.-.j \ HCCCS

Douglas A. Ducey, Governor

"

.........Ar..iz.on.a.H.e.a.lt.h.C.a.re..C.o.s.t .Co..n.ta.i.nm..e.nt.S.ys.te.m........................................J.a.m...i..S..n.y..d.e..r., .D.i.r.e..c..to.r.........
October 25, 2019

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

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

SUBJECT: FY 2020 Appropriation Status Report for the Period Ended September 30, 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 September 30, 2019.

Status Summary - AHCCCS has submitted its Fiscal Year 2021 budget request to the Governor's Office of Strategic Planning and Budgeting pursuant to A.R.S. § 35-113 and is currently preparing an October revision including a review of the Fiscal Year 2020 rebase, therefore, for purposes of this report, projected annual expenditures remain equal to the appropriations.

Enrollment Update - September 2019 enrollment is 1,898,616 members, a 7,161 member increase over the prior month. Enrollment for October 2019 increased to 1,901,411 members,  a 2,795 member change.

Major October 2019 changes by eligibility category include: 1931 for  Families  and  Children/SOBRA - decrease of 958; Supplemental Security Income - increase of 537; Prop 204 Restoration - increase of 2,451; Adult Expansion - increase of 65 Medicare  Cost  Sharing  - increase of 321; KidsCare - increase of 619; and Federal Emergency Services - decrease of 461.

Tobacco Funds Revenue Update - Tobacco tax collections through September 2019 are $2.3 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.

•   •   •   •   •   •   •   •   •  •  •  •   •  •  •   •  •  •   •  •   •   •   •   •  •  •   •   •   •   •   •   •   •  •   •  •  •   •  •   •  •   •  •   •   •  •  •   •   •   •   •  •   •   •  •   •   •  •   •   •  •   •   •  •   •  •  •   •  •  •   •  •   •   •   •  •   't	• • • • • • • • • • • ·• •••••••••••••

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 October 25, 2019
Page 2

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

Sincerely,
9:-1/2
Jam i 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 Committ e 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 September 30, 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	10

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2019
SUMMARY OF APPROPRIATED EXPENDITURES	
		(A)	(B)		(A) - (B)				
		EXPENDITURE				PROJECTED			
	ANNUAL	PLAN	EXPENDITURES		VARIANCE	ANNUAL		ANNUALIZED	
	APPROPRIATION	YTD	YTD		YTD	EXPENDITURES		VARIANCE	

APPROPRIATIONS:									
ADMINISTRATION									
AHCCCS Operating Lump Sum	$	88,542,300	$	24,249,757	$	24,249,757	$		-	$	88,542,300	$	-	
AHCCCS Prop 204 Administration	14,182,800	5,787,570	5,787,570			-	14,182,800		-	
Information Technology	9,878,000	-	-		-	9,878,000	-	
DES Eligibility	91,874,500		23,258,164		23,258,164		-		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		7,990,770		7,990,770		-		44,358,700		-		
ADOA Data Center	19,325,800		3,118,389		3,118,389		-		19,325,800		-		
School District Suicide Prevention Coordinator	100,000		29,641		29,641		-		100,000		-		
TOTAL ADMINISTRATION	 	268,262,100		 	64,434,291		 	64,434,291		 	-			 	268,262,100		 	-			

Traditional Medicaid Services	5,178,162,100	1,347,906,833	1,347,906,833		5,178,162,100	-	
Proposition 204 Services	4,168,410,500	1,026,374,977	1,026,374,977		4,168,410,500	-	
ACA Adult Expansion	527,018,800	97,574,956	97,574,956		527,018,800	-	
KidsCare Services	106,516,300	19,204,223	19,204,223		106,516,300	-	
ALTCS Services	1,796,913,800	425,725,382	425,725,382		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	15,591,464	15,591,464		345,281,700	-	
CMDP	180,729,500	43,771,741	43,771,741		180,729,500	-	
Behavioral Health Services - in Schools	9,990,000	2,497,500	2,497,500		9,990,000	-	
Targeted Investment Program	90,000,000	-	-		90,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		18,731,393		18,731,393		-		77,646,900		-	
Supported Housing	5,324,800		1,328,628		1,328,628		-		5,324,800		-	
Crisis Services	16,391,300		4,064,075		4,064,075		-		16,391,300		-	
TOTAL PROGRAMMATIC	 	12,536,085,200		 	3,002,771,171		 	3,002,771,171		 	-			 	12,536,085,200		 	-		

-
-
-
-
-

-
-
-
-

TOTAL EXPENDITURES

  $	12,804,347,300

-

$	3,067,205,461

$	3,067,205,461	$

-	$   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	
$	15,531,246	
$	15,531,246	
-	$	60,044,200	
$	
-	
Proposition 204 - Administrative Expenditures		21,538,900	4,777,869	4,777,869	-	21,538,900		-	
Programmatic Expenditures
Traditional Medicaid Services	
1,170,113,300	
309,042,683	
309,042,683		
-	1,170,113,300	
-	
Proposition 204 Services	95,088,500	23,772,125	23,772,125		-	95,088,500	-	
ACA Adult Expansion	5,393,400	1,348,350	1,348,350		-	5,393,400	-	
KidsCare Services	7,523,800	5,999	5,999		-	7,523,800	-	
ALTCS Services	234,042,300	58,510,447	58,510,447		-	234,042,300	-	
DSH and Rural Hospitals	8,843,300	-	-	-	8,843,300	-	
CMDP	54,297,600	13,253,317	13,253,317	-	54,297,600	-	
Behavior Health Services - in Schools	3,000,000	750,000	750,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	18,731,393	18,731,393	-	77,646,900	-	
Supported Housing	5,324,800	1,328,628	1,328,628	-	5,324,800	-	
Crisis Services	14,141,100	3,501,525	3,501,525	-	14,141,100	-	
Voluntary Political Subdivision Programs	 	3,750,000	 	- 	 	- 	 	- 	 	3,750,000	 	- 	
TOTAL GF EXPENDITURES	1,760,748,100	450,553,581	450,553,581	-	1,760,748,100	-	
	FEDERAL		
Administrative Expenditures	146,947,600	35,039,049	35,039,049		-	146,947,600	-	
Proposition 204 - Administrative Expenditures	33,035,300	9,000,470	9,000,470		-	33,035,300	-	
Programmatic Expenditures
Traditional Medicaid Services	
3,176,462,800	
782,827,122	
782,827,122		
-	3,176,462,800	
-	
Proposition 204 Services	3,615,003,800	901,311,136	901,311,136		-	3,615,003,800	-	
ACA Adult Expansion	484,056,500	90,189,473	90,189,473		-	484,056,500	-	
KidsCare Services	86,764,900	16,943,161	16,943,161		-	86,764,900	-	
ALTCS Services and Nursing Facility Assessment	1,144,403,700	260,970,212	260,970,212		-	1,144,403,700	-	
DSH and Rural Hospitals	24,856,200	-	-	-	24,856,200	-	
CMDP	126,431,900	30,518,424	30,518,424		-	126,431,900	-	
Behavior Health Services - in Schools	6,990,000	1,747,500	1,747,500		-	6,990,000	-	
Targeted Investment Program	61,937,600	-	-	-	61,937,600	-	
Voluntary Political Subdivision Programs	 	240,664,300	 	10,896,874	 	10,896,874	 	- 	 	240,664,300	 	- 	
TOTAL FEDERAL EXPENDITURES	9,147,554,600	2,139,443,421	2,139,443,421	-	9,147,554,600	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF	3,906,400	-	-	-	3,906,400	-	
Programmatic Expenditures
Traditional Medicaid Services Acute Care	
46,512,900	
11,540,425	
11,540,425	
-	
46,512,900	
-	
ALTCS Services	 	268,554,800	 	60,630,705	 	60,630,705	 	- 	 	268,554,800	 	- 	
TOTAL COUNTY EXPENDITURES	318,974,100	72,171,130	72,171,130	-	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	15,438,150	15,438,150	-	61,752,600	-	
Proposition 204 Services - Emergency Health Services	16,216,300	4,054,075	4,054,075	-	16,216,300	-	
Proposition 204 Services - Proposition 204 Protection	34,054,300	8,513,575	8,513,575	-	34,054,300	-	
Proposition 204 Services - ATLSF	 	102,000,000	 	- 	 	- 	 	- 	 	102,000,000	 	- 	
TOTAL TOBACCO EXPENDITURES	214,023,200	28,005,800	28,005,800	-	214,023,200	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program	2,789,700	85,657	85,657	-	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	35,039,650	35,039,650	-	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	190,829,964	190,829,964	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	1,894,600	1,894,600	-	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	9,650,469	9,650,469	-	36,422,000	-	
Proposition 204 Services - Hospital Assessment	303,482,900	88,082,891	88,082,891	-	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	5,992,158	5,992,158	-	37,389,000	-	
ACA Adult Expansion - IGA Fund	179,900	44,975	44,975	-	179,900	-	
Traditional Medicaid Services - TPL	194,700	586,337	586,337	-	194,700	-	
ALTCS Services - TPL	-	402,478	402,478	-	-	-	
ALTCS Services - Nursing Facility Assessment	105,912,600	33,666,471	33,666,471	-	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	2,255,063	2,255,063	-	12,151,300	-	
Freedom to Work Premiums	31,200	28,077	28,077	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	562,550	562,550	-	2,250,200	-	
Voluntary Political Subdivision Programs	 	100,867,400	 	4,694,590	 	4,694,590	 	- 	 	100,867,400	 	- 	
TOTAL OTHER EXPENDITURES	1,363,047,300	377,031,529	377,031,529	-	1,363,047,300	-	
	TOTAL		
Administrative Expenditures	268,262,100	64,434,291	64,434,291	-	268,262,100	-	
Acute Care	10,739,171,400	2,577,045,788	2,577,045,788	-	10,739,171,400	-	
Long Term Care	 	1,796,913,800	 	425,725,382	 	425,725,382	 	- 	 	1,796,913,800	 	- 	
TOTAL EXPENDITURES	  $	12,804,347,300	  $	3,067,205,461	  $	3,067,205,461	  $	- 	  $	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 September 30, 2019

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,251,144,200	$	326,672,278	$	325,323,928	
Proposition 204 Services & Administrative	116,627,400	28,549,994	29,191,169	
KidsCare Services	7,523,800.00	5,998.82	5,999	
ALTCS Services	234,042,300	58,510,447	58,510,447	
Behavioral Health Traditional Medicaid Services	 	151,410,400	 	36,814,862	 	36,814,862	
TOTAL	1,760,748,100	450,553,581	449,846,406	

FEDERAL:
Acute & Administrative	7,789,954,100	1,831,011,624	1,830,166,072	
KidsCare Services	86,764,900	16,943,161	18,593,259	
ALTCS Services	1,144,403,700	260,970,212	291,607,018	
Behavioral Health Traditional Medicaid Services	 	126,431,900	 	30,518,424	 	32,327,104	
TOTAL	9,147,554,600	2,139,443,421	2,172,693,452	

COUNTY:				
Acute & Administrative	50,419,300		11,540,425		11,508,014	
ALTCS Services	 	268,554,800		 	60,630,705		 	96,758,704	
TOTAL	318,974,100		72,171,130		108,266,718	

TOBACCO FUNDS:						
Traditional Medicaid Services	61,752,600		15,438,150		15,438,150	
Proposition 204 Services	 	152,270,600		 	12,567,650		 	12,567,650	
TOTAL	214,023,200		28,005,800		28,005,800	

OTHER:

Administrative	2,789,700	85,657	85,657	
Traditional Medicaid Services - IGA Fund	10,297,700	2,574,425	2,574,425	
Acute Care - Prescription Drug Rebate Program	712,796,900	225,869,614	225,869,614	
Long Term Care - Prescription Drug Rebate Program	44,000,400	11,545,069	11,545,069	
Hospital Assessment	343,616,500	94,761,199	82,835,547	
ALTCS - Nursing Facility Assessment	105,912,600	33,666,471	72,063	
Acute TPL - Note 1	194,700	586,337	586,337	
LTC TPL - Note 1	-	402,478	402,478	
KidsCare Services - IGA Fund	76,300	-	-	
KidsCare TPL - Note 1	-	-	848.00	
Member Premiums - CHIP	12,151,300	2,255,063	2,255,063	
Member Premiums - Freedom to Work	31,200	28,077	28,077	
Targeted Investment Program	28,062,400	-	12,731,149	
Behavioral Health Traditional Medicaid Services	2,250,200	562,550	334,102	
Voluntary Political Subdivision - State Match	 	100,867,400	 	4,694,590	 	7,760,875	
TOTAL	1,363,047,300	377,031,529	347,081,304	

TOTAL REVENUE

$	12,804,347,300

$	3,067,205,461

$	3,105,893,680

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2019	
Note 1:	Third Party Liability Collections:	September 2019		September 2018		July 1, 2019		July 1, 2018	
	Gross Collections:					September 30, 2019		September 30, 2018	
	Acute	$	1,340,630		$	1,799,931		$	3,797,903		$	3,756,273	
	LTC	205,085		699,690		2,082,208		1,318,974	
	KidsCare	3,872		300		12,877		817	
	Total TPL Collections	  $	1,549,587		$	2,499,921		$	5,892,988		$	5,076,064	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	137,232	$	171,501	$	586,337	$	373,694	
LTC		42,900	282,004		402,478	415,607	
KidsCare		(162)	(12)		848	(34)	
Total Expenditure Offsets	  $	179,970		$	453,493		$	989,663		$	789,267		

Note 2: Authorized Positions
Actual Positions as of September 30, 2019

`

FY 20 Total

1,188.0
1,100.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2019

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2019	$ 5,258,991	
	Revenues	1,996,880	
	Transfers-In	 	154,830	
	Total Revenues	 	2,151,710	
	Expenditures	3,635,438	
	Transfers-out	 	924,350	
	Total Expenditures	 	4,559,788	
	Ending Balance September 30, 2019	  $ 2,850,914	

Of the $2,850,914 ending balance, $607,722 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through October 2019.

Note 4:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of September 30, 2019 Expenditures
Appropriation	State Match	Federal	Total

DSH Voluntary

$	40,980,200

$	4,694,590	$

10,896,874	$

15,591,464

GME Voluntary	304,301,500	-	-	-

Total Voluntary Political Subdivision Program Expenditures

$	345,281,700

$	4,694,590	$

10,896,874	$

15,591,464

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	326,111,126	324,280,404	0	0	0	0	0	0	0	0	0	975,528,201	
CAPITATION - AIMHS	292,639	307,037	323,631	0	0	0	0	0	0	0	0	0	923,307	
CAPITATION - LTC	250,917,794	252,209,107	252,943,113	0	0	0	0	0	0	0	0	0	756,070,014	
MENTAL HEALTH - CHILD	865	2,317	-1,031	0	0	0	0	0	0	0	0	0	2,151	
MENTAL HEALTH - ADULT	340,947	351,310	462,496	0	0	0	0	0	0	0	0	0	1,154,752	
MENTAL HEALTH - GENERAL	755	1,398	-2,562	0	0	0	0	0	0	0	0	0	-410	
MENTAL HEALTH - CMDP	11,210,666	11,149,954	11,526,705	0	0	0	0	0	0	0	0	0	33,887,325	
MENTAL HEALTH - DD	7,458,766	7,517,688	7,570,387	0	0	0	0	0	0	0	0	0	22,546,841	
MENTAL HEALTH - RBHA CRISIS	3,210,728	3,227,109	3,238,920	0	0	0	0	0	0	0	0	0	9,676,757	
FEE FOR SERVICE - ACUTE	48,820,855	49,681,027	42,280,433	0	0	0	0	0	0	0	0	0	140,782,315	
FFS - PRIOR QUARTER COVERAGE	953,544	609,982	539,248	0	0	0	0	0	0	0	0	0	2,102,774	
EMERGENCY SERVICES - FEDERAL	4,491,141	3,725,509	4,435,620	0	0	0	0	0	0	0	0	0	12,652,270	
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	548,881	453,761	0	0	0	0	0	0	0	0	0	1,952,411	
QMB - FEE FOR SERVICE	660,278	490,123	440,696	0	0	0	0	0	0	0	0	0	1,591,097	
STATE ONLY TRBHA FFS	158,244	111,819	158,545	0	0	0	0	0	0	0	0	0	428,608	
FFS TRBHA FEE FOR SERVICE	12,287,430	11,525,809	8,927,578	0	0	0	0	0	0	0	0	0	32,740,817	
INPATIENT INMATES FFS	244,004	235,027	245,518	0	0	0	0	0	0	0	0	0	724,549	
MARICOPA CTY INMATES FFS	19,819	22,216	24,325	0	0	0	0	0	0	0	0	0	66,359	
COCONINO COUNTY INMATES FFS	3,561	3,210	464	0	0	0	0	0	0	0	0	0	7,236	
PINAL COUNTY INMATES FFS	2,190	0	0	0	0	0	0	0	0	0	0	0	2,190	
PIMA COUNTY INMATES FFS	4,917	34,617	15,870	0	0	0	0	0	0	0	0	0	55,403	
FEE FOR SERVICE - LTC	14,641,720	12,577,411	12,175,076	0	0	0	0	0	0	0	0	0	39,394,208	
LFFS - PRIOR QUARTER COVERAGE	72,181	86,245	50,352	0	0	0	0	0	0	0	0	0	208,778	
MARICOPA CTY INMATES LTC FFS	0	419	0	0	0	0	0	0	0	0	0	0	419	
COCONINO COUNTY INMATES LTC F	415	4,825	220	0	0	0	0	0	0	0	0	0	5,460	
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	884,889	830,814	0	0	0	0	0	0	0	0	0	3,273,384	
REINSURANCE - ACC	13,954,921	15,652,135	16,821,600	0	0	0	0	0	0	0	0	0	46,428,657	
REINSURANCE - LTC	6,843,752	5,361,382	6,418,046	0	0	0	0	0	0	0	0	0	18,623,180	
SMIB - ACC	15,867,509	15,869,518	16,032,517	0	0	0	0	0	0	0	0	0	47,769,544	
HIB - ACC	775,609	843,035	893,679	0	0	0	0	0	0	0	0	0	2,512,323	
Q1	2,951,192	2,997,689	3,029,726	0	0	0	0	0	0	0	0	0	8,978,607	
SMIB - LTC	4,094,296	4,092,510	4,109,180	0	0	0	0	0	0	0	0	0	12,295,985	
HIB - LTC	381,353	383,342	394,397	0	0	0	0	0	0	0	0	0	1,159,091	
SUBTOTAL	728,338,191	726,618,665	718,619,725	0	0	0	0	0	0	0	0	0	2,173,576,582	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL
TITLE XIX PROP 204
CAPITATION - ACC	278,294,618	280,267,513	279,144,066	0	0	0	0	0	0	0	0	0	837,706,197	
CAPITATION - AIMHS	134,306	142,743	148,769	0	0	0	0	0	0	0	0	0	425,819	
MENTAL HEALTH - ADULT	414,838	404,766	357,960	0	0	0	0	0	0	0	0	0	1,177,564	
MENTAL HEALTH - GENERAL	-2,350	-4,545	-6,979	0	0	0	0	0	0	0	0	0	-13,874	
MENTAL HEALTH - CMDP	0	393	762	0	0	0	0	0	0	0	0	0	1,155	
MENTAL HEALTH - RBHA CRISIS	3,634,857	3,668,731	3,689,681	0	0	0	0	0	0	0	0	0	10,993,269	
FEE FOR SERVICE - ACUTE	37,859,959	38,790,683	33,207,024	0	0	0	0	0	0	0	0	0	109,857,666	
FFS - PRIOR QUARTER COVERAGE	1,204,975	590,575	350,539	0	0	0	0	0	0	0	0	0	2,146,089	
EMERGENCY SERVICES - FEDERAL	3,246,745	2,798,913	3,488,929	0	0	0	0	0	0	0	0	0	9,534,587	
FFS MEDICAID IN PUBLIC SCHOOLS	723	218	330	0	0	0	0	0	0	0	0	0	1,272	
INPATIENT INMATES FFS	889,101	645,173	765,595	0	0	0	0	0	0	0	0	0	2,299,869	
STATE ONLY TRBHA FFS	399,387	372,201	456,058	0	0	0	0	0	0	0	0	0	1,227,646	
FFS TRBHA FEE FOR SERVICE	7,885,916	6,336,072	6,757,819	0	0	0	0	0	0	0	0	0	20,979,808	
MARICOPA CTY INMATES FFS	214,579	207,410	203,431	0	0	0	0	0	0	0	0	0	625,420	
PINAL COUNTY INMATES FFS	415	59	3,076	0	0	0	0	0	0	0	0	0	3,551	
PIMA COUNTY INMATES FFS	44,460	29,912	57,917	0	0	0	0	0	0	0	0	0	132,289	
MOHAVE COUNTY INMATES FFS	3,409	15,944	0	0	0	0	0	0	0	0	0	0	19,353	
COCONINO COUNTY INMATES FFS	302	3,171	0	0	0	0	0	0	0	0	0	0	3,473	
REINSURANCE - ACC	6,253,343	6,750,467	8,759,810	0	0	0	0	0	0	0	0	0	21,763,620	
SMIB - ACC	7,097,119	7,165,395	7,230,656	0	0	0	0	0	0	0	0	0	21,493,170	
HIB - ACC	6,248	4,850	4,894	0	0	0	0	0	0	0	0	0	15,992	
SUBTOTAL	347,582,951	348,190,644	344,620,338	0	0	0	0	0	0	0	0	0	1,040,393,933	

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

CAPITATION - ACC	33,607,896	33,867,589	33,417,807	0	0	0	0	0	0	0	0	0	100,893,292	
CAPITATION - AIMHS	12,254	13,041	13,411	0	0	0	0	0	0	0	0	0	38,706	
MENTAL HEALTH - ADULT	12,078	12,834	13,307	0	0	0	0	0	0	0	0	0	38,219	
MENTAL HEALTH - GENERAL	399	-806	497	0	0	0	0	0	0	0	0	0	90	
MENTAL HEALTH - CMDP	0	762	762	0	0	0	0	0	0	0	0	0	1,524	
MENTAL HEALTH - RBHA CRISIS	575,493	582,267	581,810	0	0	0	0	0	0	0	0	0	1,739,571	
FEE FOR SERVICE - ACUTE	2,872,751	3,384,201	2,596,379	0	0	0	0	0	0	0	0	0	8,853,331	
FFS - PRIOR QUARTER COVERAGE	200,446	340,753	89,570	0	0	0	0	0	0	0	0	0	630,769	
EMERGENCY SERVICES - FEDERAL	5,151,773	4,521,846	4,307,602	0	0	0	0	0	0	0	0	0	13,981,222	
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	136,082	159,112	0	0	0	0	0	0	0	0	0	574,530	
STATE ONLY TRBHA FFS	39,350	9,279	10,091	0	0	0	0	0	0	0	0	0	58,720	
INPATIENT INMATES FFS	61,395	5,936	718	0	0	0	0	0	0	0	0	0	68,049	
MARICOPA CTY INMATES FFS	8,779	2,632	4,840	0	0	0	0	0	0	0	0	0	16,252	
PIMA COUNTY INMATES FFS	11	11	0	0	0	0	0	0	0	0	0	0	21	
REINSURANCE - ACC	726,411	993,034	1,071,875	0	0	0	0	0	0	0	0	0	2,791,319	
SMIB - ACC	271	136	0	0	0	0	0	0	0	0	0	0	407	
	43,548,708	43,869,597	42,267,781	0	0	0	0	0	0	0	0	0	129,686,085	
	1,119,469,850	1,118,678,906	1,105,507,844	0	0	0	0	0	0	0	0	0	3,343,656,600	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
CAPITATION - ACC	0	0	2,131	0	0	0	0	0	0	0	0	0	2,131	
CAPITATION - AIMHS	0	23	0	0	0	0	0	0	0	0	0	0	23	
MENTAL HEALTH - RBHA CRISIS	19	21	12	0	0	0	0	0	0	0	0	0	52	
KidsCare - CAPITATION	6,102,844	6,193,197	6,245,205	0	0	0	0	0	0	0	0	0	18,541,246	
KidsCare - FEE FOR SERVICE	124,559	240,555	141,881	0	0	0	0	0	0	0	0	0	506,994	
KidsCare - MENTAL HEALTH	59,368	60,012	61,651	0	0	0	0	0	0	0	0	0	181,031	
KidsCare - REINSURANCE	200,701	116,470	178,310	0	0	0	0	0	0	0	0	0	495,481	

