
182,864.50	
1,874.72	
160,013.86	
121,984.63	
2,936,328.66	
1,686,784.93	
1,557,136.52	
6,922,225.77	

FFS TRBHA FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	319,387.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		319,387.29		

8700	SSI DISABLED FREEDO M	444.71	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	172.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	617.49	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

444.71	
172.78	
617.49	

4518	BC PATIENT FEMALE 4 5	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

455.00

455.00

TOTAL:	20,452,681.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,452,681.91		

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	20,058.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,058.67		
1017	TANF 21-44 FEMALE N O	52,130.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,130.85		
2210	SSI DISABLED NON-ME
D	84,690.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,690.30		
2220	SSI DISABLED WITH Q M	1,364.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,364.00		
SUBTOTAL:	158,243.8	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,243.82		

1116	TANF EXPANDED 21-44	1,524.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	11,776.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,640.66	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,524.14	
11,776.52	
1,340.00	
14,640.66	

3516	ADULT 40-100% MALE 2	3,699.35	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	3,265.56	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	4,102.35	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	256,690.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	99,476.60	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	17,511.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	384,745.8	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,699.35	
3,265.56	
4,102.35	
256,690.49	
99,476.60	
17,511.54	
384,745.89	

3916	NEWLY ELIGIBLE MALE	8,408.80	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	23,373.21	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	7,567.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39,349.93	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,408.80	
23,373.21	
7,567.92	
39,349.93	

596,980.30

596,980.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	82,215.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,215.38		
2110	SSI AGED NON-MEDICA
R	76,145.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,145.26		
2200	SSI DISABLED WITH M E	43,412.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,412.57		
2210	SSI DISABLED NON-ME
D	6,450.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,450.10		
5015	SOBRA PREG 14-20 FE M	5,808.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,808.31		
5017	SOBRA PREG 21-44 FE
M	29,972.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,972.75		
SUBTOTAL:	244,004.3	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,004.37		

3516	ADULT 40-100% MALE 2	6,841.48	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	740.01	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	6,206.45	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	82.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	356,063.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	8,831.44	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	503,750.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	882,515.3	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,841.48	
740.01	
6,206.45	
82.53	
356,063.45	
8,831.44	
503,750.01	
882,515.37	

3916	NEWLY ELIGIBLE MALE	57,655.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	3,740.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	61,395.21	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

57,655.11	
3,740.10	
61,395.21	

1108	TANF EXPANDED 45-64	1,594.54	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	4,499.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	491.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,585.58	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,594.54	
4,499.70	
491.34	
6,585.58	

TOTAL:	1,194,500.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,194,500.53		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 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	3,561.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,561.30		
SUBTOTAL:	3,561.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,561.30		

3716	ADULT <40% EXP MALE	193.90	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	108.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	302.05	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

	193.90	
	108.15	
	302.05	
TOTAL:			3,863.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		3,863.35	

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	3,026.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,026.28		
1016	TANF 21-44 MALE NON-	225.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.11		
1017	TANF 21-44 FEMALE N O	13,398.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,398.03		
1018	TANF 45-64 M & F NON	175.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.42		
5017	SOBRA PREG 21-44 FE M	2,993.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,993.69		
SUBTOTAL:	19,818.53	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,818.53		

3516	ADULT 40-100% MALE 2	-3,664.92	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	124,139.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	21,348.89	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	47,932.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	189,756.4	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-3,664.92	
124,139.48	
21,348.89	
47,932.97	
189,756.42	

3914	NEWLY ELIGIBLE MALE	421.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	7,974.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	382.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8,778.87	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

421.95	
7,974.24	
382.68	
8,778.87	

1116	TANF EXPANDED 21-44	19,096.08	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	5,726.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	24,822.58	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19,096.08	
5,726.50	
24,822.58	

TOTAL:	243,176.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243,176.40		

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3717	ADULT <40% EXP FEMA L	3,409.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,409.21		
SUBTOTAL:	3,409.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,409.21		

3,409.21

3,409.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	4,796.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,796.03		
5017	SOBRA PREG 21-44 FE
M	120.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120.60		
SUBTOTAL:	4,916.63	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,916.63		

3918	NEWLY ELIGIBLE M&F 4	10.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10.58

10.58

3716	ADULT <40% EXP MALE	14,403.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	5,525.63	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	24,530.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	44,460.17	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14,403.73	
5,525.63	
24,530.81	
44,460.17	

TOTAL:	49,387.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,387.38		

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending July 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	2,189.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,189.61		
SUBTOTAL:	2,189.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,189.61		

3716	ADULT <40% EXP MALE	160.48	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	254.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	415.11	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

	160.48	
	254.63	
	415.11	
TOTAL:			2,604.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		2,604.72	

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,476.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,476.55		
2100	SSI AGED WITH MEDIC A	3,396,841.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,396,841.10		
2110	SSI AGED NON-MEDICA
R	270,248.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270,248.25		
2120	SSI AGED WITH QMB	5,144,790.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,144,790.92		
2200	SSI DISABLED WITH M E	665,108.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		665,108.26		
2210	SSI DISABLED NON-ME
D	4,059,288.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,059,288.17		
2220	SSI DISABLED WITH Q M	1,084,530.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,084,530.49		
2300	SSI BLIND WITH MEDIC	2,008.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,008.80		
2310	SSI BLIND NON-MEDIC A	10,075.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,075.80		
2320	SSI BLIND WITH QMB	4,970.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,970.93		
SUBTOTAL:	14,639,339.2	7	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,639,339.27		

