Douglas A. Ducey, Governor Jami Snyder, Director

November 29, 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 October 31, 2019

Dear President Fann and Speaker Bowers:

Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended October 31, 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. In addition, an October revision and a review of the Fiscal Year 2020 rebase was prepared and for purposes of this report, projected annual expenditures remain equal to the appropriations.

Enrollment Update – October 2019 enrollment is 1,901,411 members, a 2,795 member increase over the prior month. Enrollment for November 2019 decreased to 1,895,254 members, a 6,157 member change.

Major November 2019 changes by eligibility category include: 1931 for Families and Children/SOBRA – decrease of 4,805, Supplemental Security Income – increase of 380; Prop 204 Restoration - decrease of 385; Adult Expansion – decrease of 936 Medicare Cost Sharing – increase of 272; KidsCare – decrease of 327; and Federal Emergency Services – decrease of 568.

Tobacco Funds Revenue Update - Tobacco tax collections through October 2019 are $1.3 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.

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 November 29, 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,
Jami Snyder Director

Enclosure

cc: The Honorable Douglas A. Ducey, Governor
The Honorable, David Gowan, Chairman, Senate Appropriations Committee The Honorable Regina E. Cobb, Chairman, House Appropriations Committee The Honorable Kate Brophy McGee, Chairman, Senate Health and
Human Services Committee
The Honorable Nancy Barto, Chairman, House Health and Human Services Committee Matthew Gress, Director, Governor’s Office of Strategic Planning and Budgeting Richard Stavneak, Director, Joint Legislative Budget Committee

Appropriation Status Report (ASR)
Fiscal Year 2020
Through October 31, 2019

Prepared by: Division of Business and Finance

Appropriation Status Report
Table of Contents
APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 2020…	2
Appropriated Expenditures by Funding Source…	3
Appropriated Revenue Received Detail Schedule…	5
FOOTNOTES	7
CASELOAD AND EXPENDITURES BY RATE CODE	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 October 31, 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	$	29,763,979	$	29,763,979	$		-	$	88,542,300	$	-		
AHCCCS Prop 204 Administration	14,182,800	7,183,828	7,183,828			-	14,182,800		-		
Information Technology	9,878,000	-	-		-	9,878,000	-	
DES Eligibility	91,874,500		21,329,312		21,329,312		-		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		9,829,784		9,829,784		-		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		38,031		38,031		-		100,000		-		
TOTAL ADMINISTRATION	268,262,100		71,263,323		71,263,323		-		268,262,100		-		

Traditional Medicaid Services	5,178,162,100	1,762,095,381	1,762,095,381		5,178,162,100	-	
Proposition 204 Services	4,168,410,500	1,342,550,882	1,342,550,882		4,168,410,500	-	
ACA Adult Expansion	527,018,800	142,324,390	142,324,390		527,018,800	-	
KidsCare Services	106,516,300	24,934,724	24,934,724		106,516,300	-	
ALTCS Services	1,796,913,800	572,069,422	572,069,422		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	61,722,438	61,722,438		180,729,500	-	
Behavioral Health Services - in Schools	9,990,000	3,330,000	3,330,000		9,990,000	-	
Targeted Investment Program	90,000,000	-	-		90,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		24,972,028		24,972,028		-		77,646,900		-	
Supported Housing	5,324,800		1,822,925		1,822,925		-		5,324,800		-	
Crisis Services	16,391,300		5,418,767		5,418,767		-		16,391,300		-	
TOTAL PROGRAMMATIC	12,536,085,200		3,956,832,421		3,956,832,421		-		12,536,085,200		-	

-
-
-
-
-

-
-
-
-

TOTAL EXPENDITURES

$	12,804,347,300

-

$	4,028,095,744

$	4,028,095,744	$

-	$   12,804,347,300	$	-

2

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending October 31, 2019 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		

Administrative Expenditures	
$	
60,044,200	
$	16,890,852	
$	16,890,852	
-	$	
60,044,200	
$	
-	
Proposition 204 - Administrative Expenditures		21,538,900	6,262,480	6,262,480	-	21,538,900		-	

Programmatic Expenditures									
Traditional Medicaid Services		1,170,113,300	413,512,379	413,512,379	-	1,170,113,300		-	
Proposition 204 Services		95,088,500	31,696,167	31,696,167	-	95,088,500		-	
ACA Adult Expansion		5,393,400	1,797,800	1,797,800	-	5,393,400		-	
KidsCare Services		7,523,800	672,913	672,913	-	7,523,800		-	
ALTCS Services		234,042,300	78,014,100	78,014,100	-	234,042,300		-	
DSH and Rural Hospitals		8,843,300	-	-	-	8,843,300		-	
CMDP	54,297,600	18,604,226	18,604,226	-	54,297,600	-	
Behavior Health Services - in Schools	3,000,000	1,000,000	1,000,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	24,972,028	24,972,028	-	77,646,900	-	
Supported Housing	5,324,800	1,822,925	1,822,925	-	5,324,800	-	
Crisis Services	14,141,100	4,668,700	4,668,700	-	14,141,100	-	
Voluntary Political Subdivision Programs	 	3,750,000 	 	- 	 	- 	 	- 	 	3,750,000 	 	- 	
TOTAL GF EXPENDITURES	1,760,748,100	599,914,570	599,914,570	-	1,760,748,100	-	
	FEDERAL		
Administrative Expenditures	146,947,600	37,232,016	37,232,016		-	146,947,600	-	
Proposition 204 - Administrative Expenditures	33,035,300	10,751,132	10,751,132		-	33,035,300	-	

Programmatic Expenditures	
Traditional Medicaid Services	3,176,462,800	1,071,264,540	1,071,264,540		-	3,176,462,800	-	
Proposition 204 Services	3,615,003,800	1,183,190,497	1,183,190,497		-	3,615,003,800	-	
ACA Adult Expansion	484,056,500	132,047,147	132,047,147		-	484,056,500	-	
KidsCare Services	86,764,900	21,209,393	21,209,393		-	86,764,900	-	
ALTCS Services and Nursing Facility Assessment	1,144,403,700	359,562,079	359,562,079		-	1,144,403,700	-	
DSH and Rural Hospitals	24,856,200	-	-		-	24,856,200	-	
CMDP	126,431,900	43,118,212	43,118,212		-	126,431,900	-	
Behavior Health Services - in Schools	6,990,000	2,330,000	2,330,000		-	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	2,871,601,891	2,871,601,891	-	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	15,387,233	15,387,233	-	46,512,900	-	
ALTCS Services	 	268,554,800 	 	88,078,918 	 	88,078,918 	 	- 	 	268,554,800 	 	- 	
TOTAL COUNTY EXPENDITURES	318,974,100	103,466,151	103,466,151	-	318,974,100	-	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending October 31, 2019 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

	TOBACCO FUNDS				

Programmatic Expenditures					
Traditional Medicaid Services - Medically Needy		61,752,600	20,944,131	20,944,131	-	61,752,600	-	
Proposition 204 Services - Emergency Health Services		16,216,300	5,756,011	5,756,011	-	16,216,300	-	
Proposition 204 Services - Proposition 204 Protection		34,054,300	12,087,622	12,087,622	-	34,054,300	-	
Proposition 204 Services - ATLSF	 	102,000,000 	 	- 	 	- 	 	- 	 	102,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	214,023,200	38,787,764	38,787,764	-	214,023,200	-	
	OTHER		
Administrative Expenditures						
Prescription Drug Rebate Program	2,789,700	126,843	126,843	-	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	46,719,533	46,719,533	-	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	2,526,133	2,526,133	-	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	109,179,411	109,179,411	-	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	8,434,468	8,434,468	-	37,389,000	-	
ACA Adult Expansion - IGA Fund	179,900	44,975	44,975	-	179,900	-	
Traditional Medicaid Services - TPL	194,700	824,861	824,861	-	194,700	-	
ALTCS Services - TPL	-	571,251	571,251	-	-	-	
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	3,052,417	3,052,417	-	12,151,300	-	
Freedom to Work Premiums	31,200	38,315	38,315	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	750,067	750,067	-	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	414,325,368	414,325,368	-	1,363,047,300	-	
	TOTAL		
Administrative Expenditures	268,262,100	71,263,323	71,263,323	-	268,262,100	-	
Acute Care	10,739,171,400	3,384,763,000	3,384,763,000	-	10,739,171,400	-	
Long Term Care	 	1,796,913,800 	 	572,069,422 	 	572,069,422 	 	- 	 	1,796,913,800 	 	- 	
TOTAL EXPENDITURES	$	12,804,347,300	$	4,028,095,744	$	4,028,095,744	$	-	$	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 October 31, 2019

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,251,144,200		$	433,201,031		$	431,403,231	
Proposition 204 Services & Administrative	116,627,400		37,958,647		38,599,822	
KidsCare Services	7,523,800.00		672,913.44		672,913	
ALTCS Services	234,042,300		78,014,100		78,014,100	
Behavioral Health Traditional Medicaid Services	151,410,400		50,067,879		50,067,879	
TOTAL	1,760,748,100		599,914,570		598,757,946	

FEDERAL:
Acute & Administrative	7,789,954,100		2,447,712,206		2,449,819,215	
KidsCare Services	86,764,900		21,209,393		23,727,389	
ALTCS Services	1,144,403,700		359,562,079		390,350,216	
Behavioral Health Traditional Medicaid Services	126,431,900		43,118,212		45,485,681	
TOTAL	9,147,554,600		2,871,601,891		2,909,382,501	

COUNTY:
Acute & Administrative	

50,419,300		

15,387,233		

15,645,263	
ALTCS Services	268,554,800		88,078,918		96,758,704	
TOTAL	318,974,100		103,466,151		112,403,967	

TOBACCO FUNDS:
Traditional Medicaid Services	

61,752,600		

20,944,131		

20,944,131	
Proposition 204 Services	152,270,600		17,843,633		17,843,633	
TOTAL	214,023,200		38,787,764		38,787,764	

OTHER:

Administrative	2,789,700		126,843		126,843	
Traditional Medicaid Services - IGA Fund	10,297,700		2,574,425		2,574,425	
Acute Care - Prescription Drug Rebate Program	712,796,900		237,549,497		237,549,497	
Long Term Care - Prescription Drug Rebate Program	44,000,400		12,176,602		12,176,602	
Hospital Assessment	343,616,500		118,300,029		83,799,268	
ALTCS - Nursing Facility Assessment	105,912,600		33,666,471		73,592	
Acute TPL - Note 1	194,700		824,861		824,861	
LTC TPL - Note 1	-		571,251		571,251	
KidsCare Services - IGA Fund	76,300		-		-	
KidsCare TPL - Note 1	-		-		491.00	
Member Premiums - CHIP	12,151,300		3,052,417		3,052,417	
Member Premiums - Freedom to Work	31,200		38,315		38,315	
Targeted Investment Program	28,062,400		-		12,731,149	
Behavioral Health Traditional Medicaid Services	2,250,200		750,067		511,702	
Voluntary Political Subdivision - State Match	100,867,400		4,694,590		7,760,875	
TOTAL	1,363,047,300		414,325,368		361,791,288	

TOTAL REVENUE

$	12,804,347,300

$	4,028,095,744

$	4,021,123,465

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending October 31, 2019	
Note 1:	Third Party Liability Collections:	October 2019		October 2018		July 1, 2019		July 1, 2018	
	Gross Collections:					October 31, 2019		October 31, 2018	
	Acute	$	2,414,287		$	1,645,117		$	6,212,190		$	5,401,390	
	LTC	892,227		680,116		2,974,434		1,999,090	
	KidsCare	34,302		984		47,179		1,801	
	Total TPL Collections	$	3,340,816		$	2,326,217		$	9,233,803		$	7,402,281	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	238,524		$	216,408		$	824,861		$	590,102		
LTC		168,773		146,698			571,251		562,305		
KidsCare		(357)		-			491		(34)		
Total Expenditure Offsets	$	406,940		$	363,106		$	1,396,603		$	1,152,373		

Note 2: Authorized Positions
Actual Positions as of October 31, 2019

`

FY 20 Total

1,188.0
1,109.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2019	$	5,258,991	
	Revenues	3,351,515	
	Transfers-In	199,013	
	Total Revenues	3,550,528	
	
Expenditures	
3,933,761	
	Transfers-out	924,350	
	Total Expenditures	4,858,111	
	
Ending Balance October 31, 2019	
$	3,951,409	

Of the $3,951,409 ending balance, $1,664,034 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through November 2019.

Note 4:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of October 31, 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	334,612,762	0	0	0	0	0	0	0	0	1,310,140,964	
CAPITATION - AIMHS	292,639	307,037	323,631	334,345	0	0	0	0	0	0	0	0	1,257,652	
CAPITATION - LTC	250,917,794	252,209,107	253,136,674	286,967,455	0	0	0	0	0	0	0	0	1,043,231,030	
MENTAL HEALTH - CHILD	865	2,317	-1,031	-270	0	0	0	0	0	0	0	0	1,881	
MENTAL HEALTH - ADULT	340,947	351,310	462,496	348,822	0	0	0	0	0	0	0	0	1,503,574	
MENTAL HEALTH - GENERAL	755	1,398	-2,562	3,511	0	0	0	0	0	0	0	0	3,101	
MENTAL HEALTH - CMDP	11,210,666	11,149,954	11,526,705	12,227,439	0	0	0	0	0	0	0	0	46,114,764	
MENTAL HEALTH - DD	7,458,766	7,517,688	7,570,387	6,293	0	0	0	0	0	0	0	0	22,553,134	
MENTAL HEALTH - RBHA CRISIS	3,210,728	3,227,109	3,238,920	4,390,161	0	0	0	0	0	0	0	0	14,066,917	
FEE FOR SERVICE - ACUTE	48,820,855	49,681,027	42,280,433	52,930,957	0	0	0	0	0	0	0	0	193,713,272	
FFS - PRIOR QUARTER COVERAGE	953,544	609,982	539,248	471,399	0	0	0	0	0	0	0	0	2,574,173	
EMERGENCY SERVICES - FEDERAL	4,491,141	3,725,509	4,435,620	4,558,207	0	0	0	0	0	0	0	0	17,210,477	
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	1,089,683	0	0	0	0	0	0	0	0	3,042,094	
QMB - FEE FOR SERVICE	660,278	490,123	440,696	367,062	0	0	0	0	0	0	0	0	1,958,159	
STATE ONLY TRBHA FFS	158,244	111,819	158,545	188,541	0	0	0	0	0	0	0	0	617,149	
FFS TRBHA FEE FOR SERVICE	12,287,430	11,525,809	8,927,578	12,220,179	0	0	0	0	0	0	0	0	44,960,997	
INPATIENT INMATES FFS	244,004	235,027	245,518	346,036	0	0	0	0	0	0	0	0	1,070,585	
MARICOPA CTY INMATES FFS	19,819	22,216	24,325	1,088	0	0	0	0	0	0	0	0	67,448	
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	8,259	0	0	0	0	0	0	0	0	10,449	
PIMA COUNTY INMATES FFS	4,917	34,617	15,870	30,493	0	0	0	0	0	0	0	0	85,896	
FEE FOR SERVICE - LTC	14,641,720	12,577,411	12,175,076	14,560,491	0	0	0	0	0	0	0	0	53,954,699	
LFFS - PRIOR QUARTER COVERAGE	72,181	86,245	50,352	44,819	0	0	0	0	0	0	0	0	253,596	
MARICOPA CTY INMATES LTC FFS	0	419	0	3,723	0	0	0	0	0	0	0	0	4,141	
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	1,915,460	0	0	0	0	0	0	0	0	5,188,844	
REINSURANCE - ACC	13,954,921	15,652,135	16,821,600	19,456,077	0	0	0	0	0	0	0	0	65,884,734	
REINSURANCE - LTC	6,843,752	5,361,382	6,418,046	5,182,315	0	0	0	0	0	0	0	0	23,805,495	
SMIB - ACC	15,867,509	15,869,518	16,032,517	16,042,978	0	0	0	0	0	0	0	0	63,812,522	
HIB - ACC	775,609	843,035	893,679	881,950	0	0	0	0	0	0	0	0	3,394,274	
Q1	2,951,192	2,997,689	3,029,726	3,060,005	0	0	0	0	0	0	0	0	12,038,612	
SMIB - LTC	4,094,296	4,092,510	4,109,180	4,112,907	0	0	0	0	0	0	0	0	16,408,892	
HIB - LTC	381,353	383,342	394,397	388,191	0	0	0	0	0	0	0	0	1,547,282	
SUBTOTAL	728,338,191	726,618,665	718,813,286	776,751,337	0	0	0	0	0	0	0	0	2,950,521,480	

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	292,004,987	0	0	0	0	0	0	0	0	1,129,711,184	
CAPITATION - AIMHS	134,306	142,743	148,769	156,410	0	0	0	0	0	0	0	0	582,228	
MENTAL HEALTH - ADULT	414,838	404,766	357,960	339,574	0	0	0	0	0	0	0	0	1,517,137	
MENTAL HEALTH - GENERAL	-2,350	-4,545	-6,979	-1,026	0	0	0	0	0	0	0	0	-14,900	
MENTAL HEALTH - CMDP	0	393	762	818	0	0	0	0	0	0	0	0	1,973	
MENTAL HEALTH - RBHA CRISIS	3,634,857	3,668,731	3,689,681	4,433,299	0	0	0	0	0	0	0	0	15,426,568	
FEE FOR SERVICE - ACUTE	37,859,959	38,790,683	33,207,024	40,310,956	0	0	0	0	0	0	0	0	150,168,622	
FFS - PRIOR QUARTER COVERAGE	1,204,975	590,575	350,539	247,496	0	0	0	0	0	0	0	0	2,393,585	
EMERGENCY SERVICES - FEDERAL	3,246,745	2,798,913	3,488,929	3,312,152	0	0	0	0	0	0	0	0	12,846,739	
FFS MEDICAID IN PUBLIC SCHOOLS	723	218	330	768	0	0	0	0	0	0	0	0	2,040	
INPATIENT INMATES FFS	889,101	645,173	765,595	723,663	0	0	0	0	0	0	0	0	3,023,531	
STATE ONLY TRBHA FFS	399,387	372,201	456,058	565,497	0	0	0	0	0	0	0	0	1,793,142	
FFS TRBHA FEE FOR SERVICE	7,885,916	6,336,072	6,757,819	9,050,014	0	0	0	0	0	0	0	0	30,029,822	
MARICOPA CTY INMATES FFS	214,579	207,410	203,431	152,268	0	0	0	0	0	0	0	0	777,688	
PINAL COUNTY INMATES FFS	415	59	3,076	244	0	0	0	0	0	0	0	0	3,795	
PIMA COUNTY INMATES FFS	44,460	29,912	57,917	22,647	0	0	0	0	0	0	0	0	154,935	
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	165	0	0	0	0	0	0	0	0	3,638	
REINSURANCE - ACC	6,253,343	6,750,467	8,759,810	5,851,025	0	0	0	0	0	0	0	0	27,614,646	
SMIB - ACC	7,097,119	7,165,395	7,230,656	7,256,687	0	0	0	0	0	0	0	0	28,749,857	
HIB - ACC	6,248	4,850	4,894	4,894	0	0	0	0	0	0	0	0	20,886	
SUBTOTAL	347,582,951	348,190,644	344,620,338	364,432,537	0	0	0	0	0	0	0	0	1,404,826,470	