6,487,491	6,610,278	6,629,190	0	0	0	0	0	0	0	0	0	19,726,959	

TOTAL TITLE XXI

1,125,957,341	1,125,289,184	1,112,137,034	0	0	0	0	0	0	0	0	0	3,363,383,559	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 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	48,959.09	44,661.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,674.89		
1007	TANF 21-44 FEMALE WI	45,256.87	48,452.58	37,289.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,999.00		
1008	TANF 45-64 M & F WIT	58,324.80	51,372.72	55,455.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,153.25		
1009	TANF 65+ M & F WITH	16,091.48	14,740.77	12,841.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,674.18		
100F	TANF 21-44 MALE WITH	40.03	581.66	1,451.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,073.56		
100G	TANF 21-44 FEMALE WI	2,488.06	2,248.29	2,866.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,603.13		
100H	TANF 45-64 M & F WIT	4,175.05	3,092.89	2,374.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,642.51		
100J	TANF 65+ M & F WITH	212.66	202.84	436.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852.35		
1011	TANF <1 M & F NON-ME	5,612,601.91	5,647,107.46	5,662,986.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,922,696.02		
1012	TANF 01-05 M & F NON	3,457,250.59	3,441,533.14	3,420,435.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,319,219.53		
1013	TANF 06-13 M & F NON	6,124,074.11	6,152,446.23	6,168,589.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,445,109.52		
1014	TANF 14-20 MALE NON-	1,914,202.78	1,884,287.16	1,883,566.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,682,056.71		
1015	TANF 14-20 FEMALE N O	2,353,294.72	2,342,821.82	2,327,116.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,023,233.44		
1016	TANF 21-44 MALE NON-	9,364,324.51	9,454,366.22	9,451,614.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,270,305.35		
1017	TANF 21-44 FEMALE N O	32,620,357.05	32,728,554.66	32,775,784.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,124,695.78		
1018	TANF 45-64 M & F NON	7,767,766.58	7,784,035.25	7,762,785.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,314,586.97		
1019	TANF 65+ M & F NON-M	31,052.28	29,784.99	31,822.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,659.77		
101A	TANF < 1 M & F NON-M	352,937.84	334,377.43	295,390.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		982,705.62		
101B	TANF 01-05 M & F NON	31,695.97	27,524.01	22,926.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,146.14		
101C	TANF 06-13 M & F NON	16,670.28	19,749.31	20,214.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,633.73		
101D	TANF 14-20 MALE NON-	9,808.43	14,845.50	11,848.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,502.50		
101E	TANF 14-20 FEMALE N O	18,630.37	20,897.05	23,373.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,900.48		
101F	TANF 21-44 MALE NON-	246,596.25	255,429.76	194,158.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		696,184.72		
101G	TANF 21-44 FEMALE N O	615,659.33	583,850.07	465,507.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,665,016.77		
101H	TANF 44-64 M & F NON	131,317.46	152,039.59	104,634.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		387,991.76		
101J	TANF 65+ N & F NON-M	198.84	566.38	1,210.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,975.85		
1024	TANF 14-20 MALE WITH	1,991.65	1,834.56	1,834.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,660.77		
1026	TANF 21-44 MALE WITH	30,833.82	25,161.04	23,949.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,944.76		
1027	TANF 21-44 FEMALE WI	33,845.08	29,934.75	39,393.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,173.22		
1028	TANF 45-64 M & F WIT	32,482.04	30,194.61	33,485.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,162.53		
1029	TANF 65+ M & F WITH	9,312.30	9,417.77	6,856.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,586.13		
102F	TANF 21-44 MALE WITH	0.00	77.29	129.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206.54		
102G	TANF 21-44 FEMALE WI	0.00	67.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.86		
102H	TANF 44-64 M & F WIT	0.00	0.00	38.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
102J	TANF 65+ M & F WITH	0.00	258.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258.92		
2100	SSI AGED WITH MEDIC A	712,678.64	703,164.71	703,123.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,118,966.83		

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	52,660.57	41,774.04	32,514.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,949.35		
2110	SSI AGED NON-MEDICA
R	8,462,181.12	8,547,064.99	8,567,191.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,576,437.29		
211Z	SSI AGED NON-MEDICA R	216,958.62	161,562.33	135,278.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		513,799.32		
2120	SSI AGED WITH QMB	5,479,950.99	5,524,156.46	5,564,371.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,568,479.11		
212Z	SSI AGED WITH QMB P P	4,799.26	6,473.36	9,408.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,681.05		
2200	SSI DISABLED WITH M
E	1,774,556.51	1,758,603.98	1,757,956.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,291,117.42		
220Z	SSI DISABLED WITH M E	96,386.79	59,787.78	85,084.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241,259.37		
2210	SSI DISABLED NON-ME
D	70,901,267.74	70,892,010.70	70,871,863.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		212,665,141.99		
221Z	SSI DISABLED NON-ME D	942,051.13	933,821.38	825,347.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,701,220.17		
2220	SSI DISABLED WITH Q
M	14,966,350.81	14,971,834.15	14,896,450.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,834,635.40		
222Z	SSI DISABLED WITH Q M	31,562.80	38,109.67	39,444.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,116.95		
2300	SSI BLIND WITH MEDIC	7,894.62	8,025.40	7,600.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,520.98		
2310	SSI BLIND NON-MEDIC A	633,695.19	633,652.52	642,091.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,909,439.14		
231Z	SSI BLIND NON-MEDIC
A	5,251.90	10,051.71	22,411.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,715.06		
2320	SSI BLIND WITH QMB	47,291.74	47,835.53	47,975.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143,102.74		
232Z	SSI BLIND WITH QMB P	0.00	84.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84.17		
4302	SOBRA CHILD 01-05 M	384.93	668.23	677.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,730.83		
4303	SOBRA CHILD 06-13 M	671.85	839.07	526.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,037.71		
4305	SOBRA CHILD 14-20 FE	598.98	472.87	136.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,208.55		
430B	SOBRA CHILD 01-05 M	0.00	283.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283.30		
430C	SOBRA CHILD 06-13 M	0.00	146.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146.96		
4311	SOBRA CHILD <1 M & F	20,305,933.37	20,224,322.07	20,036,959.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,567,214.50		
4312	SOBRA CHILD 01-05 M	30,346,403.53	30,479,033.09	30,485,312.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,310,748.97		
4313	SOBRA CHILD 06-13 M	39,139,381.16	39,428,777.53	39,455,204.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,023,363.01		
4314	SOBRA CHILD 14-20 MA	10,797,911.21	10,918,285.83	10,979,617.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,695,814.42		
4315	SOBRA CHILD 14-20 FE	10,814,438.27	10,921,113.04	10,946,037.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,681,588.99		
431A	SOBRA CHILD < 1 M &	255,349.52	216,051.62	182,881.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		654,282.85		
431B	SOBRA CHILD 01-05 M	734,288.72	672,792.26	556,972.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,964,053.67		
431C	SOBRA CHILD 6-13 M&F	698,553.25	730,808.98	551,793.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,981,155.49		
431D	SOBRA CHILD 14-20 MA	203,649.34	208,008.27	168,887.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		580,545.60		
431E	SOBRA CHILD 14-20 FE	210,973.01	203,192.73	181,516.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		595,682.30		
4322	SOBRA CHILD 01-05 M	191.11	191.11	191.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		573.33		
4323	SOBRA CHILD 06-13 M	0.00	0.00	145.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145.06		
4325	SOBRA CHILD 14-20 FE	194.52	400.68	400.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		995.88		
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	18,676.51	18,335.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,888.35		

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5008	SOBRA PREG 45-64 FE M	253.60	253.60	253.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		760.80		
500G	SOBRA PREG 21-44 FE
M	3,420.46	2,107.63	794.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,322.75		
5013	SOBRA PREG 09-13 FE M	370.17	851.31	672.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,893.49		
5015	SOBRA PREG 14-20 FE
M	530,163.48	543,226.36	547,975.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,621,365.63		
5017	SOBRA PREG 21-44 FE M	5,865,449.13	5,991,687.07	6,062,054.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,919,190.88		
5018	SOBRA PREG 45-64 FE
M	17,581.17	19,841.48	22,726.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,149.19		
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	38,879.61	39,907.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,431.46		
501G	SOBRA PREG 21-44 FE M	403,573.06	413,507.29	339,988.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,157,068.56		
501H	SOBRA PREG 45-64 FE
M	54.35	1,725.17	6,412.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,191.87		
5027	SOBRA PREG 21-44 FE M	14,542.79	19,007.23	29,474.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,024.13		
5028	SOBRA PREG 45-64 FE
M	2,368.16	2,368.16	2,368.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,104.48		
SUBTOTAL:	295,696,553.19	296,536,345.61	295,713,370.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		887,946,269.61		

3100	TRANSPLANT OPTION 1	66.00	49.50	49.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	66.00	49.50	49.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

165.00

165.00

9910	TANF & SOBRA CHILDR E	1,876,376.98	1,947,736.11	1,669,626.73	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	40,998.47	29,471.44	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	112,169.53	93,219.96	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	13,030,963.00	12,617,882.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,051,779.2	9 15,131,867.11	14,410,200.7	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,493,739.82	
100,409.47	
315,752.45	
38,683,945.38	
44,593,847.12	

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	62,172.63	66,275.38	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	186,394.63	189,604.33	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	397,105.71	390,756.75	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	99,237.82	96,608.20	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	5,202.89	15,376.84	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	10,003.20	2,474.46	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	13,442.99	5,261.04	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	5,050.11	3,741.60	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	1,252.85	1,073.55	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	38,413.55	38,265.78	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	277,526.66	267,373.68	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	9,828,241.10	9,777,971.60	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	27,093,093.80	27,010,065.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
145.06	
196,307.06	
554,442.18	
1,183,784.57	
294,687.91	
24,171.69	
22,054.03	
28,519.90	
15,523.36	
186.83	
3,579.25	
115,094.39	
819,991.97	
29,465,931.41	
81,095,725.71	

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	9,163,569.86	9,196,300.84	9,258,902.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,618,772.94		
1119	TANF EXPANDED 65+ M
&	30,255.92	28,131.96	28,000.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,388.63		
111D	TANF EXPANDED 14-20	2,490.39	1,152.78	1,523.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,166.38		
111E	TANF EXPANDED 14-20	7,437.73	5,473.69	3,147.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,058.55		
111F	TANF EXPANDED 21-44	267,373.80	262,773.96	215,068.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		745,216.00		
111G	TANF EXPANDED 21-44	525,020.23	509,660.72	400,174.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,434,855.56		
111H	TANF EXPANDED 45-64	178,932.04	172,494.14	159,074.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		510,500.93		
111J	TANF EXPANDED 65+ M
&	592.01	928.69	367.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,888.68		
1126	TANF EXPANDED 21-44	297,942.68	293,773.27	291,620.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		883,336.54		
1127	TANF EXPANDED 21-44	790,701.02	789,295.29	779,113.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,359,109.45		
1128	TANF EXPANDED 45-64	900,768.88	921,413.73	924,623.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,746,805.80		
1129	TANF EXPANDED 65+ M
&	256,772.30	259,581.62	263,961.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		780,315.21		
112F	TANF EXPANDED 21-44	0.00	2,931.30	4,191.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,123.12		
112G	TANF EXPANDED 21-44	2,213.20	5,170.00	2,450.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,833.60		
112H	TANF EXPANDED 45-64	6,227.67	1,063.02	540.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,830.76		
112J	TANF EXPANDED 65+ M
&	3,111.80	878.74	906.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,897.41		
2400	SSI AGED EXPANDED WI	40,745.64	49,658.35	38,234.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128,638.61		
240Z	SSI AGED EXPANDED
WI	26,984.10	40,705.46	35,897.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,587.50		
2410	SSI AGED EXPANDED N O	116,302.77	124,836.95	115,780.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		356,920.67		
241Z	SSI AGED EXPANDED N
O	15,686.56	0.00	2,707.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,393.91		
2420	SSI AGED EXPANDED WI	5,409,424.18	5,439,222.61	5,476,481.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,325,128.25		
242Z	SSI AGED EXPANDED
WI	10,566.52	4,568.42	7,433.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,567.94		
2520	SSI BLIND EXPANDED W	191.11	191.11	191.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		573.33		
2600	SSI DISABLED EXPAND
E	95,669.32	118,092.54	108,033.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321,795.61		
260Z	SSI DISABLED EXPAND E	60,164.41	59,191.60	53,022.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172,378.26		
2610	SSI DISABLED EXPAND
E	1,902,019.15	1,915,769.99	1,925,963.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,743,752.17		
261Z	SSI DISABLED EXPAND E	41,560.30	39,967.68	26,817.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,345.11		
2620	SSI DISABLED EXPAND
E	10,627,342.37	10,666,934.37	10,681,274.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,975,551.00		
262Z	SSI DISABLED EXPAND E	24,786.63	13,062.99	25,997.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,846.64		
SUBTOTAL:	68,743,011.0	7 68,940,363.76	68,696,349.0	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,379,723.88		

3506	ADULT 40-100% MALE 2	5,764.11	5,307.37	5,088.93	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	10,614.95	5,047.64	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	53,388.43	56,444.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,160.41	
17,903.59	
162,751.14	

9911	SB PAYMENT FOR TAN F	1,192,225.73	1,197,905.14	1,182,328.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,192,225.73	1,197,905.14	1,182,328.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,572,459.14

3,572,459.14

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3509	ADULT 40-100% M&F 65	4,596.56	10,268.05	12,020.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,884.94		
350F	ADULT 40-100% MALE 2	0.00	2,062.59	763.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,826.37		
350G	ADULT 40-100% FEMAL E	4,201.57	6,234.75	255.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,691.56		
350H	ADULT 40-100% M&F 45	8,724.34	4,663.08	738.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,125.66		
3514	ADULT 40-100% MALE 1	3,584,131.94	3,587,963.14	3,598,856.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,770,951.31		
3515	ADULT 40-100% FEMAL E	3,935,913.21	4,002,324.39	3,958,410.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,896,648.27		
3516	ADULT 40-100% MALE 2	12,328,492.47	12,442,821.52	12,405,190.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,176,504.09		
3517	ADULT 40-100% FEMAL E	10,396,684.34	10,406,343.92	10,410,485.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,213,513.86		
3518	ADULT 40-100% M&F 45	24,233,844.77	24,325,890.22	24,129,566.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,689,301.45		
3519	ADULT 40-100% M&F 65	4,796.70	2,957.31	3,486.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,240.23		
351D	ADULT 40-100% MALE 1	69,871.09	58,513.99	62,621.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,006.14		
351E	ADULT 40-100% FEMAL E	96,620.75	91,285.70	76,978.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264,885.37		
351F	ADULT 40-100% MALE 2	378,306.71	316,217.93	260,303.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		954,828.51		
351G	ADULT 40-100% FEMAL E	314,532.51	292,594.59	213,966.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		821,093.85		
351H	ADULT 40-100% M&F 45	571,004.41	500,509.79	406,418.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,477,932.58		
351J	ADULT 40-100% M&F 65	1,126.81	546.10	1,825.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,497.92		
3526	ADULT 40-100% MALE 2	512.80	1,005.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,518.23		
3528	ADULT 40-100% M&F 45	1,367.52	642.20	984.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,994.12		
3529	ADULT 40-100% M&F 65	0.00	1,303.23	1,524.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,827.85		
352F	ADULT 40-100% MALE 2	2,314.23	916.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,230.61		
352G	ADULT 40-100% FEMAL E	0.00	0.00	696.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		696.12		
352H	ADULT 40-100% M&F 45	2,899.38	0.00	1,124.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,023.76		
3704	ADULT <40% EXP MALE	0.00	636.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		636.94		
3706	ADULT <40% EXP MALE	27,591.56	35,651.38	38,300.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,543.21		
3707	ADULT <40% EXP FEMA L	3,910.19	8,759.02	9,934.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,603.46		
3708	ADULT <40% EXP M&F
4	57,244.70	70,221.48	68,023.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,489.58		
3709	ADULT <40% EXP M&F 6	3,342.45	6,220.57	8,040.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,603.22		
370F	ADULT <40% EXP MALE	10,732.30	5,515.81	10,662.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,910.50		
370G	ADULT <40% EXP FEMA L	497.19	1,324.21	2,550.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,371.97		
370H	ADULT <40% EXP M&F
4	9,493.54	14,470.80	7,660.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,625.10		
370J	ADULT <40% EXP M&F 6	0.00	516.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		516.40		
3714	ADULT <40% EXP MALE	6,531,198.24	6,617,691.46	6,705,629.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,854,519.33		
3715	ADULT <40% EXP FEMA L	5,936,403.04	6,019,300.20	6,069,309.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,025,012.88		
3716	ADULT <40% EXP MALE	48,789,421.85	49,743,271.72	49,815,793.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148,348,487.38		
3717	ADULT <40% EXP FEMA L	29,124,659.29	29,572,690.93	29,617,599.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,314,949.37		
3718	ADULT <40% EXP M&F
4	56,709,300.26	57,223,557.83	57,236,759.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,169,617.99		

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	4,322.81	5,789.39	5,237.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,349.53		
371D	ADULT <40% EXP MALE	173,398.88	166,910.98	142,642.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		482,952.78		
371E	ADULT <40% EXP FEMA L	170,863.21	142,486.87	112,122.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425,472.77		
371F	ADULT <40% EXP MALE	1,729,093.63	1,542,732.32	1,328,885.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,600,711.51		
371G	ADULT <40% EXP FEMA L	1,025,917.09	813,958.12	707,195.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,547,070.84		
371H	ADULT <40% EXP M&F
4	1,427,011.49	1,300,300.84	1,052,563.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,779,875.33		
371J	ADULT <40% EXP M&F 6	0.00	0.00	762.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		762.31		
3726	ADULT <40% EXP MALE	1,897.66	3,045.53	1,010.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,953.51		
3727	ADULT <40% EXP FEMA L	1,521.58	1,175.63	1,175.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,872.84		
3728	ADULT <40% EXP M&F
4	0.00	3,480.51	1,898.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,379.49		
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	540.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		868.51		
372H	ADULT <40% EXP M&F
4	0.00	0.00	470.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		470.95		
SUBTOTAL:	207,740,499.54	209,424,624.92	208,557,027.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		625,722,151.63		

3906	NEWLY ELIGIBLE MALE	9,297.77	14,217.05	12,452.76	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	1,864.82	1,094.53	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	29,828.28	34,320.74	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	11,872.96	14,126.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	291.08	646.70	387.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	0.00	533.44	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	5,840.75	11,434.48	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	1,307,972.39	1,305,516.72	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	1,490,965.19	1,512,565.73	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	7,430,921.64	7,329,980.30	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	11,049,496.25	10,920,753.22	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	11,192,210.15	11,132,291.41	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	376.91	749.95	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	25,533.98	27,119.68	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	40,350.46	37,851.72	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	235,207.91	218,621.78	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	387,794.23	305,099.35	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	269,795.17	240,089.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

35,967.58	
4,176.51	
98,072.90	
33,185.09	
1,325.18	
533.44	
20,513.89	
3,897,749.06	
4,469,111.83	
22,125,806.87	
32,839,488.51	
33,487,492.33	
1,602.13	
87,816.02	
124,105.09	
730,560.56	
1,117,866.80	
840,757.20	

9935	BIRTH SUPP PAYMENT A	151,291.91	252,079.35	221,179.92	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	452,539.98	487,181.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	618,881.2	2	704,619.33	708,361.4	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
624,551.18	
1,407,310.78	
2,031,861.96	

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3926	NEWLY ELIGIBLE MALE	530.47	0.00	126.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		657.21		
3927	NEWLY ELIGIBLE FEMA L	2,368.16	2,368.16	2,368.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,104.48		
3928	NEWLY ELIGIBLE M&F
4	0.00	384.57	384.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		769.14		
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		764.22		
392F	NEWLY ELIGIBLE MALE	231.01	0.00	348.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		579.54		
SUBTOTAL:	33,320,140.2	6 33,498,181.01	33,107,684.3	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,926,005.58		

287,755.48	369,407.99	310,122.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
287,755.48	369,407.99	310,122.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9939

BIRTH SUPP PAYMENT N

967,286.10

967,286.10

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	138.81	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	7,453,485.41	7,433,353.84	7,295,647.88	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	2,132,648.44	2,105,881.37	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	2,056,948.94	2,037,169.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	0.00	40.49	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	196,010.17	140,848.92	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	53,566.33	47,207.23	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	55,686.38	38,746.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,929,326.2	8 11,928,393.40	11,665,501.2	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

138.81	
22,182,487.13	
6,364,240.59	
6,134,370.73	
40.49	
539,999.65	
157,971.23	
143,972.32	
35,523,220.95	

9944	BIRTH SUPP PAYMENT S	11,882.90	58,943.98	23,471.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,882.90	58,943.98	23,471.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

94,298.60

94,298.60

4517	BC PATIENT FEMALE 2 1	10,376.74	10,793.95	10,912.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	47,200.02	47,554.26	46,398.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	245.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	142.44	662.53	1,902.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	6,761.14	474.81	281.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	4,771.12	4,771.12	4,440.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	2,661.05	2,661.05	2,759.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4
5	0.00	0.00	637.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	71,912.51	67,163.00	67,332.1	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
32,082.78	
141,153.02	
245.28	
2,707.11	
7,517.57	
13,982.80	
8,081.28	
637.83	
206,407.67	

8600	SSI BLIND FREEDOM/W O	2,514.53	2,514.53	146.37	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	136.70	136.70	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	1,579,599.67	1,566,938.09	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	68,765.46	95,285.10	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	482,840.23	465,242.51	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	31,884.99	36,076.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,175.43	
410.10	
4,704,948.48	
203,920.79	
1,451,567.97	
97,690.82	

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8720	SSI DISABLED FREEDO M	234,348.44	222,168.42	214,558.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		671,075.30		
872Z	SSI DISABLED FREEDO
M	6,655.98	453.87	22,093.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,203.32		
SUBTOTAL:	2,375,150.96	2,388,363.87	2,400,477.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,163,992.21		

2,131.34

6015	KIDS 14-19 FEMALE NO	0.00	0.00	2,131.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	2,131.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,131.34

636,844,407.74

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

1,914,129,820.79

TOTAL:	637,039,184.43 640,246,228.62

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 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	89.86	94.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		273.60		
1007	TANF 21-44 FEMALE WI	106.74	102.58	84.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293.88		
1008	TANF 45-64 M & F WIT	178.61	170.54	178.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		528.07		
1009	TANF 65+ M & F WITH	99.53	90.51	78.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268.96		
100F	TANF 21-44 MALE WITH	0.29	4.11	6.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.05		
100G	TANF 21-44 FEMALE WI	2.91	6.29	2.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.63		
100H	TANF 45-64 M & F WIT	14.60	3.52	2.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.18		
100J	TANF 65+ M & F WITH	1.43	1.47	2.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.53		
1011	TANF <1 M & F NON-ME	9,979.28	10,037.99	10,057.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,075.26		
1012	TANF 01-05 M & F NON	18,993.92	18,921.51	18,927.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,842.97		
1013	TANF 06-13 M & F NON	34,139.11	34,275.13	34,370.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,784.96		
1014	TANF 14-20 MALE NON-	9,849.08	9,736.84	9,761.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,347.31		
1015	TANF 14-20 FEMALE N O	12,309.27	12,300.27	12,271.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,880.66		
1016	TANF 21-44 MALE NON-	24,304.85	24,468.54	24,434.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,208.05		
1017	TANF 21-44 FEMALE N O	83,159.05	83,428.43	83,491.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250,078.71		
1018	TANF 45-64 M & F NON	19,720.09	19,730.33	19,681.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,132.16		
1019	TANF 65+ M & F NON-M	78.99	75.92	80.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		235.72		
101A	TANF < 1 M & F NON-M	622.00	588.68	516.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,727.23		
101B	TANF 01-05 M & F NON	200.41	160.77	137.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.51		
101C	TANF 06-13 M & F NON	91.26	107.35	109.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308.19		
101D	TANF 14-20 MALE NON-	54.36	79.67	69.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203.06		
101E	TANF 14-20 FEMALE N O	99.54	114.09	110.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		324.12		
101F	TANF 21-44 MALE NON-	653.45	692.46	519.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,865.45		
101G	TANF 21-44 FEMALE N O	1,627.34	1,538.61	1,238.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,404.01		
101H	TANF 44-64 M & F NON	355.51	400.40	291.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,046.99		
101J	TANF 65+ N & F NON-M	0.64	1.67	3.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.46		
1024	TANF 14-20 MALE WITH	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1026	TANF 21-44 MALE WITH	60.00	53.27	54.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167.90		
1027	TANF 21-44 FEMALE WI	95.99	92.13	93.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		282.11		
1028	TANF 45-64 M & F WIT	108.90	105.00	101.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315.06		
1029	TANF 65+ M & F WITH	47.70	48.38	47.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143.08		
102F	TANF 21-44 MALE WITH	0.00	0.61	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.61		
102G	TANF 21-44 FEMALE WI	0.00	0.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.41		
102H	TANF 44-64 M & F WIT	0.00	0.00	0.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.20		
102J	TANF 65+ M & F WITH	0.00	1.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.35		
2100	SSI AGED WITH MEDIC A	4,122.71	4,063.81	4,030.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,217.11		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	283.43	232.59	193.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		709.06		
2110	SSI AGED NON-MEDICA
R	6,783.06	6,849.40	6,866.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,499.39		
211Z	SSI AGED NON-MEDICA R	187.29	129.52	110.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.26		
2120	SSI AGED WITH QMB	31,783.16	31,989.36	32,152.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,924.79		
212Z	SSI AGED WITH QMB P P	32.92	44.99	61.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.85		
2200	SSI DISABLED WITH M
E	3,555.63	3,532.68	3,532.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,621.19		
220Z	SSI DISABLED WITH M E	164.92	159.53	143.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		467.74		
2210	SSI DISABLED NON-ME
D	51,491.33	51,464.64	51,465.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,421.00		
221Z	SSI DISABLED NON-ME D	759.58	802.25	717.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,279.36		
2220	SSI DISABLED WITH Q
M	26,441.87	26,456.91	26,414.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,313.04		
222Z	SSI DISABLED WITH Q M	37.02	44.89	66.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148.76		
2300	SSI BLIND WITH MEDIC	28.00	28.99	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.99		
2310	SSI BLIND NON-MEDIC A	499.60	500.08	506.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,506.41		
231Z	SSI BLIND NON-MEDIC
A	4.50	8.28	24.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.56		
2320	SSI BLIND WITH QMB	225.80	229.88	231.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		686.68		
232Z	SSI BLIND WITH QMB P	0.00	0.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.64		
4302	SOBRA CHILD 01-05 M	3.00	4.93	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.93		
4303	SOBRA CHILD 06-13 M	5.00	6.06	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.06		
4305	SOBRA CHILD 14-20 FE	4.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
430B	SOBRA CHILD 01-05 M	0.00	1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.93		
430C	SOBRA CHILD 06-13 M	0.00	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.93		
4311	SOBRA CHILD <1 M & F	35,979.41	35,835.08	35,526.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,341.34		
4312	SOBRA CHILD 01-05 M	166,797.05	167,404.10	167,216.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		501,417.94		
4313	SOBRA CHILD 06-13 M	215,941.09	217,553.86	217,670.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		651,165.00		
4314	SOBRA CHILD 14-20 MA	58,666.27	59,328.82	59,632.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,627.80		
4315	SOBRA CHILD 14-20 FE	58,655.28	59,190.73	59,306.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,152.72		
431A	SOBRA CHILD < 1 M &	446.25	383.74	320.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,150.65		
431B	SOBRA CHILD 01-05 M	4,091.48	3,709.51	3,111.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,912.71		
431C	SOBRA CHILD 6-13 M&F	3,855.59	4,029.36	3,035.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,920.21		
431D	SOBRA CHILD 14-20 MA	1,094.86	1,112.84	911.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,119.18		
431E	SOBRA CHILD 14-20 FE	1,138.00	1,088.17	967.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,193.21		
4322	SOBRA CHILD 01-05 M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4323	SOBRA CHILD 06-13 M	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4325	SOBRA CHILD 14-20 FE	1.41	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.41		
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	29.30	34.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.71		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5008	SOBRA PREG 45-64 FE M	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
500G	SOBRA PREG 21-44 FE
M	3.59	4.76	0.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.21		
5013	SOBRA PREG 09-13 FE M	2.06	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.06		
5015	SOBRA PREG 14-20 FE
M	2,792.94	2,852.61	2,886.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,531.80		
5017	SOBRA PREG 21-44 FE M	15,577.98	15,919.95	16,021.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,519.87		
5018	SOBRA PREG 45-64 FE
M	38.47	49.97	52.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141.01		
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	207.98	196.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		647.48		
501G	SOBRA PREG 21-44 FE M	1,105.01	1,101.06	926.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,132.60		
501H	SOBRA PREG 45-64 FE
M	0.16	4.86	13.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.40		
5027	SOBRA PREG 21-44 FE M	32.00	37.00	37.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.40		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	909,956.0	5	913,841.68	911,256.6	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,735,054.34		