TOTAL:

14,641,720.07

0.00

0.00

0.00

0.00

0.00

0.00

0.00

14,641,720.07

0.00	0.00

0.00

0.00

8720	SSI DISABLED FREEDO M	2,380.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,380.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

2,380.80

2,380.80

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	61,523.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,523.02		
2110	SSI AGED NON-MEDICA
R	891.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		891.34		
2200	SSI DISABLED WITH M E	4,110.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,110.68		
2210	SSI DISABLED NON-ME
D	5,636.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,636.33		
2220	SSI DISABLED WITH Q M	19.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.67		
SUBTOTAL:	72,181.04	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,181.04		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

72,181.04

TOTAL:

72,181.04

0.00

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2220	SSI DISABLED WITH Q M	27,259.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,259.79		
SUBTOTAL:	27,259.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,259.79		

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

27,259.79

0.00

27,259.79

0.00	0.00

0.00

0.00

COCONINO COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	415.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415.40		
SUBTOTAL:	415.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415.40		

415.40

415.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	37,904.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,904.12		
1013	TANF 06-13 M & F NON	66,306.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,306.45		
1014	TANF 14-20 MALE NON-	8,676.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,676.21		
1015	TANF 14-20 FEMALE N O	4,890.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,890.64		
2210	SSI DISABLED NON-ME
D	274,297.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,297.27		
2220	SSI DISABLED WITH Q M	391.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.92		
2310	SSI BLIND NON-MEDIC
A	2,652.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,652.31		
4312	SOBRA CHILD 01-05 M	170,389.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,389.43		
4313	SOBRA CHILD 06-13 M	266,108.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		266,108.81		
4314	SOBRA CHILD 14-20 MA	22,058.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,058.21		
4315	SOBRA CHILD 14-20 FE	10,521.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,521.23		
SUBTOTAL:	864,196.6	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		864,196.60		

124.10

3514	ADULT 40-100% MALE 1	29.06	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	282.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	288.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	599.33	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

29.06	
282.21	
288.06	
599.33	

3914	NEWLY ELIGIBLE MALE	65.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	65.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

65.66

65.66

2600	SSI DISABLED EXPAND E	124.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	124.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
124.10

4413	SOBRA 100-133% M&F
6	78,148.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	5,916.87	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	1,508.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	85,573.14	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
78,148.02	
5,916.87	
1,508.25	
85,573.14	

TOTAL:	950,558.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		950,558.83		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	12,928.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,928.83		
2200	SSI DISABLED WITH M E	2,586.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,586.31		
2210	SSI DISABLED NON-ME
D	1,533,543.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,533,543.66		
2220	SSI DISABLED WITH Q M	5,358.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,358.58		
2310	SSI BLIND NON-MEDIC
A	3,264.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,264.10		
SUBTOTAL:	1,557,681.48	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,557,681.48		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

1,557,681.48

TOTAL:

1,557,681.48

0.00

ACC REINSURANCE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	725,577.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		725,577.26		
1012	TANF 01-05 M & F NON	4,347.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,347.40		
1013	TANF 06-13 M & F NON	324,791.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		324,791.53		
1014	TANF 14-20 MALE NON-	81,483.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,483.94		
1015	TANF 14-20 FEMALE N O	25,303.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,303.51		
1016	TANF 21-44 MALE NON-	180,616.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,616.91		
1017	TANF 21-44 FEMALE N O	454,160.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454,160.18		
1018	TANF 45-64 M & F NON	37,034.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,034.63		
1019	TANF 65+ M & F NON-M	587.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		587.11		
2100	SSI AGED WITH MEDIC A	36,402.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,402.32		
2110	SSI AGED NON-MEDICA
R	112,670.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,670.07		
2200	SSI DISABLED WITH M E	130,347.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,347.89		
2210	SSI DISABLED NON-ME
D	5,846,572.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,846,572.17		
2310	SSI BLIND NON-MEDIC A	11,949.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,949.45		
4311	SOBRA CHILD <1 M & F	2,735,784.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,735,784.55		
4312	SOBRA CHILD 01-05 M	811,967.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		811,967.95		
4313	SOBRA CHILD 06-13 M	1,033,377.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,033,377.89		
4314	SOBRA CHILD 14-20 MA	539,123.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		539,123.31		
4315	SOBRA CHILD 14-20 FE	253,541.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253,541.95		
5015	SOBRA PREG 14-20 FE M	1,806.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,806.25		
5017	SOBRA PREG 21-44 FE
M	13,329.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,329.82		
SUBTOTAL:	13,360,776.0	9	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,360,776.09		

3506	ADULT 40-100% MALE 2	368.52	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	0.01	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	690,465.05	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	3,932.89	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	131,761.99	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	39,682.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