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	35,613,658	0	0	0	0	0	0	0	0	136,506,950	
CAPITATION - AIMHS	12,254	13,041	13,411	13,456	0	0	0	0	0	0	0	0	52,162	
MENTAL HEALTH - ADULT	12,078	12,834	13,307	10,299	0	0	0	0	0	0	0	0	48,518	
MENTAL HEALTH - GENERAL	399	-806	497	0	0	0	0	0	0	0	0	0	90	
MENTAL HEALTH - CMDP	0	762	762	818	0	0	0	0	0	0	0	0	2,342	
MENTAL HEALTH - RBHA CRISIS	575,493	582,267	581,810	696,263	0	0	0	0	0	0	0	0	2,435,834	
FEE FOR SERVICE - ACUTE	2,872,751	3,384,201	2,596,379	3,610,161	0	0	0	0	0	0	0	0	12,463,492	
FFS - PRIOR QUARTER COVERAGE	200,446	340,753	89,570	110,297	0	0	0	0	0	0	0	0	741,065	
EMERGENCY SERVICES - FEDERAL	5,151,773	4,521,846	4,307,602	4,739,519	0	0	0	0	0	0	0	0	18,720,740	
FFS MEDICAID IN PUBLIC SCHOOLS	66	0	0	34	0	0	0	0	0	0	0	0	100	
FFS TRBHA FEE FOR SERVICE	279,336	136,082	159,112	163,246	0	0	0	0	0	0	0	0	737,776	
STATE ONLY TRBHA FFS	39,350	9,279	10,091	52,331	0	0	0	0	0	0	0	0	111,051	
INPATIENT INMATES FFS	61,395	5,936	718	18,994	0	0	0	0	0	0	0	0	87,043	
MARICOPA CTY INMATES FFS	8,779	2,632	4,840	20,343	0	0	0	0	0	0	0	0	36,595	
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	1,559,407	0	0	0	0	0	0	0	0	4,350,726	
SMIB - ACC	271	136	0	0	0	0	0	0	0	0	0	0	407	
	43,548,708	43,869,597	42,267,781	46,608,827	0	0	0	0	0	0	0	0	176,294,913	
	1,119,469,850	1,118,678,906	1,105,701,405	1,187,792,702	0	0	0	0	0	0	0	0	4,531,642,863	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
CAPITATION - ACC	0	0	2,131	2,575	0	0	0	0	0	0	0	0	4,706	
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	6,672,896	0	0	0	0	0	0	0	0	25,214,142	
KidsCare - FEE FOR SERVICE	124,559	240,555	141,881	280,744	0	0	0	0	0	0	0	0	787,739	
KidsCare - MENTAL HEALTH	59,368	60,012	61,651	79,894	0	0	0	0	0	0	0	0	260,926	
KidsCare - REINSURANCE	200,701	116,470	178,310	68,995	0	0	0	0	0	0	0	0	564,476	

6,487,491	6,610,278	6,629,190	7,105,104	0	0	0	0	0	0	0	0	26,832,063	

TOTAL TITLE XXI

1,125,957,341	1,125,289,184	1,112,330,595	1,194,897,806	0	0	0	0	0	0	0	0	4,558,474,926	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	42,054.34	48,959.09	44,661.46	42,858.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178,533.09		
1007	TANF 21-44 FEMALE WI	45,256.87	48,452.58	37,289.55	36,573.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167,572.35		
1008	TANF 45-64 M & F WIT	58,324.80	51,372.72	55,455.73	59,288.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,441.98		
1009	TANF 65+ M & F WITH	16,091.48	14,740.77	12,841.93	10,830.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,504.39		
100F	TANF 21-44 MALE WITH	40.03	581.66	1,451.87	603.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,677.27		
100G	TANF 21-44 FEMALE WI	2,488.06	2,248.29	2,866.78	99.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,702.74		
100H	TANF 45-64 M & F WIT	4,175.05	3,092.89	2,374.57	461.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,104.02		
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	5,864,005.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,786,701.98		
1012	TANF 01-05 M & F NON	3,457,250.59	3,441,533.14	3,420,435.80	3,663,284.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,982,504.33		
1013	TANF 06-13 M & F NON	6,124,074.11	6,152,446.23	6,168,589.18	6,578,134.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,023,244.11		
1014	TANF 14-20 MALE NON-	1,914,202.78	1,884,287.16	1,883,566.77	2,025,538.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,707,594.87		
1015	TANF 14-20 FEMALE N O	2,353,294.72	2,342,821.82	2,327,116.90	2,475,096.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,498,330.26		
1016	TANF 21-44 MALE NON-	9,364,324.51	9,454,366.22	9,451,614.62	9,776,592.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,046,898.19		
1017	TANF 21-44 FEMALE N O	32,620,357.05	32,728,554.66	32,775,784.07	33,752,027.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,876,722.90		
1018	TANF 45-64 M & F NON	7,767,766.58	7,784,035.25	7,762,785.14	8,000,237.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,314,824.38		
1019	TANF 65+ M & F NON-M	31,052.28	29,784.99	31,822.50	32,621.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,281.03		
101A	TANF < 1 M & F NON-M	352,937.84	334,377.43	295,390.35	340,918.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,323,624.55		
101B	TANF 01-05 M & F NON	31,695.97	27,524.01	22,926.16	34,432.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116,578.28		
101C	TANF 06-13 M & F NON	16,670.28	19,749.31	20,214.14	31,451.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,084.93		
101D	TANF 14-20 MALE NON-	9,808.43	14,845.50	11,848.57	9,602.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,104.75		
101E	TANF 14-20 FEMALE N O	18,630.37	20,897.05	23,373.06	14,812.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,713.23		
101F	TANF 21-44 MALE NON-	246,596.25	255,429.76	194,158.71	213,830.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		910,014.89		
101G	TANF 21-44 FEMALE N O	615,659.33	583,850.07	465,507.37	483,973.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,148,990.73		
101H	TANF 44-64 M & F NON	131,317.46	152,039.59	104,634.71	127,378.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		515,370.31		
101J	TANF 65+ N & F NON-M	198.84	566.38	1,210.63	1,307.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,283.64		
1024	TANF 14-20 MALE WITH	1,991.65	1,834.56	1,834.56	1,768.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,429.52		
1026	TANF 21-44 MALE WITH	30,833.82	25,161.04	23,949.90	20,548.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,493.20		
1027	TANF 21-44 FEMALE WI	33,845.08	29,934.75	39,393.39	30,840.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,013.81		
1028	TANF 45-64 M & F WIT	32,482.04	30,194.61	33,485.88	38,169.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,332.28		
1029	TANF 65+ M & F WITH	9,312.30	9,417.77	6,856.06	8,190.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,776.27		
102F	TANF 21-44 MALE WITH	0.00	77.29	129.25	15.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221.96		
102G	TANF 21-44 FEMALE WI	0.00	67.86	0.00	200.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268.02		
102H	TANF 44-64 M & F WIT	0.00	0.00	38.22	581.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		619.58		
102J	TANF 65+ M & F WITH	0.00	258.92	0.00	56.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315.61		
2100	SSI AGED WITH MEDIC A	712,678.64	703,164.71	703,123.48	667,339.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,786,306.23		

ACC CAPITATION - AMOUNTS
For The Period Ending October 31, 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	42,682.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,631.62		
2110	SSI AGED NON-MEDICA
R	8,462,181.12	8,547,064.99	8,567,191.18	8,623,372.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,199,809.47		
211Z	SSI AGED NON-MEDICA R	216,958.62	161,562.33	135,278.37	170,335.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		684,134.39		
2120	SSI AGED WITH QMB	5,479,950.99	5,524,156.46	5,564,371.66	5,231,743.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,800,223.07		
212Z	SSI AGED WITH QMB P P	4,799.26	6,473.36	9,408.43	3,946.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,627.44		
2200	SSI DISABLED WITH M
E	1,774,556.51	1,758,603.98	1,757,956.93	1,793,548.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,084,666.16		
220Z	SSI DISABLED WITH M E	96,386.79	59,787.78	85,084.80	74,882.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316,141.84		
2210	SSI DISABLED NON-ME
D	70,901,267.74	70,892,010.70	70,871,863.55	71,601,739.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284,266,881.65		
221Z	SSI DISABLED NON-ME D	942,051.13	933,821.38	825,347.66	868,410.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,569,630.22		
2220	SSI DISABLED WITH Q
M	14,966,350.81	14,971,834.15	14,896,450.44	15,280,370.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,115,005.89		
222Z	SSI DISABLED WITH Q M	31,562.80	38,109.67	39,444.48	60,437.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,554.51		
2300	SSI BLIND WITH MEDIC	7,894.62	8,025.40	7,600.96	7,717.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,238.07		
2310	SSI BLIND NON-MEDIC A	633,695.19	633,652.52	642,091.43	647,172.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,556,611.30		
231Z	SSI BLIND NON-MEDIC
A	5,251.90	10,051.71	22,411.45	23,240.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,955.90		
2320	SSI BLIND WITH QMB	47,291.74	47,835.53	47,975.47	45,708.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188,811.44		
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	625.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,356.80		
4303	SOBRA CHILD 06-13 M	671.85	839.07	526.79	627.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,664.79		
4305	SOBRA CHILD 14-20 FE	598.98	472.87	136.70	127.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,335.95		
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	20,542,211.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,109,426.09		
4312	SOBRA CHILD 01-05 M	30,346,403.53	30,479,033.09	30,485,312.35	31,804,708.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,115,457.19		
4313	SOBRA CHILD 06-13 M	39,139,381.16	39,428,777.53	39,455,204.32	41,184,424.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,207,787.09		
4314	SOBRA CHILD 14-20 MA	10,797,911.21	10,918,285.83	10,979,617.38	11,498,504.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,194,318.86		
4315	SOBRA CHILD 14-20 FE	10,814,438.27	10,921,113.04	10,946,037.68	11,446,085.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,127,674.18		
431A	SOBRA CHILD < 1 M &	255,349.52	216,051.62	182,881.71	205,334.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		859,617.59		
431B	SOBRA CHILD 01-05 M	734,288.72	672,792.26	556,972.69	630,508.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,594,561.86		
431C	SOBRA CHILD 6-13 M&F	698,553.25	730,808.98	551,793.26	609,387.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,590,542.74		
431D	SOBRA CHILD 14-20 MA	203,649.34	208,008.27	168,887.99	169,048.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		749,593.88		
431E	SOBRA CHILD 14-20 FE	210,973.01	203,192.73	181,516.56	172,528.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		768,210.66		
4322	SOBRA CHILD 01-05 M	191.11	191.11	191.11	168.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		741.97		
4323	SOBRA CHILD 06-13 M	0.00	0.00	145.06	136.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281.15		
4325	SOBRA CHILD 14-20 FE	194.52	400.68	400.68	370.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,366.82		
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	21,167.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,055.55		

ACC CAPITATION - AMOUNTS
For The Period Ending October 31, 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	350.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,111.70		
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	164.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,057.97		
5015	SOBRA PREG 14-20 FE
M	530,163.48	543,226.36	547,975.79	575,638.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,197,004.12		
5017	SOBRA PREG 21-44 FE M	5,865,449.13	5,991,687.07	6,062,054.68	6,276,120.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,195,311.21		
5018	SOBRA PREG 45-64 FE
M	17,581.17	19,841.48	22,726.54	27,536.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87,685.19		
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	38,171.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163,602.61		
501G	SOBRA PREG 21-44 FE M	403,573.06	413,507.29	339,988.21	336,778.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,493,846.76		
501H	SOBRA PREG 45-64 FE
M	54.35	1,725.17	6,412.35	1,312.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,504.15		
5027	SOBRA PREG 21-44 FE M	14,542.79	19,007.23	29,474.11	31,109.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,133.93		
5028	SOBRA PREG 45-64 FE
M	2,368.16	2,368.16	2,368.16	168.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,273.12		
SUBTOTAL:	295,696,553.19	296,536,345.61	295,713,370.81	304,392,294.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,192,338,563.89		

3100	TRANSPLANT OPTION 1	66.00	49.50	49.50	16.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	66.00	49.50	49.50	16.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

181.50

181.50

9910	TANF & SOBRA CHILDR E	1,876,376.98	1,947,736.11	1,669,626.73	1,696,043.77	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	24,783.24	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	81,102.59	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	13,836,500.01	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 15,638,429.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,189,783.59	
125,192.71	
396,855.04	
52,520,445.39	
60,232,276.73	

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	67,509.70	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	195,221.68	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	385,635.97	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	86,501.34	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	3,812.05	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	19,488.51	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	21,637.90	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	2,629.70	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	1,122.19	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	41,902.37	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	289,322.19	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	9,925,394.92	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	27,682,271.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
145.06	
263,816.76	
749,663.86	
1,569,420.54	
381,189.25	
27,983.74	
41,542.54	
50,157.80	
18,153.06	
186.83	
4,701.44	
156,996.76	
1,109,314.16	
39,391,326.33	
108,777,997.25	

ACC CAPITATION - AMOUNTS
For The Period Ending October 31, 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	9,429,506.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,048,279.76		
1119	TANF EXPANDED 65+ M
&	30,255.92	28,131.96	28,000.75	28,862.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,251.41		
111D	TANF EXPANDED 14-20	2,490.39	1,152.78	1,523.21	3,036.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,202.71		
111E	TANF EXPANDED 14-20	7,437.73	5,473.69	3,147.13	10,374.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,432.73		
111F	TANF EXPANDED 21-44	267,373.80	262,773.96	215,068.24	235,644.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		980,860.82		
111G	TANF EXPANDED 21-44	525,020.23	509,660.72	400,174.61	489,416.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,924,271.98		
111H	TANF EXPANDED 45-64	178,932.04	172,494.14	159,074.75	150,035.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		660,536.38		
111J	TANF EXPANDED 65+ M
&	592.01	928.69	367.98	904.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,792.96		
1126	TANF EXPANDED 21-44	297,942.68	293,773.27	291,620.59	306,418.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,189,754.96		
1127	TANF EXPANDED 21-44	790,701.02	789,295.29	779,113.14	789,198.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,148,307.82		
1128	TANF EXPANDED 45-64	900,768.88	921,413.73	924,623.19	928,434.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,675,240.32		
1129	TANF EXPANDED 65+ M
&	256,772.30	259,581.62	263,961.29	248,104.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,028,420.10		
112F	TANF EXPANDED 21-44	0.00	2,931.30	4,191.82	114.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,237.37		
112G	TANF EXPANDED 21-44	2,213.20	5,170.00	2,450.40	1,114.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,948.35		
112H	TANF EXPANDED 45-64	6,227.67	1,063.02	540.07	7,528.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,359.06		
112J	TANF EXPANDED 65+ M
&	3,111.80	878.74	906.87	814.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,711.81		
2400	SSI AGED EXPANDED WI	40,745.64	49,658.35	38,234.62	42,281.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,920.08		
240Z	SSI AGED EXPANDED
WI	26,984.10	40,705.46	35,897.94	27,426.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,013.89		
2410	SSI AGED EXPANDED N O	116,302.77	124,836.95	115,780.95	113,521.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		470,441.72		
241Z	SSI AGED EXPANDED N
O	15,686.56	0.00	2,707.35	12,150.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,544.80		
2420	SSI AGED EXPANDED WI	5,409,424.18	5,439,222.61	5,476,481.46	5,251,359.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,576,487.37		
242Z	SSI AGED EXPANDED
WI	10,566.52	4,568.42	7,433.00	9,127.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,695.23		
2520	SSI BLIND EXPANDED W	191.11	191.11	191.11	168.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		741.97		
2600	SSI DISABLED EXPAND
E	95,669.32	118,092.54	108,033.75	124,095.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		445,890.66		
260Z	SSI DISABLED EXPAND E	60,164.41	59,191.60	53,022.25	48,257.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,636.05		
2610	SSI DISABLED EXPAND
E	1,902,019.15	1,915,769.99	1,925,963.03	1,963,514.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,707,266.84		
261Z	SSI DISABLED EXPAND E	41,560.30	39,967.68	26,817.13	29,654.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,999.21		
2620	SSI DISABLED EXPAND
E	10,627,342.37	10,666,934.37	10,681,274.26	10,916,058.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,891,609.37		
262Z	SSI DISABLED EXPAND E	24,786.63	13,062.99	25,997.02	38,102.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,949.13		
SUBTOTAL:	68,743,011.0	7 68,940,363.76	68,696,349.0	5 69,927,676.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		276,307,400.24		

3506	ADULT 40-100% MALE 2	5,764.11	5,307.37	5,088.93	7,318.11	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	5,979.70	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	53,201.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

23,478.52	
23,883.29	
215,952.42	

9911	SB PAYMENT FOR TAN F	1,192,225.73	1,197,905.14	1,182,328.27	976,597.96	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	976,597.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,549,057.10