3100	TRANSPLANT OPTION 1	4.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10.00

10.00

9910	TANF & SOBRA CHILDR E	320.00	331.00	284.00	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	7.00	5.00	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	19.00	16.00	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	2,224.00	2,153.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,568.00	2,581.00	2,458.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
935.00	
17.00	
54.00	
6,601.00	
7,607.00	

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	214.97	217.96	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	430.85	418.07	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	1,241.98	1,227.12	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	650.13	632.39	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	14.68	26.10	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	28.93	15.20	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	52.51	25.08	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	35.69	27.08	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	7.00	6.00	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	210.83	211.15	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	1,490.04	1,445.15	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	26,359.12	26,183.36	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	71,178.63	70,984.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
655.93	
1,283.48	
3,690.83	
1,923.78	
61.15	
74.74	
118.60	
100.66	
1.00	
20.00	
633.00	
4,423.25	
78,968.25	
213,029.03	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	24,281.16	24,369.33	24,474.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,125.39		
1119	TANF EXPANDED 65+ M
&	83.32	77.45	77.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237.77		
111D	TANF EXPANDED 14-20	13.79	6.07	8.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.44		
111E	TANF EXPANDED 14-20	41.42	29.93	17.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.79		
111F	TANF EXPANDED 21-44	718.90	716.67	595.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,030.59		
111G	TANF EXPANDED 21-44	1,419.51	1,364.36	1,077.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,861.46		
111H	TANF EXPANDED 45-64	496.90	473.74	431.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,402.60		
111J	TANF EXPANDED 65+ M
&	1.67	2.70	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.37		
1126	TANF EXPANDED 21-44	763.98	778.79	773.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,316.32		
1127	TANF EXPANDED 21-44	1,658.56	1,669.60	1,651.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,980.07		
1128	TANF EXPANDED 45-64	2,534.08	2,564.62	2,606.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,704.87		
1129	TANF EXPANDED 65+ M
&	1,524.12	1,537.88	1,571.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,633.53		
112F	TANF EXPANDED 21-44	0.00	2.84	7.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.55		
112G	TANF EXPANDED 21-44	4.97	5.84	5.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.98		
112H	TANF EXPANDED 45-64	16.91	7.39	3.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.17		
112J	TANF EXPANDED 65+ M
&	4.82	6.37	6.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.04		
2400	SSI AGED EXPANDED WI	227.17	239.12	215.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		681.42		
240Z	SSI AGED EXPANDED
WI	188.57	198.61	194.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		581.85		
2410	SSI AGED EXPANDED N O	95.13	101.60	93.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		290.55		
241Z	SSI AGED EXPANDED N
O	12.57	0.00	2.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.73		
2420	SSI AGED EXPANDED WI	26,237.74	26,428.76	26,615.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,282.19		
242Z	SSI AGED EXPANDED
WI	50.54	25.46	32.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108.72		
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2600	SSI DISABLED EXPAND
E	203.51	221.75	186.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611.50		
260Z	SSI DISABLED EXPAND E	139.05	119.04	107.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		365.23		
2610	SSI DISABLED EXPAND
E	1,467.82	1,478.74	1,490.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,437.42		
261Z	SSI DISABLED EXPAND E	33.02	32.33	22.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.43		
2620	SSI DISABLED EXPAND
E	16,996.27	17,035.00	17,062.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,094.06		
262Z	SSI DISABLED EXPAND E	41.28	27.03	37.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.09		
SUBTOTAL:	180,908.2	8	181,437.38	180,791.1	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		543,136.83		

3506	ADULT 40-100% MALE 2	6.00	5.12	6.53	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	6.09	4.63	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	67.89	75.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

17.65	
11.94	
216.12	

9911	SB PAYMENT FOR TAN F	203.00	204.00	201.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	203.00	204.00	201.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
608.00

608.00

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3509	ADULT 40-100% M&F 65	7.00	16.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.00		
350F	ADULT 40-100% MALE 2	0.00	0.87	0.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.73		
350G	ADULT 40-100% FEMAL E	1.77	2.89	0.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.02		
350H	ADULT 40-100% M&F 45	4.62	4.08	1.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.80		
3514	ADULT 40-100% MALE 1	5,628.35	5,645.27	5,650.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,923.88		
3515	ADULT 40-100% FEMAL E	6,154.09	6,255.84	6,190.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,600.81		
3516	ADULT 40-100% MALE 2	18,543.88	18,724.72	18,647.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,916.21		
3517	ADULT 40-100% FEMAL E	15,666.52	15,700.84	15,719.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,086.98		
3518	ADULT 40-100% M&F 45	37,448.72	37,572.65	37,317.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,339.04		
3519	ADULT 40-100% M&F 65	8.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
351D	ADULT 40-100% MALE 1	107.37	91.34	100.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		298.83		
351E	ADULT 40-100% FEMAL E	151.90	141.38	122.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415.56		
351F	ADULT 40-100% MALE 2	592.51	485.14	409.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,487.63		
351G	ADULT 40-100% FEMAL E	497.72	447.95	333.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,279.10		
351H	ADULT 40-100% M&F 45	894.72	807.69	643.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,346.13		
351J	ADULT 40-100% M&F 65	2.00	1.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
3526	ADULT 40-100% MALE 2	0.90	1.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.31		
3528	ADULT 40-100% M&F 45	1.80	1.00	1.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.03		
3529	ADULT 40-100% M&F 65	0.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
352F	ADULT 40-100% MALE 2	4.09	1.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.67		
352G	ADULT 40-100% FEMAL E	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
352H	ADULT 40-100% M&F 45	2.18	0.00	0.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.94		
3704	ADULT <40% EXP MALE	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3706	ADULT <40% EXP MALE	24.30	33.18	33.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.13		
3707	ADULT <40% EXP FEMA L	3.22	7.07	12.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.45		
3708	ADULT <40% EXP M&F
4	69.28	82.50	84.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236.42		
3709	ADULT <40% EXP M&F 6	5.00	9.32	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.32		
370F	ADULT <40% EXP MALE	6.31	6.24	9.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.52		
370G	ADULT <40% EXP FEMA L	0.77	1.90	1.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.49		
370H	ADULT <40% EXP M&F
4	10.17	19.09	6.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.97		
370J	ADULT <40% EXP M&F 6	0.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.67		
3714	ADULT <40% EXP MALE	10,088.70	10,200.34	10,314.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,603.17		
3715	ADULT <40% EXP FEMA L	9,173.98	9,315.29	9,393.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,882.86		
3716	ADULT <40% EXP MALE	69,372.63	70,752.32	70,889.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211,013.95		
3717	ADULT <40% EXP FEMA L	40,598.88	41,281.54	41,336.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,216.66		
3718	ADULT <40% EXP M&F
4	82,032.08	82,785.12	82,884.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		247,701.46		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	7.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
371D	ADULT <40% EXP MALE	267.37	258.29	210.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		736.42		
371E	ADULT <40% EXP FEMA L	271.22	220.41	179.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		670.84		
371F	ADULT <40% EXP MALE	2,522.08	2,263.41	1,955.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,740.93		
371G	ADULT <40% EXP FEMA L	1,522.51	1,206.36	1,033.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,762.50		
371H	ADULT <40% EXP M&F
4	2,167.78	1,988.52	1,594.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,750.38		
371J	ADULT <40% EXP M&F 6	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3726	ADULT <40% EXP MALE	3.18	5.00	1.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.78		
3727	ADULT <40% EXP FEMA L	2.48	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.48		
3728	ADULT <40% EXP M&F
4	0.00	3.00	3.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.20		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.51		
372H	ADULT <40% EXP M&F
4	0.00	0.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.73		
SUBTOTAL:	303,949.6	1	306,439.32	305,225.7	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		915,614.68		

3906	NEWLY ELIGIBLE MALE	13.21	15.49	16.06	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	4.61	3.00	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	69.13	73.43	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	25.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.77	1.48	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	0.00	1.38	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	5.03	27.91	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	3,121.58	3,122.24	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	3,604.90	3,646.42	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	17,133.92	16,970.49	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	25,775.37	25,504.82	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	25,803.75	25,652.50	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	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	83.05	62.33	67.48	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	100.13	92.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	668.38	562.71	524.11	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	908.94	726.00	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	652.01	570.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

44.76	
10.61	
210.42	
74.00	
3.18	
1.38	
39.05	
9,308.05	
10,792.23	
51,088.53	
76,663.44	
77,194.87	
4.00	
212.86	
304.98	
1,755.20	
2,640.16	
2,013.36	

9935	BIRTH SUPP PAYMENT A	26.00	43.00	38.00	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	77.00	83.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	106.00	120.00	121.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
107.00	
240.00	
347.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3926	NEWLY ELIGIBLE MALE	1.38	0.00	0.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.64		
3927	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
3928	NEWLY ELIGIBLE M&F
4	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
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		2.00		
392F	NEWLY ELIGIBLE MALE	0.61	0.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.34		
SUBTOTAL:	77,486.10	77,850.76	77,034.2	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232,371.06		

49.00	63.00	53.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
49.00	63.00	53.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9939

BIRTH SUPP PAYMENT N

165.00

165.00

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.77	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	41,633.68	41,477.67	40,700.23	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	11,806.85	11,644.38	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	11,435.49	11,306.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	0.00	0.22	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	1,089.10	774.26	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	295.37	252.42	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	304.19	212.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	66,501.36	66,409.66	64,889.7	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.77	
123,811.58	
35,252.51	
34,091.67	
0.22	
2,992.19	
864.52	
787.33	
197,800.79	

9944	BIRTH SUPP PAYMENT S	2.00	10.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	10.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.00

16.00

4517	BC PATIENT FEMALE 2 1	22.89	24.00	24.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	127.00	128.33	124.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	0.38	1.70	4.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	19.22	1.28	0.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	8.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	7.00	7.00	7.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4
5	0.00	0.00	1.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	184.49	170.89	169.9	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
71.25	
379.66	
0.58	
6.71	
21.16	
23.00	
21.26	
1.73	
525.35	

8600	SSI BLIND FREEDOM/W O	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W
O	1.00	1.00	1.00	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	2,075.92	2,084.18	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	108.56	115.27	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	361.22	348.08	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	26.48	28.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.00	
3.00	
6,249.52	
291.82	
1,085.74	
76.09	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8720	SSI DISABLED FREEDO M	342.00	333.87	331.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,007.74		
872Z	SSI DISABLED FREEDO
M	4.53	3.47	11.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.18		
SUBTOTAL:	2,904.59	2,912.52	2,920.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,738.09		

0.90

6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.90

TOTAL:	1,544,822.48	1,552,043.21	1,545,129.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,641,995.04		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending September 30, 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	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
1009	TANF 65+ M & F WITH	0.00	33.40	33.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
1011	TANF <1 M & F NON-ME	1,753.50	1,803.60	1,820.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,377.40		
1012	TANF 01-05 M & F NON	1,402.80	1,469.60	1,786.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,659.30		
1013	TANF 06-13 M & F NON	1,285.90	1,369.40	1,603.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,258.50		
1014	TANF 14-20 MALE NON-	334.00	450.90	467.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,252.50		
1015	TANF 14-20 FEMALE N O	484.30	467.60	467.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,419.50		
1016	TANF 21-44 MALE NON-	1,419.50	1,553.10	1,937.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,909.80		
1017	TANF 21-44 FEMALE N O	5,761.50	6,496.30	7,565.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,822.90		
1018	TANF 45-64 M & F NON	2,638.60	2,772.20	3,056.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,466.90		
1019	TANF 65+ M & F NON-M	0.00	0.00	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.70		
1026	TANF 21-44 MALE WITH	0.00	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.40		
2100	SSI AGED WITH MEDIC A	83.50	133.60	133.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350.70		
2110	SSI AGED NON-MEDICA
R	116.90	116.90	200.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		434.20		
2120	SSI AGED WITH QMB	1,035.40	1,169.00	1,269.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,473.60		
2200	SSI DISABLED WITH M E	400.80	467.60	517.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,386.10		
2210	SSI DISABLED NON-ME
D	6,379.40	7,047.40	7,849.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,275.80		
2220	SSI DISABLED WITH Q M	2,271.20	2,338.00	2,538.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,147.60		
2310	SSI BLIND NON-MEDIC
A	66.80	66.80	83.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217.10		
2320	SSI BLIND WITH QMB	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.10		
4311	SOBRA CHILD <1 M & F	4,876.40	4,809.60	5,160.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,846.30		
4312	SOBRA CHILD 01-05 M	14,762.80	16,416.10	18,169.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,348.50		
4313	SOBRA CHILD 06-13 M	14,094.80	16,132.20	17,985.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,212.90		
4314	SOBRA CHILD 14-20 MA	2,822.30	3,039.40	3,573.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,435.50		
4315	SOBRA CHILD 14-20 FE	2,922.50	3,306.60	4,024.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,253.80		
5015	SOBRA PREG 14-20 FE M	116.90	116.90	100.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334.00		
5017	SOBRA PREG 21-44 FE
M	751.50	651.30	718.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,120.90		
5018	SOBRA PREG 45-64 FE M	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.10		
SUBTOTAL:	65,848.10	72,294.30	81,145.3	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		219,287.70		

1108	TANF EXPANDED 45-64	33.40	33.40	50.10	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	133.60	183.70	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	33.40	33.40	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	83.50	66.80	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	1,135.60	1,369.40	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	3,774.20	4,024.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
116.90	
434.20	
100.20	
233.80	
3,390.10	
11,105.50	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	1,987.30	2,271.20	2,404.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,663.30		
1119	TANF EXPANDED 65+ M
&	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.10		
1126	TANF EXPANDED 21-44	50.10	50.10	66.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167.00		
1127	TANF EXPANDED 21-44	66.80	66.80	83.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217.10		
1128	TANF EXPANDED 45-64	350.70	334.00	317.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,002.00		
1129	TANF EXPANDED 65+ M
&	250.50	233.80	233.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		718.10		
2420	SSI AGED EXPANDED WI	1,452.90	1,753.50	1,920.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,126.90		
2610	SSI DISABLED EXPAND
E	133.60	150.30	200.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		484.30		
2620	SSI DISABLED EXPAND E	751.50	768.20	784.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,304.60		
SUBTOTAL:	9,519.00	10,838.30	11,756.8	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,114.10		

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	50.10	83.50	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	83.50	167.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	450.90	517.70	484.30	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	868.40	968.60	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	1,837.00	1,953.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,955.90	3,356.70	3,657.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.70	
167.00	
317.30	
1,452.90	
2,638.60	
5,377.40	
9,969.90	

4413	SOBRA 100-133% M&F
6	1,786.90	1,887.10	2,271.20	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	417.50	467.60	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	400.80	450.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,945.20	
1,202.40	
1,185.70	

3514	ADULT 40-100% MALE 1	83.50	133.60	150.30	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	183.70	200.40	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	751.50	818.30	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	751.50	818.30	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	2,889.10	3,122.90	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	
3706	ADULT <40% EXP MALE	0.00	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	16.70	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	417.50	467.60	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	551.10	567.80	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	5,845.00	6,529.70	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	3,456.90	3,941.20	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	8,734.10	9,569.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	21,192.30	23,730.70	26,219.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
367.40	
517.70	
2,221.10	
2,237.80	
8,617.20	
16.70	
33.40	
16.70	
1,185.70	
1,486.30	
17,468.20	
10,521.00	
26,452.80	
71,142.00	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,438.20	2,705.40	3,189.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,333.30		

4618	CC PATIENT FEMALE 4 5	0.00	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

33.40

33.40

8700	SSI DISABLED FREEDO M	50.10	83.50	83.50	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	16.70	16.70	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	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	83.50	116.90	100.2	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
217.10	
50.10	
33.40	
300.60	

341,181.00

102,037.00	113,059.00	126,085.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending September 30, 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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1009	TANF 65+ M & F WITH	0.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1011	TANF <1 M & F NON-ME	105.00	108.00	109.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322.00		
1012	TANF 01-05 M & F NON	84.00	88.00	107.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		279.00		
1013	TANF 06-13 M & F NON	77.00	82.00	96.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255.00		
1014	TANF 14-20 MALE NON-	20.00	27.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.00		
1015	TANF 14-20 FEMALE N O	29.00	28.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.00		
1016	TANF 21-44 MALE NON-	85.00	93.00	116.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		294.00		
1017	TANF 21-44 FEMALE N O	345.00	389.00	453.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,187.00		
1018	TANF 45-64 M & F NON	158.00	166.00	183.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1026	TANF 21-44 MALE WITH	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2100	SSI AGED WITH MEDIC A	5.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
2110	SSI AGED NON-MEDICA
R	7.00	7.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
2120	SSI AGED WITH QMB	62.00	70.00	76.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208.00		
2200	SSI DISABLED WITH M E	24.00	28.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.00		
2210	SSI DISABLED NON-ME
D	382.00	422.00	470.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,274.00		
2220	SSI DISABLED WITH Q M	136.00	140.00	152.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		428.00		
2310	SSI BLIND NON-MEDIC
A	4.00	4.00	5.00	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	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4311	SOBRA CHILD <1 M & F	292.00	288.00	309.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		889.00		
4312	SOBRA CHILD 01-05 M	884.00	983.00	1,088.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,955.00		
4313	SOBRA CHILD 06-13 M	844.00	966.00	1,077.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,887.00		
4314	SOBRA CHILD 14-20 MA	169.00	182.00	214.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		565.00		
4315	SOBRA CHILD 14-20 FE	175.00	198.00	241.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		614.00		
5015	SOBRA PREG 14-20 FE M	7.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
5017	SOBRA PREG 21-44 FE
M	45.00	39.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.00		
5018	SOBRA PREG 45-64 FE M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	3,943.00	4,329.00	4,859.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,131.00		

1108	TANF EXPANDED 45-64	2.00	2.00	3.00	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	8.00	11.00	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	2.00	2.00	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	5.00	4.00	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	68.00	82.00	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	226.00	241.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7.00	
26.00	
6.00	
14.00	
203.00	
665.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	119.00	136.00	144.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		399.00		
1119	TANF EXPANDED 65+ M
&	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1126	TANF EXPANDED 21-44	3.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1127	TANF EXPANDED 21-44	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1128	TANF EXPANDED 45-64	21.00	20.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.00		
1129	TANF EXPANDED 65+ M
&	15.00	14.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.00		
2420	SSI AGED EXPANDED WI	87.00	105.00	115.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		307.00		
2610	SSI DISABLED EXPAND
E	8.00	9.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
2620	SSI DISABLED EXPAND E	45.00	46.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.00		
SUBTOTAL:	570.00	649.00	704.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,923.00		

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	3.00	5.00	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	5.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	27.00	31.00	29.00	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	52.00	58.00	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	110.00	117.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	177.00	201.00	219.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
10.00	
19.00	
87.00	
158.00	
322.00	
597.00	

4413	SOBRA 100-133% M&F
6	107.00	113.00	136.00	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	25.00	28.00	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	24.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

356.00	
72.00	
71.00	

3514	ADULT 40-100% MALE 1	5.00	8.00	9.00	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	11.00	12.00	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	45.00	49.00	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	45.00	49.00	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	173.00	187.00	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	
3706	ADULT <40% EXP MALE	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	1.00	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	25.00	28.00	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	33.00	34.00	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	350.00	391.00	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	207.00	236.00	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	523.00	573.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,269.00	1,421.00	1,570.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22.00	
31.00	
133.00	
134.00	
516.00	
1.00	
2.00	
1.00	
71.00	
89.00	
1,046.00	
630.00	
1,584.00	
4,260.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	146.00	162.00	191.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		499.00		

8700	SSI DISABLED FREEDO M	3.00	5.00	5.00	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	1.00	1.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13.00	
3.00	
2.00	
18.00	

4618	CC PATIENT FEMALE 4 5	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

2.00

2.00

TOTAL:	6,110.00	6,770.00	7,550.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,430.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending September 30, 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	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.42		
1008	TANF 45-64 M & F WIT	22.71	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.55		
1009	TANF 65+ M & F WITH	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.13		
1011	TANF <1 M & F NON-ME	204.39	204.39	181.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		590.46		
1012	TANF 01-05 M & F NON	431.49	545.04	499.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,476.15		
1013	TANF 06-13 M & F NON	408.78	431.49	408.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,249.05		
1014	TANF 14-20 MALE NON-	22.71	45.42	68.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.26		
1015	TANF 14-20 FEMALE N O	181.68	295.23	363.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		840.27		
1016	TANF 21-44 MALE NON-	567.75	681.30	681.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,930.35		
1017	TANF 21-44 FEMALE N O	4,428.45	4,791.81	4,905.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,125.62		
1018	TANF 45-64 M & F NON	1,544.28	1,612.41	1,748.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,905.36		
1027	TANF 21-44 FEMALE WI	0.00	0.00	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.71		
2100	SSI AGED WITH MEDIC A	181.68	181.68	204.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567.75		
2110	SSI AGED NON-MEDICA
R	45.42	45.42	68.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.97		
2120	SSI AGED WITH QMB	1,975.77	2,112.03	2,157.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,245.25		
2200	SSI DISABLED WITH M E	681.30	704.01	749.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,134.74		
2210	SSI DISABLED NON-ME
D	4,110.51	4,428.45	4,610.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,149.09		
2220	SSI DISABLED WITH Q M	2,861.46	3,020.43	3,156.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,038.58		
2310	SSI BLIND NON-MEDIC
A	22.71	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.55		
2320	SSI BLIND WITH QMB	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.26		
4311	SOBRA CHILD <1 M & F	908.40	953.82	749.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,611.65		
4312	SOBRA CHILD 01-05 M	5,473.11	5,813.76	6,358.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,645.67		
4313	SOBRA CHILD 06-13 M	4,678.26	5,518.53	5,904.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,101.39		
4314	SOBRA CHILD 14-20 MA	976.53	1,226.34	1,294.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,497.34		
4315	SOBRA CHILD 14-20 FE	1,657.83	1,725.96	1,907.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,291.43		
5015	SOBRA PREG 14-20 FE M	113.55	113.55	90.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		317.94		
5017	SOBRA PREG 21-44 FE
M	1,021.95	1,135.50	1,317.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,474.63		
SUBTOTAL:	32,611.56	35,768.25	37,607.7	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,987.57		

1108	TANF EXPANDED 45-64	45.42	45.42	45.42	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	22.71	22.71	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	22.71	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	249.81	272.52	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	3,088.56	3,247.53	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	1,521.57	1,589.70	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	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
136.26	
68.13	
45.42	
794.85	
9,220.26	
4,587.42	
68.13	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	90.84	113.55	158.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		363.36		
1129	TANF EXPANDED 65+ M
&	249.81	295.23	295.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		840.27		
2410	SSI AGED EXPANDED N O	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.13		
2420	SSI AGED EXPANDED
WI	1,703.25	1,884.93	1,930.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,518.53		
2610	SSI DISABLED EXPAND E	68.13	45.42	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.26		
2620	SSI DISABLED EXPAND
E	567.75	567.75	613.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,748.67		
SUBTOTAL:	7,448.88	7,903.08	8,243.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,595.69		

3908	NEWLY ELIGIBLE M&F 4	22.71	45.42	22.71	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	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	22.71	68.13	68.13	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	22.71	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	181.68	158.97	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	658.59	749.43	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	1,112.79	1,112.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,953.06	2,089.32	2,134.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