368.52	
0.01	
690,465.05	
3,932.89	
131,761.99	
39,682.33	

1116	TANF EXPANDED 21-44	252,404.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	415,948.62	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	137,286.59	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	15,468.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	3,420.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	143,236.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	967,764.7	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
252,404.63	
415,948.62	
137,286.59	
15,468.37	
3,420.44	
143,236.05	
967,764.70	

ACC REINSURANCE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	355,332.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355,332.76		
3708	ADULT <40% EXP M&F 4	91,183.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,183.40		
3714	ADULT <40% EXP MALE	8,573.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,573.53		
3715	ADULT <40% EXP FEMA L	125,669.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,669.32		
3716	ADULT <40% EXP MALE	1,543,686.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,543,686.80		
3717	ADULT <40% EXP FEMA L	54,757.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,757.63		
3718	ADULT <40% EXP M&F
4	2,239,328.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,239,328.78		
3719	ADULT <40% EXP M&F 6	835.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		835.50		
SUBTOTAL:	5,285,578.51	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,285,578.51		

4413	SOBRA 100-133% M&F
6	241,947.24	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	323,930.80	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	21,318.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	587,196.0	8	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

241,947.24	
323,930.80	
21,318.04	
587,196.08	

8710	SSI DISABLED FREEDO M	6,949.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,949.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,949.00

6,949.00

3914	NEWLY ELIGIBLE MALE	19,597.86	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	16,701.76	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	216,039.59	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	90,890.38	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	383,181.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	726,410.8	2	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19,597.86	
16,701.76	
216,039.59	
90,890.38	
383,181.23	
726,410.82	

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

20,934,675.20

0.00

20,934,675.20

0.00	0.00

0.00

0.00

LONG TERM CARE REINSURANCE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	24,561.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,561.23		
2100	SSI AGED WITH MEDIC A	111,580.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,580.83		
2110	SSI AGED NON-MEDICA
R	69,649.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,649.07		
2200	SSI DISABLED WITH M E	314,831.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,831.72		
2210	SSI DISABLED NON-ME
D	6,285,457.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,285,457.34		
2310	SSI BLIND NON-MEDIC A	1,504.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,504.99		
SUBTOTAL:	6,807,585.18	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,807,585.18		

8710	SSI DISABLED FREEDO M	36,167.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36,167.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
36,167.00

36,167.00

6,843,752.18

6,843,752.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC SMIB
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	49,447.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,447.00		
1010	TANF NON-MEDICARE	677.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		677.50		
1020	TANF WITH QMB	44,961.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,961.50		
2100	SSI AGED WITH MEDIC A	31,102.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,102.20		
2110	SSI AGED NON-MEDICA
R	539,823.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		539,823.00		
2120	SSI AGED WITH QMB	4,358,353.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,358,353.50		
2200	SSI DISABLED WITH M E	79,390.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,390.30		
2210	SSI DISABLED NON-ME
D	457,985.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457,985.50		
2220	SSI DISABLED WITH Q M	3,875,518.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,875,518.60		
2300	SSI BLIND WITH MEDIC	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.50		
2310	SSI BLIND NON-MEDIC A	4,607.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,607.00		
2320	SSI BLIND WITH QMB	38,872.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,872.00		
4320	SOBRA CHILD WITH Q MB	271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271.00		
5020	SOBRA PREGNANT WO
MAN	3,658.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,658.50		
8020	QMB ONLY	803,619.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		803,619.00		
8040	SLMB	5,415,089.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,415,089.00		
8888	SMIB ONLY NOT ELIGIB	-40,718.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-40,718.50		
9999	SMIB ONLY NOT ELIGIB	159,459.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,459.10		
SUBTOTAL:	15,822,251.7	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,822,251.70		

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

271.00

271.00

1100	TANF EXPANDED FPR FI	200,075.30	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	406.50	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	904,239.60	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	13,524.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	3,641,606.30	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	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	13,273.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	2,323,858.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,097,118.90	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
200,075.30	
406.50	
904,239.60	
13,524.00	
3,641,606.30	
135.50	
13,273.00	
2,323,858.70	
7,097,118.90	

8720	SSI DISABLED FREEDO M	45,257.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	45,257.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
45,257.00

45,257.00

TOTAL:	22,964,898.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,964,898.60		

ACC HIB
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1020	TANF WITH QMB	1,311.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,311.00		
2100	SSI AGED WITH MEDIC A	917.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		917.70		
2110	SSI AGED NON-MEDICA
R	7,866.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,866.00		
2120	SSI AGED WITH QMB	516,393.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		516,393.00		
2210	SSI DISABLED NON-ME D	4,807.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,807.00		
2220	SSI DISABLED WITH Q
M	246,186.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246,186.50		
2310	SSI BLIND NON-MEDIC A	437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		437.00		
2320	SSI BLIND WITH QMB	1,114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,114.00		
8020	QMB ONLY	4,259.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,259.70		
9999	SMIB ONLY NOT ELIGIB	-7,682.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,682.70		
SUBTOTAL:	775,609.2	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		775,609.20		

1120	TANF EXPANDED FOR FI	1,551.00	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	4,697.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,248.40	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,551.00	
4,697.40	
6,248.40	