4,549,057.10

ACC CAPITATION - AMOUNTS
For The Period Ending October 31, 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	15,029.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,914.32		
350F	ADULT 40-100% MALE 2	0.00	2,062.59	763.78	53.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,879.57		
350G	ADULT 40-100% FEMAL E	4,201.57	6,234.75	255.24	1,524.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,215.57		
350H	ADULT 40-100% M&F 45	8,724.34	4,663.08	738.24	589.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,714.77		
3514	ADULT 40-100% MALE 1	3,584,131.94	3,587,963.14	3,598,856.23	3,826,030.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,596,981.64		
3515	ADULT 40-100% FEMAL E	3,935,913.21	4,002,324.39	3,958,410.67	4,148,105.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,044,754.14		
3516	ADULT 40-100% MALE 2	12,328,492.47	12,442,821.52	12,405,190.10	13,075,156.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,251,660.56		
3517	ADULT 40-100% FEMAL E	10,396,684.34	10,406,343.92	10,410,485.60	10,920,791.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,134,305.67		
3518	ADULT 40-100% M&F 45	24,233,844.77	24,325,890.22	24,129,566.46	25,165,183.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,854,485.13		
3519	ADULT 40-100% M&F 65	4,796.70	2,957.31	3,486.22	3,624.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,864.89		
351D	ADULT 40-100% MALE 1	69,871.09	58,513.99	62,621.06	62,052.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253,059.04		
351E	ADULT 40-100% FEMAL E	96,620.75	91,285.70	76,978.92	72,929.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		337,814.77		
351F	ADULT 40-100% MALE 2	378,306.71	316,217.93	260,303.87	284,982.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,239,811.07		
351G	ADULT 40-100% FEMAL E	314,532.51	292,594.59	213,966.75	241,271.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,062,365.18		
351H	ADULT 40-100% M&F 45	571,004.41	500,509.79	406,418.38	452,726.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,930,658.72		
351J	ADULT 40-100% M&F 65	1,126.81	546.10	1,825.01	2,864.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,362.61		
3526	ADULT 40-100% MALE 2	512.80	1,005.43	0.00	598.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,116.31		
3528	ADULT 40-100% M&F 45	1,367.52	642.20	984.40	1,899.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,893.88		
3529	ADULT 40-100% M&F 65	0.00	1,303.23	1,524.62	1,601.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,428.87		
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	152.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,176.16		
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	50,842.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152,386.11		
3707	ADULT <40% EXP FEMA L	3,910.19	8,759.02	9,934.25	10,776.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,379.46		
3708	ADULT <40% EXP M&F
4	57,244.70	70,221.48	68,023.40	77,774.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		273,263.62		
3709	ADULT <40% EXP M&F 6	3,342.45	6,220.57	8,040.20	9,598.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,201.80		
370F	ADULT <40% EXP MALE	10,732.30	5,515.81	10,662.39	4,379.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,289.64		
370G	ADULT <40% EXP FEMA L	497.19	1,324.21	2,550.57	29,039.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,410.99		
370H	ADULT <40% EXP M&F
4	9,493.54	14,470.80	7,660.76	7,614.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,239.24		
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	7,024,225.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,878,744.42		
3715	ADULT <40% EXP FEMA L	5,936,403.04	6,019,300.20	6,069,309.64	6,350,497.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,375,510.14		
3716	ADULT <40% EXP MALE	48,789,421.85	49,743,271.72	49,815,793.81	53,042,463.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,390,951.09		
3717	ADULT <40% EXP FEMA L	29,124,659.29	29,572,690.93	29,617,599.15	31,388,885.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,703,834.72		
3718	ADULT <40% EXP M&F
4	56,709,300.26	57,223,557.83	57,236,759.90	60,235,140.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		231,404,758.57		

ACC CAPITATION - AMOUNTS
For The Period Ending October 31, 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	6,191.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,541.25		
371D	ADULT <40% EXP MALE	173,398.88	166,910.98	142,642.92	149,675.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		632,628.32		
371E	ADULT <40% EXP FEMA L	170,863.21	142,486.87	112,122.69	121,004.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		546,477.69		
371F	ADULT <40% EXP MALE	1,729,093.63	1,542,732.32	1,328,885.56	1,459,959.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,060,671.10		
371G	ADULT <40% EXP FEMA L	1,025,917.09	813,958.12	707,195.63	877,496.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,424,567.35		
371H	ADULT <40% EXP M&F
4	1,427,011.49	1,300,300.84	1,052,563.00	1,236,360.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,016,235.81		
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	4,101.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,055.19		
3727	ADULT <40% EXP FEMA L	1,521.58	1,175.63	1,175.63	3,047.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,920.10		
3728	ADULT <40% EXP M&F
4	0.00	3,480.51	1,898.98	2,527.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,906.55		
372F	ADULT <40% EXP MALE	1,485.99	0.00	0.00	1,682.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,168.21		
372G	ADULT <40% EXP FEMA L	327.59	540.92	0.00	467.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,336.35		
372H	ADULT <40% EXP M&F
4	0.00	0.00	470.95	42.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		513.68		
SUBTOTAL:	207,740,499.54	209,424,624.92	208,557,027.17	220,437,459.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		846,159,610.88		

3906	NEWLY ELIGIBLE MALE	9,297.77	14,217.05	12,452.76	15,498.83	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	1,648.32	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	40,956.00	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	16,362.64	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	118.81	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	411.96	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	2,855.21	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	1,443,342.47	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	1,606,583.66	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	7,755,694.51	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	11,581,238.32	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	11,815,690.47	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	409.28	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	23,581.76	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	32,289.49	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	242,758.31	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	342,030.80	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	291,740.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

51,466.41	
5,824.83	
139,028.90	
49,547.73	
1,443.99	
945.40	
23,369.10	
5,341,091.53	
6,075,695.49	
29,881,501.38	
44,420,726.83	
45,303,182.80	
2,011.41	
111,397.78	
156,394.58	
973,318.87	
1,459,897.60	
1,132,497.41	

9935	BIRTH SUPP PAYMENT A	151,291.91	252,079.35	221,179.92	136,085.21	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	527,168.62	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	663,253.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
760,636.39	
1,934,479.40	
2,695,115.79	

ACC CAPITATION - AMOUNTS
For The Period Ending October 31, 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	493.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,150.38		
3927	NEWLY ELIGIBLE FEMA L	2,368.16	2,368.16	2,368.16	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,679.24		
3928	NEWLY ELIGIBLE M&F
4	0.00	384.57	384.57	852.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,621.75		
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		
392H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	31.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.82		
SUBTOTAL:	33,320,140.2	6 33,498,181.01	33,107,684.3	1 35,217,163.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,143,168.99		

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	7,542,742.30	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	2,166,925.23	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	2,122,812.18	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	159,465.84	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	42,520.74	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	38,595.94	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 12,073,062.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

138.81	
29,725,229.43	
8,531,165.82	
8,257,182.91	
40.49	
699,465.49	
200,491.97	
182,568.26	
47,596,283.18	

9944	BIRTH SUPP PAYMENT S	11,882.90	58,943.98	23,471.72	24,770.76	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	24,770.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

119,069.36

119,069.36

9939	BIRTH SUPP PAYMENT N	287,755.48	369,407.99	310,122.63	396,494.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	287,755.48	369,407.99	310,122.63	396,494.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,363,780.57

1,363,780.57

4517	BC PATIENT FEMALE 2 1	10,376.74	10,793.95	10,912.09	10,415.24	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	48,796.77	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	1,447.39	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	3,948.99	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	4,876.72	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	3,797.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	2,792.25	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	698.54	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	76,773.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
42,498.02	
189,949.79	
245.28	
4,154.50	
11,466.56	
18,859.52	
11,878.88	
2,792.25	
1,336.37	
283,181.17	

8600	SSI BLIND FREEDOM/W O	2,514.53	2,514.53	146.37	133.78	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	127.40	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	1,606,076.36	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	62,384.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,309.21	
537.50	
6,311,024.84	
266,305.16	

ACC CAPITATION - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	503,485.23	482,840.23	465,242.51	478,632.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,930,200.07		
871Z	SSI DISABLED FREEDO
M	29,729.13	31,884.99	36,076.70	15,507.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,197.87		
8720	SSI DISABLED FREEDO M	234,348.44	222,168.42	214,558.44	237,099.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		908,174.84		
872Z	SSI DISABLED FREEDO
M	6,655.98	453.87	22,093.47	7,454.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,658.27		
SUBTOTAL:	2,375,150.96	2,388,363.87	2,400,477.38	2,407,415.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,571,407.76		

6015	KIDS 14-19 FEMALE NO	0.00	0.00	2,131.34	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	2,131.34	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,706.10

4,706.10

2,576,363,803.26

637,039,184.43	640,246,228.62	636,844,407.74	662,233,982.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	89.69	89.86	94.05	83.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		356.71		
1007	TANF 21-44 FEMALE WI	106.74	102.58	84.56	88.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382.25		
1008	TANF 45-64 M & F WIT	178.61	170.54	178.92	199.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		727.69		
1009	TANF 65+ M & F WITH	99.53	90.51	78.92	84.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		353.44		
100F	TANF 21-44 MALE WITH	0.29	4.11	6.65	4.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.56		
100G	TANF 21-44 FEMALE WI	2.91	6.29	2.43	0.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.23		
100H	TANF 45-64 M & F WIT	14.60	3.52	2.06	3.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.51		
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	10,140.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,215.68		
1012	TANF 01-05 M & F NON	18,993.92	18,921.51	18,927.54	19,412.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,255.04		
1013	TANF 06-13 M & F NON	34,139.11	34,275.13	34,370.72	35,161.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,946.68		
1014	TANF 14-20 MALE NON-	9,849.08	9,736.84	9,761.39	10,065.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,412.99		
1015	TANF 14-20 FEMALE N O	12,309.27	12,300.27	12,271.12	12,577.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,457.91		
1016	TANF 21-44 MALE NON-	24,304.85	24,468.54	24,434.66	24,611.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,819.53		
1017	TANF 21-44 FEMALE N O	83,159.05	83,428.43	83,491.23	83,874.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		333,953.00		
1018	TANF 45-64 M & F NON	19,720.09	19,730.33	19,681.74	19,798.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,930.91		
1019	TANF 65+ M & F NON-M	78.99	75.92	80.81	80.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316.32		
101A	TANF < 1 M & F NON-M	622.00	588.68	516.55	592.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,319.57		
101B	TANF 01-05 M & F NON	200.41	160.77	137.33	188.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		686.93		
101C	TANF 06-13 M & F NON	91.26	107.35	109.58	170.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		479.10		
101D	TANF 14-20 MALE NON-	54.36	79.67	69.03	51.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		254.78		
101E	TANF 14-20 FEMALE N O	99.54	114.09	110.49	79.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403.29		
101F	TANF 21-44 MALE NON-	653.45	692.46	519.54	565.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,431.39		
101G	TANF 21-44 FEMALE N O	1,627.34	1,538.61	1,238.06	1,261.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,665.31		
101H	TANF 44-64 M & F NON	355.51	400.40	291.08	312.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,359.36		
101J	TANF 65+ N & F NON-M	0.64	1.67	3.15	3.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.83		
1024	TANF 14-20 MALE WITH	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1026	TANF 21-44 MALE WITH	60.00	53.27	54.63	53.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221.30		
1027	TANF 21-44 FEMALE WI	95.99	92.13	93.99	86.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368.18		
1028	TANF 45-64 M & F WIT	108.90	105.00	101.16	90.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		405.94		
1029	TANF 65+ M & F WITH	47.70	48.38	47.00	49.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192.62		
102F	TANF 21-44 MALE WITH	0.00	0.61	1.00	0.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.73		
102G	TANF 21-44 FEMALE WI	0.00	0.41	0.00	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.47		
102H	TANF 44-64 M & F WIT	0.00	0.00	0.20	3.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.51		
102J	TANF 65+ M & F WITH	0.00	1.35	0.00	0.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.79		
2100	SSI AGED WITH MEDIC A	4,122.71	4,063.81	4,030.59	4,108.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,325.21		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 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	276.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		985.93		
2110	SSI AGED NON-MEDICA
R	6,783.06	6,849.40	6,866.93	6,935.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,434.84		
211Z	SSI AGED NON-MEDICA R	187.29	129.52	110.45	137.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		564.65		
2120	SSI AGED WITH QMB	31,783.16	31,989.36	32,152.27	32,229.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128,154.07		
212Z	SSI AGED WITH QMB P P	32.92	44.99	61.94	25.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165.14		
2200	SSI DISABLED WITH M
E	3,555.63	3,532.68	3,532.88	3,539.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,161.09		
220Z	SSI DISABLED WITH M E	164.92	159.53	143.29	159.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		627.47		
2210	SSI DISABLED NON-ME
D	51,491.33	51,464.64	51,465.03	51,603.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,024.90		
221Z	SSI DISABLED NON-ME D	759.58	802.25	717.53	700.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,979.86		
2220	SSI DISABLED WITH Q
M	26,441.87	26,456.91	26,414.26	26,455.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,768.21		
222Z	SSI DISABLED WITH Q M	37.02	44.89	66.85	48.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		197.46		
2300	SSI BLIND WITH MEDIC	28.00	28.99	26.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.99		
2310	SSI BLIND NON-MEDIC A	499.60	500.08	506.73	512.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,019.27		
231Z	SSI BLIND NON-MEDIC
A	4.50	8.28	24.78	19.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.32		
2320	SSI BLIND WITH QMB	225.80	229.88	231.00	229.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		916.60		
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	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.93		
4303	SOBRA CHILD 06-13 M	5.00	6.06	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.06		
4305	SOBRA CHILD 14-20 FE	4.00	3.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
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	35,428.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,769.70		
4312	SOBRA CHILD 01-05 M	166,797.05	167,404.10	167,216.79	167,017.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		668,435.10		
4313	SOBRA CHILD 06-13 M	215,941.09	217,553.86	217,670.05	217,534.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		868,699.97		
4314	SOBRA CHILD 14-20 MA	58,666.27	59,328.82	59,632.71	59,750.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237,377.99		
4315	SOBRA CHILD 14-20 FE	58,655.28	59,190.73	59,306.71	59,371.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		236,524.41		
431A	SOBRA CHILD < 1 M &	446.25	383.74	320.66	352.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,502.74		
431B	SOBRA CHILD 01-05 M	4,091.48	3,709.51	3,111.72	3,350.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,263.44		
431C	SOBRA CHILD 6-13 M&F	3,855.59	4,029.36	3,035.26	3,207.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,127.79		
431D	SOBRA CHILD 14-20 MA	1,094.86	1,112.84	911.48	886.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,006.04		
431E	SOBRA CHILD 14-20 FE	1,138.00	1,088.17	967.04	896.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,089.50		
4322	SOBRA CHILD 01-05 M	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4323	SOBRA CHILD 06-13 M	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4325	SOBRA CHILD 14-20 FE	1.41	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.41		
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	34.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125.71		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.06		
5015	SOBRA PREG 14-20 FE
M	2,792.94	2,852.61	2,886.25	2,885.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,417.41		
5017	SOBRA PREG 21-44 FE M	15,577.98	15,919.95	16,021.94	16,183.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,703.52		
5018	SOBRA PREG 45-64 FE
M	38.47	49.97	52.57	61.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202.05		
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	199.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		847.01		
501G	SOBRA PREG 21-44 FE M	1,105.01	1,101.06	926.53	904.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,036.70		
501H	SOBRA PREG 45-64 FE
M	0.16	4.86	13.38	3.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.31		
5027	SOBRA PREG 21-44 FE M	32.00	37.00	37.40	36.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143.38		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
SUBTOTAL:	909,956.0	5	913,841.68	911,256.6	1	914,835.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,649,889.54		

3100	TRANSPLANT OPTION 1	4.00	3.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	3.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11.00

11.00

9910	TANF & SOBRA CHILDR E	320.00	331.00	284.00	274.00	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	4.00	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	13.00	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	2,234.00	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	2,525.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,209.00	
21.00	
67.00	
8,835.00	
10,132.00	

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	224.57	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	409.24	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	1,228.75	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	631.88	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	10.53	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	21.09	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	46.96	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	19.59	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	6.00	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	222.71	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	1,470.14	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	26,015.22	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	71,016.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
880.50	
1,692.72	
4,919.58	
2,555.66	
71.68	
95.83	
165.56	
120.25	
1.00	
26.00	
855.71	
5,893.39	
104,983.47	
284,045.37	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 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	24,379.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,505.14		
1119	TANF EXPANDED 65+ M
&	83.32	77.45	77.00	78.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315.92		
111D	TANF EXPANDED 14-20	13.79	6.07	8.58	17.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.54		
111E	TANF EXPANDED 14-20	41.42	29.93	17.44	33.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122.47		
111F	TANF EXPANDED 21-44	718.90	716.67	595.02	637.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,668.27		
111G	TANF EXPANDED 21-44	1,419.51	1,364.36	1,077.59	1,259.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,120.47		
111H	TANF EXPANDED 45-64	496.90	473.74	431.96	405.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,807.74		
111J	TANF EXPANDED 65+ M
&	1.67	2.70	1.00	2.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.70		
1126	TANF EXPANDED 21-44	763.98	778.79	773.55	785.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,101.74		
1127	TANF EXPANDED 21-44	1,658.56	1,669.60	1,651.91	1,644.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,624.11		
1128	TANF EXPANDED 45-64	2,534.08	2,564.62	2,606.17	2,585.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,289.89		
1129	TANF EXPANDED 65+ M
&	1,524.12	1,537.88	1,571.53	1,601.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,235.09		
112F	TANF EXPANDED 21-44	0.00	2.84	7.71	0.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.44		
112G	TANF EXPANDED 21-44	4.97	5.84	5.17	7.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.60		
112H	TANF EXPANDED 45-64	16.91	7.39	3.87	12.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.89		
112J	TANF EXPANDED 65+ M
&	4.82	6.37	6.85	6.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.27		
2400	SSI AGED EXPANDED WI	227.17	239.12	215.13	247.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		928.60		
240Z	SSI AGED EXPANDED
WI	188.57	198.61	194.67	205.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		787.29		
2410	SSI AGED EXPANDED N O	95.13	101.60	93.82	91.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382.45		
241Z	SSI AGED EXPANDED N
O	12.57	0.00	2.16	9.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.37		
2420	SSI AGED EXPANDED WI	26,237.74	26,428.76	26,615.69	26,756.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,038.27		
242Z	SSI AGED EXPANDED
WI	50.54	25.46	32.72	52.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.91		
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2600	SSI DISABLED EXPAND
E	203.51	221.75	186.24	232.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		844.24		
260Z	SSI DISABLED EXPAND E	139.05	119.04	107.14	120.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		486.17		
2610	SSI DISABLED EXPAND
E	1,467.82	1,478.74	1,490.86	1,530.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,967.82		
261Z	SSI DISABLED EXPAND E	33.02	32.33	22.08	23.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.59		
2620	SSI DISABLED EXPAND
E	16,996.27	17,035.00	17,062.79	17,051.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,146.04		
262Z	SSI DISABLED EXPAND E	41.28	27.03	37.78	40.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146.62		
SUBTOTAL:	180,908.2	8	181,437.38	180,791.1	7	181,142.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		724,279.37		

3506	ADULT 40-100% MALE 2	6.00	5.12	6.53	7.41	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	5.51	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	71.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

25.06	
17.45	
287.82	

9911	SB PAYMENT FOR TAN F	203.00	204.00	201.00	158.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	203.00	204.00	201.00	158.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
766.00