90.84	
22.71	
158.97	
45.42	
499.62	
1,998.48	
3,361.08	
6,177.12	

4413	SOBRA 100-133% M&F
6	386.07	363.36	476.91	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	181.68	181.68	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	136.26	204.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	635.88	681.30	862.9	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,226.34	
476.91	
476.91	
2,180.16	

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

68.13

68.13

3514	ADULT 40-100% MALE 1	136.26	113.55	113.55	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	295.23	317.94	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	363.36	454.20	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	340.65	386.07	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	1,771.38	1,839.51	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	22.71	22.71	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	204.39	249.81	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	317.94	340.65	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	2,021.19	2,157.45	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	1,725.96	1,680.54	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	6,267.96	6,517.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,059.01	13,444.32	14,080.2	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
363.36	
840.27	
1,180.92	
1,067.37	
5,064.33	
68.13	
613.17	
976.53	
5,972.73	
5,064.33	
18,372.39	
39,583.53	

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

 
136.26

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.26		
SUBTOTAL:	90.84	90.84	90.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272.52		

6013	KIDS 6-13 M & F NON-	0.00	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22.71

22.71

177,887.43

54,821.94	60,022.53	63,042.96	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 September 30, 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1008	TANF 45-64 M & F WIT	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1009	TANF 65+ M & F WITH	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1011	TANF <1 M & F NON-ME	9.00	9.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
1012	TANF 01-05 M & F NON	19.00	24.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65.00		
1013	TANF 06-13 M & F NON	18.00	19.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.00		
1014	TANF 14-20 MALE NON-	1.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1015	TANF 14-20 FEMALE N O	8.00	13.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.00		
1016	TANF 21-44 MALE NON-	25.00	30.00	30.00	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	195.00	211.00	216.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		622.00		
1018	TANF 45-64 M & F NON	68.00	71.00	77.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		216.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2100	SSI AGED WITH MEDIC A	8.00	8.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
2110	SSI AGED NON-MEDICA
R	2.00	2.00	3.00	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	87.00	93.00	95.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		275.00		
2200	SSI DISABLED WITH M E	30.00	31.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94.00		
2210	SSI DISABLED NON-ME
D	181.00	195.00	203.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		579.00		
2220	SSI DISABLED WITH Q M	126.00	133.00	139.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		398.00		
2310	SSI BLIND NON-MEDIC
A	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2320	SSI BLIND WITH QMB	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
4311	SOBRA CHILD <1 M & F	40.00	42.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.00		
4312	SOBRA CHILD 01-05 M	241.00	256.00	280.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		777.00		
4313	SOBRA CHILD 06-13 M	206.00	243.00	260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		709.00		
4314	SOBRA CHILD 14-20 MA	43.00	54.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154.00		
4315	SOBRA CHILD 14-20 FE	73.00	76.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		233.00		
5015	SOBRA PREG 14-20 FE M	5.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
5017	SOBRA PREG 21-44 FE
M	45.00	50.00	58.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153.00		
SUBTOTAL:	1,436.00	1,575.00	1,656.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,667.00		

1108	TANF EXPANDED 45-64	2.00	2.00	2.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	1.00	1.00	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	11.00	12.00	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	136.00	143.00	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	67.00	70.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
3.00	
2.00	
35.00	
406.00	
202.00	
3.00	

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	4.00	5.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
1129	TANF EXPANDED 65+ M
&	11.00	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.00		
2410	SSI AGED EXPANDED N O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2420	SSI AGED EXPANDED
WI	75.00	83.00	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243.00		
2610	SSI DISABLED EXPAND E	3.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2620	SSI DISABLED EXPAND
E	25.00	25.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.00		
SUBTOTAL:	328.00	348.00	363.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,039.00		

3908	NEWLY ELIGIBLE M&F 4	1.00	2.00	1.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1.00	3.00	3.00	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	1.00	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	8.00	7.00	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	29.00	33.00	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	49.00	49.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	86.00	92.00	94.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00	
1.00	
7.00	
2.00	
22.00	
88.00	
148.00	
272.00	

4413	SOBRA 100-133% M&F
6	17.00	16.00	21.00	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	8.00	8.00	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	6.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28.00	30.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

54.00	
21.00	
21.00	
96.00	

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

3.00

3.00

3514	ADULT 40-100% MALE 1	6.00	5.00	5.00	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	13.00	14.00	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	16.00	20.00	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	15.00	17.00	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	78.00	81.00	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	1.00	1.00	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	9.00	11.00	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	14.00	15.00	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	89.00	95.00	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	76.00	74.00	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	276.00	287.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	531.00	592.00	620.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16.00	
37.00	
52.00	
47.00	
223.00	
3.00	
27.00	
43.00	
263.00	
223.00	
809.00	
1,743.00	

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

 
6.00

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
SUBTOTAL:	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		

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

 
1.00

1.00

TOTAL:	2,414.00	2,643.00	2,776.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,833.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending September 30, 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	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149.40		
1009	TANF 65+ M & F WITH	49.80	49.80	74.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.30		
1011	TANF <1 M & F NON-ME	1,045.80	946.20	1,045.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,037.80		
1012	TANF 01-05 M & F NON	2,191.20	1,992.00	2,116.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,299.70		
1013	TANF 06-13 M & F NON	2,340.60	2,539.80	2,714.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,594.50		
1014	TANF 14-20 MALE NON-	423.30	597.60	771.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,792.80		
1015	TANF 14-20 FEMALE N O	1,767.90	1,767.90	1,992.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,527.80		
1016	TANF 21-44 MALE NON-	6,474.00	6,548.70	6,648.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,671.00		
1017	TANF 21-44 FEMALE N O	23,904.00	24,053.40	24,800.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,757.80		
1018	TANF 45-64 M & F NON	7,519.80	7,445.10	7,569.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,534.50		
1019	TANF 65+ M & F NON-M	24.90	24.90	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
1026	TANF 21-44 MALE WITH	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.70		
1028	TANF 45-64 M & F WIT	24.90	49.80	74.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149.40		
1029	TANF 65+ M & F WITH	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
2100	SSI AGED WITH MEDIC A	1,444.20	1,469.10	1,444.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,357.50		
2110	SSI AGED NON-MEDICA
R	199.20	174.30	199.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572.70		
2120	SSI AGED WITH QMB	5,229.00	5,453.10	5,453.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,135.20		
2200	SSI DISABLED WITH M E	3,336.60	3,560.70	3,635.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,532.70		
2210	SSI DISABLED NON-ME
D	18,077.40	18,351.30	18,525.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,954.30		
2220	SSI DISABLED WITH Q M	8,341.50	8,490.90	8,715.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,547.40		
2300	SSI BLIND WITH MEDIC	49.80	49.80	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.50		
2310	SSI BLIND NON-MEDIC A	273.90	298.80	298.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		871.50		
2320	SSI BLIND WITH QMB	99.60	99.60	124.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323.70		
4311	SOBRA CHILD <1 M & F	3,884.40	3,610.50	3,411.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,906.20		
4312	SOBRA CHILD 01-05 M	31,847.10	32,046.30	32,768.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,661.80		
4313	SOBRA CHILD 06-13 M	42,330.00	44,421.60	45,865.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,617.40		
4314	SOBRA CHILD 14-20 MA	10,034.70	10,308.60	11,080.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,423.80		
4315	SOBRA CHILD 14-20 FE	11,727.90	12,300.60	12,450.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,478.50		
5007	SOBRA PREG 21-44 FE M	0.00	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
5013	SOBRA PREG 09-13 FE
M	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.70		
5015	SOBRA PREG 14-20 FE M	473.10	522.90	572.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,568.70		
5017	SOBRA PREG 21-44 FE
M	2,838.60	2,888.40	2,863.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,590.50		
5018	SOBRA PREG 45-64 FE M	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.70		
SUBTOTAL:	186,102.6	0	190,236.00	195,440.1	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		571,778.70		

1106

TANF EXPANDED 21-44

24.90

24.90

24.90

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

74.70

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	249.00	249.00	224.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		722.10		
1109	TANF EXPANDED 65+ M
&	174.30	199.20	174.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		547.80		
1113	TANF EXPANDED 06-13	0.00	0.00	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
1115	TANF EXPANDED 14-20	249.00	224.10	174.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		647.40		
1116	TANF EXPANDED 21-44	3,237.00	3,212.10	3,361.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,810.60		
1117	TANF EXPANDED 21-44	9,935.10	10,134.30	10,308.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,378.00		
1118	TANF EXPANDED 45-64	5,004.90	4,955.10	4,880.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,840.40		
1119	TANF EXPANDED 65+ M
&	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
1126	TANF EXPANDED 21-44	99.60	99.60	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		298.80		
1127	TANF EXPANDED 21-44	249.00	224.10	224.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		697.20		
1128	TANF EXPANDED 45-64	498.00	547.80	597.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,643.40		
1129	TANF EXPANDED 65+ M
&	498.00	498.00	522.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,518.90		
2410	SSI AGED EXPANDED N O	99.60	99.60	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		298.80		
2420	SSI AGED EXPANDED
WI	3,311.70	3,486.00	3,436.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,233.90		
2610	SSI DISABLED EXPAND E	124.50	174.30	149.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		448.20		
2620	SSI DISABLED EXPAND
E	1,593.60	1,643.40	1,718.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,955.10		
SUBTOTAL:	25,373.10	25,796.40	26,020.5	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,190.00		

3906	NEWLY ELIGIBLE MALE	24.90	24.90	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	249.00	249.00	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	348.60	323.70	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	1,369.50	1,394.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

49.80	
24.90	
722.10	
971.10	
4,033.80	

3508	ADULT 40-100% M&F 45	0.00	24.90	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	398.40	423.30	398.40	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	672.30	722.10	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	1,294.80	1,294.80	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	1,145.40	996.00	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	3,859.50	3,984.00	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	24.90	24.90	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	2,514.90	2,838.60	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	2,913.30	2,888.40	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	18,600.30	19,521.60	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	9,636.30	9,785.70	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	19,920.00	19,994.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	58,714.20	61,029.90	62,449.2	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
24.90	
1,220.10	
1,992.00	
3,934.20	
3,411.30	
11,678.10	
74.70	
7,719.00	
8,466.00	
56,224.20	
28,585.20	
58,863.60	
182,193.30	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	2,589.60	2,639.40	2,465.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,694.10		
3918	NEWLY ELIGIBLE M&F
4	2,913.30	2,963.10	3,187.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,063.60		
SUBTOTAL:	7,345.50	7,594.50	7,619.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,559.40		

4413	SOBRA 100-133% M&F
6	2,813.70	2,938.20	2,913.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	946.20	1,070.70	1,195.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	996.00	1,045.80	996.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,755.90	5,054.70	5,104.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,665.20	
3,212.10	
3,037.80	
14,915.10	

8710	SSI DISABLED FREEDO M	49.80	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.80	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
149.40

149.40

868,785.90

282,341.10	289,761.30	296,683.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending September 30, 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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1009	TANF 65+ M & F WITH	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1011	TANF <1 M & F NON-ME	42.00	38.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122.00		
1012	TANF 01-05 M & F NON	88.00	80.00	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253.00		
1013	TANF 06-13 M & F NON	94.00	102.00	109.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		305.00		
1014	TANF 14-20 MALE NON-	17.00	24.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.00		
1015	TANF 14-20 FEMALE N O	71.00	71.00	80.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222.00		
1016	TANF 21-44 MALE NON-	260.00	263.00	267.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		790.00		
1017	TANF 21-44 FEMALE N O	960.00	966.00	996.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,922.00		
1018	TANF 45-64 M & F NON	302.00	299.00	304.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		905.00		
1019	TANF 65+ M & F NON-M	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1026	TANF 21-44 MALE WITH	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1028	TANF 45-64 M & F WIT	1.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1029	TANF 65+ M & F WITH	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2100	SSI AGED WITH MEDIC A	58.00	59.00	58.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.00		
2110	SSI AGED NON-MEDICA
R	8.00	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.00		
2120	SSI AGED WITH QMB	210.00	219.00	219.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		648.00		
2200	SSI DISABLED WITH M E	134.00	143.00	146.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		423.00		
2210	SSI DISABLED NON-ME
D	726.00	737.00	744.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,207.00		
2220	SSI DISABLED WITH Q M	335.00	341.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,026.00		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2310	SSI BLIND NON-MEDIC A	11.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.00		
2320	SSI BLIND WITH QMB	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
4311	SOBRA CHILD <1 M & F	156.00	145.00	137.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		438.00		
4312	SOBRA CHILD 01-05 M	1,279.00	1,287.00	1,316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,882.00		
4313	SOBRA CHILD 06-13 M	1,700.00	1,784.00	1,842.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,326.00		
4314	SOBRA CHILD 14-20 MA	403.00	414.00	445.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,262.00		
4315	SOBRA CHILD 14-20 FE	471.00	494.00	500.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,465.00		
5007	SOBRA PREG 21-44 FE M	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5013	SOBRA PREG 09-13 FE
M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
5015	SOBRA PREG 14-20 FE M	19.00	21.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.00		
5017	SOBRA PREG 21-44 FE
M	114.00	116.00	115.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345.00		
5018	SOBRA PREG 45-64 FE M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	7,474.00	7,640.00	7,849.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,963.00		

1106

TANF EXPANDED 21-44

1.00

1.00

1.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

3.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	10.00	10.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
1109	TANF EXPANDED 65+ M
&	7.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
1113	TANF EXPANDED 06-13	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1115	TANF EXPANDED 14-20	10.00	9.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
1116	TANF EXPANDED 21-44	130.00	129.00	135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394.00		
1117	TANF EXPANDED 21-44	399.00	407.00	414.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,220.00		
1118	TANF EXPANDED 45-64	201.00	199.00	196.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		596.00		
1119	TANF EXPANDED 65+ M
&	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1126	TANF EXPANDED 21-44	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1127	TANF EXPANDED 21-44	10.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.00		
1128	TANF EXPANDED 45-64	20.00	22.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.00		
1129	TANF EXPANDED 65+ M
&	20.00	20.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.00		
2410	SSI AGED EXPANDED N O	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
2420	SSI AGED EXPANDED
WI	133.00	140.00	138.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		411.00		
2610	SSI DISABLED EXPAND E	5.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
2620	SSI DISABLED EXPAND
E	64.00	66.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.00		
SUBTOTAL:	1,019.00	1,036.00	1,045.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,100.00		

3906	NEWLY ELIGIBLE MALE	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	10.00	10.00	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	14.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	51.00	55.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
1.00	
29.00	
39.00	
162.00	

3508	ADULT 40-100% M&F 45	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	16.00	17.00	16.00	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	27.00	29.00	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	52.00	52.00	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	46.00	40.00	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	155.00	160.00	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	1.00	1.00	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	101.00	114.00	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	117.00	116.00	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	747.00	784.00	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	387.00	393.00	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	800.00	803.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,358.00	2,451.00	2,508.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
49.00	
80.00	
158.00	
137.00	
469.00	
3.00	
310.00	
340.00	
2,258.00	
1,148.00	
2,364.00	
7,317.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	104.00	106.00	99.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		309.00		
3918	NEWLY ELIGIBLE M&F
4	117.00	119.00	128.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		364.00		
SUBTOTAL:	295.00	305.00	306.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906.00		

8710	SSI DISABLED FREEDO M	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6.00

6.00

4413	SOBRA 100-133% M&F
6	113.00	118.00	117.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	38.00	43.00	48.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	40.00	42.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	191.00	203.00	205.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
348.00	
129.00	
122.00	
599.00	

TOTAL:	11,339.00	11,637.00	11,915.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,891.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	8,388.64	12,582.96	8,388.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,360.24		
1010	TANF NON-MEDICARE	1,661,849.71	1,910,910.01	2,172,000.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,744,760.11		
1020	TANF WITH QMB	20,971.60	20,971.60	20,971.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,914.80		
2100	SSI AGED WITH MEDIC A	35,053,635.97	35,173,656.27	35,136,281.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,363,574.21		
210Z	SSI AGED WITH MEDIC
A	1,732,093.67	1,894,450.16	1,631,535.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,258,078.86		
2110	SSI AGED NON-MEDICA R	3,603,820.94	3,588,951.22	3,570,026.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,762,798.65		
211Z	SSI AGED NON-MEDICA
R	101,176.43	20,587.31	54,593.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,356.89		
2120	SSI AGED WITH QMB	26,288,894.99	26,531,693.06	26,828,758.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,649,346.97		
212Z	SSI AGED WITH QMB P P	53,559.58	52,446.69	41,429.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,435.77		
2200	SSI DISABLED WITH M
E	15,658,939.46	15,620,560.12	15,518,145.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,797,644.97		
220Z	SSI DISABLED WITH M E	241,491.30	210,523.92	148,685.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		600,700.87		
2210	SSI DISABLED NON-ME
D	136,360,868.15	136,890,501.12	137,386,032.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		410,637,401.45		
221Z	SSI DISABLED NON-ME D	220,330.68	212,099.65	164,951.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		597,382.06		
2220	SSI DISABLED WITH Q
M	29,326,623.98	29,529,057.68	29,674,499.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,530,181.61		
222Z	SSI DISABLED WITH Q M	36,101.66	3,297.05	17,224.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,623.13		
2300	SSI BLIND WITH MEDIC	2,719.44	2,719.44	165.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,603.88		
2310	SSI BLIND NON-MEDIC A	108,525.41	110,540.42	91,496.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310,562.00		
2320	SSI BLIND WITH QMB	20,374.22	15,937.16	9,178.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,489.78		
SUBTOTAL:	250,500,365.83	251,801,485.84	252,474,364.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		754,776,216.25		

8700	SSI DISABLED FREEDO M	155,943.28	136,803.98	166,698.11	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	7,623.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	193,336.11	189,285.16	228,187.85	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	18,307.27	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	55,601.45	73,572.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	0.00	0.00	290.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	417,428.1	9	407,621.04	468,748.7	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
459,445.37	
7,623.18	
610,809.12	
24,777.45	
190,852.42	
290.41	
1,293,797.95	

756,070,014.20

250,917,794.02	252,209,106.88	252,943,113.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1010	TANF NON-MEDICARE	393.91	454.32	516.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,365.15		
1020	TANF WITH QMB	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
2100	SSI AGED WITH MEDIC A	11,901.36	11,949.18	11,925.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,776.11		
210Z	SSI AGED WITH MEDIC
A	562.03	623.08	527.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,712.64		
2110	SSI AGED NON-MEDICA R	611.47	610.68	604.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,826.66		
211Z	SSI AGED NON-MEDICA
R	16.60	3.70	9.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.32		
2120	SSI AGED WITH QMB	9,350.65	9,436.56	9,532.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,319.76		
212Z	SSI AGED WITH QMB P P	17.29	17.74	14.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.74		
2200	SSI DISABLED WITH M
E	4,466.83	4,466.23	4,430.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,363.28		
220Z	SSI DISABLED WITH M E	78.72	70.28	48.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		197.18		
2210	SSI DISABLED NON-ME
D	30,896.55	31,019.03	31,105.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,021.07		
221Z	SSI DISABLED NON-ME D	35.96	35.18	26.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97.34		
2220	SSI DISABLED WITH Q
M	7,937.60	7,999.85	8,044.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,981.90		
222Z	SSI DISABLED WITH Q M	11.96	1.08	5.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.05		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2310	SSI BLIND NON-MEDIC A	24.00	24.64	22.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.04		
2320	SSI BLIND WITH QMB	6.00	4.99	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.99		
SUBTOTAL:	66,319.93	66,726.54	66,823.7	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,870.23		

8700	SSI DISABLED FREEDO M	42.00	36.25	45.99	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	2.74	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	31.50	39.00	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	2.48	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	15.00	19.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	0.00	0.00	0.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	91.98	87.97	104.9	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
124.24	
2.74	
102.49	
3.48	
51.89	
0.10	
284.94	

TOTAL:	66,411.91	66,814.51	66,928.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200,155.17		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending September 30, 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	368.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		729.54		
1013	TANF 06-13 M & F NON	0.00	581.41	-227.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		353.75		
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	372.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		608.94		
2210	SSI DISABLED NON-ME
D	0.00	305.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		305.69		
221Z	SSI DISABLED NON-ME D	0.00	0.00	67.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.66		
4311	SOBRA CHILD <1 M & F	-365.58	-23.83	-1,504.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,893.47		
4312	SOBRA CHILD 01-05 M	-100.40	1,427.57	203.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,531.14		
4313	SOBRA CHILD 06-13 M	292.16	-195.37	-41.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.67		
4314	SOBRA CHILD 14-20 MA	-0.83	-91.81	101.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.85		
4315	SOBRA CHILD 14-20 FE	-301.20	-464.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-766.02		
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	1,910.97	-1,030.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,745.02		

4415

SOBRA 100-133% FEMA L

405.96

405.96

0.00	405.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	405.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

S000	STATE-ONLY BHS	0.00	0.00	-0.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-0.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-0.07

-0.07

2,150.91

864.84	2,316.93	-1,030.86	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 September 30, 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		
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		
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		

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

4415

SOBRA 100-133% FEMA L

0.00

0.00

SUBTOTAL:

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 - ADULT
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	27,128.70	27,368.37	30,877.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,374.85		
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	473.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,229.32		
1018	TANF 45-64 M & F NON	0.00	0.00	20,190.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,190.63		
101D	TANF 14-20 MALE NON-	47.31	0.00	710.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		757.76		
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		
101G	TANF 21-44 FEMALE N O	0.00	0.00	1,894.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,894.53		
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	-275.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.86		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	2,396.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,396.02		
211Z	SSI AGED NON-MEDICA R	0.00	0.00	316.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316.46		
2120	SSI AGED WITH QMB	9,121.46	6,202.90	7,229.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,553.87		
2200	SSI DISABLED WITH M E	6,705.80	6,218.03	9,375.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,299.56		
220Z	SSI DISABLED WITH M
E	1,230.03	0.00	1,706.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,936.28		
2210	SSI DISABLED NON-ME D	191,817.13	229,386.03	284,569.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		705,773.07		
221Z	SSI DISABLED NON-ME
D	4,176.42	1,262.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,439.03		
2220	SSI DISABLED WITH Q M	70,948.72	70,948.72	97,309.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239,206.47		
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	1,706.25	1,706.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,118.75		
4314	SOBRA CHILD 14-20 MA	1,680.63	0.00	113.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,794.38		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	157.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157.88		
431E	SOBRA CHILD 14-20 FE	0.00	2,036.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,036.49		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	1,375.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,375.06		
5010	SOBRA PREGNANT WO
MAN	0.00	2,368.16	2,368.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,736.32		
5017	SOBRA PREG 21-44 FE M	0.00	993.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		993.10		
SUBTOTAL:	331,641.4	6	348,490.66	462,495.8	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,142,627.95		

1100	TANF EXPANDED FPR FI	5,780.66	5,780.66	5,780.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	0.00	1,680.63	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	0.00	0.00	625.63	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	30,073.11	27,704.95	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	8,457.99	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	

 
17,341.98	
1,680.63	
625.63	
84,016.43	
8,457.99	
1,604.24	
3,738.47	
5,500.24	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111H	TANF EXPANDED 45-64	0.00	5,347.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,347.46		
1120	TANF EXPANDED FOR FI	1,466.58	1,466.58	1,466.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,399.74		
2420	SSI AGED EXPANDED
WI	10,037.64	10,037.64	10,037.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,112.92		
260Z	SSI DISABLED EXPAND E	440.32	1,772.15	534.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,747.22		
2610	SSI DISABLED EXPAND
E	0.00	0.00	2,368.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,368.16		
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		2,520.94		
2620	SSI DISABLED EXPAND
E	28,947.74	27,878.25	29,268.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,094.43		
262Z	SSI DISABLED EXPAND E	0.00	1,145.88	1,499.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,645.71		
SUBTOTAL:	86,275.20	93,640.35	79,286.6	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259,202.19		

3910	NEWLY ELIGIBLE FOR F	11,840.80	11,840.80	13,307.38	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	
391H	NEWLY ELIGIBLE M&F 4	0.00	993.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,077.62	12,833.90	13,307.3	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

36,988.98	
236.82	
993.10	
38,218.90	

3510	ADULT 40-100% FOR FI	49,075.49	46,707.33	45,143.84	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	1,341.96	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	
351F	ADULT 40-100% MALE 2	0.00	0.00	3,394.36	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	831.06	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	209,370.50	194,071.35	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	2,368.16	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	40,933.89	21,535.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	38,663.11	4,447.86	-455.00	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	2,368.16	-1,706.25	1,023.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	10,405.58	7,629.19	5,307.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA L	13,048.25	0.00	1,308.13	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	381.96	1,375.06	5,170.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	328,562.8	5	311,125.74	278,672.9	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
140,926.66	
1,341.96	
1,816.33	
3,394.36	
3,122.83	
612,104.59	
2,902.91	
63,784.47	
42,655.97	
1,685.66	
23,342.14	
14,356.38	
6,927.26	
918,361.52	

8700	SSI DISABLED FREEDO M	5,118.75	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,938.08	
SUBTOTAL:	5,118.75	2,819.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,938.08	
																
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	768,909.98	833,762.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,370,534.94	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending September 30, 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	
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	
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	
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	
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
101G

101H	TANF 21-44 FEMALE N O
TANF 44-64 M & F NON	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	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

211Z	SSI AGED NON-MEDICA
R
SSI AGED NON-MEDICA
R	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

220Z

SSI DISABLED WITH M E

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

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

n. 0.00

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	

221Z

2220	SSI DISABLED NON-ME D
SSI DISABLED WITH Q
M	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
222Z

2310	SSI DISABLED WITH Q M
SSI BLIND NON-MEDIC
A	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

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

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	
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

5010

5017

SOBRA PREGNANT WO MAN
SOBRA PREG 21-44 FE
M

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SUBTOTAL:

0.00

0.00	0.00

0.00	0.00	0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
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 September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
260Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2610	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
261Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
262Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00

0.00

0.00

0.00

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	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	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

3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G

3710

3714	ADULT 40-100% FEMAL E
AHC CARE EXPANDED
FO
ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
Current and prior month data is	0.00	0.00	0.00	0.00
und0.00er r0e.00   vis0i.0o0      n. 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	0.00
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	0.00
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA	0.00
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F	0.00
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
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 - GENERAL
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1013	TANF 06-13 M & F NON	0.00	178.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178.47		
1014	TANF 14-20 MALE NON-	0.00	-0.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.24		
1015	TANF 14-20 FEMALE N O	0.00	0.00	20.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.76		
1016	TANF 21-44 MALE NON-	-1.81	-6.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7.92		
1017	TANF 21-44 FEMALE N O	593.22	420.31	329.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,343.42		
101G	TANF 21-44 FEMALE N
O	-57.94	0.00	141.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.12		
2100	SSI AGED WITH MEDIC A	70.96	2,067.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,138.51		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	-140.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-140.84		
211Z	SSI AGED NON-MEDICA R	0.00	0.00	-18.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-18.60		
2210	SSI DISABLED NON-ME
D	0.00	-1,650.64	-3,733.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,383.95		
221Z	SSI DISABLED NON-ME D	135.05	0.00	846.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		981.41		
2220	SSI DISABLED WITH Q
M	0.00	159.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159.44		
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	182.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.15		
4315	SOBRA CHILD 14-20 FE	0.00	70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.53		
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	1,422.27	-2,554.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-339.65		

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

1116	TANF EXPANDED 21-44	-182.58	-717.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	1,192.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	70.53	-1,693.00	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	159.44	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	38.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-112.05	-1,019.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-900.06	
1,192.81	
-1,622.47	
159.44	
38.57	
-1,131.71	

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	-227.52	-5.05	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	846.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	0.00	-22.67	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	
3714	ADULT <40% EXP MALE	0.00	797.20	-195.66	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	-3,513.00	-2,336.03	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	-946.56	-1,462.31	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	-13.68	-3,605.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
209.24	
-236.48	
-3.41	
-154.08	
-22.67	
634.77	
601.54	
-6,655.07	
-3,880.94	
-3,638.96	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		211.59		
371E	ADULT <40% EXP FEMA
L	0.00	0.00	-79.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-79.72		
371F	ADULT <40% EXP MALE	-100.56	400.96	141.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441.46		
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		-43.00		
371H	ADULT <40% EXP M&F
4	0.00	0.00	-282.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-282.12		
SUBTOTAL:	-2,393.56	-3,525.27	-6,979.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-12,897.85		

3916	NEWLY ELIGIBLE MALE	398.60	-839.72	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	825.85	496.72	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	-746.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	-44.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	398.60	-805.62	496.7	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-441.12	
1,322.57	
-746.84	
-44.91	
89.70	

S000	STATE-ONLY BHS	-37.60	-24.63	-7.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-37.60	-24.63	-7.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-70.00

-70.00

-14,193.78

-1,196.12	-3,952.91	-9,044.75	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 September 30, 2019

221Z

2220	SSI DISABLED NON-ME D
SSI DISABLED WITH Q
M	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
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	

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

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	
211Z

2210	SSI AGED NON-MEDICA R
SSI DISABLED NON-ME
D	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

4315

SOBRA CHILD 14-20 FE

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

0.00

visio

0.00

0.00

M
SUBTOTAL:

n.