781,857.60

781,857.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

Q1
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	2,963,042.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,963,042.50		
9999	SMIB ONLY NOT ELIGIB	-11,850.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-11,850.50		
SUBTOTAL:	2,951,192.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,951,192.00		

TOTAL:	2,951,192.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,951,192.00		

LTC SMIB
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.50		
1020	TANF WITH QMB	677.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		677.50		
2100	SSI AGED WITH MEDIC A	1,149,367.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,149,367.50		
2110	SSI AGED NON-MEDICA
R	224,638.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,638.00		
2120	SSI AGED WITH QMB	1,237,088.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,237,088.50		
2200	SSI DISABLED WITH M E	399,084.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		399,084.90		
2210	SSI DISABLED NON-ME
D	14,092.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,092.00		
2220	SSI DISABLED WITH Q M	1,066,637.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,066,637.10		
2300	SSI BLIND WITH MEDIC	271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271.00		
2310	SSI BLIND NON-MEDIC A	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.50		
2320	SSI BLIND WITH QMB	813.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		813.00		
SUBTOTAL:	4,092,940.50	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,092,940.50		

8720	SSI DISABLED FREEDO M	1,355.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,355.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,355.00

1,355.00

4,094,295.50

4,094,295.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC HIB
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA
R	1,311.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,311.00		
2120	SSI AGED WITH QMB	366,800.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		366,800.40		
2200	SSI DISABLED WITH M E	1,354.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,354.70		
2220	SSI DISABLED WITH Q
M	11,405.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,405.70		
2320	SSI BLIND WITH QMB	480.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		480.70		
SUBTOTAL:	381,352.5	0	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381,352.50		

TOTAL:	381,352.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381,352.50		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,459.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,459.38		
1007	TANF 21-44 FEMALE WI	1,844.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,844.01		
1008	TANF 45-64 M & F WIT	8,360.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,360.17		
1009	TANF 65+ M & F WITH	6,203.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,203.96		
1011	TANF <1 M & F NON-ME	1,069,634.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,069,634.86		
1012	TANF 01-05 M & F NON	371,200.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		371,200.65		
1013	TANF 06-13 M & F NON	550,058.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		550,058.56		
1014	TANF 14-20 MALE NON-	193,092.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193,092.30		
1015	TANF 14-20 FEMALE N O	384,301.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384,301.30		
1016	TANF 21-44 MALE NON-	1,656,199.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,656,199.06		
1017	TANF 21-44 FEMALE N O	5,602,026.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,602,026.93		
1018	TANF 45-64 M & F NON	2,596,861.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,596,861.71		
1019	TANF 65+ M & F NON-M	4,301.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,301.94		
1026	TANF 21-44 MALE WITH	379.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		379.83		
1027	TANF 21-44 FEMALE WI	8,469.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,469.49		
1028	TANF 45-64 M & F WIT	3,753.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,753.41		
1029	TANF 65+ M & F WITH	3,340.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,340.01		
2100	SSI AGED WITH MEDIC A	112,980.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,980.76		
2110	SSI AGED NON-MEDICA
R	181,290.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,290.38		
2120	SSI AGED WITH QMB	409,253.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		409,253.22		
2200	SSI DISABLED WITH M E	264,684.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264,684.94		
2210	SSI DISABLED NON-ME
D	6,718,110.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,718,110.37		
2220	SSI DISABLED WITH Q M	768,151.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		768,151.66		
2300	SSI BLIND WITH MEDIC	2,403.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,403.28		
2310	SSI BLIND NON-MEDIC A	115,995.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,995.95		
2320	SSI BLIND WITH QMB	10,555.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,555.01		
4311	SOBRA CHILD <1 M & F	2,800,114.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,800,114.73		
4312	SOBRA CHILD 01-05 M	4,665,875.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,665,875.72		
4313	SOBRA CHILD 06-13 M	6,595,816.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,595,816.61		
4314	SOBRA CHILD 14-20 MA	1,460,742.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,460,742.34		
4315	SOBRA CHILD 14-20 FE	2,086,542.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,086,542.45		
5007	SOBRA PREG 21-44 FE M	93.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93.41		
5015	SOBRA PREG 14-20 FE
M	517,147.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		517,147.34		
5017	SOBRA PREG 21-44 FE M	2,680,800.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,680,800.23		
5018	SOBRA PREG 45-64 FE
M	3,229.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,229.98		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	41,855,275.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,855,275.95		

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

0.00

1106	TANF EXPANDED 21-44	3,391.33	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	2,480.75	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	20,017.87	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
&	38,152.86	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	7,145.19	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	33,259.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	642,062.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	2,742,049.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,633,277.35	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
&	2,275.00	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	18,947.85	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	28,437.12	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	70,837.75	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
&	49,296.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	7,581.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	19,508.42	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	406,622.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	3,029.19	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	101,796.44	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	234,227.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,064,397.88	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,391.33	
2,480.75	
20,017.87	
38,152.86	
7,145.19	
33,259.78	
642,062.91	
2,742,049.38	
1,633,277.35	
2,275.00	
18,947.85	
28,437.12	
70,837.75	
49,296.78	
7,581.25	
19,508.42	
406,622.89	
3,029.19	
101,796.44	
234,227.77	
6,064,397.88	