766.00

ACC CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 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	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.00		
350F	ADULT 40-100% MALE 2	0.00	0.87	0.86	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.76		
350G	ADULT 40-100% FEMAL E	1.77	2.89	0.36	1.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.49		
350H	ADULT 40-100% M&F 45	4.62	4.08	1.10	1.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.86		
3514	ADULT 40-100% MALE 1	5,628.35	5,645.27	5,650.26	5,745.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,669.25		
3515	ADULT 40-100% FEMAL E	6,154.09	6,255.84	6,190.88	6,225.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,826.32		
3516	ADULT 40-100% MALE 2	18,543.88	18,724.72	18,647.61	18,854.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,770.91		
3517	ADULT 40-100% FEMAL E	15,666.52	15,700.84	15,719.62	15,856.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,943.07		
3518	ADULT 40-100% M&F 45	37,448.72	37,572.65	37,317.67	37,391.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,730.42		
3519	ADULT 40-100% M&F 65	8.00	5.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
351D	ADULT 40-100% MALE 1	107.37	91.34	100.12	93.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.87		
351E	ADULT 40-100% FEMAL E	151.90	141.38	122.28	109.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524.91		
351F	ADULT 40-100% MALE 2	592.51	485.14	409.98	420.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,908.57		
351G	ADULT 40-100% FEMAL E	497.72	447.95	333.43	358.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,638.08		
351H	ADULT 40-100% M&F 45	894.72	807.69	643.72	707.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,053.92		
351J	ADULT 40-100% M&F 65	2.00	1.00	3.00	4.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.46		
3526	ADULT 40-100% MALE 2	0.90	1.41	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.31		
3528	ADULT 40-100% M&F 45	1.80	1.00	1.23	2.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.77		
3529	ADULT 40-100% M&F 65	0.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
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	0.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.19		
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	40.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131.92		
3707	ADULT <40% EXP FEMA L	3.22	7.07	12.16	12.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.37		
3708	ADULT <40% EXP M&F
4	69.28	82.50	84.64	87.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		324.28		
3709	ADULT <40% EXP M&F 6	5.00	9.32	12.00	14.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.67		
370F	ADULT <40% EXP MALE	6.31	6.24	9.97	4.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.02		
370G	ADULT <40% EXP FEMA L	0.77	1.90	1.82	14.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.89		
370H	ADULT <40% EXP M&F
4	10.17	19.09	6.71	4.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.23		
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	10,384.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,987.57		
3715	ADULT <40% EXP FEMA L	9,173.98	9,315.29	9,393.59	9,445.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,328.78		
3716	ADULT <40% EXP MALE	69,372.63	70,752.32	70,889.00	72,351.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283,364.99		
3717	ADULT <40% EXP FEMA L	40,598.88	41,281.54	41,336.24	41,987.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,204.15		
3718	ADULT <40% EXP M&F
4	82,032.08	82,785.12	82,884.26	83,686.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		331,387.93		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 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	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
371D	ADULT <40% EXP MALE	267.37	258.29	210.76	235.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		972.36		
371E	ADULT <40% EXP FEMA L	271.22	220.41	179.21	181.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852.53		
371F	ADULT <40% EXP MALE	2,522.08	2,263.41	1,955.44	2,106.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,847.07		
371G	ADULT <40% EXP FEMA L	1,522.51	1,206.36	1,033.63	1,184.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,946.99		
371H	ADULT <40% EXP M&F
4	2,167.78	1,988.52	1,594.08	1,806.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,557.24		
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	4.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.13		
3727	ADULT <40% EXP FEMA L	2.48	2.00	2.00	3.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.12		
3728	ADULT <40% EXP M&F
4	0.00	3.00	3.20	3.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.13		
372F	ADULT <40% EXP MALE	2.46	0.00	0.00	2.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.10		
372G	ADULT <40% EXP FEMA L	0.51	1.00	0.00	0.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.82		
372H	ADULT <40% EXP M&F
4	0.00	0.00	0.73	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.79		
SUBTOTAL:	303,949.6	1	306,439.32	305,225.7	5	309,463.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,225,077.91		

3906	NEWLY ELIGIBLE MALE	13.21	15.49	16.06	16.36	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	4.00	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	80.91	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	34.00	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	0.29	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	1.00	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	7.04	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	3,256.63	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	3,677.55	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	17,013.38	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	25,619.45	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	25,817.83	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	1.00	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	56.10	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	77.04	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	550.66	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	786.17	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	625.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

61.12	
14.61	
291.33	
108.00	
3.47	
2.38	
46.09	
12,564.68	
14,469.78	
68,101.91	
102,282.89	
103,012.70	
5.00	
268.96	
382.02	
2,305.86	
3,426.33	
2,639.21	

9935	BIRTH SUPP PAYMENT A	26.00	43.00	38.00	22.00	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	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	106.00	120.00	121.0	0	107.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
129.00	
325.00	
454.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.64		
3927	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
3928	NEWLY ELIGIBLE M&F
4	0.00	1.00	1.00	1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.93		
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		
392H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.06		
SUBTOTAL:	77,486.10	77,850.76	77,034.2	0	77,629.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310,000.31		

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	40,304.10	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	11,512.04	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	11,269.60	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	847.55	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	225.00	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	205.40	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	64,363.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.77	
164,115.68	
46,764.55	
45,361.27	
0.22	
3,839.74	
1,089.52	
992.73	
262,164.48	

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

20.00

20.00

9939	BIRTH SUPP PAYMENT N	49.00	63.00	53.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.00	63.00	53.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
229.00

229.00

4517	BC PATIENT FEMALE 2 1	22.89	24.00	24.36	27.70	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	127.19	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	4.28	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	10.71	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	7.41	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	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	7.58	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	184.49	170.89	169.9	7	196.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
98.95	
506.85	
0.58	
10.99	
31.87	
30.41	
31.26	
7.58	
3.73	
722.22	

8600	SSI BLIND FREEDOM/W O	2.00	2.00	1.00	1.00	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	1.00	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	2,074.99	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	97.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6.00	
4.00	
8,324.51	
389.07	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	376.44	361.22	348.08	354.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,440.50		
871Z	SSI DISABLED FREEDO
M	21.21	26.48	28.40	13.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89.24		
8720	SSI DISABLED FREEDO M	342.00	333.87	331.87	341.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,349.53		
872Z	SSI DISABLED FREEDO
M	4.53	3.47	11.18	10.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.48		
SUBTOTAL:	2,904.59	2,912.52	2,920.98	2,894.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,632.33		

6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.90	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.90	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.90

1.90

TOTAL:	1,544,822.48	1,552,043.21	1,545,129.35	1,553,385.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,195,380.06		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	33.40	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	33.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100.20		
1011	TANF <1 M & F NON-ME	1,753.50	1,803.60	1,820.30	1,870.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,247.80		
1012	TANF 01-05 M & F NON	1,402.80	1,469.60	1,786.90	1,803.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,462.90		
1013	TANF 06-13 M & F NON	1,285.90	1,369.40	1,603.20	1,670.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,928.50		
1014	TANF 14-20 MALE NON-	334.00	450.90	467.60	484.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,736.80		
1015	TANF 14-20 FEMALE N O	484.30	467.60	467.60	534.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,953.90		
1016	TANF 21-44 MALE NON-	1,419.50	1,553.10	1,937.20	2,271.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,181.00		
1017	TANF 21-44 FEMALE N O	5,761.50	6,496.30	7,565.10	8,249.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,072.70		
1018	TANF 45-64 M & F NON	2,638.60	2,772.20	3,056.10	3,189.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,656.60		
1019	TANF 65+ M & F NON-M	0.00	0.00	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.40		
1026	TANF 21-44 MALE WITH	0.00	16.70	16.70	33.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.70		
2100	SSI AGED WITH MEDIC A	83.50	133.60	133.60	133.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		484.30		
2110	SSI AGED NON-MEDICA
R	116.90	116.90	200.40	267.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		701.40		
2120	SSI AGED WITH QMB	1,035.40	1,169.00	1,269.20	1,402.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,876.40		
2200	SSI DISABLED WITH M E	400.80	467.60	517.70	567.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,953.90		
2210	SSI DISABLED NON-ME
D	6,379.40	7,047.40	7,849.00	8,750.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,026.60		
2220	SSI DISABLED WITH Q M	2,271.20	2,338.00	2,538.40	2,738.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,886.40		
2310	SSI BLIND NON-MEDIC
A	66.80	66.80	83.50	100.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		317.30		
2320	SSI BLIND WITH QMB	16.70	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
4311	SOBRA CHILD <1 M & F	4,876.40	4,809.60	5,160.30	5,394.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,240.40		
4312	SOBRA CHILD 01-05 M	14,762.80	16,416.10	18,169.60	19,505.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,854.10		
4313	SOBRA CHILD 06-13 M	14,094.80	16,132.20	17,985.90	19,438.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,651.70		
4314	SOBRA CHILD 14-20 MA	2,822.30	3,039.40	3,573.80	3,757.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,193.00		
4315	SOBRA CHILD 14-20 FE	2,922.50	3,306.60	4,024.70	4,408.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,662.60		
5015	SOBRA PREG 14-20 FE M	116.90	116.90	100.20	83.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417.50		
5017	SOBRA PREG 21-44 FE
M	751.50	651.30	718.10	651.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,772.20		
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	87,391.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		306,678.80		

1108	TANF EXPANDED 45-64	33.40	33.40	50.10	83.50	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	183.70	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	33.40	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	83.50	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	1,603.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
200.40	
617.90	
133.60	
317.30	
4,993.30	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	3,306.60	3,774.20	4,024.70	4,759.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,865.00		
1118	TANF EXPANDED 45-64	1,987.30	2,271.20	2,404.80	2,638.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,301.90		
1119	TANF EXPANDED 65+ M
&	16.70	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
1126	TANF EXPANDED 21-44	50.10	50.10	66.80	83.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250.50		
1127	TANF EXPANDED 21-44	66.80	66.80	83.50	66.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283.90		
1128	TANF EXPANDED 45-64	350.70	334.00	317.30	367.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,369.40		
1129	TANF EXPANDED 65+ M
&	250.50	233.80	233.80	250.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		968.60		
2420	SSI AGED EXPANDED WI	1,452.90	1,753.50	1,920.50	1,987.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,114.20		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.70		
2610	SSI DISABLED EXPAND E	133.60	150.30	200.40	183.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		668.00		
2620	SSI DISABLED EXPAND
E	751.50	768.20	784.90	851.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,156.30		
SUBTOTAL:	9,519.00	10,838.30	11,756.8	0	13,209.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,323.80		

4413	SOBRA 100-133% M&F
6	1,786.90	1,887.10	2,271.20	2,204.40	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	534.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3908	NEWLY ELIGIBLE M&F 4	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	33.40	50.10	83.50	83.50	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	167.00	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	567.80	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	968.60	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	2,020.70	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	3,807.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.70	
250.50	
484.30	
2,020.70	
3,607.20	
7,398.10	
13,777.50	

8,149.60

3514	ADULT 40-100% MALE 1	83.50	133.60	150.30	150.30	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	200.40	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	935.20	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	851.70	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	3,340.00	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	16.70	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	517.70	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	634.60	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	6,930.50	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	4,475.60	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	10,253.80	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	28,306.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
517.70	
718.10	
3,156.30	
3,089.50	
11,957.20	
16.70	
33.40	
33.40	
1,703.40	
2,120.90	
24,398.70	
14,996.60	
36,706.60	
99,448.50	

1,736.80

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	334.00	400.80	450.90	417.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,603.20		
SUBTOTAL:	2,438.20	2,705.40	3,189.70	3,156.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,489.60		

8700	SSI DISABLED FREEDO M	50.10	83.50	83.50	50.10	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	50.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

267.20	
50.10	
33.40	
350.70	

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

 
50.10

50.10

477,119.00

102,037.00	113,059.00	126,085.00	135,938.00	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	2.00	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1011	TANF <1 M & F NON-ME	105.00	108.00	109.00	112.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		434.00		
1012	TANF 01-05 M & F NON	84.00	88.00	107.00	108.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		387.00		
1013	TANF 06-13 M & F NON	77.00	82.00	96.00	100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355.00		
1014	TANF 14-20 MALE NON-	20.00	27.00	28.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.00		
1015	TANF 14-20 FEMALE N O	29.00	28.00	28.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117.00		
1016	TANF 21-44 MALE NON-	85.00	93.00	116.00	136.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		430.00		
1017	TANF 21-44 FEMALE N O	345.00	389.00	453.00	494.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,681.00		
1018	TANF 45-64 M & F NON	158.00	166.00	183.00	191.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		698.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1026	TANF 21-44 MALE WITH	0.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2100	SSI AGED WITH MEDIC A	5.00	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
2110	SSI AGED NON-MEDICA
R	7.00	7.00	12.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.00		
2120	SSI AGED WITH QMB	62.00	70.00	76.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292.00		
2200	SSI DISABLED WITH M E	24.00	28.00	31.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117.00		
2210	SSI DISABLED NON-ME
D	382.00	422.00	470.00	524.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,798.00		
2220	SSI DISABLED WITH Q M	136.00	140.00	152.00	164.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		592.00		
2310	SSI BLIND NON-MEDIC
A	4.00	4.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4311	SOBRA CHILD <1 M & F	292.00	288.00	309.00	323.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,212.00		
4312	SOBRA CHILD 01-05 M	884.00	983.00	1,088.00	1,168.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,123.00		
4313	SOBRA CHILD 06-13 M	844.00	966.00	1,077.00	1,164.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,051.00		
4314	SOBRA CHILD 14-20 MA	169.00	182.00	214.00	225.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		790.00		
4315	SOBRA CHILD 14-20 FE	175.00	198.00	241.00	264.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		878.00		
5015	SOBRA PREG 14-20 FE M	7.00	7.00	6.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
5017	SOBRA PREG 21-44 FE
M	45.00	39.00	43.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.00		
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	5,233.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,364.00		

1108	TANF EXPANDED 45-64	2.00	2.00	3.00	5.00	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	11.00	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	2.00	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	5.00	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	96.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12.00	
37.00	
8.00	
19.00	
299.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	198.00	226.00	241.00	285.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		950.00		
1118	TANF EXPANDED 45-64	119.00	136.00	144.00	158.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		557.00		
1119	TANF EXPANDED 65+ M
&	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1126	TANF EXPANDED 21-44	3.00	3.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
1127	TANF EXPANDED 21-44	4.00	4.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
1128	TANF EXPANDED 45-64	21.00	20.00	19.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.00		
1129	TANF EXPANDED 65+ M
&	15.00	14.00	14.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.00		
2420	SSI AGED EXPANDED WI	87.00	105.00	115.00	119.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		426.00		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2610	SSI DISABLED EXPAND E	8.00	9.00	12.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.00		
2620	SSI DISABLED EXPAND
E	45.00	46.00	47.00	51.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189.00		
SUBTOTAL:	570.00	649.00	704.0	0	791.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,714.00		

4413	SOBRA 100-133% M&F
6	107.00	113.00	136.00	132.00	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	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	5.00	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	10.00	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	34.00	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	58.00	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	121.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	177.00	201.00	219.0	0	228.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
15.00	
29.00	
121.00	
216.00	
443.00	
825.00	

488.00

3514	ADULT 40-100% MALE 1	5.00	8.00	9.00	9.00	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	12.00	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	56.00	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	51.00	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	200.00	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	1.00	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	31.00	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	38.00	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	415.00	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	268.00	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	614.00	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	1,695.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
31.00	
43.00	
189.00	
185.00	
716.00	
1.00	
2.00	
2.00	
102.00	
127.00	
1,461.00	
898.00	
2,198.00	
5,955.00	

104.00

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	20.00	24.00	27.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96.00		
SUBTOTAL:	146.00	162.00	191.00	189.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		688.00		

8700	SSI DISABLED FREEDO M	3.00	5.00	5.00	3.00	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	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.00	
3.00	
2.00	
21.00	

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

 
3.00

3.00

TOTAL:	6,110.00	6,770.00	7,550.00	8,140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,570.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	22.71	22.71	0.00	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.13		
1008	TANF 45-64 M & F WIT	22.71	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.97		
1009	TANF 65+ M & F WITH	22.71	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.84		
1011	TANF <1 M & F NON-ME	204.39	204.39	181.68	181.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		772.14		
1012	TANF 01-05 M & F NON	431.49	545.04	499.62	522.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,998.48		
1013	TANF 06-13 M & F NON	408.78	431.49	408.78	522.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,771.38		
1014	TANF 14-20 MALE NON-	22.71	45.42	68.13	136.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272.52		
1015	TANF 14-20 FEMALE N O	181.68	295.23	363.36	363.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,203.63		
1016	TANF 21-44 MALE NON-	567.75	681.30	681.30	681.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,611.65		
1017	TANF 21-44 FEMALE N O	4,428.45	4,791.81	4,905.36	5,155.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,280.79		
1018	TANF 45-64 M & F NON	1,544.28	1,612.41	1,748.67	1,703.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,608.61		
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		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	22.71	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	204.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		772.14		
2110	SSI AGED NON-MEDICA
R	45.42	45.42	68.13	68.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227.10		
2120	SSI AGED WITH QMB	1,975.77	2,112.03	2,157.45	2,429.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,675.22		
2200	SSI DISABLED WITH M E	681.30	704.01	749.43	749.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,884.17		
2210	SSI DISABLED NON-ME
D	4,110.51	4,428.45	4,610.13	4,950.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,099.87		
2220	SSI DISABLED WITH Q M	2,861.46	3,020.43	3,156.69	3,292.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,331.53		
2310	SSI BLIND NON-MEDIC
A	22.71	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.97		
2320	SSI BLIND WITH QMB	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.68		
4311	SOBRA CHILD <1 M & F	908.40	953.82	749.43	749.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,361.08		
4312	SOBRA CHILD 01-05 M	5,473.11	5,813.76	6,358.80	6,608.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,254.28		
4313	SOBRA CHILD 06-13 M	4,678.26	5,518.53	5,904.60	6,313.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,414.77		
4314	SOBRA CHILD 14-20 MA	976.53	1,226.34	1,294.47	1,317.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,814.52		
4315	SOBRA CHILD 14-20 FE	1,657.83	1,725.96	1,907.64	2,021.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,312.62		
5015	SOBRA PREG 14-20 FE M	113.55	113.55	90.84	90.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408.78		
5017	SOBRA PREG 21-44 FE
M	1,021.95	1,135.50	1,317.18	1,385.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,859.94		
SUBTOTAL:	32,611.56	35,768.25	37,607.7	6	39,651.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,639.23		

1108	TANF EXPANDED 45-64	45.42	45.42	45.42	45.42	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	22.71	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	22.71	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	249.81	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	3,270.24	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	1,680.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
181.68	
90.84	
68.13	
1,044.66	
12,490.50	
6,267.96	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	22.71	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.84		
1128	TANF EXPANDED 45-64	90.84	113.55	158.97	181.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		545.04		
1129	TANF EXPANDED 65+ M
&	249.81	295.23	295.23	295.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,135.50		
2410	SSI AGED EXPANDED N O	22.71	22.71	22.71	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.55		
2420	SSI AGED EXPANDED
WI	1,703.25	1,884.93	1,930.35	2,021.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,539.72		
2610	SSI DISABLED EXPAND E	68.13	45.42	22.71	90.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227.10		
2620	SSI DISABLED EXPAND
E	567.75	567.75	613.17	613.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,361.84		
SUBTOTAL:	7,448.88	7,903.08	8,243.73	8,561.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,157.36		