0.00

5017

SOBRA PREG 21-44 FE

0.00

0.00

0.00

0.00

0.00	0.00	0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

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

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
371E	ADULT <40% EXP FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		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		

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

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	

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

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	675,910.00	670,888.15	500,674.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,847,472.70		
1011	TANF <1 M & F NON-ME	248.11	953.72	-5,125.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,923.44		
1012	TANF 01-05 M & F NON	-15,379.82	-11,274.85	-15,393.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-42,047.78		
1013	TANF 06-13 M & F NON	-2,418.26	-7,544.45	3,346.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-6,616.20		
1014	TANF 14-20 MALE NON-	-811.16	-1,806.09	1,478.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,138.87		
1015	TANF 14-20 FEMALE N O	-368.71	-1,388.95	1,344.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-413.45		
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	93.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-167.27		
101C	TANF 06-13 M & F NON	1,300.68	-970.35	-792.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-462.22		
101D	TANF 14-20 MALE NON-	751.24	516.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,267.43		
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	259,937.48	275,290.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		793,980.29		
221Z	SSI DISABLED NON-ME D	232.93	-271.78	-3,810.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,848.85		
2220	SSI DISABLED WITH Q
M	762.00	762.00	762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,286.00		
2310	SSI BLIND NON-MEDIC A	762.00	762.00	762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,286.00		
4310	SOBRA CHILD NON-ME
DI	10,445,633.40	10,379,896.70	10,747,274.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,572,805.05		
4311	SOBRA CHILD <1 M & F	13,625.43	15,714.43	26,374.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,714.66		
4312	SOBRA CHILD 01-05 M	-74,721.61	-78,041.28	-39,438.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-192,201.33		
4313	SOBRA CHILD 06-13 M	-105,628.37	-106,985.86	-26,667.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-239,281.36		
4314	SOBRA CHILD 14-20 MA	-43,134.77	-38,503.25	2,887.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-78,750.14		
4315	SOBRA CHILD 14-20 FE	-40,754.75	-20,963.64	-19,790.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-81,509.15		
431A	SOBRA CHILD < 1 M &	1,940.81	16,788.88	6,353.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,083.16		
431B	SOBRA CHILD 01-05 M	12,785.94	9,798.85	10,136.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,721.58		
431C	SOBRA CHILD 6-13 M&F	25,205.14	21,852.27	12,251.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,309.39		
431D	SOBRA CHILD 14-20 MA	16,781.28	5,724.71	4,846.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,352.16		
431E	SOBRA CHILD 14-20 FE	11,745.14	9,190.46	4,671.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,607.49		
5010	SOBRA PREGNANT WO MAN	13,738.15	13,995.75	20,755.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,489.15		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		817.98		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		762.00		
SUBTOTAL:	11,197,408.6	0 11,139,124.99	11,509,774.2	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,846,307.82		

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	589.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

589.94

762.00

3710	AHC CARE EXPANDED FO	0.00	0.00	762.00	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	393.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	393.29	762.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

1,155.29

393.29

762.00

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
391D	NEWLY ELIGIBLE MALE	0.00	172.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172.06		
SUBTOTAL:	0.00	762.00	762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,524.00		

4410	SOBRA 100-133% FOR F	12,926.90	12,373.25	10,432.55	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	1,928.22	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	1,680.42	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	-782.54	2,635.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	0.00	0.00	127.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	127.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,257.40	11,590.71	16,931.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
35,732.70	
3,020.72	
1,680.42	
1,091.27	
127.00	
127.00	
41,779.11	

S000	STATE-ONLY BHS	0.00	-762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-762.00

-762.00

33,890,004.22

11,210,666.00	11,151,108.99	11,528,229.23	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 September 30, 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 O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1017	TANF 21-44 FEMALE N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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

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

5015	SOBRA PREGNANT WO MAN
SOBRA PREG 14-20 FE
M	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
																
3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	

4310

SOBRA CHILD NON-ME
DI

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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

 
0.00

0.00

TOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	
Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	204.75	398.47	398.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,001.69		
1010	TANF NON-MEDICARE	88,390.05	113,571.24	121,494.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323,455.76		
101Z	TANF ALTCS NON-MEDI C	0.00	0.00	-422.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-422.76		
1020	TANF WITH QMB	796.94	796.94	796.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,390.82		
2100	SSI AGED WITH MEDIC A	53,657.95	54,298.49	54,342.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162,298.97		
2110	SSI AGED NON-MEDICA
R	2,380.90	2,380.90	2,380.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,142.70		
2120	SSI AGED WITH QMB	90,544.71	90,470.79	91,379.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,395.12		
2200	SSI DISABLED WITH M E	391,262.61	392,589.11	387,859.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,171,711.10		
2210	SSI DISABLED NON-ME
D	5,853,769.90	5,880,424.06	5,923,149.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,657,343.33		
221Z	SSI DISABLED NON-ME D	123.42	-299.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-175.59		
2220	SSI DISABLED WITH Q
M	968,050.49	973,390.07	978,398.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,919,839.28		
2310	SSI BLIND NON-MEDIC A	1,463.86	1,668.61	1,531.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,664.12		
2320	SSI BLIND WITH QMB	398.47	204.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		603.22		
4312	SOBRA CHILD 01-05 M	0.00	299.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299.01		
SUBTOTAL:	7,451,044.05	7,510,193.43	7,561,309.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,522,546.77		

8700	SSI DISABLED FREEDO M	4,554.83	3,929.55	4,328.02	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	979.63	1,765.54	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	2,585.65	2,984.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,721.64	7,494.83	9,077.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,812.40	
3,531.08	
7,950.68	
24,294.16	

22,546,840.93

7,458,765.69	7,517,688.26	7,570,386.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending September 30, 2019

SUBTOTAL:

Cu0.0r0   ren0.0t0      an0.d00

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

2220

2310	SSI DISABLED WITH Q M
SSI BLIND NON-MEDIC
A	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
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	
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	

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	
101Z	TANF ALTCS NON-MEDI C	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2210

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

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

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

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 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	524.04	554.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,650.54		
1007	TANF 21-44 FEMALE WI	697.86	633.68	569.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,900.54		
1008	TANF 45-64 M & F WIT	1,292.20	1,256.05	1,295.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,843.63		
1009	TANF 65+ M & F WITH	784.65	740.61	658.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,183.94		
1011	TANF <1 M & F NON-ME	13,774.43	13,889.53	14,044.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,708.64		
1012	TANF 01-05 M & F NON	26,627.12	26,500.41	26,825.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,952.99		
1013	TANF 06-13 M & F NON	48,891.34	48,999.00	49,380.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,270.48		
1014	TANF 14-20 MALE NON-	29,752.48	29,183.72	29,422.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,359.06		
1015	TANF 14-20 FEMALE N O	50,257.49	49,708.32	49,693.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,659.19		
1016	TANF 21-44 MALE NON-	196,818.83	196,825.88	198,260.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		591,905.11		
1017	TANF 21-44 FEMALE N O	669,123.39	671,878.41	675,375.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,016,377.34		
1018	TANF 45-64 M & F NON	161,187.72	160,988.62	161,431.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		483,607.52		
1019	TANF 65+ M & F NON-M	674.30	651.26	689.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,014.96		
1024	TANF 14-20 MALE WITH	10.41	1.08	1.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.57		
1026	TANF 21-44 MALE WITH	387.68	364.94	366.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,119.59		
1027	TANF 21-44 FEMALE WI	653.45	638.63	661.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,953.17		
1028	TANF 45-64 M & F WIT	835.76	807.47	773.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,416.88		
1029	TANF 65+ M & F WITH	450.07	433.44	423.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,307.32		
2100	SSI AGED WITH MEDIC A	32,980.00	32,982.55	33,054.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,016.75		
2110	SSI AGED NON-MEDICA
R	53,956.16	54,404.88	54,776.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163,137.85		
2120	SSI AGED WITH QMB	256,470.33	258,178.50	259,225.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		773,874.22		
2200	SSI DISABLED WITH M E	25,887.66	25,631.83	25,902.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,421.74		
2210	SSI DISABLED NON-ME
D	277,976.12	277,927.49	278,125.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		834,028.74		
2220	SSI DISABLED WITH Q M	170,604.53	170,784.02	170,828.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		512,217.22		
2300	SSI BLIND WITH MEDIC	235.51	244.84	214.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		695.17		
2310	SSI BLIND NON-MEDIC A	3,591.59	3,599.17	3,649.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,840.57		
2320	SSI BLIND WITH QMB	1,900.92	1,912.30	1,925.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,738.61		
4302	SOBRA CHILD 01-05 M	3.24	3.24	5.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.88		
4303	SOBRA CHILD 06-13 M	9.76	9.76	10.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.37		
4305	SOBRA CHILD 14-20 FE	20.16	17.99	9.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.48		
4311	SOBRA CHILD <1 M & F	48,698.46	48,704.10	48,220.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,623.54		
4312	SOBRA CHILD 01-05 M	236,845.73	238,192.76	238,593.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		713,632.17		
4313	SOBRA CHILD 06-13 M	310,882.77	313,296.50	314,734.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		938,914.14		
4314	SOBRA CHILD 14-20 MA	155,400.15	157,444.43	158,328.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471,172.75		
4315	SOBRA CHILD 14-20 FE	157,772.95	160,194.90	160,353.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		478,321.29		
4322	SOBRA CHILD 01-05 M	1.08	1.08	1.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.24		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4323	SOBRA CHILD 06-13 M	0.00	0.00	1.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.08		
4325	SOBRA CHILD 14-20 FE	2.17	11.92	11.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.01		
5007	SOBRA PREG 21-44 FE M	148.67	173.44	218.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		540.75		
5008	SOBRA PREG 45-64 FE
M	11.36	11.36	11.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.08		
5013	SOBRA PREG 09-13 FE M	3.32	8.72	6.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.60		
5015	SOBRA PREG 14-20 FE
M	18,252.71	19,137.94	19,530.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,921.44		
5017	SOBRA PREG 21-44 FE M	118,643.32	122,268.55	124,930.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		365,842.08		
5018	SOBRA PREG 45-64 FE
M	307.55	390.33	379.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,077.13		
5027	SOBRA PREG 21-44 FE M	205.51	237.30	212.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		655.62		
SUBTOTAL:	3,073,603.35	3,089,794.99	3,103,689.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,267,087.99		

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	1,492.39	1,526.49	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	2,793.21	2,706.33	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	8,784.30	8,826.26	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	5,284.42	5,243.64	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	9.77	9.81	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	1,750.36	1,728.92	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	11,788.34	11,444.03	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	206,218.55	205,999.85	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	561,438.85	562,646.70	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	194,804.38	195,665.55	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	624.36	639.24	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	5,324.19	5,196.15	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	10,959.15	10,863.18	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	18,675.72	19,068.13	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	13,110.24	13,310.80	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	893.69	957.51	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	842.92	773.27	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	202,142.27	203,515.08	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	7.58	7.58	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	849.07	753.42	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	10,503.92	10,814.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.58	
4,517.38	
8,272.62	
26,291.59	
15,771.94	
2.17	
29.35	
5,207.44	
35,051.48	
618,988.09	
1,683,512.21	
584,365.98	
1,938.67	
15,750.63	
32,665.17	
56,301.83	
39,409.95	
2,690.94	
2,350.39	
606,435.50	
22.74	
2,364.74	
31,701.52	

3100	TRANSPLANT OPTION 1	30.32	22.74	22.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30.32	22.74	22.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
75.80

75.80

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2620	SSI DISABLED EXPAND E	99,455.39	99,763.22	99,882.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299,101.42		
SUBTOTAL:	1,353,111.57	1,358,060.90	1,361,578.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,072,751.33		

3906	NEWLY ELIGIBLE MALE	90.34	82.78	88.61	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	30.32	22.74	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	559.03	527.84	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	184.22	242.21	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	24,486.72	24,647.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

261.73	
75.80	
1,595.23	
580.35	
73,050.89	

3506	ADULT 40-100% MALE 2	39.65	24.49	41.40	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	9.33	16.91	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	452.36	545.05	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	127.98	157.70	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	44,607.83	44,699.57	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	49,196.07	48,899.21	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	144,802.87	145,001.66	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	121,415.68	121,844.58	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	285,924.77	285,254.29	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	35.83	50.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	7.58	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	7.58	7.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	16.91	15.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3704	ADULT <40% EXP MALE	0.00	7.58	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	152.75	147.20	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	37.90	71.72	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	498.45	583.32	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	66.17	90.66	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	83,112.88	84,175.98	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	75,409.29	76,563.99	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	555,978.93	563,750.56	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	317,055.36	320,391.77	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	631,593.77	635,678.13	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	71.42	58.31	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	45.18	18.94	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	7.58	16.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F
4	0.00	3.78	20.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,281,745.11	2,310,670.32	2,328,102.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
105.54	
26.24	
1,486.53	
338.44	
133,810.72	
146,432.36	
433,067.46	
363,968.19	
855,965.21	
146.86	
7.58	
30.32	
32.07	
7.58	
431.73	
124.78	
1,505.30	
196.48	
249,170.74	
226,619.99	
1,665,825.13	
949,020.50	
1,891,862.46	
199.40	
71.70	
39.65	
24.47	
6,920,517.43	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	27,726.24	28,155.12	28,588.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,469.88		
3916	NEWLY ELIGIBLE MALE	130,814.88	132,521.42	131,942.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		395,278.51		
3917	NEWLY ELIGIBLE FEMA L	195,391.19	198,499.23	198,178.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		592,068.62		
3918	NEWLY ELIGIBLE M&F
4	196,812.85	197,720.38	197,534.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		592,068.16		
3919	NEWLY ELIGIBLE M&F 6	16.91	18.66	27.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.56		
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		9.33		
3928	NEWLY ELIGIBLE M&F 4	16.91	9.33	9.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.57		
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	582,267.21	581,810.0	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,739,570.74		

4413	SOBRA 100-133% M&F
6	58,543.74	58,461.45	57,600.88	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	31,584.39	30,917.23	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	30,699.26	30,090.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	120,209.7	5	120,745.10	118,608.3	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
174,606.07	
93,813.33	
91,143.76	
359,563.16	

4517	BC PATIENT FEMALE 2 1	143.38	164.09	156.51	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	976.73	948.76	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	48.96	39.63	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	65.89	65.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,210.47	1,255.67	1,210.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
463.98	
2,877.73	
137.55	
197.67	
3,676.93	

8600	SSI BLIND FREEDOM/W O	7.58	7.58	7.58	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	9.33	9.33	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	11,003.76	11,166.46	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	2,400.00	2,331.24	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	1,869.38	1,874.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,673.94	15,290.05	15,388.6	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22.74	
27.99	
33,462.83	
7,198.01	
5,641.05	
46,352.62	

6015	KIDS 14-19 FEMALE NO	18.76	21.00	12.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	18.76	21.00	12.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
52.08

52.08

22,409,648.08

7,421,096.76	7,478,127.98	7,510,423.34	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 September 30, 2019

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

1006

1007

1008

1009

1011

1012

1013

1014

1015

1016

1017

1018

1019

1024

TANF 21-44 MALE WITH TANF 21-44 FEMALE WI TANF 45-64 M & F WIT TANF 65+ M & F WITH TANF <1 M & F NON-ME TANF 01-05 M & F NON TANF 06-13 M & F NON TANF 14-20 MALE NON-
TANF 14-20 FEMALE N O
TANF 21-44 MALE NON-

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

TANF 65+ M & F NON-M 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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	

1026

1027

TANF 21-44 MALE WITH

TANF 21-44 FEMALE WI

Cu0.00rren0.00t

an0.0d0

pr0i.00or

m0.00 ont0h.00

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

r0e.00   vis0i.0o0

n. 0.00

0.00

0.00

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

0.00

0.00

0.00

0.00

0.00

prior m

0.00

0.00

0.00

0.00

onth

0.00

0.00

data is

0.00

0.00

0.00

0.00

under re

0.00

0.00

0.00

0.00

visio

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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	
0.00	

1109	TANF EXPANDED 65+ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

2400	&
SSI AGED EXPANDED
WI	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
2410	SSI AGED EXPANDED N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	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													

1104	TANF EXPANDED 14-20	
1106	TANF EXPANDED 21-44	
1107	TANF EXPANDED 21-44	
1108	TANF EXPANDED 45-64	

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	

 
0.00

0.00

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3516	E
ADULT 40-100% MALE 2	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3518	E
ADULT 40-100% M&F 45	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

		
3529	ADULT 40-100% M&F 65	
3704	ADULT <40% EXP MALE	
3706	ADULT <40% EXP MALE	
3707	ADULT <40% EXP FEMA	

3708	L
ADULT <40% EXP M&F	
4
3709	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MALE

3715	ADULT <40% EXP FEMA
L
3716	ADULT <40% EXP MALE

3717	ADULT <40% EXP FEMA
L
3718	ADULT <40% EXP M&F
4
3719	ADULT <40% EXP M&F
6
3726	ADULT <40% EXP MALE

3727	ADULT <40% EXP FEMA
L
3728	ADULT <40% EXP M&F
4
SUBTOTAL:	

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	

0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3929	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

4517

4518

4617	BC PATIENT FEMALE 2 1
BC PATIENT FEMALE 4
5
CC PATIENT FEMALE 2
1	Cu0.00rr
0.00

0.00	en0.00
0.00

0.00	t an0.0d0
0.00

0.00	pr0i.00or
0.00

0.00	m0.00
0.00

0.00	ont0h.00
0.00

0.00	da0.0t0 a is0.00
0.00	0.00

0.00	0.00	und0.00er
0.00

0.00	r0e.00
0.00

0.00	vis0i.0o0
0.00

0.00	n. 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	

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

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	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	0.00	0.00	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 September 30, 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	4,842.01	4,556.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,578.64		
1007	TANF 21-44 FEMALE WI	5,660.13	8,315.12	3,656.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,631.42		
1008	TANF 45-64 M & F WIT	13,522.79	12,784.45	13,053.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,360.57		
1009	TANF 65+ M & F WITH	7,573.40	7,048.03	5,895.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,516.72		
1011	TANF <1 M & F NON-ME	1,704,748.88	1,215,550.25	823,687.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,743,986.96		
1012	TANF 01-05 M & F NON	321,855.78	307,163.81	292,577.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		921,597.39		
1013	TANF 06-13 M & F NON	530,515.76	501,663.79	446,044.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,478,224.25		
1014	TANF 14-20 MALE NON-	203,236.61	175,532.08	149,342.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		528,110.79		
1015	TANF 14-20 FEMALE N O	393,263.47	411,573.01	297,015.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,101,852.44		
1016	TANF 21-44 MALE NON-	1,956,741.53	2,236,067.42	1,702,040.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,894,849.36		
1017	TANF 21-44 FEMALE N O	6,391,025.27	6,861,727.73	6,092,771.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,345,524.97		
1018	TANF 45-64 M & F NON	2,566,895.07	2,988,825.03	2,296,099.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,851,819.14		
1019	TANF 65+ M & F NON-M	3,082.12	11,634.33	3,047.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,764.21		
1026	TANF 21-44 MALE WITH	5,452.82	2,600.75	875.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,928.60		
1027	TANF 21-44 FEMALE WI	8,052.27	3,119.24	1,357.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,529.08		
1028	TANF 45-64 M & F WIT	7,027.85	6,397.80	5,710.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,135.91		
1029	TANF 65+ M & F WITH	11,881.21	6,449.88	10,048.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,379.66		
2100	SSI AGED WITH MEDIC A	231,952.74	259,830.87	132,481.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		624,265.00		
2110	SSI AGED NON-MEDICA
R	164,988.00	142,495.88	96,068.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403,552.53		
2120	SSI AGED WITH QMB	696,504.68	647,287.68	605,933.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,949,725.60		
2200	SSI DISABLED WITH M E	509,724.57	597,467.37	548,111.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,655,302.97		
2210	SSI DISABLED NON-ME
D	9,349,394.09	10,282,957.71	8,326,157.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,958,509.23		
2220	SSI DISABLED WITH Q M	1,799,464.98	1,475,342.17	1,447,618.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,722,425.25		
2300	SSI BLIND WITH MEDIC	2,786.12	2,517.54	1,645.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,949.25		
2310	SSI BLIND NON-MEDIC A	105,581.25	151,794.37	90,576.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347,951.98		
2320	SSI BLIND WITH QMB	25,806.73	19,005.13	19,779.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,591.03		
4311	SOBRA CHILD <1 M & F	3,079,674.40	2,071,093.53	2,246,499.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,397,266.96		
4312	SOBRA CHILD 01-05 M	4,144,566.09	4,042,965.94	3,675,014.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,862,547.00		
4313	SOBRA CHILD 06-13 M	6,203,269.83	6,885,485.33	5,614,996.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,703,751.29		
4314	SOBRA CHILD 14-20 MA	1,874,493.90	2,011,492.36	1,644,388.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,530,374.50		
4315	SOBRA CHILD 14-20 FE	2,264,127.22	2,531,195.42	1,955,324.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,750,646.95		
5007	SOBRA PREG 21-44 FE M	1,468.11	1,067.27	1,508.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,044.36		
5013	SOBRA PREG 09-13 FE
M	0.00	581.96	1,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,401.96		
5015	SOBRA PREG 14-20 FE M	462,480.69	354,299.93	380,997.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,197,778.36		
5017	SOBRA PREG 21-44 FE
M	2,739,461.45	2,355,050.17	2,334,361.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,428,873.53		
5018	SOBRA PREG 45-64 FE M	6,539.65	455.00	2,730.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,724.65		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	50.00	0.00	687.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		737.71		
SUBTOTAL:	47,800,049.38	48,593,680.36	41,274,480.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,668,210.22		