3507	ADULT 40-100% FEMAL E	1,159.91	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	81.00	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	62,409.69	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	126,223.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	727,935.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	667,579.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	2,280,931.12	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	455.00	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	252.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	910.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,159.91	
0.00	
81.00	
62,409.69	
126,223.47	
727,935.76	
667,579.54	
2,280,931.12	
455.00	
252.48	
910.00	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3708	ADULT <40% EXP M&F 4	5,022.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,022.91		
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	332,766.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332,766.96		
3715	ADULT <40% EXP FEMA L	489,450.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		489,450.66		
3716	ADULT <40% EXP MALE	5,578,819.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,578,819.17		
3717	ADULT <40% EXP FEMA L	3,643,354.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,643,354.41		
3718	ADULT <40% EXP M&F
4	8,545,612.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,545,612.25		
3719	ADULT <40% EXP M&F 6	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455.00		
SUBTOTAL:	22,463,419.3	3	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,463,419.33		

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	
3908	NEWLY ELIGIBLE M&F 4	357.78	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	14,450.43	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	60,818.80	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	529,483.65	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	718,698.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,328,260.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,652,069.38	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	
357.78	
14,450.43	
60,818.80	
529,483.65	
718,698.65	
1,328,260.07	
0.00	
2,652,069.38	

4412	SOBRA 100-133% M&F
1	910.00	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	577,496.85	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	197,152.96	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	237,463.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,013,023.62	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
910.00	
577,496.85	
197,152.96	
237,463.81	
1,013,023.62	

4518	BC PATIENT FEMALE 4 5	4,984.51	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	2,275.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,259.51	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,984.51	
2,275.00	
7,259.51	

8700	SSI DISABLED FREEDO M	12,901.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	42,965.11	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	360.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56,227.04	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,901.78	
42,965.11	
360.15	
56,227.04	

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

74,111,672.71

74,111,672.71	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 FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	42,607.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,607.07		
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		
SUBTOTAL:	42,607.07	0.0	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,607.07		

TOTAL:	42,607.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,607.07		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 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	7,031.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,031.94		
1012	TANF 01-05 M & F NON	777.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		777.88		
1013	TANF 06-13 M & F NON	10.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.85		
1014	TANF 14-20 MALE NON-	44.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.05		
1015	TANF 14-20 FEMALE N O	2,496.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,496.60		
1016	TANF 21-44 MALE NON-	5,642.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,642.36		
1017	TANF 21-44 FEMALE N O	38,709.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,709.06		
1018	TANF 45-64 M & F NON	3,220.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,220.37		
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	437.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		437.17		
2110	SSI AGED NON-MEDICA
R	4,535.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,535.42		
2120	SSI AGED WITH QMB	-5.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5.22		
2200	SSI DISABLED WITH M E	828.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		828.88		
2210	SSI DISABLED NON-ME
D	46,209.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,209.75		
2220	SSI DISABLED WITH Q M	6,575.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,575.10		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	2,800.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,800.73		
4312	SOBRA CHILD 01-05 M	8,047.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,047.58		
4313	SOBRA CHILD 06-13 M	11,969.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,969.38		
4314	SOBRA CHILD 14-20 MA	1,518.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,518.14		
4315	SOBRA CHILD 14-20 FE	1,126.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,126.11		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE
M	905.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		905.65		
5017	SOBRA PREG 21-44 FE M	25,861.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,861.76		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	168,743.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		168,743.56		

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

0.00

1106	TANF EXPANDED 21-44	46.16	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	274.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	51,007.26	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	13,078.41	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	759.58	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	83.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	865.55	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	290.75	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:	66,406.19	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
46.16	
0.00	
274.49	
0.00	
0.00	
0.00	
51,007.26	
13,078.41	
759.58	
0.00	
0.00	
0.00	
0.00	
0.00	
83.99	
865.55	
0.00	
0.00	
290.75	
0.00	
66,406.19	

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	48.94	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	19,227.07	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	3,335.31	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	119,068.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	2,766.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
48.94	
0.00	
19,227.07	
3,335.31	
119,068.49	
0.00	
0.00	
2,766.41	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3708	ADULT <40% EXP M&F 4	101.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101.46		
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	6,640.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,640.71		
3715	ADULT <40% EXP FEMA L	462.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		462.06		
3716	ADULT <40% EXP MALE	365,435.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		365,435.81		
3717	ADULT <40% EXP FEMA L	28,305.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,305.36		
3718	ADULT <40% EXP M&F
4	250,841.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250,841.33		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	796,232.9	5	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796,232.95		

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	-31.56	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	75.94	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	106,830.30	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	4,338.29	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	35,899.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	147,112.9	2	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	
-31.56	
75.94	
106,830.30	
4,338.29	
35,899.95	
0.00	
147,112.92	

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	100.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	100.51	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	
100.51	
0.00	
100.51	

4518	BC PATIENT FEMALE 4 5	22,572.76	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:	22,572.76	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22,572.76	
0.00	
22,572.76	