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

3908	NEWLY ELIGIBLE M&F 4	22.71	45.42	22.71	22.71	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	22.71	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	68.13	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	22.71	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	113.55	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	794.85	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	1,158.21	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	2,202.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

113.55	
45.42	
227.10	
68.13	
613.17	
2,793.33	
4,519.29	
8,379.99	

4413	SOBRA 100-133% M&F
6	386.07	363.36	476.91	545.04	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	181.68	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	204.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	635.88	681.30	862.9	8	931.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,771.38	
658.59	
681.30	
3,111.27	

90.84

3514	ADULT 40-100% MALE 1	136.26	113.55	113.55	68.13	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	340.65	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	386.07	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	499.62	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	1,771.38	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	22.71	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	272.52	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	431.49	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	2,316.42	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	1,771.38	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	6,744.87	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	14,625.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
431.49	
1,180.92	
1,566.99	
1,566.99	
6,835.71	
90.84	
885.69	
1,408.02	
8,289.15	
6,835.71	
25,117.26	
54,208.77	

90.84

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8700	SSI DISABLED FREEDO M	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.68		
8710	SSI DISABLED FREEDO
M	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.68		
SUBTOTAL:	90.84	90.84	90.84	90.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		363.36		

22.71

63,042.96

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

66,086.10

243,973.53

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

TOTAL:

54,821.94

60,022.53

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1008	TANF 45-64 M & F WIT	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1009	TANF 65+ M & F WITH	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1011	TANF <1 M & F NON-ME	9.00	9.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00		
1012	TANF 01-05 M & F NON	19.00	24.00	22.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.00		
1013	TANF 06-13 M & F NON	18.00	19.00	18.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.00		
1014	TANF 14-20 MALE NON-	1.00	2.00	3.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1015	TANF 14-20 FEMALE N O	8.00	13.00	16.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53.00		
1016	TANF 21-44 MALE NON-	25.00	30.00	30.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.00		
1017	TANF 21-44 FEMALE N O	195.00	211.00	216.00	227.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		849.00		
1018	TANF 45-64 M & F NON	68.00	71.00	77.00	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		291.00		
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		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2100	SSI AGED WITH MEDIC A	8.00	8.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00		
2110	SSI AGED NON-MEDICA
R	2.00	2.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
2120	SSI AGED WITH QMB	87.00	93.00	95.00	107.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382.00		
2200	SSI DISABLED WITH M E	30.00	31.00	33.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.00		
2210	SSI DISABLED NON-ME
D	181.00	195.00	203.00	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		797.00		
2220	SSI DISABLED WITH Q M	126.00	133.00	139.00	145.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		543.00		
2310	SSI BLIND NON-MEDIC
A	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2320	SSI BLIND WITH QMB	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
4311	SOBRA CHILD <1 M & F	40.00	42.00	33.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148.00		
4312	SOBRA CHILD 01-05 M	241.00	256.00	280.00	291.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,068.00		
4313	SOBRA CHILD 06-13 M	206.00	243.00	260.00	278.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		987.00		
4314	SOBRA CHILD 14-20 MA	43.00	54.00	57.00	58.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		212.00		
4315	SOBRA CHILD 14-20 FE	73.00	76.00	84.00	89.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322.00		
5015	SOBRA PREG 14-20 FE M	5.00	5.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
5017	SOBRA PREG 21-44 FE
M	45.00	50.00	58.00	61.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		214.00		
SUBTOTAL:	1,436.00	1,575.00	1,656.00	1,746.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,413.00		

1108	TANF EXPANDED 45-64	2.00	2.00	2.00	2.00	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	1.00	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	1.00	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	11.00	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	144.00	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	74.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8.00	
4.00	
3.00	
46.00	
550.00	
276.00	

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1128	TANF EXPANDED 45-64	4.00	5.00	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
1129	TANF EXPANDED 65+ M
&	11.00	13.00	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.00		
2410	SSI AGED EXPANDED N O	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2420	SSI AGED EXPANDED
WI	75.00	83.00	85.00	89.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332.00		
2610	SSI DISABLED EXPAND E	3.00	2.00	1.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
2620	SSI DISABLED EXPAND
E	25.00	25.00	27.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.00		
SUBTOTAL:	328.00	348.00	363.0	0	377.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,416.00		

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

3908	NEWLY ELIGIBLE M&F 4	1.00	2.00	1.00	1.00	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	1.00	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	3.00	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	1.00	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	5.00	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	35.00	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	51.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	86.00	92.00	94.00	97.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.00	
2.00	
10.00	
3.00	
27.00	
123.00	
199.00	
369.00	

4413	SOBRA 100-133% M&F
6	17.00	16.00	21.00	24.00	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	8.00	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	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28.00	30.00	38.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

78.00	
29.00	
30.00	
137.00	

4.00

3514	ADULT 40-100% MALE 1	6.00	5.00	5.00	3.00	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	15.00	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	17.00	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	22.00	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	78.00	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	1.00	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	12.00	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	19.00	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	102.00	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	78.00	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	297.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	531.00	592.00	620.0	0	644.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19.00	
52.00	
69.00	
69.00	
301.00	
4.00	
39.00	
62.00	
365.00	
301.00	
1,106.00	
2,387.00	

4.00

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8700	SSI DISABLED FREEDO M	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
8710	SSI DISABLED FREEDO
M	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
SUBTOTAL:	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		

1.00

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

TOTAL:	2,414.00	2,643.00	2,776.00	2,910.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,743.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	49.80	49.80	49.80	74.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224.10		
1009	TANF 65+ M & F WITH	49.80	49.80	74.70	74.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249.00		
1011	TANF <1 M & F NON-ME	1,045.80	946.20	1,045.80	1,095.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,133.40		
1012	TANF 01-05 M & F NON	2,191.20	1,992.00	2,116.50	2,365.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,665.20		
1013	TANF 06-13 M & F NON	2,340.60	2,539.80	2,714.10	2,838.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,433.10		
1014	TANF 14-20 MALE NON-	423.30	597.60	771.90	821.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,614.50		
1015	TANF 14-20 FEMALE N O	1,767.90	1,767.90	1,992.00	2,041.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,569.60		
1016	TANF 21-44 MALE NON-	6,474.00	6,548.70	6,648.30	6,623.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,294.40		
1017	TANF 21-44 FEMALE N O	23,904.00	24,053.40	24,800.40	24,974.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,732.50		
1018	TANF 45-64 M & F NON	7,519.80	7,445.10	7,569.60	7,768.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,303.30		
1019	TANF 65+ M & F NON-M	24.90	24.90	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149.40		
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	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.30		
1029	TANF 65+ M & F WITH	24.90	24.90	0.00	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.70		
2100	SSI AGED WITH MEDIC A	1,444.20	1,469.10	1,444.20	1,494.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,851.50		
2110	SSI AGED NON-MEDICA
R	199.20	174.30	199.20	149.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		722.10		
2120	SSI AGED WITH QMB	5,229.00	5,453.10	5,453.10	5,577.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,712.80		
2200	SSI DISABLED WITH M E	3,336.60	3,560.70	3,635.40	3,685.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,217.90		
2210	SSI DISABLED NON-ME
D	18,077.40	18,351.30	18,525.60	18,774.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,728.90		
2220	SSI DISABLED WITH Q M	8,341.50	8,490.90	8,715.00	8,839.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,386.90		
2300	SSI BLIND WITH MEDIC	49.80	49.80	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149.40		
2310	SSI BLIND NON-MEDIC A	273.90	298.80	298.80	323.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,195.20		
2320	SSI BLIND WITH QMB	99.60	99.60	124.50	124.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		448.20		
4311	SOBRA CHILD <1 M & F	3,884.40	3,610.50	3,411.30	3,311.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,217.90		
4312	SOBRA CHILD 01-05 M	31,847.10	32,046.30	32,768.40	32,793.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129,455.10		
4313	SOBRA CHILD 06-13 M	42,330.00	44,421.60	45,865.80	46,363.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178,981.20		
4314	SOBRA CHILD 14-20 MA	10,034.70	10,308.60	11,080.50	11,329.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,753.30		
4315	SOBRA CHILD 14-20 FE	11,727.90	12,300.60	12,450.00	12,798.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,277.10		
5007	SOBRA PREG 21-44 FE M	0.00	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.70		
5013	SOBRA PREG 09-13 FE
M	24.90	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
5015	SOBRA PREG 14-20 FE M	473.10	522.90	572.70	597.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,166.30		
5017	SOBRA PREG 21-44 FE
M	2,838.60	2,888.40	2,863.50	2,863.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,454.00		
5018	SOBRA PREG 45-64 FE M	24.90	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
SUBTOTAL:	186,102.6	0	190,236.00	195,440.1	0	197,905.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		769,683.90		

1106

TANF EXPANDED 21-44

24.90

24.90

24.90

24.90

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

99.60

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending October 31, 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	224.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		946.20		
1109	TANF EXPANDED 65+ M
&	174.30	199.20	174.30	174.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		722.10		
1113	TANF EXPANDED 06-13	0.00	0.00	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
1115	TANF EXPANDED 14-20	249.00	224.10	174.30	174.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		821.70		
1116	TANF EXPANDED 21-44	3,237.00	3,212.10	3,361.50	3,436.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,246.80		
1117	TANF EXPANDED 21-44	9,935.10	10,134.30	10,308.60	10,731.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,109.90		
1118	TANF EXPANDED 45-64	5,004.90	4,955.10	4,880.40	5,004.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,845.30		
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	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		398.40		
1127	TANF EXPANDED 21-44	249.00	224.10	224.10	224.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		921.30		
1128	TANF EXPANDED 45-64	498.00	547.80	597.60	547.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,191.20		
1129	TANF EXPANDED 65+ M
&	498.00	498.00	522.90	547.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,066.70		
2410	SSI AGED EXPANDED N O	99.60	99.60	99.60	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		398.40		
2420	SSI AGED EXPANDED
WI	3,311.70	3,486.00	3,436.20	3,535.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,769.70		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
2610	SSI DISABLED EXPAND
E	124.50	174.30	149.40	149.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		597.60		
2620	SSI DISABLED EXPAND E	1,593.60	1,643.40	1,718.10	1,718.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,673.20		
SUBTOTAL:	25,373.10	25,796.40	26,020.5	0	26,742.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,932.60		

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	273.90	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	249.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

49.80	
24.90	
996.00	
1,220.10	

3508	ADULT 40-100% M&F 45	0.00	24.90	0.00	24.90	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	498.00	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	771.90	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	1,419.30	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	1,070.70	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	4,158.30	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	24.90	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	2,739.00	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	3,037.80	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	20,667.00	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	10,034.70	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	20,517.60	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	64,964.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
49.80	
1,718.10	
2,763.90	
5,353.50	
4,482.00	
15,836.40	
99.60	
10,458.00	
11,503.80	
76,891.20	
38,619.90	
79,381.20	
247,157.40	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	1,269.90	1,369.50	1,394.40	1,294.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,328.60		
3917	NEWLY ELIGIBLE FEMA L	2,589.60	2,639.40	2,465.10	2,365.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,059.60		
3918	NEWLY ELIGIBLE M&F
4	2,913.30	2,963.10	3,187.20	3,261.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,325.50		
SUBTOTAL:	7,345.50	7,594.50	7,619.40	7,445.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,004.50		

8710	SSI DISABLED FREEDO M	49.80	49.80	49.80	74.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.80	49.80	49.80	74.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

224.10

224.10

4413	SOBRA 100-133% M&F
6	2,813.70	2,938.20	2,913.30	2,963.10	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	1,095.60	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	996.00	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	5,054.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,628.30	
4,307.70	
4,033.80	
19,969.80	

1,170,972.30

282,341.10	289,761.30	296,683.50	302,186.40	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1009	TANF 65+ M & F WITH	2.00	2.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1011	TANF <1 M & F NON-ME	42.00	38.00	42.00	44.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.00		
1012	TANF 01-05 M & F NON	88.00	80.00	85.00	95.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		348.00		
1013	TANF 06-13 M & F NON	94.00	102.00	109.00	114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		419.00		
1014	TANF 14-20 MALE NON-	17.00	24.00	31.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105.00		
1015	TANF 14-20 FEMALE N O	71.00	71.00	80.00	82.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		304.00		
1016	TANF 21-44 MALE NON-	260.00	263.00	267.00	266.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,056.00		
1017	TANF 21-44 FEMALE N O	960.00	966.00	996.00	1,003.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,925.00		
1018	TANF 45-64 M & F NON	302.00	299.00	304.00	312.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,217.00		
1019	TANF 65+ M & F NON-M	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1029	TANF 65+ M & F WITH	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2100	SSI AGED WITH MEDIC A	58.00	59.00	58.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		235.00		
2110	SSI AGED NON-MEDICA
R	8.00	7.00	8.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
2120	SSI AGED WITH QMB	210.00	219.00	219.00	224.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		872.00		
2200	SSI DISABLED WITH M E	134.00	143.00	146.00	148.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		571.00		
2210	SSI DISABLED NON-ME
D	726.00	737.00	744.00	754.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,961.00		
2220	SSI DISABLED WITH Q M	335.00	341.00	350.00	355.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,381.00		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2310	SSI BLIND NON-MEDIC A	11.00	12.00	12.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.00		
2320	SSI BLIND WITH QMB	4.00	4.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
4311	SOBRA CHILD <1 M & F	156.00	145.00	137.00	133.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		571.00		
4312	SOBRA CHILD 01-05 M	1,279.00	1,287.00	1,316.00	1,317.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,199.00		
4313	SOBRA CHILD 06-13 M	1,700.00	1,784.00	1,842.00	1,862.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,188.00		
4314	SOBRA CHILD 14-20 MA	403.00	414.00	445.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,717.00		
4315	SOBRA CHILD 14-20 FE	471.00	494.00	500.00	514.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,979.00		
5007	SOBRA PREG 21-44 FE M	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
5013	SOBRA PREG 09-13 FE
M	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
5015	SOBRA PREG 14-20 FE M	19.00	21.00	23.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.00		
5017	SOBRA PREG 21-44 FE
M	114.00	116.00	115.00	115.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		460.00		
5018	SOBRA PREG 45-64 FE M	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
SUBTOTAL:	7,474.00	7,640.00	7,849.00	7,948.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,911.00		

1106

TANF EXPANDED 21-44

1.00

1.00

1.00

1.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

4.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending October 31, 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	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.00		
1109	TANF EXPANDED 65+ M
&	7.00	8.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
1113	TANF EXPANDED 06-13	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1115	TANF EXPANDED 14-20	10.00	9.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
1116	TANF EXPANDED 21-44	130.00	129.00	135.00	138.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		532.00		
1117	TANF EXPANDED 21-44	399.00	407.00	414.00	431.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,651.00		
1118	TANF EXPANDED 45-64	201.00	199.00	196.00	201.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		797.00		
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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
1127	TANF EXPANDED 21-44	10.00	9.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.00		
1128	TANF EXPANDED 45-64	20.00	22.00	24.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.00		
1129	TANF EXPANDED 65+ M
&	20.00	20.00	21.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.00		
2410	SSI AGED EXPANDED N O	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
2420	SSI AGED EXPANDED
WI	133.00	140.00	138.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		553.00		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2610	SSI DISABLED EXPAND
E	5.00	7.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
2620	SSI DISABLED EXPAND E	64.00	66.00	69.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268.00		
SUBTOTAL:	1,019.00	1,036.00	1,045.00	1,074.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,174.00		

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	11.00	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	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
1.00	
40.00	
49.00	

3508	ADULT 40-100% M&F 45	0.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	16.00	17.00	16.00	20.00	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	31.00	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	57.00	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	43.00	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	167.00	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	1.00	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	110.00	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	122.00	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	830.00	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	403.00	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	824.00	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	2,609.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
69.00	
111.00	
215.00	
180.00	
636.00	
4.00	
420.00	
462.00	
3,088.00	
1,551.00	
3,188.00	
9,926.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	51.00	55.00	56.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		214.00		
3917	NEWLY ELIGIBLE FEMA L	104.00	106.00	99.00	95.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		404.00		
3918	NEWLY ELIGIBLE M&F
4	117.00	119.00	128.00	131.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		495.00		
SUBTOTAL:	295.00	305.00	306.0	0	299.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,205.00		

8710	SSI DISABLED FREEDO M	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9.00

9.00

4413	SOBRA 100-133% M&F
6	113.00	118.00	117.00	119.00	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	44.00	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	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	191.00	203.00	205.0	0	203.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
467.00	
173.00	
162.00	
802.00	

TOTAL:	11,339.00	11,637.00	11,915.00	12,136.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,027.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	8,388.64	12,582.96	8,388.64	19,010.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,370.76		
1010	TANF NON-MEDICARE	1,661,849.71	1,910,910.01	2,172,000.39	2,518,290.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,263,051.09		
1020	TANF WITH QMB	20,971.60	20,971.60	20,971.60	19,010.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,925.32		
2100	SSI AGED WITH MEDIC A	35,053,635.97	35,173,656.27	35,192,043.97	39,134,738.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,554,074.23		
210Z	SSI AGED WITH MEDIC
A	1,732,093.67	1,894,450.16	1,631,535.03	2,025,571.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,283,650.58		
2110	SSI AGED NON-MEDICA R	3,603,820.94	3,588,951.22	3,571,776.99	4,155,910.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,920,460.06		
211Z	SSI AGED NON-MEDICA
R	101,176.43	20,587.31	54,593.15	170,167.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		346,524.33		
2120	SSI AGED WITH QMB	26,288,894.99	26,531,693.06	26,919,643.96	29,858,898.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,599,130.88		
212Z	SSI AGED WITH QMB P P	53,559.58	52,446.69	41,429.50	22,115.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,551.04		
2200	SSI DISABLED WITH M
E	15,658,939.46	15,620,560.12	15,526,866.46	17,415,845.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,222,211.05		
220Z	SSI DISABLED WITH M E	241,491.30	210,523.92	148,685.65	226,958.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		827,658.98		
2210	SSI DISABLED NON-ME
D	136,360,868.15	136,890,501.12	137,407,556.47	156,969,550.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567,628,475.98		
221Z	SSI DISABLED NON-ME D	220,330.68	212,099.65	164,951.73	216,450.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		813,832.26		
2220	SSI DISABLED WITH Q
M	29,326,623.98	29,529,057.68	29,688,987.13	33,510,873.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,055,542.00		
222Z	SSI DISABLED WITH Q M	36,101.66	3,297.05	17,224.42	15,278.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,902.06		
2300	SSI BLIND WITH MEDIC	2,719.44	2,719.44	212.67	165.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,816.55		
2310	SSI BLIND NON-MEDIC A	108,525.41	110,540.42	91,578.43	100,852.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		411,496.53		
2320	SSI BLIND WITH QMB	20,374.22	15,937.16	9,369.05	12,502.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,183.28		
SUBTOTAL:	250,500,365.83	251,801,485.84	252,667,815.24	286,392,190.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,041,361,856.98		