1106	TANF EXPANDED 21-44	5,110.76	1,764.45	2,329.25	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	10,056.41	8,533.12	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	47,914.79	28,663.49	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	44,251.43	31,503.60	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	831.96	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	7,678.68	16,731.72	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	55,435.70	30,773.76	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	786,349.11	669,332.96	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	2,763,283.47	2,491,623.82	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	2,084,851.76	1,459,759.58	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	6,686.67	2,730.00	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	26,606.09	16,901.42	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	44,593.66	46,430.88	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	134,264.39	111,496.05	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	79,296.36	63,543.18	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	12,930.61	8,460.23	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	34,342.19	12,647.48	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	605,978.95	543,157.63	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	9,409.72	4,649.50	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	301,664.91	166,066.27	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	431,872.38	403,893.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,871,706.59	7,490,063.69	6,119,227.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,204.46	
26,427.25	
120,462.38	
117,653.74	
831.96	
29,395.40	
133,075.13	
2,298,334.11	
7,931,937.59	
5,085,194.99	
10,326.67	
76,998.59	
137,297.70	
404,490.69	
226,654.79	
30,680.70	
58,649.36	
1,758,950.81	
28,453.15	
695,247.47	
1,300,731.12	
20,480,998.06	

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

3614	AHC CARE/MI MALE 14-	0.00	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	-1,320.00	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	-5,610.00	-330.00	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	-2,640.00	-75.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-10,230.00	-735.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-660.00	
-1,650.00	
-5,940.00	
-2,715.63	
-10,965.63	

1,848.34

618.26

3507	ADULT 40-100% FEMAL E	427.00	191.26	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	138.56	673.58	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	43.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

150.55

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	82,193.78	72,082.38	61,562.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,838.80		
3515	ADULT 40-100% FEMAL E	133,768.02	149,460.55	112,076.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		395,304.82		
3516	ADULT 40-100% MALE 2	929,328.88	812,103.33	787,166.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,528,598.39		
3517	ADULT 40-100% FEMAL E	719,939.62	657,905.17	549,744.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,927,589.49		
3518	ADULT 40-100% M&F 45	2,471,316.14	2,775,008.27	2,356,105.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,602,429.57		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	684.21	6,334.49	1,409.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,428.36		
3707	ADULT <40% EXP FEMA L	3,777.08	1,125.81	3,880.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,783.52		
3708	ADULT <40% EXP M&F
4	4,674.03	12,630.88	7,588.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,893.04		
3709	ADULT <40% EXP M&F 6	-266.59	427.00	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		587.41		
3714	ADULT <40% EXP MALE	476,542.78	405,246.15	378,050.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,259,839.77		
3715	ADULT <40% EXP FEMA L	514,957.44	618,604.64	456,041.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,589,603.30		
3716	ADULT <40% EXP MALE	9,597,893.16	8,894,945.23	7,900,077.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,392,916.37		
3717	ADULT <40% EXP FEMA L	4,679,276.71	5,034,780.29	4,338,260.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,052,317.79		
3718	ADULT <40% EXP M&F
4	11,372,750.63	11,843,300.90	10,134,524.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,350,576.31		
3719	ADULT <40% EXP M&F 6	0.00	26,564.29	866.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,430.31		
3728	ADULT <40% EXP M&F
4	0.00	0.00	32.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.78		
SUBTOTAL:	30,988,406.2	4 31,310,849.20	27,088,531.7	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,387,787.18		

3906	NEWLY ELIGIBLE MALE	390.09	1,220.96	1,870.06	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	715.30	1,618.92	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	923.96	3,067.94	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	1,302.10	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	41,982.47	18,670.44	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	54,326.35	46,312.16	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	581,171.50	421,868.09	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	814,589.10	715,110.51	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	1,889,228.31	1,385,936.36	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	42.72	622.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,872,750.91	3,384,200.67	2,596,379.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,481.11	
2,334.22	
4,099.02	
1,302.10	
74,860.77	
176,522.77	
1,801,491.13	
2,199,004.73	
4,588,845.97	
1,389.14	
8,853,330.96	

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	577,024.99	448,753.69	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	184,917.01	233,700.68	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	243,977.81	263,975.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	904,642.2	2	1,005,919.81	946,429.7	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
455.00	
1,510,844.48	
608,818.39	
736,873.93	
2,856,991.80	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

910.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

910.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4 5	38,008.91	31,602.63	22,114.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,725.76		
4617	CC PATIENT FEMALE 2
1	0.00	455.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		910.00		
4618	CC PATIENT FEMALE 4 5	910.00	2,730.00	1,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,460.00		
SUBTOTAL:	38,918.91	34,787.63	25,299.2	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,005.76		

8700	SSI DISABLED FREEDO M	18,707.10	13,486.58	11,826.59	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	24,256.99	29,691.54	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	8,515.56	-207.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	72,415.46	46,259.13	41,311.0	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
44,020.27	
97,783.90	
18,181.51	
159,985.68	

S000	STATE-ONLY BHS	4,829.17	380.31	-7,088.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,829.17	380.31	-7,088.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-1,878.57

-1,878.57

259,493,312.08

89,553,565.50	91,855,910.80	78,083,835.78	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 September 30, 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	81.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.23		
1008	TANF 45-64 M & F WIT	250.37	0.00	136.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		386.61		
1011	TANF <1 M & F NON-ME	1,720.56	515.08	4,324.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,560.06		
1012	TANF 01-05 M & F NON	0.00	455.00	196.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		651.06		
1013	TANF 06-13 M & F NON	27,471.80	1,636.87	2,281.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,390.49		
1014	TANF 14-20 MALE NON-	696.15	2,503.24	3,247.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,447.04		
1015	TANF 14-20 FEMALE N O	3,945.81	579.34	6,069.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,594.20		
1016	TANF 21-44 MALE NON-	42,364.00	16,517.72	2,089.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,970.87		
1017	TANF 21-44 FEMALE N O	99,491.18	25,376.76	38,133.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163,001.73		
1018	TANF 45-64 M & F NON	43,845.13	11,730.98	-5,418.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,157.87		
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	8,579.22	5,435.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,458.88		
2110	SSI AGED NON-MEDICA
R	37,219.25	24,330.99	5,813.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,363.82		
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	667.14	347.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		416.02		
2210	SSI DISABLED NON-ME
D	32,328.76	6,476.19	12,815.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,620.54		
2220	SSI DISABLED WITH Q M	0.00	0.00	113.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.98		
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	103,813.91	49,833.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205,423.63		
4312	SOBRA CHILD 01-05 M	171,883.85	118,793.66	52,409.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		343,087.05		
4313	SOBRA CHILD 06-13 M	39,579.36	92,454.57	127,080.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259,114.43		
4314	SOBRA CHILD 14-20 MA	60,862.64	16,699.62	13,097.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,659.80		
4315	SOBRA CHILD 14-20 FE	39,098.46	12,346.02	27,377.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,822.10		
5007	SOBRA PREG 21-44 FE M	0.00	196.52	579.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		775.74		
5015	SOBRA PREG 14-20 FE
M	36,367.09	15,253.89	33,521.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,142.24		
5017	SOBRA PREG 21-44 FE M	145,231.52	116,182.97	137,749.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		399,164.04		
8020	QMB ONLY	0.00	0.00	-31.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-31.85		
SUBTOTAL:	848,284.8	5	575,191.34	517,202.8	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,940,679.00		

1106	TANF EXPANDED 21-44	543.51	153.95	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	334.34	30.96	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	159.89	488.11	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	579.31	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	15.47	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	23,623.07	4,214.98	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	15,728.59	16,129.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
697.46	
1,263.33	
3,955.90	
1,214.82	
2,620.66	
67,627.40	
103,883.27	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	23,861.92	7,741.48	8,059.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,662.92		
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		52.45		
1128	TANF EXPANDED 45-64	1,350.36	0.00	32.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,383.21		
2400	SSI AGED EXPANDED WI	10,489.58	10,609.14	4,624.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,723.56		
2420	SSI AGED EXPANDED
WI	791.45	260.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,052.31		
2600	SSI DISABLED EXPAND E	1,295.64	5,019.32	2,677.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,991.96		
2610	SSI DISABLED EXPAND
E	-219.23	1,500.65	1,451.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,733.01		
2620	SSI DISABLED EXPAND E	1,154.85	136.29	213.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,505.06		
SUBTOTAL:	158,581.4	5	65,862.36	37,923.5	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,367.32		

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	
3514	ADULT 40-100% MALE 1	10,702.55	6,101.44	1,459.70	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	546.60	3,181.91	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	30,601.50	51,776.52	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	13,069.79	4,690.50	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	63,138.56	28,137.05	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	13,060.08	10,832.59	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	13,005.35	9,045.42	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	140,900.73	111,795.13	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	62,701.51	28,974.08	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	181,586.87	62,722.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,046,393.49	524,712.43	312,615.8	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
18,263.69	
8,792.98	
128,511.39	
59,327.55	
206,306.58	
48,434.46	
48,910.70	
580,598.05	
212,235.40	
572,340.95	
1,883,721.75	

3906	NEWLY ELIGIBLE MALE	0.00	74.77	31.53	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	1,733.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,623.62	1,182.70	448.12	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	246.62	575.12	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	34,339.56	28,865.70	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	102,413.36	27,258.87	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	202,495.95	30,656.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	200,445.7	8	340,752.96	89,569.8	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
106.30	
1,733.91	
6,254.44	
6,101.58	
123,268.29	
174,867.67	
318,436.35	
630,768.54	

4413	SOBRA 100-133% M&F
6	97,572.50	14,475.99	11,390.95	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	2,288.41	3,105.49	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	12,616.31	6,003.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	105,114.9	1	29,380.71	20,499.9	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
123,439.44	
10,900.85	
20,655.23	
154,995.52	

8700

SSI DISABLED FREEDO M

144.13

203.30

1,545.39

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

1,892.82

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	0.00	5,206.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,206.52		
SUBTOTAL:	144.13	5,409.82	1,545.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,099.34		

TOTAL:	2,358,964.61	1,541,309.62	979,357.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,879,631.47		

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 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	3,492.52	29,766.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,474.95		
1012	TANF 01-05 M & F NON	77,421.94	71,881.43	120,924.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270,227.68		
1013	TANF 06-13 M & F NON	67,181.43	79,607.43	75,624.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,413.79		
1014	TANF 14-20 MALE NON-	44,070.56	156,398.57	56,041.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256,510.84		
1015	TANF 14-20 FEMALE N O	346,405.17	185,300.28	245,335.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		777,040.53		
1016	TANF 21-44 MALE NON-	573.09	-107.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		465.54		
1017	TANF 21-44 FEMALE N O	2,136,707.54	1,669,785.38	1,971,352.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,777,845.12		
1018	TANF 45-64 M & F NON	9,102.32	9,101.37	7,812.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,016.62		
2100	SSI AGED WITH MEDIC A	22,518.78	19,427.61	17,554.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,500.96		
2110	SSI AGED NON-MEDICA
R	1,723,508.17	1,475,976.91	1,832,508.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,031,993.10		
2120	SSI AGED WITH QMB	144.29	32.85	8.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185.74		
2200	SSI DISABLED WITH M E	9,179.10	14,416.02	3,482.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,078.03		
2210	SSI DISABLED NON-ME
D	52,112.74	40,196.05	75,208.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167,517.29		
SUBTOTAL:	4,491,141.36	3,725,508.87	4,435,619.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,652,270.19		

3906	NEWLY ELIGIBLE MALE	88.56	14.82	50.88	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	3,117.27	3,923.92	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	19,194.45	88,472.89	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	29,850.82	51,371.54	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	908,170.34	787,670.10	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	377,014.91	394,652.08	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	3,182,337.19	2,981,192.49	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	2,146.60	267.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

154.26	
9,094.86	
136,474.77	
106,227.37	
2,704,610.91	
1,366,692.54	
9,655,496.03	
2,470.78	

1107	TANF EXPANDED 21-44	0.00	1,521.24	1,510.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	27,446.45	10,432.05	1,520.67	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	693.95	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	27,447.75	23,663.99	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	633,556.96	1,181,537.17	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	1,397,255.06	1,504,032.78	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	707,418.75	727,295.22	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	15,225.69	28,192.75	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	502.58	2,268.40	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	79.06	646.63	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	2,926.42	15,402.26	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	2,547.66	2,165.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,246,744.83	2,798,913.22	3,488,929.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,031.37	
39,399.17	
4,345.21	
92,485.80	
2,386,493.42	
4,623,025.47	
2,301,046.17	
48,402.94	
4,305.56	
2,667.30	
19,684.21	
9,700.53	
9,534,587.15	

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	5,151,773.36	4,521,846.40	4,307,601.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,981,221.52		

36,168,078.86

12,889,659.55	11,046,268.49	12,232,150.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FEDERAL ESP CHRONIC SERVICES
For The Period Ending September 30, 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:	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		

QMB - FEE FOR SERVICE
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	660,202.07	490,087.07	440,384.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,590,673.95		
8040	SLMB	75.68	15.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.19		
8050	QI1	0.00	20.66	311.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		331.98		
SUBTOTAL:	660,277.7	5	490,123.24	440,696.1	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,591,097.12		

0.00

0.00

0.00

0.00

TOTAL:

660,277.75

490,123.24

440,696.13

0.00

0.00

0.00

0.00

0.00

1,591,097.12

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 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	24.64	24.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		551.90		
1011	TANF <1 M & F NON-ME	13,327.71	2,555.41	440.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,323.74		
1012	TANF 01-05 M & F NON	7,865.88	6,230.65	3,847.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,944.06		
1013	TANF 06-13 M & F NON	307,867.77	285,146.24	121,253.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		714,267.05		
1014	TANF 14-20 MALE NON-	72,162.55	27,686.96	22,237.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,086.92		
1015	TANF 14-20 FEMALE N O	109,108.33	104,274.36	91,303.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		304,686.66		
1016	TANF 21-44 MALE NON-	482,746.26	346,671.53	408,164.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,237,582.04		
1017	TANF 21-44 FEMALE N O	1,459,385.50	1,078,950.83	1,248,877.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,787,213.35		
1018	TANF 45-64 M & F NON	285,431.75	240,088.50	276,977.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		802,497.91		
1028	TANF 45-64 M & F WIT	184.73	173.16	1,730.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,087.92		
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	15,788.14	15,154.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,121.24		
2110	SSI AGED NON-MEDICA
R	3,423.10	2,391.21	7,023.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,837.77		
2120	SSI AGED WITH QMB	66,532.03	48,594.38	50,139.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,265.71		
2200	SSI DISABLED WITH M E	63,339.72	50,009.45	55,104.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		168,453.48		
2210	SSI DISABLED NON-ME
D	2,142,025.20	1,716,824.90	1,550,850.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,409,700.41		
2220	SSI DISABLED WITH Q M	388,879.11	342,330.15	328,681.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,059,891.14		
2310	SSI BLIND NON-MEDIC
A	36,358.35	59,301.51	24,367.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,027.22		
2320	SSI BLIND WITH QMB	5,271.02	1,918.97	1,852.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,042.17		
4311	SOBRA CHILD <1 M & F	6,460.61	6,068.40	6,860.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,389.02		
4312	SOBRA CHILD 01-05 M	239,174.74	187,542.33	207,568.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		634,285.50		
4313	SOBRA CHILD 06-13 M	3,963,253.67	4,322,269.98	2,531,999.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,817,523.09		
4314	SOBRA CHILD 14-20 MA	974,878.74	1,029,423.72	690,182.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,694,485.08		
4315	SOBRA CHILD 14-20 FE	1,157,053.84	1,207,668.34	895,132.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,259,854.83		
5013	SOBRA PREG 09-13 FE M	0.00	910.00	3,640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,550.00		
5015	SOBRA PREG 14-20 FE
M	14,079.10	20,092.68	21,250.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,422.10		
5017	SOBRA PREG 21-44 FE M	146,024.25	157,851.29	176,250.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		480,125.56		
5027	SOBRA PREG 21-44 FE
M	0.00	34.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.36		
SUBTOTAL:	11,966,970.4	8 11,260,822.09	8,740,912.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,968,705.23		

1107	TANF EXPANDED 21-44	176.33	0.00	41.93	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	4,257.24	3,024.37	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	212.27	305.73	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	455.00	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	7,220.23	6,005.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
218.26	
9,607.28	
1,205.20	
3,500.00	
21,824.86	

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	167,952.92	117,356.15	142,575.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427,884.67		
1117	TANF EXPANDED 21-44	457,969.90	350,831.66	341,891.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,150,693.37		
1118	TANF EXPANDED 45-64	151,584.86	119,327.65	157,762.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		428,675.27		
1126	TANF EXPANDED 21-44	5,497.39	1,646.16	1,878.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,022.19		
1127	TANF EXPANDED 21-44	310.16	265.12	710.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,285.68		
1128	TANF EXPANDED 45-64	12,149.05	12,375.62	7,302.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,827.59		
1129	TANF EXPANDED 65+ M
&	4,153.95	4,207.54	4,482.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,844.17		
2400	SSI AGED EXPANDED WI	12.41	0.00	388.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		400.58		
2410	SSI AGED EXPANDED N
O	506.92	1,365.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,326.92		
2420	SSI AGED EXPANDED WI	50,579.11	39,035.81	31,403.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,018.09		
2600	SSI DISABLED EXPAND
E	1,408.72	0.00	68.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,477.44		
2610	SSI DISABLED EXPAND E	11,220.70	10,544.09	14,761.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,526.55		
2620	SSI DISABLED EXPAND
E	85,511.04	31,421.19	54,808.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,740.68		
SUBTOTAL:	963,690.3	5	700,065.73	768,322.7	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,432,078.80		

3514	ADULT 40-100% MALE 1	10,776.55	6,979.68	14,745.82	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	20,184.70	10,536.08	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	171,916.87	101,835.28	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	110,911.35	119,048.69	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	132,898.26	181,110.94	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	1,848.25	686.56	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	101,710.03	126,356.83	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	90,822.12	102,482.58	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	2,271,124.33	2,612,206.29	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	1,402,493.82	1,389,894.21	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	1,325,116.92	1,330,593.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,922,225.77	5,636,006.33	5,989,496.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
32,502.05	
47,781.75	
423,533.40	
327,579.22	
496,873.70	
4,409.53	
388,080.72	
315,289.33	
7,819,659.28	
4,479,172.96	
4,212,846.84	
18,547,728.78	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	29.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	7,754.44	3,904.60	1,619.22	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	4,135.36	9,020.96	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	31,099.63	60,616.47	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	31,309.32	28,567.30	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	65,633.51	59,258.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	279,335.5	3	136,082.42	159,112.1	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
29.55	
13,278.26	
23,203.15	
223,113.15	
122,267.69	
192,638.34	
574,530.14	

431,831.11

4413	SOBRA 100-133% M&F
6	173,365.54	159,239.19	99,226.38	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	56,370.35	48,420.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

186,202.07

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	64,610.03	48,795.79	38,281.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151,687.47		
SUBTOTAL:	319,387.29	264,405.33	185,928.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		769,720.65		

8700	SSI DISABLED FREEDO M	444.71	126.96	282.09	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	126.96	282.0	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

853.76	
172.78	
1,026.54	

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

 
1,365.00

1,365.00

TOTAL:	20,452,681.91	17,997,963.86	15,844,509.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,295,155.14		

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending September 30, 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	22,328.76	18,380.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,768.14		
1017	TANF 21-44 FEMALE N O	52,130.85	26,691.95	54,079.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,902.13		
1018	TANF 45-64 M & F NON	0.00	0.00	19,006.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,006.49		
2210	SSI DISABLED NON-ME D	84,690.30	48,792.04	60,634.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194,116.50		
2220	SSI DISABLED WITH Q
M	1,364.00	1,364.00	1,399.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,127.00		
5017	SOBRA PREG 21-44 FE M	0.00	12,642.60	5,045.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,687.88		
SUBTOTAL:	158,243.8	2	111,819.35	158,544.9	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		428,608.14		

1116	TANF EXPANDED 21-44	1,524.14	15,016.02	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	13,479.28	32,504.28	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	14,294.96	3,363.52	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	1,364.00	1,364.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,640.66	44,154.26	37,231.8	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,540.16	
57,760.08	
17,658.48	
4,068.00	
96,026.72	

3516	ADULT 40-100% MALE 2	3,699.35	11,299.46	14,172.51	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	6,096.56	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	8,237.37	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	196,357.48	205,599.33	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	32,250.19	107,768.46	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	88,139.25	76,952.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	384,745.8	9	328,046.38	418,826.5	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
29,171.32	
9,362.12	
12,339.72	
658,647.30	
239,495.25	
182,603.14	
1,131,618.85	

3916	NEWLY ELIGIBLE MALE	8,408.80	0.00	3,363.52	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	5,915.56	4,204.40	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	3,363.52	2,522.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39,349.93	9,279.08	10,090.5	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,772.32	
33,493.17	
13,454.08	
58,719.57	

0.00

0.00

0.00

0.00

TOTAL:

596,980.30

493,299.07

624,693.91

0.00

0.00

0.00

0.00

0.00

1,714,973.28

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending September 30, 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	125,849.80	34,955.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243,020.19		
2110	SSI AGED NON-MEDICA
R	76,145.26	43,432.58	94,089.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213,667.18		
2200	SSI DISABLED WITH M E	43,412.57	37,118.69	31,528.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,059.55		
2210	SSI DISABLED NON-ME
D	6,450.10	54.14	3,268.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,773.03		
2220	SSI DISABLED WITH Q M	0.00	5,818.84	74,831.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,650.13		
5015	SOBRA PREG 14-20 FE
M	5,808.31	0.00	132.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,941.10		
5017	SOBRA PREG 21-44 FE M	29,972.75	22,752.76	6,712.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,437.63		
SUBTOTAL:	244,004.3	7	235,026.81	245,517.6	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		724,548.81		

3516	ADULT 40-100% MALE 2	6,841.48	1,043.90	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	740.94	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	9,180.28	182.95	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	46,870.71	19.96	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	219,599.64	362,377.63	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	5,563.08	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	358,915.48	389,514.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	1,647.10	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	643,561.13	752,095.2	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,885.38	
1,480.95	
15,569.68	
46,973.20	
938,040.72	
14,394.52	
1,252,180.15	
1,647.10	
2,278,171.70	

3916	NEWLY ELIGIBLE MALE	57,655.11	4,600.84	464.10	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	1,335.35	253.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	61,395.21	5,936.19	717.6	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

62,720.05	
5,329.02	
68,049.07	

1108	TANF EXPANDED 45-64	1,594.54	0.00	13,423.28	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	948.51	76.49	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	663.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,585.58	1,611.63	13,499.7	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
15,017.82	
5,524.70	
1,154.46	
21,696.98	

TOTAL:	1,194,500.53	886,135.76	1,011,830.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,092,466.56		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 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		
4314	SOBRA CHILD 14-20 MA	0.00	3,210.12	464.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,674.59		
SUBTOTAL:	3,561.30	3,210.12	464.4	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,235.89		

3716	ADULT <40% EXP MALE	193.90	3,027.13	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	144.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	302.05	3,171.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,221.03	
252.27	
3,473.30	

10,709.19

3,863.35	6,381.37	464.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 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	69.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,095.47		
1015	TANF 14-20 FEMALE N O	0.00	0.00	12,412.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,412.80		
1016	TANF 21-44 MALE NON-	225.11	11,662.99	331.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,219.16		
1017	TANF 21-44 FEMALE N O	13,398.03	846.61	57.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,302.48		
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		
4314	SOBRA CHILD 14-20 MA	0.00	3,866.44	533.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,399.46		
5017	SOBRA PREG 21-44 FE M	2,993.69	5,770.49	10,990.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,754.40		
SUBTOTAL:	19,818.53	22,215.72	24,324.9	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,359.19		

3516	ADULT 40-100% MALE 2	-3,664.92	32.56	3,991.13	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	1,673.02	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	137,777.39	109,944.32	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	807.55	21,060.04	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	68,199.66	63,769.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	189,756.4	2	206,817.16	200,437.6	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

358.77	
1,673.02	
371,861.19	
43,216.48	
179,901.72	
597,011.18	

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	2,632.44	4,832.23	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	8.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8,778.87	2,632.44	4,840.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

421.95	
15,438.91	
390.82	
16,251.68	

1116	TANF EXPANDED 21-44	19,096.08	276.04	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	316.48	2,993.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	24,822.58	592.52	2,993.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19,372.12	
9,036.67	
28,408.79	

TOTAL:	243,176.40	232,257.84	232,596.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		708,030.84		

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 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	15,943.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,352.82		
SUBTOTAL:	3,409.21	15,943.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,352.82		

19,352.82

3,409.21	15,943.61	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 September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	0.00	843.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		843.13		
2100	SSI AGED WITH MEDIC
A	0.00	0.00	8,468.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,468.49		
2120	SSI AGED WITH QMB	0.00	62.68	6,060.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,123.27		
2210	SSI DISABLED NON-ME D	4,796.03	24,528.06	793.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,117.50		
5017	SOBRA PREG 21-44 FE
M	120.60	9,182.78	547.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,850.60		
SUBTOTAL:	4,916.63	34,616.65	15,869.7	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,402.99		

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

21.16

21.16

3716	ADULT <40% EXP MALE	14,403.73	29,550.56	33,133.43	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	16,749.93	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	361.46	8,033.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	44,460.17	29,912.02	57,916.6	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
77,087.72	
22,275.56	
32,925.51	
132,288.79	

TOTAL:	49,387.38	64,539.25	73,786.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		187,712.94		

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 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	967.16	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	2,109.20	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	59.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	415.11	59.26	3,076.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,127.64	
2,109.20	
313.89	
3,550.73	