8700	SSI DISABLED FREEDO M	57.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	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:	57.08	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
57.08	
0.00	
0.00	
57.08	

S000	STATE-ONLY BHS	4,829.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,829.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,829.17

4,829.17

1,206,055.14

1,206,055.14	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 - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8020	QMB ONLY	617,512.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617,512.03		
8040	SLMB	75.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.68		
SUBTOTAL:	617,587.7	0.0	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617,587.71		

TOTAL:	617,587.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617,587.71		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,365.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,365.00		
2100	SSI AGED WITH MEDIC A	249,129.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249,129.13		
2110	SSI AGED NON-MEDICA
R	62,182.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,182.20		
2120	SSI AGED WITH QMB	359,948.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		359,948.35		
2200	SSI DISABLED WITH M E	64,376.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,376.04		
2210	SSI DISABLED NON-ME
D	1,137,487.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,137,487.58		
2220	SSI DISABLED WITH Q M	153,160.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,160.28		
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	8,478.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,478.78		
2320	SSI BLIND WITH QMB	604.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		604.35		
SUBTOTAL:	2,036,731.71	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,036,731.71		

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

2,036,731.71

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

2,036,731.71

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending July 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	6,413.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,413.95		
2110	SSI AGED NON-MEDICA
R	25,720.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,720.01		
2120	SSI AGED WITH QMB	11,865.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,865.96		
2200	SSI DISABLED WITH M E	11,704.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,704.99		
2210	SSI DISABLED NON-ME
D	73,355.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,355.72		
2220	SSI DISABLED WITH Q M	2,493.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,493.77		
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:	131,554.40	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,554.40		

TOTAL:

131,554.40

0.00

0.00

0.00

0.00

0.00

0.00

0.00

131,554.40

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

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	5,720.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,720.54		
1007	TANF 21-44 FEMALE WI	3,816.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,816.12		
1008	TANF 45-64 M & F WIT	5,162.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,162.62		
1009	TANF 65+ M & F WITH	1,369.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,369.44		
1011	TANF <1 M & F NON-ME	628,082.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		628,082.08		
1012	TANF 01-05 M & F NON	-50,122.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-50,122.75		
1013	TANF 06-13 M & F NON	-19,553.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-19,553.65		
1014	TANF 14-20 MALE NON-	10,100.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,100.26		
1015	TANF 14-20 FEMALE N O	6,465.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,465.57		
1016	TANF 21-44 MALE NON-	294,900.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		294,900.11		
1017	TANF 21-44 FEMALE N O	750,289.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		750,289.28		
1018	TANF 45-64 M & F NON	-33,187.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-33,187.01		
1019	TANF 65+ M & F NON-M	-1,219.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,219.82		
1026	TANF 21-44 MALE WITH	5,072.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,072.99		
1027	TANF 21-44 FEMALE WI	-417.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-417.22		
1028	TANF 45-64 M & F WIT	3,274.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,274.44		
1029	TANF 65+ M & F WITH	8,541.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,541.20		
2100	SSI AGED WITH MEDIC A	118,534.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,534.81		
2110	SSI AGED NON-MEDICA
R	-20,837.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-20,837.80		
2120	SSI AGED WITH QMB	287,256.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287,256.68		
2200	SSI DISABLED WITH M E	244,210.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,210.75		
2210	SSI DISABLED NON-ME
D	2,585,073.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,585,073.97		
2220	SSI DISABLED WITH Q M	1,024,738.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,024,738.22		
2300	SSI BLIND WITH MEDIC	382.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382.84		
2310	SSI BLIND NON-MEDIC A	-10,414.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-10,414.70		
2320	SSI BLIND WITH QMB	15,251.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,251.72		
4311	SOBRA CHILD <1 M & F	276,758.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		276,758.94		
4312	SOBRA CHILD 01-05 M	-529,357.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-529,357.21		
4313	SOBRA CHILD 06-13 M	-404,516.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-404,516.16		
4314	SOBRA CHILD 14-20 MA	412,233.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		412,233.42		
4315	SOBRA CHILD 14-20 FE	176,458.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,458.66		
5007	SOBRA PREG 21-44 FE M	1,374.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,374.70		
5015	SOBRA PREG 14-20 FE
M	-55,572.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-55,572.30		
5017	SOBRA PREG 21-44 FE M	32,799.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,799.46		
5018	SOBRA PREG 45-64 FE
M	3,309.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,309.67		
5027	SOBRA PREG 21-44 FE M	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.00		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	5,776,029.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,776,029.87		

3316	AHC CARE MALE 21-44	-153.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-153.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-153.38

-153.38

1106	TANF EXPANDED 21-44	1,673.27	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	5,356.97	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	23,591.74	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
&	3,745.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	-2,160.19	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	13,605.89	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	149,581.87	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	-78,097.49	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	-93,453.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	-1,365.00	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	14,543.23	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	17,836.04	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	87,892.50	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
&	34,518.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	1,624.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	-8,714.28	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	203,191.34	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	11,364.74	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	125,429.10	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	230,737.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	740,902.5	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,673.27	
5,356.97	
23,591.74	
3,745.85	
-2,160.19	
13,605.89	
149,581.87	
-78,097.49	
-93,453.28	
-1,365.00	
14,543.23	
17,836.04	
87,892.50	
34,518.47	
1,624.62	
-8,714.28	
203,191.34	
11,364.74	
125,429.10	
230,737.13	
740,902.52	