8700	SSI DISABLED FREEDO M	155,943.28	136,803.98	166,698.11	213,746.58	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	10,001.70	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	260,157.44	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	73,682.35	91,359.01	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	468,858.7	2	575,264.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
673,191.95	
17,624.88	
870,966.56	
24,777.45	
282,321.43	
290.41	
1,869,172.68	

1,043,231,029.66

250,917,794.02	252,209,106.88	253,136,673.96	286,967,454.80	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 October 31, 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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
1010	TANF NON-MEDICARE	393.91	454.32	516.92	526.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,891.73		
1020	TANF WITH QMB	5.00	5.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
2100	SSI AGED WITH MEDIC A	11,901.36	11,949.18	11,925.57	12,001.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,777.43		
210Z	SSI AGED WITH MEDIC
A	562.03	623.08	527.53	634.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,347.55		
2110	SSI AGED NON-MEDICA R	611.47	610.68	604.51	598.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,425.33		
211Z	SSI AGED NON-MEDICA
R	16.60	3.70	9.02	26.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.34		
2120	SSI AGED WITH QMB	9,350.65	9,436.56	9,532.55	9,570.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,890.47		
212Z	SSI AGED WITH QMB P P	17.29	17.74	14.71	7.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.48		
2200	SSI DISABLED WITH M
E	4,466.83	4,466.23	4,430.22	4,447.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,811.18		
220Z	SSI DISABLED WITH M E	78.72	70.28	48.18	70.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267.66		
2210	SSI DISABLED NON-ME
D	30,896.55	31,019.03	31,105.49	31,176.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,198.02		
221Z	SSI DISABLED NON-ME D	35.96	35.18	26.20	33.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131.17		
2220	SSI DISABLED WITH Q
M	7,937.60	7,999.85	8,044.45	8,080.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,062.45		
222Z	SSI DISABLED WITH Q M	11.96	1.08	5.01	4.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.77		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2310	SSI BLIND NON-MEDIC A	24.00	24.64	22.40	21.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.36		
2320	SSI BLIND WITH QMB	6.00	4.99	3.00	4.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.62		
SUBTOTAL:	66,319.93	66,726.54	66,823.7	6	67,215.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267,085.56		

8700	SSI DISABLED FREEDO M	42.00	36.25	45.99	51.93	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	2.99	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	38.00	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	21.96	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	114.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
176.17	
5.73	
140.49	
3.48	
73.85	
0.10	
399.82	

TOTAL:	66,411.91	66,814.51	66,928.75	67,330.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267,485.38		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	360.61	0.00	368.93	21.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		750.97		
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	-639.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-30.08		
2210	SSI DISABLED NON-ME
D	0.00	305.69	0.00	-752.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-447.13		
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	-70.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,964.42		
4312	SOBRA CHILD 01-05 M	-100.40	1,427.57	203.97	1,154.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,685.47		
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	16.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.81		
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	-270.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,474.95		

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

1,880.84

864.84	2,316.93	-1,030.86	-270.07	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	27,128.70	27,368.37	30,877.78	30,079.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,453.89		
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	913.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,142.94		
1018	TANF 45-64 M & F NON	0.00	0.00	20,190.63	1,223.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,414.29		
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	83.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,055.46		
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	1,436.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,560.33		
210Z	SSI AGED WITH MEDIC
A	0.00	0.00	0.00	10,618.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,618.52		
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	8,135.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,689.67		
2200	SSI DISABLED WITH M E	6,705.80	6,218.03	9,375.73	5,561.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,860.60		
220Z	SSI DISABLED WITH M
E	1,230.03	0.00	1,706.25	2,617.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,553.61		
2210	SSI DISABLED NON-ME D	191,817.13	229,386.03	284,569.91	201,387.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		907,161.01		
221Z	SSI DISABLED NON-ME
D	4,176.42	1,262.61	0.00	1,777.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,216.86		
2220	SSI DISABLED WITH Q M	70,948.72	70,948.72	97,309.03	75,572.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,778.91		
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	1,649.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,768.03		
4314	SOBRA CHILD 14-20 MA	1,680.63	0.00	113.75	159.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,953.99		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	157.88	913.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,071.50		
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	5,149.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,885.84		
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		
501G	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	1,542.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,542.87		
SUBTOTAL:	331,641.4	6	348,490.66	462,495.8	3	348,821.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,491,449.60		

1100	TANF EXPANDED FPR FI	5,780.66	5,780.66	5,780.66	5,873.32	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	28,585.90	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	-1,589.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
23,215.30	
1,680.63	
625.63	
112,602.33	
8,457.99	
14.77	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		3,738.47		
111G	TANF EXPANDED 21-44	5,500.24	0.00	0.00	2,491.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,991.94		
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	1,493.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,892.88		
2420	SSI AGED EXPANDED
WI	10,037.64	10,037.64	10,037.64	10,710.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,823.48		
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	30,593.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116,687.43		
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	78,158.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		337,360.34		

3910	NEWLY ELIGIBLE FOR F	11,840.80	11,840.80	13,307.38	10,299.04	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	10,299.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

47,288.02	
236.82	
993.10	
48,517.94	

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	
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

7,938.08

3510	ADULT 40-100% FOR FI	49,075.49	46,707.33	45,143.84	49,294.58	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	1,328.91	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	3,697.07	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	187,344.50	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	5,490.74	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	3,838.82	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	3,733.64	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	83.06	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	6,604.07	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	261,415.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
190,221.24	
2,670.87	
1,816.33	
7,091.43	
3,122.83	
799,449.09	
2,902.91	
69,275.21	
46,494.79	
1,685.66	
27,075.78	
14,439.44	
13,531.33	
1,179,776.91	

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	
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

4,186.30

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	767,862.18	768,909.98	833,762.78	698,694.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,069,229.17		

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

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
210Z

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	

2200

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

SSI DISABLED 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

220Z

2210

221Z

2220

222Z

2310

4314

4315

431E

5007

5010

5017

501G

SSI DISABLED WITH M
E
SSI DISABLED NON-ME
D
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI DISABLED WITH Q
M
SSI BLIND NON-MEDIC
A
SOBRA CHILD 14-20 MA

SOBRA CHILD 14-20 FE

SOBRA CHILD 14-20 FE

SOBRA PREG 21-44 FE M
SOBRA PREGNANT WO
MAN
SOBRA PREG 21-44 FE
M
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

211Z	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	

SUBTOTAL:

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
111H	TANF EXPANDED 45-64	0.00	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	

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	

	

0.00

0.00	

0.00

0.00	

0.00

0.00	

0.00

0.00	

0.00

0.00	

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	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	L
ADULT <40% EXP M&F
4	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	4													
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	

351F

351G	E
ADULT 40-100% MALE 2

ADULT 40-100% FEMAL E	Current and prior month data is under revision.	
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	

													

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

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

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending October 31, 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		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	-5.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5.95		
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		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	-36.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-36.91		
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		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	2,707.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,707.42		
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	846.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,005.80		
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	3,510.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,171.27		

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	-4.54	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	

 
209.24	
-241.02	
-3.41	
-154.08	
-22.67	
634.77	
601.54	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		-6,655.07		
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		-3,880.94		
3718	ADULT <40% EXP M&F
4	-19.73	-13.68	-3,605.55	-1,021.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,660.36		
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	-1,025.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-13,923.79		

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

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	

-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

2,484.98

-11,708.80

TOTAL:

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

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

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

SUBTOTAL:

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	
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
211Z

2120	SSI AGED NON-MEDICA R
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

0.00	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	
4312	SOBRA CHILD 01-05 M	
4314	SOBRA CHILD 14-20 MA	
4315	SOBRA CHILD 14-20 FE	
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	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	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	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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	Cu0.00rr	en0.00	t an0.0d0	pr0i.00or	m0.00	ont0h.00	da0.0t0 a is0.00	und0.00er	r0e.00	vis0i.0o0	n. 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:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	675,910.00	670,888.15	500,674.55	532,532.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,380,005.37		
1011	TANF <1 M & F NON-ME	248.11	953.72	-5,125.27	13,521.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,598.45		
1012	TANF 01-05 M & F NON	-15,379.82	-11,274.85	-15,393.11	-14,326.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-56,373.80		
1013	TANF 06-13 M & F NON	-2,418.26	-7,544.45	3,346.51	2,532.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,083.52		
1014	TANF 14-20 MALE NON-	-811.16	-1,806.09	1,478.38	4,248.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,109.34		
1015	TANF 14-20 FEMALE N O	-368.71	-1,388.95	1,344.21	1,730.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,316.83		
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		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	26.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.39		
101B	TANF 01-05 M & F NON	-261.17	93.90	0.00	-3,216.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,384.10		
101C	TANF 06-13 M & F NON	1,300.68	-970.35	-792.55	76.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-386.02		
101D	TANF 14-20 MALE NON-	751.24	516.19	0.00	25.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,292.83		
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	289,225.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,083,206.17		
221Z	SSI DISABLED NON-ME D	232.93	-271.78	-3,810.00	1,516.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,332.40		
2220	SSI DISABLED WITH Q
M	762.00	762.00	762.00	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,103.98		
2310	SSI BLIND NON-MEDIC A	762.00	762.00	762.00	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,103.98		
4310	SOBRA CHILD NON-ME
DI	10,445,633.40	10,379,896.70	10,747,274.95	11,347,873.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,920,678.25		
4311	SOBRA CHILD <1 M & F	13,625.43	15,714.43	26,374.80	64,140.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,855.34		
4312	SOBRA CHILD 01-05 M	-74,721.61	-78,041.28	-39,438.44	-22,022.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-214,224.21		
4313	SOBRA CHILD 06-13 M	-105,628.37	-106,985.86	-26,667.13	-38,539.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-277,821.20		
4314	SOBRA CHILD 14-20 MA	-43,134.77	-38,503.25	2,887.88	-13,089.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-91,839.44		
4315	SOBRA CHILD 14-20 FE	-40,754.75	-20,963.64	-19,790.76	-8,327.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-89,836.37		
431A	SOBRA CHILD < 1 M &	1,940.81	16,788.88	6,353.47	1,731.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,814.74		
431B	SOBRA CHILD 01-05 M	12,785.94	9,798.85	10,136.79	6,573.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,295.20		
431C	SOBRA CHILD 6-13 M&F	25,205.14	21,852.27	12,251.98	22,429.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,738.43		
431D	SOBRA CHILD 14-20 MA	16,781.28	5,724.71	4,846.17	2,208.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,560.30		
431E	SOBRA CHILD 14-20 FE	11,745.14	9,190.46	4,671.89	1,089.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,696.72		
5010	SOBRA PREGNANT WO MAN	13,738.15	13,995.75	20,755.25	22,862.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,352.11		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	817.98	-1,746.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-928.18		
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 12,214,712.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,061,020.03		

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	762.00	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,579.98

3710	AHC CARE EXPANDED FO	0.00	0.00	762.00	817.98	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	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,579.98	
393.29	
1,973.27	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		
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	762.0	0	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,341.98		

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

4410	SOBRA 100-133% FOR F	12,926.90	12,373.25	10,432.55	10,404.37	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	1,952.60	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	369.41	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	-554.12	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	554.12	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	12,726.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
46,137.07	
4,973.32	
2,049.83	
537.15	
681.12	
127.00	
54,505.49	

46,119,078.77

11,210,666.00	11,151,108.99	11,528,229.23	12,229,074.55	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 October 31, 2019

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1015	TANF 14-20 FEMALE N 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

101A	TANF 21-44 FEMALE N
O
TANF < 1 M & F NON-M	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

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

Cu0.00rren0.00t

an0.0d0

pr0i.00or

m0.00 ont0h.00

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

r0e.00   vis0i.0o0

n. 0.00

0.00

4310	SOBRA CHILD NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
	DI															
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

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

5015

501E

SOBRA PREG 14-20 FE M
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

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	
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	
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	

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

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

Current and prior month data is under revision.

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

0.00

0.00

4410	SOBRA 100-133% FOR 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	

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

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending October 31, 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	2,457.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		325,912.76		
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	273.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,171,984.22		
2210	SSI DISABLED NON-ME
D	5,853,769.90	5,880,424.06	5,923,149.37	3,563.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,660,906.39		
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	6,293.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,528,839.95		

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	

22,553,134.11

7,458,765.69	7,517,688.26	7,570,386.98	6,293.18	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 October 31, 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

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	

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	

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		

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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	37.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.95		
1006	TANF 21-44 MALE WITH	572.44	524.04	554.06	610.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,260.98		
1007	TANF 21-44 FEMALE WI	697.86	633.68	569.00	684.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,584.87		
1008	TANF 45-64 M & F WIT	1,292.20	1,256.05	1,295.38	1,740.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,584.56		
1009	TANF 65+ M & F WITH	784.65	740.61	658.68	876.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,060.81		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	1,298.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,298.21		
1011	TANF <1 M & F NON-ME	13,774.43	13,889.53	14,044.68	17,835.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,543.84		
1012	TANF 01-05 M & F NON	26,627.12	26,500.41	26,825.46	34,791.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,744.06		
1013	TANF 06-13 M & F NON	48,891.34	48,999.00	49,380.14	63,910.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211,180.57		
1014	TANF 14-20 MALE NON-	29,752.48	29,183.72	29,422.86	36,763.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,122.57		
1015	TANF 14-20 FEMALE N O	50,257.49	49,708.32	49,693.38	60,864.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210,523.36		
1016	TANF 21-44 MALE NON-	196,818.83	196,825.88	198,260.40	238,341.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		830,246.47		
1017	TANF 21-44 FEMALE N O	669,123.39	671,878.41	675,375.54	809,952.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,826,330.33		
1018	TANF 45-64 M & F NON	161,187.72	160,988.62	161,431.18	193,858.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		677,465.84		
1019	TANF 65+ M & F NON-M	674.30	651.26	689.40	813.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,828.71		
1020	TANF WITH QMB	0.00	0.00	0.00	40.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.74		
1024	TANF 14-20 MALE WITH	10.41	1.08	1.08	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.93		
1026	TANF 21-44 MALE WITH	387.68	364.94	366.97	429.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,549.46		
1027	TANF 21-44 FEMALE WI	653.45	638.63	661.09	729.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,682.23		
1028	TANF 45-64 M & F WIT	835.76	807.47	773.65	772.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,189.47		
1029	TANF 65+ M & F WITH	450.07	433.44	423.81	508.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,815.88		
2100	SSI AGED WITH MEDIC A	32,980.00	32,982.55	33,054.20	141,547.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240,564.16		
2110	SSI AGED NON-MEDICA
R	53,956.16	54,404.88	54,776.81	70,837.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		233,975.14		
2120	SSI AGED WITH QMB	256,470.33	258,178.50	259,225.39	392,946.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,166,820.61		
2200	SSI DISABLED WITH M E	25,887.66	25,631.83	25,902.25	69,776.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,198.44		
2210	SSI DISABLED NON-ME
D	277,976.12	277,927.49	278,125.13	480,981.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,315,009.85		
2220	SSI DISABLED WITH Q M	170,604.53	170,784.02	170,828.67	276,883.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		789,100.35		
2300	SSI BLIND WITH MEDIC	235.51	244.84	214.82	270.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		966.04		
2310	SSI BLIND NON-MEDIC A	3,591.59	3,599.17	3,649.81	4,587.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,428.48		
2320	SSI BLIND WITH QMB	1,900.92	1,912.30	1,925.39	2,370.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,109.21		
4302	SOBRA CHILD 01-05 M	3.24	3.24	5.40	6.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.68		
4303	SOBRA CHILD 06-13 M	9.76	9.76	10.85	13.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.07		
4305	SOBRA CHILD 14-20 FE	20.16	17.99	9.33	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.06		
4311	SOBRA CHILD <1 M & F	48,698.46	48,704.10	48,220.98	60,494.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,118.43		
4312	SOBRA CHILD 01-05 M	236,845.73	238,192.76	238,593.68	299,784.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,013,417.10		
4313	SOBRA CHILD 06-13 M	310,882.77	313,296.50	314,734.87	397,068.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,335,982.58		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4314	SOBRA CHILD 14-20 MA	155,400.15	157,444.43	158,328.17	193,512.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		664,685.14		
4315	SOBRA CHILD 14-20 FE	157,772.95	160,194.90	160,353.44	196,109.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		674,430.56		
4322	SOBRA CHILD 01-05 M	1.08	1.08	1.08	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.60		
4323	SOBRA CHILD 06-13 M	0.00	0.00	1.08	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.44		
4325	SOBRA CHILD 14-20 FE	2.17	11.92	11.92	14.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.28		
5007	SOBRA PREG 21-44 FE M	148.67	173.44	218.64	246.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		786.84		
5008	SOBRA PREG 45-64 FE
M	11.36	11.36	11.36	13.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.67		
5013	SOBRA PREG 09-13 FE M	3.32	8.72	6.56	4.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.90		
5015	SOBRA PREG 14-20 FE
M	18,252.71	19,137.94	19,530.79	23,029.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,951.02		
5017	SOBRA PREG 21-44 FE M	118,643.32	122,268.55	124,930.21	148,505.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		514,347.27		
5018	SOBRA PREG 45-64 FE
M	307.55	390.33	379.25	514.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,591.69		
5027	SOBRA PREG 21-44 FE M	205.51	237.30	212.81	245.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901.29		
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.79		
SUBTOTAL:	3,073,603.35	3,089,794.99	3,103,689.65	4,224,649.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,491,737.53		

3100

TRANSPLANT OPTION 1

84.59

84.59

30.32	22.74	22.74	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
30.32	22.74	22.74	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

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	1,911.12	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	3,112.08	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	10,438.23	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	6,303.39	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	9.74	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	2,149.70	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	13,774.08	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	244,953.36	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	670,631.58	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	233,366.67	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	777.36	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	6,328.05	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	12,849.54	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	22,623.30	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	16,421.55	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	1,046.58	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	900.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.58	
6,428.50	
11,384.70	
36,729.82	
22,075.33	
2.17	
39.09	
7,357.14	
48,825.56	
863,941.45	
2,354,143.79	
817,732.65	
2,716.03	
22,078.68	
45,514.71	
78,925.13	
55,831.50	
3,737.52	
3,250.45	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2420	SSI AGED EXPANDED WI	200,778.15	202,142.27	203,515.08	246,928.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		853,364.33		
2520	SSI BLIND EXPANDED
W	7.58	7.58	7.58	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.53		
2600	SSI DISABLED EXPAND E	762.25	849.07	753.42	803.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,168.14		
2610	SSI DISABLED EXPAND
E	10,383.49	10,503.92	10,814.11	13,250.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,952.10		
2620	SSI DISABLED EXPAND E	99,455.39	99,763.22	99,882.81	119,843.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		418,944.88		
SUBTOTAL:	1,353,111.57	1,358,060.90	1,361,578.86	1,628,431.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,701,182.78		