5,740.34

2,604.72	59.26	3,076.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,476.55	1,365.00	12,020.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,862.54		
2100	SSI AGED WITH MEDIC A	3,396,841.10	2,978,203.93	2,902,681.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,277,726.08		
2110	SSI AGED NON-MEDICA
R	270,248.25	199,558.99	170,599.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		640,407.21		
2120	SSI AGED WITH QMB	5,144,790.92	4,353,539.64	4,195,426.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,693,757.50		
2200	SSI DISABLED WITH M E	665,108.26	517,747.79	541,296.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,724,152.69		
2210	SSI DISABLED NON-ME
D	4,059,288.17	3,443,509.73	3,375,066.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,877,864.14		
2220	SSI DISABLED WITH Q M	1,084,530.49	1,067,376.31	963,365.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,115,272.21		
2300	SSI BLIND WITH MEDIC	2,008.80	2,245.08	1,590.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,843.99		
2310	SSI BLIND NON-MEDIC A	10,075.80	9,689.37	10,601.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,366.96		
2320	SSI BLIND WITH QMB	4,970.93	1,483.22	264.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,718.91		
SUBTOTAL:	14,639,339.2	7 12,574,719.06	12,172,913.9	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,386,972.23		

8720	SSI DISABLED FREEDO M	2,380.80	2,692.35	2,162.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,380.80	2,692.35	2,162.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

7,235.40

7,235.40

TOTAL:	14,641,720.07	12,577,411.41	12,175,076.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,394,207.63		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 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	81,067.68	60,616.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,207.61		
2110	SSI AGED NON-MEDICA
R	891.34	0.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		921.34		
2200	SSI DISABLED WITH M E	4,110.68	3,582.31	7,628.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,321.56		
2210	SSI DISABLED NON-ME
D	5,636.33	1,595.00	-17,970.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-10,738.89		
2220	SSI DISABLED WITH Q M	19.67	0.00	46.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.05		
SUBTOTAL:	72,181.04	86,244.99	50,351.6	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,777.67		

50,351.64

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

208,777.67

TOTAL:

72,181.04

86,244.99

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending September 30, 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:	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		

COCONINO COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending September 30, 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	4,824.76	219.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,459.94		
SUBTOTAL:	415.40	4,824.76	219.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,459.94		

5,459.94

415.40	4,824.76	219.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	418.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		418.80		
SUBTOTAL:	0.00	418.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		418.80		

TOTAL:	0.00	418.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		418.80		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending September 30, 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	18,644.88	18,077.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,626.02		
1013	TANF 06-13 M & F NON	66,306.45	34,537.50	30,933.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,777.92		
1014	TANF 14-20 MALE NON-	8,676.21	4,254.94	4,356.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,287.86		
1015	TANF 14-20 FEMALE N O	4,890.64	2,240.60	3,653.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,784.97		
2210	SSI DISABLED NON-ME
D	274,297.27	169,632.61	140,315.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		584,245.12		
2220	SSI DISABLED WITH Q M	391.92	153.36	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		585.28		
2310	SSI BLIND NON-MEDIC
A	2,652.31	2,038.76	585.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,276.14		
4312	SOBRA CHILD 01-05 M	170,389.43	100,660.33	74,587.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345,637.41		
4313	SOBRA CHILD 06-13 M	266,108.81	157,297.68	134,113.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		557,520.18		
4314	SOBRA CHILD 14-20 MA	22,058.21	12,674.72	8,832.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,565.48		
4315	SOBRA CHILD 14-20 FE	10,521.23	4,139.37	3,902.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,563.27		
SUBTOTAL:	864,196.6	0	506,274.75	419,398.3	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,789,869.65		

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	
2610	SSI DISABLED EXPAND
E	0.00	0.00	15.18	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	62.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	124.10	62.05	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
124.10	
15.18	
62.05	
201.33	

3514	ADULT 40-100% MALE 1	29.06	8.84	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	127.30	198.68	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	20.10	116.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	599.33	156.24	314.9	2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
37.90	
608.19	
424.40	
1,070.49	

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

4413	SOBRA 100-133% M&F
6	78,148.02	39,845.81	32,383.47	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	2,225.28	1,542.52	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	534.76	436.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	85,573.14	42,605.85	34,362.4	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
150,377.30	
9,684.67	
2,479.50	
162,541.47	

950,558.83

549,098.89

454,090.88

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

1,953,748.60

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	12,928.83	7,704.40	11,737.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,370.31		
2200	SSI DISABLED WITH M E	2,586.31	606.85	362.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,555.28		
2210	SSI DISABLED NON-ME
D	1,533,543.66	873,651.18	817,014.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,224,208.96		
2220	SSI DISABLED WITH Q M	5,358.58	2,675.67	559.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,593.57		
2310	SSI BLIND NON-MEDIC
A	3,264.10	251.23	1,140.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,656.28		
SUBTOTAL:	1,557,681.48	884,889.33	830,813.5	9	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,273,384.40		

TOTAL:	1,557,681.48	884,889.33	830,813.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,273,384.40		

ACC REINSURANCE
For The Period Ending September 30, 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	-437.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-437.59		
1007	TANF 21-44 FEMALE WI	0.00	-1,897.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,897.75		
1008	TANF 45-64 M & F WIT	0.00	-1,064.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,064.16		
1011	TANF <1 M & F NON-ME	725,577.26	1,379,619.06	1,432,792.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,537,988.56		
1012	TANF 01-05 M & F NON	4,347.40	32,160.78	45,922.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,430.77		
1013	TANF 06-13 M & F NON	324,791.53	193,449.53	186,177.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		704,418.66		
1014	TANF 14-20 MALE NON-	81,483.94	198,980.19	109,178.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		389,642.63		
1015	TANF 14-20 FEMALE N O	25,303.51	119,152.30	148,991.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293,447.30		
1016	TANF 21-44 MALE NON-	180,616.91	142,894.03	150,910.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		474,421.00		
1017	TANF 21-44 FEMALE N O	454,160.18	326,646.13	492,410.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,273,216.72		
1018	TANF 45-64 M & F NON	37,034.63	198,804.51	125,576.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361,415.53		
1019	TANF 65+ M & F NON-M	587.11	11,355.64	3,681.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,623.83		
2100	SSI AGED WITH MEDIC A	36,402.32	37,326.88	-30,071.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,657.31		
2110	SSI AGED NON-MEDICA
R	112,670.07	397,755.12	277,933.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		788,358.39		
2200	SSI DISABLED WITH M E	130,347.89	55,514.79	4,376.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190,238.75		
2210	SSI DISABLED NON-ME
D	5,846,572.17	6,706,943.88	8,305,555.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,859,071.85		
2310	SSI BLIND NON-MEDIC A	11,949.45	9,724.98	13,371.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,045.78		
4311	SOBRA CHILD <1 M & F	2,735,784.55	1,807,996.36	2,408,428.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,952,209.47		
4312	SOBRA CHILD 01-05 M	811,967.95	925,721.48	609,324.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,347,013.69		
4313	SOBRA CHILD 06-13 M	1,033,377.89	800,538.20	912,119.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,746,035.83		
4314	SOBRA CHILD 14-20 MA	539,123.31	607,332.68	786,856.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,933,312.61		
4315	SOBRA CHILD 14-20 FE	253,541.95	1,134,418.78	573,956.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,961,917.38		
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	114,984.27	27,660.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,975.02		
SUBTOTAL:	13,360,776.0	9 15,197,920.09	16,585,151.6	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,143,847.83		

1106	TANF EXPANDED 21-44	0.00	4,184.74	-2,545.36	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	37.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	252,404.63	255,407.01	137,284.29	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	188,931.01	90,011.33	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	208,421.23	242,830.03	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	3,003.59	518.96	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	40,843.87	6,947.74	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	1,096.56	67,024.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,639.38	
37.87	
645,095.93	
694,890.96	
588,537.85	
3,522.55	
63,259.98	
71,541.12	

3100	TRANSPLANT OPTION 1	0.00	3,395.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	3,395.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,395.06

3,395.06

ACC REINSURANCE
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2610	SSI DISABLED EXPAND E	143,236.05	152,119.17	134,456.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		429,811.78		
SUBTOTAL:	967,764.70	854,007.18	676,565.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,498,337.42		

3908	NEWLY ELIGIBLE M&F 4	0.00	5,076.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	19,597.86	-19,198.61	109,020.28	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	207,640.03	575,393.43	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	173,080.30	62,776.58	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	626,435.59	324,684.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	726,410.8	2	993,033.64	1,071,874.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,076.33	
109,419.53	
16,701.76	
999,073.05	
326,747.26	
1,334,301.26	
2,791,319.19	

4413	SOBRA 100-133% M&F
6	241,947.24	262,349.92	95,062.65	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	165,898.00	130,166.48	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	4,910.52	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	433,158.44	225,229.1	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

599,359.81	
619,995.28	
26,228.56	
1,245,583.65	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	882.41	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	3,356.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	4,239.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

882.41	
3,356.87	
4,239.28	

8700	SSI DISABLED FREEDO M	0.00	3,555.13	2,238.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,794.11

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	10,336.96	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	4,382.89	546,385.89	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	16,695.99	1,664.78	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	377,386.31	225,885.55	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	63,581.93	30,811.74	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	355,332.76	430,840.86	1,361,544.44	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	19,414.37	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	-490.64	-12,430.53	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	91,183.40	34,962.66	-2,057.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	8,573.53	159,376.97	69,058.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	125,669.32	28,161.24	33,550.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1,543,686.80	2,368,686.42	1,814,431.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	54,757.63	203,263.13	925,005.80	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	2,239,328.78	2,199,410.31	3,069,799.97	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	835.50	-135.39	179.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,285,578.51	5,896,459.64	8,083,244.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
368.52	
10,336.97	
1,241,233.83	
22,293.66	
735,033.85	
134,076.00	
2,147,718.06	
19,414.37	
-12,921.17	
124,088.90	
237,009.15	
187,380.61	
5,726,804.86	
1,183,026.56	
7,508,539.06	
879.78	
19,265,283.01	

ACC REINSURANCE
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	6,949.00	14,106.75	4,741.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,797.12		
SUBTOTAL:	6,949.00	17,661.88	6,980.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,591.23		

70,983,596.67

20,934,675.20	23,395,635.93	26,653,285.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE REINSURANCE
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	24,561.23	-15,106.07	63,031.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,486.32		
2100	SSI AGED WITH MEDIC A	111,580.83	328,992.29	236,109.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		676,682.58		
2110	SSI AGED NON-MEDICA
R	69,649.07	75,558.87	47,319.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192,527.01		
2200	SSI DISABLED WITH M E	314,831.72	463,347.96	539,913.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,318,093.13		
2210	SSI DISABLED NON-ME
D	6,285,457.34	4,503,314.71	5,531,672.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,320,444.95		
2310	SSI BLIND NON-MEDIC A	1,504.99	5,274.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,779.07		
SUBTOTAL:	6,807,585.18	5,361,381.84	6,418,046.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,587,013.06		

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

TOTAL:	6,843,752.18	5,361,381.84	6,418,046.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,623,180.06		

ACC SMIB
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	49,447.00	52,667.50	49,591.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151,706.00		
1010	TANF NON-MEDICARE	677.50	406.50	406.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,490.50		
1020	TANF WITH QMB	44,961.50	39,964.50	37,916.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,842.00		
2100	SSI AGED WITH MEDIC A	31,102.20	35,121.60	38,203.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,427.30		
2110	SSI AGED NON-MEDICA
R	539,823.00	550,536.20	542,519.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,632,878.70		
2120	SSI AGED WITH QMB	4,358,353.50	4,430,488.50	4,459,947.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,248,789.40		
2200	SSI DISABLED WITH M E	79,390.30	75,152.80	78,504.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		233,047.40		
2210	SSI DISABLED NON-ME
D	457,985.50	459,066.50	459,745.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,376,797.50		
2220	SSI DISABLED WITH Q M	3,875,518.60	3,899,421.50	3,898,474.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,673,414.10		
2300	SSI BLIND WITH MEDIC	135.50	135.50	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406.50		
2310	SSI BLIND NON-MEDIC A	4,607.00	4,200.50	4,336.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,143.50		
2320	SSI BLIND WITH QMB	38,872.00	35,636.50	36,178.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,687.00		
4320	SOBRA CHILD WITH Q MB	271.00	271.00	1,626.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,168.00		
5020	SOBRA PREGNANT WO
MAN	3,658.50	4,739.50	4,200.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,598.50		
8000	SMIB ONLY NOT ELIGIB	0.00	-271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-271.00		
8020	QMB ONLY	803,619.00	813,138.30	802,950.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,419,707.40		
8040	SLMB	5,415,089.00	5,424,721.20	5,454,262.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,294,072.30		
8888	SMIB ONLY NOT ELIGIB	-40,718.50	-27,017.20	-34,454.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-102,189.90		
9999	SMIB ONLY NOT ELIGIB	159,459.10	25,881.20	152,852.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338,193.10		
SUBTOTAL:	15,822,251.7	0 15,824,261.10	15,987,395.5	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,633,908.30		

3520	ADULT 40-100% FOR FI	0.00	271.00	542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	0.00	135.50	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	406.50	677.5	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

813.00	
271.00	
1,084.00	

3920	NEWLY ELIGIBLE FOR F	271.00	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

406.50

1100	TANF EXPANDED FPR FI	200,075.30	203,897.00	200,246.00	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	271.00	271.00	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	916,836.10	926,189.10	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	13,136.00	13,821.00	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	135.50	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	3,683,900.40	3,718,121.60	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	135.50	135.50	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	14,223.00	13,955.00	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	2,332,589.70	2,357,103.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,097,118.90	7,164,988.70	7,229,978.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
604,218.30	
948.50	
2,747,264.80	
40,481.00	
135.50	
11,043,628.30	
406.50	
41,451.00	
7,013,551.80	
21,492,085.70	

ACC SMIB
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	271.00	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406.50		

8620	SSI BLIND FREEDOM/W O	0.00	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	45,257.00	45,121.50	45,121.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	45,257.00	45,257.00	45,121.5	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
135.50	
135,500.00	
135,635.50	

69,263,120.00

22,964,898.60	23,035,048.80	23,263,172.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC HIB
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1020	TANF WITH QMB	1,311.00	1,311.00	1,311.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,933.00		
2100	SSI AGED WITH MEDIC A	917.70	2,665.70	1,704.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,287.70		
2110	SSI AGED NON-MEDICA
R	7,866.00	4,807.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,673.00		
2120	SSI AGED WITH QMB	516,393.00	581,314.30	611,385.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,709,092.50		
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	258,399.50	275,849.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		780,435.30		
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	1,551.00	1,551.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,216.00		
8020	QMB ONLY	4,259.70	4,259.70	5,613.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,133.10		
9999	SMIB ONLY NOT ELIGIB	-7,682.70	-11,273.20	-3,735.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-22,691.20		
SUBTOTAL:	775,609.2	0	843,035.00	893,679.2	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,512,323.40		

1120	TANF EXPANDED FOR FI	1,551.00	240.00	240.00	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	4,610.00	4,653.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,248.40	4,850.00	4,893.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,031.00	
13,961.10	
15,992.10	

TOTAL:	781,857.60	847,885.00	898,572.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,528,315.50		

Q1
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	2,963,042.50	3,006,531.50	3,027,725.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,997,299.50		
9999	SMIB ONLY NOT ELIGIB	-11,850.50	-8,842.50	2,000.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-18,692.50		
SUBTOTAL:	2,951,192.00	2,997,689.00	3,029,726.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,978,607.00		

8,978,607.00

2,951,192.00	2,997,689.00	3,029,726.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC SMIB
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	135.50	542.00	271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		948.50		
1020	TANF WITH QMB	677.50	677.50	677.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,032.50		
2100	SSI AGED WITH MEDIC A	1,149,367.50	1,145,754.60	1,146,101.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,441,223.80		
2110	SSI AGED NON-MEDICA
R	224,638.00	229,025.80	228,886.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		682,550.10		
2120	SSI AGED WITH QMB	1,237,088.50	1,251,357.50	1,255,583.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,744,029.80		
2200	SSI DISABLED WITH M E	399,084.90	384,519.80	388,578.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,172,183.00		
2210	SSI DISABLED NON-ME
D	14,092.00	14,769.50	16,937.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,799.00		
2220	SSI DISABLED WITH Q M	1,066,637.10	1,062,882.00	1,069,433.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,198,952.60		
2300	SSI BLIND WITH MEDIC	271.00	135.50	271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		677.50		
2310	SSI BLIND NON-MEDIC A	135.50	135.50	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406.50		
2320	SSI BLIND WITH QMB	813.00	948.50	542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,303.50		
SUBTOTAL:	4,092,940.50	4,090,748.20	4,107,418.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,291,106.80		

8720	SSI DISABLED FREEDO M	1,355.00	1,761.50	1,761.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,355.00	1,761.50	1,761.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,878.00

4,878.00

TOTAL:	4,094,295.50	4,092,509.70	4,109,179.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,295,984.80		

LTC HIB
For The Period Ending September 30, 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	-874.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-874.00		
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	370,188.20	376,589.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,113,577.80		
2200	SSI DISABLED WITH M E	1,354.70	-1,354.70	437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		437.00		
2220	SSI DISABLED WITH Q
M	11,405.70	14,901.70	16,889.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,197.10		
2320	SSI BLIND WITH QMB	480.70	480.70	480.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,442.10		
SUBTOTAL:	381,352.5	0	383,341.90	394,396.6	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,159,091.00		

1,159,091.00

381,352.50	383,341.90	394,396.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	2,376.85	536.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,372.23		
1007	TANF 21-44 FEMALE WI	1,844.01	2,435.65	604.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,883.66		
1008	TANF 45-64 M & F WIT	8,360.17	6,104.83	4,135.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,600.71		
1009	TANF 65+ M & F WITH	6,203.96	2,264.15	1,795.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,263.24		
1011	TANF <1 M & F NON-ME	1,069,634.86	501,655.84	518,233.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,089,524.07		
1012	TANF 01-05 M & F NON	371,200.65	232,647.74	216,168.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		820,016.77		
1013	TANF 06-13 M & F NON	550,058.56	373,315.59	287,418.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,210,792.27		
1014	TANF 14-20 MALE NON-	193,092.30	113,486.70	79,186.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		385,765.08		
1015	TANF 14-20 FEMALE N O	384,301.30	284,458.81	191,867.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		860,627.96		
1016	TANF 21-44 MALE NON-	1,656,199.06	1,433,662.24	1,024,544.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,114,405.70		
1017	TANF 21-44 FEMALE N O	5,602,026.93	4,465,727.95	3,632,886.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,700,641.57		
1018	TANF 45-64 M & F NON	2,596,861.71	2,027,518.49	1,553,121.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,177,501.95		
1019	TANF 65+ M & F NON-M	4,301.94	11,634.33	2,923.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,860.26		
1026	TANF 21-44 MALE WITH	379.83	0.00	15.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		395.58		
1027	TANF 21-44 FEMALE WI	8,469.49	1,464.04	1,280.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,213.54		
1028	TANF 45-64 M & F WIT	3,753.41	3,189.89	3,548.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,492.11		
1029	TANF 65+ M & F WITH	3,340.01	1,770.48	5,504.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,615.19		
2100	SSI AGED WITH MEDIC A	112,980.76	60,316.34	46,750.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,047.26		
2110	SSI AGED NON-MEDICA
R	181,290.38	92,702.15	72,010.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		346,002.67		
2120	SSI AGED WITH QMB	409,253.22	316,117.24	254,509.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		979,879.74		
2200	SSI DISABLED WITH M E	264,684.94	158,980.48	165,849.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589,515.01		
2210	SSI DISABLED NON-ME
D	6,718,110.37	5,424,125.36	3,919,293.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,061,529.35		
2220	SSI DISABLED WITH Q M	768,151.66	555,419.51	446,900.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,770,472.04		
2300	SSI BLIND WITH MEDIC	2,403.28	1,253.88	1,539.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,196.95		
2310	SSI BLIND NON-MEDIC A	115,995.95	93,912.22	52,379.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,288.02		
2320	SSI BLIND WITH QMB	10,555.01	6,761.49	4,295.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,611.74		
4311	SOBRA CHILD <1 M & F	2,800,114.73	1,259,315.50	1,415,197.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,474,628.18		
4312	SOBRA CHILD 01-05 M	4,665,875.72	3,219,933.46	2,727,788.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,613,597.28		
4313	SOBRA CHILD 06-13 M	6,595,816.61	5,325,072.19	3,862,761.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,783,650.00		
4314	SOBRA CHILD 14-20 MA	1,460,742.34	1,340,303.97	1,028,941.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,829,987.64		
4315	SOBRA CHILD 14-20 FE	2,086,542.45	1,869,853.40	1,314,627.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,271,023.31		
5007	SOBRA PREG 21-44 FE M	93.41	904.06	96.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,094.22		
5013	SOBRA PREG 09-13 FE
M	0.00	455.00	1,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,275.00		
5015	SOBRA PREG 14-20 FE M	517,147.34	253,118.58	308,182.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,078,448.44		
5017	SOBRA PREG 21-44 FE
M	2,680,800.23	1,488,299.21	1,648,387.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,817,487.37		
5018	SOBRA PREG 45-64 FE M	3,229.98	455.00	2,730.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,414.98		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	32.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.85		
SUBTOTAL:	41,855,275.95	30,931,012.62	24,797,865.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,584,153.94		

1106	TANF EXPANDED 21-44	3,391.33	1,198.94	1,322.27	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	4,561.57	2,680.44	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	25,054.98	16,684.41	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	32,644.28	18,568.82	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	705.00	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	4,691.18	4,095.00	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	32,741.20	20,115.04	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	479,589.10	439,082.74	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	2,019,248.54	1,627,929.14	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	1,412,304.58	1,012,725.41	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	6,034.52	2,730.00	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	10,431.87	9,899.28	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	17,378.23	13,881.39	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	45,539.49	39,815.09	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	34,288.18	33,109.18	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	6,766.27	4,252.60	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	33,062.60	11,495.50	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	302,609.17	225,812.29	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	6,041.58	937.78	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	148,270.26	82,877.19	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	152,088.25	140,672.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,064,397.88	4,775,249.79	3,708,685.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,912.54	
9,722.76	
61,757.26	
89,365.96	
705.00	
15,931.37	
86,116.02	
1,560,734.75	
6,389,227.06	
4,058,307.34	
11,039.52	
39,279.00	
59,696.74	
156,192.33	
116,694.14	
18,600.12	
64,066.52	
935,044.35	
10,008.55	
332,943.89	
526,988.40	
14,548,333.62	

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

3614	AHC CARE/MI MALE 14-	0.00	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	-1,320.00	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	-5,610.00	-330.00	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	-2,640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-10,230.00	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-660.00	
-1,650.00	
-5,940.00	
-2,640.00	
-10,890.00	

91.00

1,351.17

3507	ADULT 40-100% FEMAL E	1,159.91	191.26	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	91.00	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	43.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

124.40

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	62,409.69	50,399.74	38,081.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,890.77		
3515	ADULT 40-100% FEMAL E	126,223.47	102,765.83	67,081.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		296,070.34		
3516	ADULT 40-100% MALE 2	727,935.76	485,813.77	396,851.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,610,601.33		
3517	ADULT 40-100% FEMAL E	667,579.54	460,943.19	314,517.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,443,040.15		
3518	ADULT 40-100% M&F 45	2,280,931.12	1,866,834.84	1,194,937.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,342,703.07		
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		455.00		
3706	ADULT <40% EXP MALE	252.48	1,629.66	582.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,465.08		
3707	ADULT <40% EXP FEMA L	910.00	1,023.38	3,655.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,588.95		
3708	ADULT <40% EXP M&F
4	5,022.91	7,067.77	5,582.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,673.48		
3709	ADULT <40% EXP M&F 6	0.00	427.00	427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		854.00		
3714	ADULT <40% EXP MALE	332,766.96	250,547.34	182,697.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		766,012.16		
3715	ADULT <40% EXP FEMA L	489,450.66	370,107.48	272,561.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,132,119.36		
3716	ADULT <40% EXP MALE	5,578,819.17	4,600,936.70	3,846,127.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,025,883.15		
3717	ADULT <40% EXP FEMA L	3,643,354.41	2,910,869.26	2,243,667.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,797,891.03		
3718	ADULT <40% EXP M&F
4	8,545,612.25	7,023,601.87	5,412,793.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,982,007.56		
3719	ADULT <40% EXP M&F 6	455.00	21,292.98	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,202.98		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	22,463,419.3	3 18,154,543.07	13,980,062.5	8	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,598,024.98		

3906	NEWLY ELIGIBLE MALE	0.00	455.00	1,473.15	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	357.78	177.34	1,397.65	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	556.98	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	16,678.30	12,345.50	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	43,379.95	24,006.14	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	345,547.17	280,056.51	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	604,063.21	510,260.55	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	1,331,268.67	853,434.40	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	2,341,569.64	1,683,530.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,928.15	
0.00	
1,932.77	
556.98	
43,474.23	
128,204.89	
1,155,087.33	
1,833,022.41	
3,512,963.14	
0.00	
6,677,169.90	

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	447,620.64	345,015.57	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	138,160.37	155,034.46	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	175,607.59	149,384.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,013,023.62	761,388.60	649,434.4	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
910.00	
1,370,133.06	
490,347.79	
562,455.82	
2,423,846.67	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

910.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

910.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4 5	4,984.51	6,853.69	7,700.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,538.34		
4617	CC PATIENT FEMALE 2
1	0.00	455.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		910.00		
4618	CC PATIENT FEMALE 4 5	2,275.00	2,730.00	1,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,825.00		
SUBTOTAL:	7,259.51	10,038.69	10,885.1	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,183.34		