3507	ADULT 40-100% FEMAL E	-732.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	1,036.20	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	26.15	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	19,735.15	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	7,544.55	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	182,166.05	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	49,024.77	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	71,316.53	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	-455.00	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	431.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	100.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-732.91	
1,036.20	
26.15	
19,735.15	
7,544.55	
182,166.05	
49,024.77	
71,316.53	
-455.00	
431.73	
100.67	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3708	ADULT <40% EXP M&F 4	-450.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-450.34		
3709	ADULT <40% EXP M&F
6	-266.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-266.59		
3714	ADULT <40% EXP MALE	137,135.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,135.11		
3715	ADULT <40% EXP FEMA L	25,044.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,044.72		
3716	ADULT <40% EXP MALE	3,653,638.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,653,638.18		
3717	ADULT <40% EXP FEMA L	1,007,616.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,007,616.94		
3718	ADULT <40% EXP M&F
4	2,576,297.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,576,297.05		
3719	ADULT <40% EXP M&F 6	-455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-455.00		
SUBTOTAL:	7,728,753.96	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,728,753.96		

3906	NEWLY ELIGIBLE MALE	390.09	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	-250.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	-211.01	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	14,989.52	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	162,137.59	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	-53,731.82	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	-50,478.72	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	723.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	73,568.61	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
390.09	
-250.66	
-211.01	
14,989.52	
162,137.59	
-53,731.82	
-50,478.72	
723.62	
73,568.61	

4412	SOBRA 100-133% M&F
1	-455.00	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	-92,431.05	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	-7,052.77	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	-8,543.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-108,481.91	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-455.00	
-92,431.05	
-7,052.77	
-8,543.09	
-108,481.91	

4518	BC PATIENT FEMALE 4 5	10,451.64	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	-1,365.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,086.64	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10,451.64	
-1,365.00	
9,086.64	

8700	SSI DISABLED FREEDO M	5,748.24	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	870.26	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	9,512.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,131.34	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,748.24	
870.26	
9,512.84	
16,131.34	

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

14,235,837.65

14,235,837.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending July 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-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending July 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		

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

0.00

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

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	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
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 July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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 FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	

4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

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

0.00	
0.00	
0.00	
0.00	

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

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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 July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	111.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111.55		
2100	SSI AGED WITH MEDIC A	3,141,298.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,141,298.02		
2110	SSI AGED NON-MEDICA
R	182,346.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,346.04		
2120	SSI AGED WITH QMB	4,772,976.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,772,976.61		
2200	SSI DISABLED WITH M E	589,027.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589,027.23		
2210	SSI DISABLED NON-ME
D	2,848,444.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,848,444.87		
2220	SSI DISABLED WITH Q M	928,876.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		928,876.44		
2300	SSI BLIND WITH MEDIC	2,008.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,008.80		
2310	SSI BLIND NON-MEDIC A	1,597.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,597.02		
2320	SSI BLIND WITH QMB	4,366.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,366.58		
SUBTOTAL:	12,471,053.16	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,471,053.16		

8720	SSI DISABLED FREEDO M	2,380.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,380.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

2,380.80

2,380.80

12,473,433.96

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

12,473,433.96

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending July 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-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

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

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending July 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		
SUBTOTAL:	0.00	0.0	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00

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 CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending July 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		
SUBTOTAL:	0.00	0.0	0.0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

KidsCare - CAPITATION AMOUNTS
For The Period Ending July 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	163,955.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163,955.19		
6012	KIDS 1-5 M & F NON-M	1,543,957.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,543,957.96		
6013	KIDS 6-13 M & F NON-	2,896,611.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,896,611.35		
6014	KIDS 14-19 MALE NON-	741,190.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		741,190.91		
6015	KIDS 14-19 FEMALE NO	751,128.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		751,128.68		
9960	KIDSCARE KICK PAYME N	6,000.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,000.27		
SUBTOTAL:	6,102,844.36	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,102,844.36		

6,102,844.36

6,102,844.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	283.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283.84		
6012	KIDS 1-5 M & F NON-M	8,605.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,605.77		
6013	KIDS 6-13 M & F NON-	16,171.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,171.73		
6014	KIDS 14-19 MALE NON-	4,132.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,132.98		
6015	KIDS 14-19 FEMALE NO	4,170.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,170.12		
9960	KIDSCARE KICK PAYME N	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	33,365.44	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,365.44		

TOTAL:	33,365.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,365.44		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending July 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	372.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		372.22		
6012	KIDS 1-5 M & F NON-M	14,030.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,030.25		
6013	KIDS 6-13 M & F NON-	24,067.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,067.99		
6014	KIDS 14-19 MALE NON-	10,487.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,487.13		
6015	KIDS 14-19 FEMALE NO	10,410.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,410.58		
SUBTOTAL:	59,368.17	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,368.17		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