3906	NEWLY ELIGIBLE MALE	90.34	82.78	88.61	131.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

393.55

3506	ADULT 40-100% MALE 2	39.65	24.49	41.40	58.32	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	20.37	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	600.48	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	222.90	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	54,256.41	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	58,478.67	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	174,623.31	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	146,377.38	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	342,923.16	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	57.12	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	4.80	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	17.58	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	17.58	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	176.19	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	93.48	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	675.90	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	132.24	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	101,106.72	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	92,135.04	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	681,361.83	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	386,374.98	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	764,995.80	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	78.69	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	29.16	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	20.37	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	29.16	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	2,804,867.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
163.86	
46.61	
2,087.01	
561.34	
188,067.13	
204,911.03	
607,690.77	
510,345.57	
1,198,888.37	
203.98	
12.38	
47.90	
49.65	
7.58	
607.92	
218.26	
2,181.20	
328.72	
350,277.46	
318,755.03	
2,347,186.96	
1,335,395.48	
2,656,858.26	
278.09	
100.86	
60.02	
53.63	
9,725,385.07	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3907	NEWLY ELIGIBLE FEMA L	22.74	30.32	22.74	35.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.96		
3908	NEWLY ELIGIBLE M&F
4	508.36	559.03	527.84	691.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,286.37		
3909	NEWLY ELIGIBLE M&F 6	153.92	184.22	242.21	325.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		905.52		
3914	NEWLY ELIGIBLE MALE	23,916.71	24,486.72	24,647.46	30,396.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,446.95		
3915	NEWLY ELIGIBLE FEMA L	27,726.24	28,155.12	28,588.52	34,391.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,861.04		
3916	NEWLY ELIGIBLE MALE	130,814.88	132,521.42	131,942.21	156,760.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		552,039.25		
3917	NEWLY ELIGIBLE FEMA L	195,391.19	198,499.23	198,178.20	236,087.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		828,155.63		
3918	NEWLY ELIGIBLE M&F
4	196,812.85	197,720.38	197,534.93	237,401.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		829,469.77		
3919	NEWLY ELIGIBLE M&F 6	16.91	18.66	27.99	23.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86.72		
3926	NEWLY ELIGIBLE MALE	9.33	0.00	0.00	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.12		
3928	NEWLY ELIGIBLE M&F 4	16.91	9.33	9.33	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.15		
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	696,263.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,435,834.14		

4517	BC PATIENT FEMALE 2 1	143.38	164.09	156.51	211.74	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	1,105.80	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	47.55	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	87.48	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	1,452.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

675.72	
3,983.53	
185.10	
285.15	
5,129.50	

8600	SSI BLIND FREEDOM/W O	7.58	7.58	7.58	8.79	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	11.58	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	13,668.99	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	3,172.20	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	2,438.91	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	19,300.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

31.53	
39.57	
47,131.82	
10,370.21	
8,079.96	
65,653.09	

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

4413	SOBRA 100-133% M&F
6	58,543.74	58,461.45	57,600.88	71,698.76	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	36,784.27	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	36,266.41	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	144,749.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
246,304.83	
130,597.60	
127,410.17	
504,312.60	

31,929,371.38

7,421,096.76	7,478,127.98	7,510,423.34	9,519,723.30	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 October 31, 2019

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE		TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1015

1016	TANF 14-20 FEMALE N O
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

0.00	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	

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

1024	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1026	TANF 21-44 MALE WITH	0.00	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	

1019

1020

TANF 65+ M & F NON-M

TANF WITH QMB

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

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	0.00	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

2300

2310

2320

4302

4303

4305

4311

4312

4313

D
SSI DISABLED WITH Q
M
SSI BLIND WITH MEDIC

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

SOBRA CHILD 01-05 M SOBRA CHILD 06-13 M SOBRA CHILD 14-20 FE SOBRA CHILD <1 M & F SOBRA CHILD 01-05 M 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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		
5028	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		
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		

3100

TRANSPLANT OPTION 1

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

SUBTOTAL:

1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2520	SSI BLIND EXPANDED
W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2610	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	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
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

3518

Current and prior month data is under revision.

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

3508	E
ADULT 40-100% M&F 45	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
3715	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3716	L
ADULT <40% EXP MALE	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3717	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3718	L
ADULT <40% EXP M&F
4	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3726	6
ADULT <40% EXP MALE	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
3727	ADULT <40% EXP 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	
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	4													
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

													

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3928	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3929	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	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

SOBRA 100-133% FEMA L

4415

SOBRA 100-133% MALE

4414

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA 100-133% M&F
6

4413

0.00	
0.00	
0.00	
0.00	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	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

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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	7,179.92	4,842.01	4,556.71	7,527.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,106.32		
1007	TANF 21-44 FEMALE WI	5,660.13	8,315.12	3,656.17	5,435.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,067.20		
1008	TANF 45-64 M & F WIT	13,522.79	12,784.45	13,053.33	12,421.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,782.41		
1009	TANF 65+ M & F WITH	7,573.40	7,048.03	5,895.29	8,756.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,273.39		
1011	TANF <1 M & F NON-ME	1,704,748.88	1,215,550.25	823,687.83	1,172,271.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,916,258.52		
1012	TANF 01-05 M & F NON	321,855.78	307,163.81	292,577.80	407,348.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,328,945.59		
1013	TANF 06-13 M & F NON	530,515.76	501,663.79	446,044.70	600,476.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,078,700.59		
1014	TANF 14-20 MALE NON-	203,236.61	175,532.08	149,342.10	162,062.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		690,173.37		
1015	TANF 14-20 FEMALE N O	393,263.47	411,573.01	297,015.96	394,439.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,496,291.86		
1016	TANF 21-44 MALE NON-	1,956,741.53	2,236,067.42	1,702,040.41	2,119,924.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,014,774.01		
1017	TANF 21-44 FEMALE N O	6,391,025.27	6,861,727.73	6,092,771.97	7,036,002.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,381,527.38		
1018	TANF 45-64 M & F NON	2,566,895.07	2,988,825.03	2,296,099.04	2,805,525.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,657,345.04		
1019	TANF 65+ M & F NON-M	3,082.12	11,634.33	3,047.76	2,043.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,807.87		
1026	TANF 21-44 MALE WITH	5,452.82	2,600.75	875.03	1,475.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,404.35		
1027	TANF 21-44 FEMALE WI	8,052.27	3,119.24	1,357.57	1,942.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,471.93		
1028	TANF 45-64 M & F WIT	7,027.85	6,397.80	5,710.26	5,594.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,730.85		
1029	TANF 65+ M & F WITH	11,881.21	6,449.88	10,048.57	5,614.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,994.30		
2100	SSI AGED WITH MEDIC A	231,952.74	259,830.87	132,481.39	252,617.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		876,882.63		
2110	SSI AGED NON-MEDICA
R	164,988.00	142,495.88	96,068.65	168,374.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		571,926.77		
2120	SSI AGED WITH QMB	696,504.68	647,287.68	605,933.24	718,218.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,667,944.59		
2200	SSI DISABLED WITH M E	509,724.57	597,467.37	548,111.03	834,347.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,489,650.51		
2210	SSI DISABLED NON-ME
D	9,349,394.09	10,282,957.71	8,326,157.43	10,142,149.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,100,658.35		
2220	SSI DISABLED WITH Q M	1,799,464.98	1,475,342.17	1,447,618.10	1,801,133.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,523,558.68		
2300	SSI BLIND WITH MEDIC	2,786.12	2,517.54	1,645.59	4,405.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,355.07		
2310	SSI BLIND NON-MEDIC A	105,581.25	151,794.37	90,576.36	88,921.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		436,873.35		
2320	SSI BLIND WITH QMB	25,806.73	19,005.13	19,779.17	28,930.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,521.94		
4311	SOBRA CHILD <1 M & F	3,079,674.40	2,071,093.53	2,246,499.03	2,674,686.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,071,953.95		
4312	SOBRA CHILD 01-05 M	4,144,566.09	4,042,965.94	3,675,014.97	4,913,834.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,776,381.75		
4313	SOBRA CHILD 06-13 M	6,203,269.83	6,885,485.33	5,614,996.13	7,496,805.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,200,557.24		
4314	SOBRA CHILD 14-20 MA	1,874,493.90	2,011,492.36	1,644,388.24	2,133,480.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,663,854.52		
4315	SOBRA CHILD 14-20 FE	2,264,127.22	2,531,195.42	1,955,324.31	2,727,565.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,478,212.46		
5007	SOBRA PREG 21-44 FE M	1,468.11	1,067.27	1,508.98	1,106.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,150.58		
5013	SOBRA PREG 09-13 FE
M	0.00	581.96	1,820.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,856.96		
5015	SOBRA PREG 14-20 FE M	462,480.69	354,299.93	380,997.74	383,826.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,581,604.41		
5017	SOBRA PREG 21-44 FE
M	2,739,461.45	2,355,050.17	2,334,361.91	2,722,854.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,151,728.43		
5018	SOBRA PREG 45-64 FE M	6,539.65	455.00	2,730.00	936.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,661.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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	4,998.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,736.59		
SUBTOTAL:	47,800,049.38	48,593,680.36	41,274,480.48	51,848,514.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,516,724.76		

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

-153.38

-153.38

1106	TANF EXPANDED 21-44	5,110.76	1,764.45	2,329.25	6,481.93	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	15,689.95	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	37,229.57	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	39,298.37	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	455.00	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	10,369.73	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	47,872.52	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	856,470.22	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	2,967,220.64	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	1,801,625.60	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	5,229.94	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	19,718.27	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	44,526.02	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	158,559.91	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	73,013.66	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	14,681.25	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	10,079.54	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	663,308.68	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	8,662.35	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	483,531.83	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	491,808.45	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	7,755,833.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
15,686.39	
42,117.20	
157,691.95	
156,952.11	
1,286.96	
39,765.13	
180,947.65	
3,154,804.33	
10,899,158.23	
6,886,820.59	
15,556.61	
96,716.86	
181,823.72	
563,050.60	
299,668.45	
45,361.95	
68,728.90	
2,422,259.49	
37,115.50	
1,178,779.30	
1,792,539.57	
28,236,831.49	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	-227.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	-133.62	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	-421.38	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	-257.17	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	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-10,230.00	-735.63	-1,699.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-227.42	
-133.62	
-660.00	
-2,071.38	
-6,197.17	
-3,375.63	
-12,665.22	

3507

ADULT 40-100% FEMAL E

427.00

191.26

0.00

809.96

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

1,428.22

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3508	ADULT 40-100% M&F 45	1,036.20	138.56	673.58	2,267.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,115.64		
3509	ADULT 40-100% M&F 65	107.15	0.00	43.40	193.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		344.13		
3514	ADULT 40-100% MALE 1	82,193.78	72,082.38	61,562.64	82,938.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		298,777.01		
3515	ADULT 40-100% FEMAL E	133,768.02	149,460.55	112,076.25	145,651.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		540,956.61		
3516	ADULT 40-100% MALE 2	929,328.88	812,103.33	787,166.18	844,775.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,373,373.99		
3517	ADULT 40-100% FEMAL E	719,939.62	657,905.17	549,744.70	603,380.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,530,970.06		
3518	ADULT 40-100% M&F 45	2,471,316.14	2,775,008.27	2,356,105.16	2,633,073.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,235,503.40		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	42.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.48		
3706	ADULT <40% EXP MALE	684.21	6,334.49	1,409.66	5,705.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,133.79		
3707	ADULT <40% EXP FEMA L	3,777.08	1,125.81	3,880.63	1,961.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,745.29		
3708	ADULT <40% EXP M&F
4	4,674.03	12,630.88	7,588.13	11,215.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,108.84		
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	595,254.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,855,094.22		
3715	ADULT <40% EXP FEMA L	514,957.44	618,604.64	456,041.22	607,313.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,196,917.08		
3716	ADULT <40% EXP MALE	9,597,893.16	8,894,945.23	7,900,077.98	9,737,004.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,129,920.55		
3717	ADULT <40% EXP FEMA L	4,679,276.71	5,034,780.29	4,338,260.79	5,090,995.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,143,313.27		
3718	ADULT <40% EXP M&F
4	11,372,750.63	11,843,300.90	10,134,524.78	12,188,745.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,539,322.23		
3719	ADULT <40% EXP M&F 6	0.00	26,564.29	866.02	5,037.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,467.39		
3727	ADULT <40% EXP FEMA
L	0.00	0.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455.00		
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:	30,988,406.2	4 31,310,849.20	27,088,531.7	4 32,556,822.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,944,609.39		

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	539,325.33	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	185,130.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

455.00	
2,050,169.81	
793,948.43	

3906	NEWLY ELIGIBLE MALE	390.09	1,220.96	1,870.06	13,333.02	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	4,252.02	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	8,206.79	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	3,834.68	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	36,730.14	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	64,345.38	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	1,315,650.66	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	729,554.22	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	1,432,121.03	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	2,133.41	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	3,610,161.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,814.13	
6,586.24	
12,305.81	
5,136.78	
111,590.91	
240,868.15	
3,117,141.79	
2,928,558.95	
6,020,967.00	
3,522.55	
12,463,492.31	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	228,920.72	243,977.81	263,975.40	261,842.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		998,716.57		
SUBTOTAL:	904,642.22	1,005,919.81	946,429.77	986,298.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,843,289.81		

8700	SSI DISABLED FREEDO M	18,707.10	13,486.58	11,826.59	23,094.07	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	53,320.99	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	1,545.80	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	77,960.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

67,114.34	
151,104.89	
19,727.31	
237,946.54	

S000	STATE-ONLY BHS	4,829.17	380.31	-7,088.05	-11.03	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	-11.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-1,889.60

-1,889.60

4517	BC PATIENT FEMALE 2 1	0.00	0.00	910.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	38,008.91	31,602.63	22,114.22	8,712.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	455.00	455.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	910.00	2,730.00	1,820.00	8,572.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	38,918.91	34,787.63	25,299.2	2	18,194.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,365.00	
100,438.40	
1,365.00	
14,032.24	
117,200.64	

0.00

0.00

0.00

96,852,074.66

TOTAL:

89,553,565.50

91,855,910.80

78,083,835.78

0.00

0.00

0.00

0.00

0.00

356,345,386.74

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	41.58	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	2,713.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,100.05		
1011	TANF <1 M & F NON-ME	1,720.56	515.08	4,324.42	811.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,371.76		
1012	TANF 01-05 M & F NON	0.00	455.00	196.06	221.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		872.12		
1013	TANF 06-13 M & F NON	27,471.80	1,636.87	2,281.82	1,603.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,994.01		
1014	TANF 14-20 MALE NON-	696.15	2,503.24	3,247.65	5,629.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,076.43		
1015	TANF 14-20 FEMALE N O	3,945.81	579.34	6,069.05	4,082.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,677.09		
1016	TANF 21-44 MALE NON-	42,364.00	16,517.72	2,089.15	5,485.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,456.45		
1017	TANF 21-44 FEMALE N O	99,491.18	25,376.76	38,133.79	23,054.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186,055.80		
1018	TANF 45-64 M & F NON	43,845.13	11,730.98	-5,418.24	1,206.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,363.94		
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	3,380.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,839.37		
2110	SSI AGED NON-MEDICA
R	37,219.25	24,330.99	5,813.58	11,051.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,415.81		
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	256.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		672.68		
2210	SSI DISABLED NON-ME
D	32,328.76	6,476.19	12,815.59	596.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,217.06		
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	29,589.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		235,012.78		
4312	SOBRA CHILD 01-05 M	171,883.85	118,793.66	52,409.54	33,938.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		377,025.28		
4313	SOBRA CHILD 06-13 M	39,579.36	92,454.57	127,080.50	57,433.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316,548.38		
4314	SOBRA CHILD 14-20 MA	60,862.64	16,699.62	13,097.54	40,879.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,539.22		
4315	SOBRA CHILD 14-20 FE	39,098.46	12,346.02	27,377.62	56,688.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,510.13		
5007	SOBRA PREG 21-44 FE M	0.00	196.52	579.22	267.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,043.37		
5015	SOBRA PREG 14-20 FE
M	36,367.09	15,253.89	33,521.26	33,931.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,073.84		
5017	SOBRA PREG 21-44 FE M	145,231.52	116,182.97	137,749.55	145,267.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		544,431.62		
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	458,088.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,398,767.97		

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	29.47	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	466.45	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	222.55	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	92.85	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	43,736.96	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	5,618.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
697.46	
1,292.80	
4,422.35	
1,437.37	
2,713.51	
111,364.36	
109,501.92	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 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	1,234.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,897.39		
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	-491.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		892.17		
2400	SSI AGED EXPANDED WI	10,489.58	10,609.14	4,624.84	2,514.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,237.79		
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	785.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,777.88		
2610	SSI DISABLED EXPAND
E	-219.23	1,500.65	1,451.59	778.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,511.99		
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	54,989.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		317,356.81		

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	519.38	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	-340.59	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	441.36	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	7,997.21	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	11,198.71	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	90,480.50	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	110,296.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

106.30	
2,253.29	
5,913.85	
6,542.94	
131,265.50	
186,066.38	
408,916.85	
741,065.11	

4413	SOBRA 100-133% M&F
6	97,572.50	14,475.99	11,390.95	8,926.66	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	2,113.04	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	1,789.67	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	12,829.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

132,366.10	
13,013.89	
22,444.90	
167,824.89	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	1,407.26	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	4,501.99	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	192.50	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	4,117.83	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	3,724.50	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	28,494.20	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	1,874.60	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	2,151.36	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	44,057.11	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	17,765.00	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	84,219.76	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	192,506.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,407.26	
22,765.68	
8,985.48	
132,629.22	
63,052.05	
234,800.78	
50,309.06	
51,062.06	
624,655.16	
230,000.40	
656,560.71	
2,076,227.86	

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 October 31, 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	480.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,686.90		
SUBTOTAL:	144.13	5,409.82	1,545.39	480.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,579.72		

TOTAL:	2,358,964.61	1,541,309.62	979,357.24	829,190.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,708,822.36		