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

8700	SSI DISABLED FREEDO M	12,901.78	6,600.67	1,644.15	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	12,399.39	15,477.51	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	179.51	353.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	56,227.04	19,179.57	17,475.0	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
21,146.60	
70,842.01	
893.03	
92,881.64	

TOTAL:	74,111,672.71	56,982,751.98	44,847,279.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,941,704.09		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	42,607.07	41,818.90	47,825.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,251.50		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	42,607.07	41,818.90	47,825.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,251.50		

0.00

0.00

0.00

0.00

TOTAL:

42,607.07

41,818.90

47,825.53

0.00

0.00

0.00

0.00

0.00

132,251.50

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	2,402.11	8,987.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,421.53		
1012	TANF 01-05 M & F NON	777.88	2,632.04	96.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,506.27		
1013	TANF 06-13 M & F NON	10.85	0.00	200.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211.26		
1014	TANF 14-20 MALE NON-	44.05	0.00	144.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188.75		
1015	TANF 14-20 FEMALE N O	2,496.60	341.21	1,369.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,207.56		
1016	TANF 21-44 MALE NON-	5,642.36	1,117.64	5,118.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,878.38		
1017	TANF 21-44 FEMALE N O	38,709.06	5,112.40	66,186.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,007.47		
1018	TANF 45-64 M & F NON	3,220.37	9,395.06	5,423.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,038.93		
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	627.96	2,107.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,172.46		
2110	SSI AGED NON-MEDICA
R	4,535.42	5,494.64	3,476.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,506.29		
2120	SSI AGED WITH QMB	-5.22	718.26	13,438.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,151.51		
2200	SSI DISABLED WITH M E	828.88	4,440.65	346.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,616.17		
2210	SSI DISABLED NON-ME
D	46,209.75	8,576.13	356,427.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		411,212.95		
2220	SSI DISABLED WITH Q M	6,575.10	48.79	92,736.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,360.70		
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	5,483.06	19,664.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,948.09		
4312	SOBRA CHILD 01-05 M	8,047.58	7,985.21	39,028.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,061.43		
4313	SOBRA CHILD 06-13 M	11,969.38	4,816.54	6,351.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,137.29		
4314	SOBRA CHILD 14-20 MA	1,518.14	858.50	2,084.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,461.21		
4315	SOBRA CHILD 14-20 FE	1,126.11	886.24	3,376.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,388.41		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	905.65	5,633.71	579.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,119.22		
5017	SOBRA PREG 21-44 FE
M	25,861.76	19,139.00	21,533.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,533.96		
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		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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:	168,743.56	85,709.15	648,677.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		903,129.84		

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	6.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	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	
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	1,078.55	842.36	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	13,068.34	786.63	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	4,179.58	16,027.61	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	4,937.74	215.68	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	108.16	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	691.16	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	162.41	2,285.59	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	189.92	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	437.47	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	788.57	889.90	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	24.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	66,406.19	24,246.61	22,474.4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
46.16	
6.60	
274.49	
0.00	
0.00	
1,920.91	
0.00	
64,862.23	
33,285.60	
5,913.00	
0.00	
0.00	
108.16	
691.16	
0.00	
2,531.99	
1,055.47	
0.00	
437.47	
1,969.22	
24.82	
113,127.28	

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

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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

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	

0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	48.94	194.06	123.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		366.10		
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		0.00		
3516	ADULT 40-100% MALE 2	19,227.07	9,299.28	27,140.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,666.97		
3517	ADULT 40-100% FEMAL E	3,335.31	6,034.54	665.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,035.53		
3518	ADULT 40-100% M&F 45	119,068.49	118,784.75	153,724.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391,577.27		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	0.00	2,422.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,422.45		
3707	ADULT <40% EXP FEMA L	2,766.41	0.00	176.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,942.53		
3708	ADULT <40% EXP M&F
4	101.46	3,941.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,042.46		
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	2,828.56	1,785.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,255.26		
3715	ADULT <40% EXP FEMA L	462.06	1,931.76	1,739.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,133.67		
3716	ADULT <40% EXP MALE	365,435.81	51,493.65	58,404.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		475,333.83		
3717	ADULT <40% EXP FEMA L	28,305.36	19,951.64	62,170.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,427.84		
3718	ADULT <40% EXP M&F
4	250,841.33	74,155.25	56,080.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381,076.65		
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		
3728	ADULT <40% EXP M&F
4	0.00	0.00	32.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.78		
SUBTOTAL:	796,232.9	5	291,036.94	362,043.4	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,449,313.34		

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	-31.56	79.56	213.22	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	412.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	106,830.30	19,913.04	1,211.58	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	9,527.29	3,870.61	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	113,393.19	158,430.66	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	143,325.71	163,726.0	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
261.22	
488.57	
127,954.92	
17,736.19	
307,723.80	
0.00	
454,164.70	

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	2,095.60	986.25	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	7.51	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	2,095.60	993.7	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
3,081.85	
108.02	
0.00	
3,189.87	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4 5	22,572.76	13,720.73	3,192.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,485.62		
4617	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	22,572.76	13,720.73	3,192.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,485.62		

S000	STATE-ONLY BHS	4,829.17	369.28	-7,088.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,829.17	369.28	-7,088.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-1,889.60

-1,889.60

8700	SSI DISABLED FREEDO M	57.08	79.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	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	79.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
136.30	
0.00	
0.00	
136.30	

TOTAL:	1,206,055.14	560,583.24	1,194,018.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,960,657.35		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	617,512.03	448,268.17	392,559.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,458,339.48		
8040	SLMB	75.68	15.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.19		
8050	QI1	0.00	0.00	311.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		311.32		
SUBTOTAL:	617,587.71	448,283.6	8	392,870.6	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,458,741.99		

0.00

0.00

0.00

0.00

TOTAL:

617,587.71

448,283.68

392,870.60

0.00

0.00

0.00

0.00

0.00

1,458,741.99

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,365.00	1,365.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,730.00		
2100	SSI AGED WITH MEDIC A	249,129.13	166,906.44	235,451.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		651,486.81		
2110	SSI AGED NON-MEDICA
R	62,182.20	66,431.52	41,317.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,931.34		
2120	SSI AGED WITH QMB	359,948.35	251,228.84	236,600.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		847,777.28		
2200	SSI DISABLED WITH M E	64,376.04	44,880.45	44,560.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153,817.22		
2210	SSI DISABLED NON-ME
D	1,137,487.58	1,052,503.74	822,964.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,012,955.95		
2220	SSI DISABLED WITH Q M	153,160.28	111,134.47	98,763.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		363,058.51		
2300	SSI BLIND WITH MEDIC	0.00	608.28	239.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		847.40		
2310	SSI BLIND NON-MEDIC A	8,478.78	5,005.00	4,989.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,472.92		
2320	SSI BLIND WITH QMB	604.35	90.44	264.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		959.55		
SUBTOTAL:	2,036,731.71	1,700,154.18	1,485,151.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,222,036.98		

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

 

0.00

0.00

TOTAL:	2,036,731.71	1,700,154.18	1,485,151.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,222,036.98		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	12,020.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,020.99		
2100	SSI AGED WITH MEDIC A	6,413.95	27,718.44	11,302.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,435.27		
2110	SSI AGED NON-MEDICA
R	25,720.01	775.26	473.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,969.11		
2120	SSI AGED WITH QMB	11,865.96	23,336.47	4,003.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,206.33		
2200	SSI DISABLED WITH M E	11,704.99	147.31	163.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,015.78		
2210	SSI DISABLED NON-ME
D	73,355.72	69,642.29	33,336.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,335.00		
2220	SSI DISABLED WITH Q M	2,493.77	1,494.83	26,114.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,102.62		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	131,554.40	123,114.60	87,416.1	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		342,085.10		

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

131,554.40

123,114.60

87,416.10

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

342,085.10

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 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	2,465.16	4,020.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,206.41		
1007	TANF 21-44 FEMALE WI	3,816.12	5,879.47	3,052.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,747.76		
1008	TANF 45-64 M & F WIT	5,162.62	6,679.62	8,917.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,759.86		
1009	TANF 65+ M & F WITH	1,369.44	4,783.88	4,100.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,253.48		
1011	TANF <1 M & F NON-ME	628,082.08	711,492.30	296,466.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,636,041.36		
1012	TANF 01-05 M & F NON	-50,122.75	71,884.03	76,313.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,074.35		
1013	TANF 06-13 M & F NON	-19,553.65	128,348.20	158,426.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267,220.72		
1014	TANF 14-20 MALE NON-	10,100.26	62,045.38	70,011.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,156.96		
1015	TANF 14-20 FEMALE N O	6,465.57	126,772.99	103,778.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237,016.92		
1016	TANF 21-44 MALE NON-	294,900.11	801,287.54	672,377.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,768,565.28		
1017	TANF 21-44 FEMALE N O	750,289.28	2,390,887.38	2,393,699.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,534,875.93		
1018	TANF 45-64 M & F NON	-33,187.01	951,911.48	737,553.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,656,278.26		
1019	TANF 65+ M & F NON-M	-1,219.82	0.00	123.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,096.05		
1026	TANF 21-44 MALE WITH	5,072.99	2,600.75	859.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,533.02		
1027	TANF 21-44 FEMALE WI	-417.22	1,655.20	77.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,315.54		
1028	TANF 45-64 M & F WIT	3,274.44	3,207.91	2,161.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,643.80		
1029	TANF 65+ M & F WITH	8,541.20	4,679.40	4,543.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,764.47		
2100	SSI AGED WITH MEDIC A	118,534.81	198,886.57	83,623.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		401,045.28		
2110	SSI AGED NON-MEDICA
R	-20,837.80	44,299.09	20,582.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,043.57		
2120	SSI AGED WITH QMB	287,256.68	330,452.18	337,985.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		955,694.35		
2200	SSI DISABLED WITH M E	244,210.75	434,046.24	381,914.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,060,171.79		
2210	SSI DISABLED NON-ME
D	2,585,073.97	4,850,256.22	4,050,436.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,485,766.93		
2220	SSI DISABLED WITH Q M	1,024,738.22	919,873.87	907,980.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,852,592.51		
2300	SSI BLIND WITH MEDIC	382.84	1,263.66	105.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,752.30		
2310	SSI BLIND NON-MEDIC A	-10,414.70	57,882.15	38,196.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,663.96		
2320	SSI BLIND WITH QMB	15,251.72	12,243.64	15,483.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,979.29		
4311	SOBRA CHILD <1 M & F	276,758.94	806,294.97	811,636.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,894,690.69		
4312	SOBRA CHILD 01-05 M	-529,357.21	815,047.27	908,198.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,193,888.29		
4313	SOBRA CHILD 06-13 M	-404,516.16	1,555,596.60	1,745,883.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,896,964.00		
4314	SOBRA CHILD 14-20 MA	412,233.42	670,329.89	613,362.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,695,925.65		
4315	SOBRA CHILD 14-20 FE	176,458.66	660,455.78	637,320.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,474,235.23		
5007	SOBRA PREG 21-44 FE M	1,374.70	163.21	1,412.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,950.14		
5013	SOBRA PREG 09-13 FE
M	0.00	126.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126.96		
5015	SOBRA PREG 14-20 FE M	-55,572.30	95,547.64	72,235.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,210.70		
5017	SOBRA PREG 21-44 FE
M	32,799.46	847,611.96	664,440.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,544,852.20		
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		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	50.00	0.00	654.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		704.86		
SUBTOTAL:	5,776,029.87	17,576,958.59	15,827,937.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,180,926.44		

1106	TANF EXPANDED 21-44	1,673.27	565.51	1,006.98	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	5,488.24	5,852.68	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	22,859.81	11,979.08	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	11,607.15	12,934.78	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	126.96	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	1,908.95	11,794.36	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	22,694.50	10,658.72	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	293,691.67	229,463.59	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	739,855.35	847,667.07	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	667,609.44	446,818.49	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	652.15	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	16,174.22	7,002.14	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	27,215.43	32,441.33	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	88,724.90	70,989.80	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	45,008.18	30,434.00	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	6,001.93	1,922.04	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	1,279.59	962.06	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	303,369.78	317,345.34	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	3,368.14	3,274.25	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	152,606.08	82,299.18	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	279,759.31	263,221.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	740,902.5	2,690,567.29	2,388,067.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,245.76	
16,697.89	
58,430.63	
28,287.78	
126.96	
11,543.12	
46,959.11	
672,737.13	
1,509,424.93	
1,020,974.65	
-712.85	
37,719.59	
77,492.80	
247,607.20	
109,960.65	
9,548.59	
-6,472.63	
823,906.46	
18,007.13	
360,334.36	
773,717.90	
5,819,537.16	

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

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-75.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-75.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
-75.63	
-75.63	

1,757.34

-732.91

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	47.56	673.58	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	

26.15

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	19,735.15	21,488.58	23,358.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,581.93		
3515	ADULT 40-100% FEMAL E	7,544.55	46,694.72	44,995.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,234.48		
3516	ADULT 40-100% MALE 2	182,166.05	316,990.28	363,173.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		862,330.09		
3517	ADULT 40-100% FEMAL E	49,024.77	190,927.44	234,561.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		474,513.81		
3518	ADULT 40-100% M&F 45	71,316.53	789,388.68	1,007,444.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,868,149.23		
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		-455.00		
3706	ADULT <40% EXP MALE	431.73	2,282.38	826.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,540.83		
3707	ADULT <40% EXP FEMA L	100.67	102.43	48.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252.04		
3708	ADULT <40% EXP M&F
4	-450.34	1,622.11	2,005.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,177.10		
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	151,870.25	193,566.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		482,572.35		
3715	ADULT <40% EXP FEMA L	25,044.72	246,565.40	181,740.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453,350.27		
3716	ADULT <40% EXP MALE	3,653,638.18	4,242,514.88	3,995,546.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,891,699.39		
3717	ADULT <40% EXP FEMA L	1,007,616.94	2,103,959.39	2,032,422.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,143,998.92		
3718	ADULT <40% EXP M&F
4	2,576,297.05	4,745,543.78	4,665,651.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,987,492.10		
3719	ADULT <40% EXP M&F 6	-455.00	5,271.31	411.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,227.33		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	7,728,753.96	12,865,269.19	12,746,425.7	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,340,448.86		

3906	NEWLY ELIGIBLE MALE	390.09	765.96	396.91	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	715.30	1,618.92	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	746.62	1,670.29	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	745.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	-211.01	25,224.61	6,111.72	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	10,533.77	22,306.02	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	215,711.29	140,600.00	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	200,998.60	200,979.35	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	444,566.45	374,071.30	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	42.72	622.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	73,568.61	899,305.32	749,122.4	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,552.96	
2,334.22	
2,166.25	
745.12	
31,125.32	
47,829.31	
518,448.88	
348,246.13	
768,159.03	
1,389.14	
1,721,996.36	

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	127,308.75	102,751.87	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	46,756.64	78,658.71	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	68,370.22	114,590.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-108,481.91	242,435.61	296,001.5	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-455.00	
137,629.57	
118,362.58	
174,418.11	
429,955.26	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4 5	10,451.64	11,028.21	11,221.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,701.80		
4617	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4618	CC PATIENT FEMALE 4 5	-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		
SUBTOTAL:	9,086.64	11,028.21	11,221.9	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,336.80		

S000	STATE-ONLY BHS	0.00	11.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	11.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11.03

11.03

8700	SSI DISABLED FREEDO M	5,748.24	6,806.69	10,182.44	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	11,857.60	14,214.03	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	8,336.05	-560.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16,131.34	27,000.34	23,836.0	6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22,737.37	
26,941.89	
17,288.48	
66,967.74	

TOTAL:	14,235,837.65	34,312,575.58	32,042,537.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,590,950.64		

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 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		
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		

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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

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	

0.00

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		0.00		
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3707	ADULT <40% EXP 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		
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		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	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	
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	

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4617	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

 
0.00	
0.00	
0.00	
0.00	

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

0.00

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:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 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	2,783,579.05	2,655,926.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,580,804.00		
2110	SSI AGED NON-MEDICA
R	182,346.04	132,352.21	128,808.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		443,506.76		
2120	SSI AGED WITH QMB	4,772,976.61	4,078,974.33	3,954,822.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,806,773.89		
2200	SSI DISABLED WITH M E	589,027.23	472,720.03	496,572.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,558,319.69		
2210	SSI DISABLED NON-ME
D	2,848,444.87	2,321,363.70	2,518,764.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,688,573.19		
2220	SSI DISABLED WITH Q M	928,876.44	954,747.01	838,487.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,722,111.08		
2300	SSI BLIND WITH MEDIC	2,008.80	1,636.80	1,350.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,996.59		
2310	SSI BLIND NON-MEDIC A	1,597.02	4,684.37	5,612.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,894.04		
2320	SSI BLIND WITH QMB	4,366.58	1,392.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,759.36		
SUBTOTAL:	12,471,053.16	10,751,450.28	10,600,346.7	1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,822,850.15		

8720	SSI DISABLED FREEDO M	2,380.80	2,692.35	2,162.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,380.80	2,692.35	2,162.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

7,235.40

7,235.40

TOTAL:	12,473,433.96	10,754,142.63	10,602,508.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,830,085.55		

LONG TERM CARE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

 

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	20.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.66		
SUBTOTAL:	0.00	20.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.66		

TOTAL:	0.00	20.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.66		

QMB - FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

0.00

0.00

0.00

0.00

TOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

KidsCare - CAPITATION AMOUNTS
For The Period Ending September 30, 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	166,288.57	166,584.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		496,827.77		
6012	KIDS 1-5 M & F NON-M	1,543,957.96	1,565,323.61	1,575,292.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,684,573.57		
6013	KIDS 6-13 M & F NON-	2,896,611.35	2,928,471.06	2,946,784.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,771,867.21		
6014	KIDS 14-19 MALE NON-	741,190.91	756,932.03	769,166.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,267,289.89		
6015	KIDS 14-19 FEMALE NO	751,128.68	770,184.18	781,392.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,302,705.31		
9960	KIDSCARE KICK PAYME N	6,000.27	5,997.30	5,984.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,982.39		
SUBTOTAL:	6,102,844.36	6,193,196.75	6,245,205.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,541,246.14		

TOTAL:	6,102,844.36	6,193,196.75	6,245,205.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,541,246.14		

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 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	288.66	289.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		861.59		
6012	KIDS 1-5 M & F NON-M	8,605.77	8,720.94	8,773.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,099.95		
6013	KIDS 6-13 M & F NON-	16,171.73	16,347.00	16,437.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,956.35		
6014	KIDS 14-19 MALE NON-	4,132.98	4,218.92	4,287.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,639.16		
6015	KIDS 14-19 FEMALE NO	4,170.12	4,274.87	4,336.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,781.41		
9960	KIDSCARE KICK PAYME N	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	33,365.44	33,851.39	34,124.6	3	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,341.46		

101,341.46

33,365.44	33,851.39	34,124.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending September 30, 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	377.84	377.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,127.79		
6012	KIDS 1-5 M & F NON-M	14,030.25	13,776.71	13,002.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,809.20		
6013	KIDS 6-13 M & F NON-	24,067.99	24,576.74	26,372.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,016.79		
6014	KIDS 14-19 MALE NON-	10,487.13	10,708.53	10,950.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,146.24		
6015	KIDS 14-19 FEMALE NO	10,410.58	10,572.35	10,948.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,931.27		
SUBTOTAL:	59,368.17	60,012.17	61,650.9	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,031.29		

TOTAL:	59,368.17	60,012.17	61,650.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,031.29		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending September 30, 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	292.00	291.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		872.00		
6012	KIDS 1-5 M & F NON-M	8,836.06	8,937.06	9,053.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,826.15		
6013	KIDS 6-13 M & F NON-	16,748.06	16,847.06	16,997.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,592.24		
6014	KIDS 14-19 MALE NON-	4,347.00	4,404.00	4,514.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,265.00		
6015	KIDS 14-19 FEMALE NO	4,353.00	4,428.00	4,520.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,301.00		
SUBTOTAL:	34,573.12	34,908.12	35,375.1	5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,856.39		

35,375.15

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

104,856.39

TOTAL:

34,573.12

34,908.12

KidsCare - FEE FOR SERVICE
For The Period Ending September 30, 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	1,147.85	637.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,068.99		
6012	KIDS 1-5 M & F NON-M	14,179.76	23,135.73	17,015.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,330.54		
6013	KIDS 6-13 M & F NON-	45,325.01	144,046.96	62,107.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,479.33		
6014	KIDS 14-19 MALE NON-	39,303.11	50,503.51	36,039.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,846.00		
6015	KIDS 14-19 FEMALE NO	25,467.01	21,720.72	26,081.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,269.52		
SUBTOTAL:	124,559.0	1	240,554.77	141,880.6	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		506,994.38		

TOTAL:	124,559.01	240,554.77	141,880.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		506,994.38		

KidsCare - REINSURANCE
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	10,129.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,129.35		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	57,524.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,524.29		
6013	KIDS 6-13 M & F NON-	85,728.15	66,080.76	85,432.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237,241.07		
6014	KIDS 14-19 MALE NON-	113,827.14	40,260.35	35,353.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,440.68		
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:	200,701.0	1	116,470.46	178,309.6	4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		495,481.11		

178,309.64

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

495,481.11

TOTAL:

200,701.01

116,470.46

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending September 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	
1000	TANF WITH MEDICARE	2.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.00	
1010	TANF NON-MEDICARE	389.91	450.32	511.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,352.15	
1020	TANF WITH QMB	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00	
2100	SSI AGED WITH MEDICA	257.99	261.42	260.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	780.07	
2110	SSI AGED NON-MEDICAR	11.00	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.00	
2120	SSI AGED WITH QMB	429.97	429.89	431.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,291.08	
2200	SSI DISABLED WITH ME	1,924.20	1,920.69	1,910.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,755.63	
2210	SSI DISABLED NON-MED	26,376.88	26,455.14	26,530.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,362.08	
221Z	SSI DISABLED NON-MED	2.51	0.00	-1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.58	
2220	SSI DISABLED WITH QM	4,868.95	4,898.69	4,922.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,690.01	
2310	SSI BLIND NON-MEDICA	13.00	13.48	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	40.48	
2320	SSI BLIND WITH QMB	2.00	0.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.99	
8700	SSI DISABLED FREEDOM	23.00	21.00	21.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	65.99	
8710	SSI DISABLED FREEDOM	3.99	5.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.99	
8720	SSI DISABLED FREEDOM	10.99	12.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36.99	
SUBTOTAL:	34,321.39	34,487.62	34,642.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	103,451.04	
TOTAL:	34,321.39	34,487.62	34,642.03	0.	0.00	0.00	0.00	0.00	0.00	0.	0.00	0.00	103,451.04	

00

00

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending September 30, 2019

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	422,468.96	427,754.94	443,218.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,293,442.56	
EPD	106,533,521.90	107,126,210.66	107,209,520.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	320,869,253.27	
TOTAL AHCCCS LTC	106,955,990.86	107,553,965.60	107,652,739.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	322,162,695.83	
DES/DD	143,961,803.16	144,655,141.28	145,290,373.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	433,907,318.37	
TOTAL DES LTC	143,961,803.16	144,655,141.28	145,290,373.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	433,907,318.37	
TOTAL LTC - CAP	250,917,794.02	252,209,106.88	252,943,113.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	756,070,014.20	

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	12,577,411.41	12,175,076.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,394,207.63	
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	12,577,411.41	12,175,076.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,394,207.63	

EPD/DD REINSURANCE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	2,639,219.53	3,741,228.89	2,917,979.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,298,427.44	
DES/DD	4,204,532.65	1,620,152.95	3,500,067.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,324,752.62	
TOTAL DES LTC	4,204,532.65	1,620,152.95	3,500,067.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,324,752.62	
TOTAL LTC - REIN	6,843,752.18	5,361,381.84	6,418,046.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,623,180.06	

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	4,475,851.60	4,503,576.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,455,175.80	

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.

142

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	932,589.80	216,051.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,352,093.88	
Subtotal	203,452.53	932,589.80	216,051.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,352,093.88	

206,373.18	932,589.80	216,051.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,355,014.53	

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	1,522.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,812.48	
00010735	CENPATICO INTEGRATED - CAP	-7,052.52	0.00	-7,362.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-14,414.86	
00010795	MERCY MARICOPA INTEGRATED - CAP	-60,720.16	10,522.46	615.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-49,582.62	
Subtotal	-66,482.80	10,522.46	-5,224.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-61,185.00	

-66,482.80	10,522.46	-5,224.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-61,185.00	

GRAND TOTAL

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

00010715	HEALTH CHOICE INTEGRATED - MM	0.88	0.00	1.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.93	
00010735	CENPATICO INTEGRATED - MM	-4.35	0.00	-4.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-8.90	
00010795	MERCY MARICOPA INTEGRATED - MM	-25.72	4.44	0.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-21.03	
Subtotal	-29.19	4.44	-3.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-28.00	

-29.19	4.44	-3.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-28.00	

GRAND TOTAL

Behavioral Health Expenditures by RHBA
For the Period Ending September 30, 2019

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

00010715
00010735
00010795

HEALTH CHOICE INTEGRATED - CAP CENPATICO INTEGRATED - CAP
MERCY MARICOPA INTEGRATED - CAP

1,289.88

0.00

1,522.60

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,812.48

-7,052.52

0.00

-7,362.34

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-14,414.86

-60,720.16

10,522.46

615.08

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-49,582.62

Subtotal

-66,482.80

10,522.46

-5,224.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-61,185.00

-66,482.80

10,522.46

-5,224.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-61,185.00

GRAND TOTAL