59,368.17

TOTAL:

59,368.17

0.00

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending July 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	289.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289.00		
6012	KIDS 1-5 M & F NON-M	8,836.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,836.06		
6013	KIDS 6-13 M & F NON-	16,748.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,748.06		
6014	KIDS 14-19 MALE NON-	4,347.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,347.00		
6015	KIDS 14-19 FEMALE NO	4,353.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,353.00		
SUBTOTAL:	34,573.12	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,573.12		

TOTAL:	34,573.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,573.12		

KidsCare - FEE FOR SERVICE
For The Period Ending July 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	284.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284.12		
6012	KIDS 1-5 M & F NON-M	14,179.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,179.76		
6013	KIDS 6-13 M & F NON-	45,325.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,325.01		
6014	KIDS 14-19 MALE NON-	39,303.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,303.11		
6015	KIDS 14-19 FEMALE NO	25,467.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,467.01		
SUBTOTAL:	124,559.0	1	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,559.01		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

124,559.01

TOTAL:

124,559.01

0.00

KidsCare - REINSURANCE
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6013	KIDS 6-13 M & F NON-	85,728.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,728.15		
6014	KIDS 14-19 MALE NON-	113,827.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,827.14		
6015	KIDS 14-19 FEMALE NO	1,145.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,145.72		
SUBTOTAL:	200,701.01	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200,701.01		

TOTAL:	200,701.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200,701.01		

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending July 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	
1000	TANF WITH MEDICARE	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	
1010	TANF NON-MEDICARE	389.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	389.91	
1020	TANF WITH QMB	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	
2100	SSI AGED WITH MEDICA	257.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	257.99	
2110	SSI AGED NON-MEDICAR	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00	
2120	SSI AGED WITH QMB	429.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	429.97	
2200	SSI DISABLED WITH ME	1,924.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,924.20	
2210	SSI DISABLED NON-MED	26,376.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26,376.88	
221Z	SSI DISABLED NON-MED	2.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.51	
2220	SSI DISABLED WITH QM	4,868.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,868.95	
2310	SSI BLIND NON-MEDICA	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13.00	
2320	SSI BLIND WITH QMB	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	
8700	SSI DISABLED FREEDOM	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.00	
8710	SSI DISABLED FREEDOM	3.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.99	
8720	SSI DISABLED FREEDOM	10.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10.99	
SUBTOTAL:	34,321.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	34,321.39	
TOTAL:	34,321.39	0.00	0.00	0.	0.00	0.00	0.00	0.00	0.00	0.	0.00	0.00	34,321.39	

00

00

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

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	422,468.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	422,468.96	
EPD	106,533,521.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	106,533,521.90	
TOTAL AHCCCS LTC	106,955,990.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	106,955,990.86	
DES/DD	143,961,803.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	143,961,803.16	
TOTAL DES LTC	143,961,803.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	143,961,803.16	
TOTAL LTC - CAP	250,917,794.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	250,917,794.02	

EPD/DD FEE-FOR-SERVICE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	14,641,720.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,641,720.07	
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	14,641,720.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,641,720.07	

EPD/DD REINSURANCE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	2,639,219.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,639,219.53	
DES/DD	4,204,532.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,204,532.65	
TOTAL DES LTC	4,204,532.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,204,532.65	
TOTAL LTC - REIN	6,843,752.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,843,752.18	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	4,475,748.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,475,748.00	

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

128

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

00010115	CRS FULLY INTEGRATED PLAN - CAP	2,920.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,920.65	
Subtotal	2,920.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,920.65	

00999155	CRS REINSURANCE ONLY	203,452.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	203,452.53	
Subtotal	203,452.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	203,452.53	

206,373.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	206,373.18	

GRAND TOTAL

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

00010115	CRS FULLY INTEGRATED PLAN - MM	2.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.96	
Subtotal	2.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.96	

2.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.96	

GRAND TOTAL

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

00010715	HEALTH CHOICE INTEGRATED - CAP	1,289.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,289.88	
00010735	CENPATICO INTEGRATED - CAP	-7,052.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7,052.52	
00010795	MERCY MARICOPA INTEGRATED - CAP	-60,720.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-60,720.16	
Subtotal	-66,482.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-66,482.80	

-66,482.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-66,482.80	

GRAND TOTAL

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

00010715	HEALTH CHOICE INTEGRATED - MM	0.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.88	
00010735	CENPATICO INTEGRATED - MM	-4.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4.35	
00010795	MERCY MARICOPA INTEGRATED - MM	-25.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-25.72	
Subtotal	-29.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-29.19	

-29.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-29.19	

GRAND TOTAL

Behavioral Health Expenditures by RHBA
For the Period Ending July 31, 2019

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

00010715	HEALTH CHOICE INTEGRATED - CAP	1,289.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,289.88	
00010735	CENPATICO INTEGRATED - CAP	-7,052.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7,052.52	
00010795	MERCY MARICOPA INTEGRATED - CAP	-60,720.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-60,720.16	
Subtotal	-66,482.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-66,482.80	

-66,482.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-66,482.80	

GRAND TOTAL