FEDERAL EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	2,216.23	3,492.52	29,766.20	3,922.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,396.97		
1012	TANF 01-05 M & F NON	77,421.94	71,881.43	120,924.31	163,993.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		434,221.51		
1013	TANF 06-13 M & F NON	67,181.43	79,607.43	75,624.93	49,537.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271,951.42		
1014	TANF 14-20 MALE NON-	44,070.56	156,398.57	56,041.71	49,472.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		305,983.28		
1015	TANF 14-20 FEMALE N O	346,405.17	185,300.28	245,335.08	327,590.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,104,631.05		
1016	TANF 21-44 MALE NON-	573.09	-107.55	0.00	553.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,019.32		
1017	TANF 21-44 FEMALE N O	2,136,707.54	1,669,785.38	1,971,352.20	2,264,596.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,042,441.74		
1018	TANF 45-64 M & F NON	9,102.32	9,101.37	7,812.93	9,840.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,857.60		
2100	SSI AGED WITH MEDIC A	22,518.78	19,427.61	17,554.57	10,826.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,327.89		
2110	SSI AGED NON-MEDICA
R	1,723,508.17	1,475,976.91	1,832,508.02	1,630,520.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,662,513.32		
2120	SSI AGED WITH QMB	144.29	32.85	8.60	56.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241.97		
2200	SSI DISABLED WITH M E	9,179.10	14,416.02	3,482.91	8,649.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,727.84		
2210	SSI DISABLED NON-ME
D	52,112.74	40,196.05	75,208.50	38,646.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,163.36		
SUBTOTAL:	4,491,141.36	3,725,508.87	4,435,619.96	4,558,207.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,210,477.27		

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	10,670.72	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	37,326.64	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	33,008.41	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	951,677.18	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	617,696.21	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	3,074,288.74	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	14,850.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

154.26	
19,765.58	
173,801.41	
139,235.78	
3,656,288.09	
1,984,388.75	
12,729,784.77	
17,321.76	

1107	TANF EXPANDED 21-44	0.00	1,521.24	1,510.13	775.83	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	4,177.76	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	4,248.75	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	15,384.13	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	631,505.29	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	1,573,771.77	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	989,496.29	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	70,655.07	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	199.13	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	37.10	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	18,337.64	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	3,563.39	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	3,312,152.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,807.20	
43,576.93	
8,593.96	
107,869.93	
3,017,998.71	
6,196,797.24	
3,290,542.46	
119,058.01	
4,504.69	
2,704.40	
38,021.85	
13,263.92	
12,846,739.30	

FEDERAL EMERGENCY SERVICES
For The Period Ending October 31, 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	4,739,518.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,720,740.40		

48,777,956.97

12,889,659.55	11,046,268.49	12,232,150.82	12,609,878.11	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1014	TANF 14-20 MALE NON-	4,719.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,719.36		
SUBTOTAL:	4,719.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,719.36		

TOTAL:	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 October 31, 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	367,061.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,957,735.92		
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:	660,277.75	490,123.24	440,696.1	3	367,061.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,958,159.09		

0.00

0.00

0.00

367,061.97

TOTAL:

660,277.75

490,123.24

440,696.13

0.00

0.00

0.00

0.00

0.00

1,958,159.09

FFS TRBHA FEE FOR SERVICE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	502.62	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	2,741.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,064.79		
1012	TANF 01-05 M & F NON	7,865.88	6,230.65	3,847.53	16,600.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,544.21		
1013	TANF 06-13 M & F NON	307,867.77	285,146.24	121,253.04	191,932.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906,199.56		
1014	TANF 14-20 MALE NON-	72,162.55	27,686.96	22,237.41	54,500.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,587.54		
1015	TANF 14-20 FEMALE N O	109,108.33	104,274.36	91,303.97	148,372.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453,059.46		
1016	TANF 21-44 MALE NON-	482,746.26	346,671.53	408,164.25	508,526.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,746,108.79		
1017	TANF 21-44 FEMALE N O	1,459,385.50	1,078,950.83	1,248,877.02	1,908,670.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,695,884.23		
1018	TANF 45-64 M & F NON	285,431.75	240,088.50	276,977.66	260,726.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,063,223.95		
1028	TANF 45-64 M & F WIT	184.73	173.16	1,730.03	2,588.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,676.86		
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	16,378.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,500.14		
2110	SSI AGED NON-MEDICA
R	3,423.10	2,391.21	7,023.46	3,567.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,405.47		
2120	SSI AGED WITH QMB	66,532.03	48,594.38	50,139.30	42,216.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,481.76		
2200	SSI DISABLED WITH M E	63,339.72	50,009.45	55,104.31	57,799.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		226,253.32		
2210	SSI DISABLED NON-ME
D	2,142,025.20	1,716,824.90	1,550,850.31	2,058,806.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,468,506.61		
2220	SSI DISABLED WITH Q M	388,879.11	342,330.15	328,681.88	351,532.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,411,423.92		
2310	SSI BLIND NON-MEDIC
A	36,358.35	59,301.51	24,367.36	15,444.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,471.55		
2320	SSI BLIND WITH QMB	5,271.02	1,918.97	1,852.18	1,952.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,994.83		
4311	SOBRA CHILD <1 M & F	6,460.61	6,068.40	6,860.01	8,565.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,954.46		
4312	SOBRA CHILD 01-05 M	239,174.74	187,542.33	207,568.43	288,173.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		922,458.53		
4313	SOBRA CHILD 06-13 M	3,963,253.67	4,322,269.98	2,531,999.44	3,877,188.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,694,711.42		
4314	SOBRA CHILD 14-20 MA	974,878.74	1,029,423.72	690,182.62	862,224.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,556,709.41		
4315	SOBRA CHILD 14-20 FE	1,157,053.84	1,207,668.34	895,132.65	1,075,681.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,335,535.95		
5013	SOBRA PREG 09-13 FE M	0.00	910.00	3,640.00	13,195.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,745.00		
5015	SOBRA PREG 14-20 FE
M	14,079.10	20,092.68	21,250.32	19,914.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,336.17		
5017	SOBRA PREG 21-44 FE M	146,024.25	157,851.29	176,250.02	173,453.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		653,579.08		
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	11,960,753.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,929,458.27		

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	608.05	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	68.72	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	2,275.00	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	1,805.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
218.26	
10,215.33	
1,273.92	
5,775.00	
23,630.51	

FFS TRBHA FEE FOR SERVICE
For The Period Ending October 31, 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	227,334.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		655,218.80		
1117	TANF EXPANDED 21-44	457,969.90	350,831.66	341,891.81	530,864.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,681,557.37		
1118	TANF EXPANDED 45-64	151,584.86	119,327.65	157,762.76	340,355.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		769,030.51		
1126	TANF EXPANDED 21-44	5,497.39	1,646.16	1,878.64	5,708.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,730.26		
1127	TANF EXPANDED 21-44	310.16	265.12	710.40	2,088.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,374.33		
1128	TANF EXPANDED 45-64	12,149.05	12,375.62	7,302.92	10,233.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,060.89		
1129	TANF EXPANDED 65+ M
&	4,153.95	4,207.54	4,482.68	4,946.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,790.72		
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	29,457.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,475.13		
2600	SSI DISABLED EXPAND
E	1,408.72	0.00	68.72	1.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,479.17		
2610	SSI DISABLED EXPAND E	11,220.70	10,544.09	14,761.76	9,766.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,292.57		
2620	SSI DISABLED EXPAND
E	85,511.04	31,421.19	54,808.45	81,212.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252,953.54		
SUBTOTAL:	963,690.3	5	700,065.73	768,322.7	2	1,246,725.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,678,803.81		

4413	SOBRA 100-133% M&F
6	173,365.54	159,239.19	99,226.38	126,346.38	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	70,673.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	361.44	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	2,088.83	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	68,243.38	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	28,589.71	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	63,962.90	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	163,246.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

29.55	
13,639.70	
25,291.98	
291,356.53	
150,857.40	
256,601.24	
737,776.40	

558,177.49

3514	ADULT 40-100% MALE 1	10,776.55	6,979.68	14,745.82	14,618.09	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	15,338.90	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	270,826.22	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	170,716.10	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	236,051.59	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	61.46	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	154,737.81	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	122,531.26	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	3,153,993.03	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	1,735,878.72	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	1,928,536.07	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	7,803,289.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
47,120.14	
63,120.65	
694,359.62	
498,295.32	
732,925.29	
4,470.99	
542,818.53	
437,820.59	
10,973,652.31	
6,215,051.68	
6,141,382.91	
26,351,018.03	

256,875.95

FFS TRBHA FEE FOR SERVICE
For The Period Ending October 31, 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	60,718.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		212,406.46		
SUBTOTAL:	319,387.29	264,405.33	185,928.03	257,739.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,027,459.90		

8700	SSI DISABLED FREEDO M	444.71	126.96	282.09	322.07	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	1,365.00	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	1,687.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,175.83	
1,365.00	
172.78	
2,713.61	

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	21,433,439.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,728,595.02		

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	20,058.67	22,328.76	18,380.71	27,455.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,223.30		
1017	TANF 21-44 FEMALE N O	52,130.85	26,691.95	54,079.33	75,587.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,489.17		
1018	TANF 45-64 M & F NON	0.00	0.00	19,006.49	5,714.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,721.22		
2210	SSI DISABLED NON-ME D	84,690.30	48,792.04	60,634.16	78,420.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,536.71		
2220	SSI DISABLED WITH Q
M	1,364.00	1,364.00	1,399.00	1,364.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,491.00		
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	188,541.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617,149.28		

3516	ADULT 40-100% MALE 2	3,699.35	11,299.46	14,172.51	14,360.32	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	15,707.33	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	310,609.08	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	135,298.62	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	84,075.25	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	560,050.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

43,531.64	
9,362.12	
28,047.05	
969,256.38	
374,793.87	
266,678.39	
1,691,669.45	

3916	NEWLY ELIGIBLE MALE	8,408.80	0.00	3,363.52	39,865.17	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	4,898.34	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	7,567.92	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	52,331.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

51,637.49	
38,391.51	
21,022.00	
111,051.00	

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	4,081.95	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	1,364.00	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	5,445.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,540.16	
61,842.03	
17,658.48	
5,432.00	
101,472.67	

0.00

0.00

0.00

806,369.12

TOTAL:

596,980.30

493,299.07

624,693.91

0.00

0.00

0.00

0.00

0.00

2,521,342.40

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	82,215.38	125,849.80	34,955.01	98,230.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		341,250.52		
2110	SSI AGED NON-MEDICA
R	76,145.26	43,432.58	94,089.34	170,616.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384,283.50		
2200	SSI DISABLED WITH M E	43,412.57	37,118.69	31,528.29	42,362.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,422.35		
2210	SSI DISABLED NON-ME
D	6,450.10	54.14	3,268.79	936.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,709.28		
2220	SSI DISABLED WITH Q M	0.00	5,818.84	74,831.29	1,429.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,079.44		
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	32,461.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,899.04		
SUBTOTAL:	244,004.3	7	235,026.81	245,517.6	3	346,036.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,070,585.23		

3516	ADULT 40-100% MALE 2	6,841.48	1,043.90	0.00	79.24	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	3,632.38	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	193.90	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	37,464.60	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	352,718.91	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	4,596.23	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	324,844.74	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	723,530.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,964.62	
5,113.33	
15,763.58	
84,437.80	
1,290,759.63	
18,990.75	
1,577,024.89	
1,647.10	
3,001,701.70	

3916	NEWLY ELIGIBLE MALE	57,655.11	4,600.84	464.10	10,899.98	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	8,093.92	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	18,993.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

73,620.03	
13,422.94	
87,042.97	

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	132.79	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	132.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
15,017.82	
5,657.49	
1,154.46	
21,829.77	

TOTAL:	1,194,500.53	886,135.76	1,011,830.27	1,088,693.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,181,159.67		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1017	TANF 21-44 FEMALE N O	3,561.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,561.30		
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	165.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	302.05	3,171.25	0.00	165.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,221.03	
417.33	
3,638.36	

10,874.25

3,863.35	6,381.37	464.47	165.06	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	3,026.28	69.19	0.00	224.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,320.29		
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	91.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,310.19		
1017	TANF 21-44 FEMALE N O	13,398.03	846.61	57.84	80.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,382.54		
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	692.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,446.90		
SUBTOTAL:	19,818.53	22,215.72	24,324.9	4	1,088.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,447.60		

3516	ADULT 40-100% MALE 2	-3,664.92	32.56	3,991.13	16,463.19	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	4,326.92	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	2,244.05	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	94,629.53	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	8,305.99	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	25,277.09	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	151,246.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,821.96	
4,326.92	
3,917.07	
466,490.72	
51,522.47	
205,178.81	
748,257.95	

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	10,852.96	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	9,337.23	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	153.09	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	20,343.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

421.95	
26,291.87	
9,337.23	
543.91	
36,594.96	

1116	TANF EXPANDED 21-44	19,096.08	276.04	0.00	218.09	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	803.37	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	1,021.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19,590.21	
9,840.04	
29,430.25	

TOTAL:	243,176.40	232,257.84	232,596.60	173,699.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		881,730.76		

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3717	ADULT <40% EXP FEMA L	3,409.21	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	2,096.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,096.29		
1017	TANF 21-44 FEMALE N O	0.00	843.13	0.00	5,000.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,843.15		
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	23,396.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,513.75		
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	30,492.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,895.55		

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

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	82.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	14,403.73	29,550.56	33,133.43	21,544.12	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	843.84	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	176.12	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	22,646.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
82.53	
98,631.84	
23,119.40	
33,101.63	
154,935.40	

TOTAL:	49,387.38	64,539.25	73,786.31	53,139.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		240,852.11		

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1017	TANF 21-44 FEMALE N O	2,189.61	0.00	0.00	8,259.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,448.64		
SUBTOTAL:	2,189.61	0.00	0.00	8,259.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,448.64		

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	244.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	415.11	59.26	3,076.36	244.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,127.64	
2,109.20	
558.02	
3,794.86	

14,243.50

2,604.72	59.26	3,076.36	8,503.16	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,476.55	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	3,464,672.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,742,398.61		
2110	SSI AGED NON-MEDICA
R	270,248.25	199,558.99	170,599.97	185,012.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		825,419.42		
2120	SSI AGED WITH QMB	5,144,790.92	4,353,539.64	4,195,426.94	5,202,790.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,896,547.77		
2200	SSI DISABLED WITH M E	665,108.26	517,747.79	541,296.64	661,374.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,385,527.47		
2210	SSI DISABLED NON-ME
D	4,059,288.17	3,443,509.73	3,375,066.24	3,847,079.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,724,943.22		
2220	SSI DISABLED WITH Q M	1,084,530.49	1,067,376.31	963,365.41	1,180,700.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,295,973.13		
2300	SSI BLIND WITH MEDIC	2,008.80	2,245.08	1,590.11	2,037.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,880.99		
2310	SSI BLIND NON-MEDIC A	10,075.80	9,689.37	10,601.79	12,667.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,034.13		
2320	SSI BLIND WITH QMB	4,970.93	1,483.22	264.76	2,694.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,413.28		
SUBTOTAL:	14,639,339.2	7 12,574,719.06	12,172,913.9	0 14,559,028.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,946,000.56		

8720	SSI DISABLED FREEDO M	2,380.80	2,692.35	2,162.25	1,462.80	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	1,462.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

8,698.20

8,698.20

TOTAL:	14,641,720.07	12,577,411.41	12,175,076.15	14,560,491.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,954,698.76		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	61,523.02	81,067.68	60,616.91	27,444.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230,652.11		
2110	SSI AGED NON-MEDICA
R	891.34	0.00	30.00	217.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,139.15		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	320.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320.84		
2200	SSI DISABLED WITH M E	4,110.68	3,582.31	7,628.57	1,865.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,187.30		
2210	SSI DISABLED NON-ME
D	5,636.33	1,595.00	-17,970.22	14,969.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,230.81		
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	44,818.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253,596.26		

253,596.26

72,181.04	86,244.99	50,351.64	44,818.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

TOTAL:	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	415.40	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	418.80	0.00	3,722.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,141.47		
SUBTOTAL:	0.00	418.80	0.00	3,722.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,141.47		

TOTAL:	0.00	418.80	0.00	3,722.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,141.47		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	37,904.12	18,644.88	18,077.02	41,557.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116,183.60		
1013	TANF 06-13 M & F NON	66,306.45	34,537.50	30,933.97	78,081.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209,859.18		
1014	TANF 14-20 MALE NON-	8,676.21	4,254.94	4,356.71	9,494.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,782.43		
1015	TANF 14-20 FEMALE N O	4,890.64	2,240.60	3,653.73	5,679.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,464.15		
2210	SSI DISABLED NON-ME
D	274,297.27	169,632.61	140,315.24	309,801.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		894,046.25		
2220	SSI DISABLED WITH Q M	391.92	153.36	40.00	11.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		596.76		
2310	SSI BLIND NON-MEDIC
A	2,652.31	2,038.76	585.07	3,217.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,493.19		
4312	SOBRA CHILD 01-05 M	170,389.43	100,660.33	74,587.65	204,872.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		550,509.52		
4313	SOBRA CHILD 06-13 M	266,108.81	157,297.68	134,113.69	317,309.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		874,829.26		
4314	SOBRA CHILD 14-20 MA	22,058.21	12,674.72	8,832.55	22,642.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,207.94		
4315	SOBRA CHILD 14-20 FE	10,521.23	4,139.37	3,902.67	11,933.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,496.64		
SUBTOTAL:	864,196.6	0	506,274.75	419,398.3	0	1,004,599.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,794,468.92		

3514	ADULT 40-100% MALE 1	29.06	8.84	0.00	136.98	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	305.58	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	217.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	599.33	156.24	314.9	2	659.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

174.88	
913.77	
641.64	
1,730.29	

3914	NEWLY ELIGIBLE MALE	65.66	0.00	0.00	34.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	65.66	0.00	0.00	34.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

100.03

100.03

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	52.03	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	56.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	124.10	62.05	15.18	108.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
124.10	
67.21	
118.35	
309.66	

4413	SOBRA 100-133% M&F
6	78,148.02	39,845.81	32,383.47	78,247.46	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	5,278.07	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	1,558.45	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	85,083.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
228,624.76	
14,962.74	
4,037.95	
247,625.45	

3,044,234.35

950,558.83	549,098.89	454,090.88	1,090,485.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	12,928.83	7,704.40	11,737.08	25,845.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,216.23		
2200	SSI DISABLED WITH M E	2,586.31	606.85	362.12	1,724.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,279.70		
2210	SSI DISABLED NON-ME
D	1,533,543.66	873,651.18	817,014.12	1,881,520.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,105,729.33		
2220	SSI DISABLED WITH Q M	5,358.58	2,675.67	559.32	4,335.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,929.47		
2310	SSI BLIND NON-MEDIC
A	3,264.10	251.23	1,140.95	2,033.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,689.33		
SUBTOTAL:	1,557,681.48	884,889.33	830,813.5	9	1,915,459.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,188,844.06		

TOTAL:	1,557,681.48	884,889.33	830,813.59	1,915,459.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,188,844.06		

ACC REINSURANCE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	-437.59	0.00	1,517.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,079.97		
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	1,534,729.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,072,717.79		
1012	TANF 01-05 M & F NON	4,347.40	32,160.78	45,922.59	341,221.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		423,652.25		
1013	TANF 06-13 M & F NON	324,791.53	193,449.53	186,177.60	201,887.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906,306.31		
1014	TANF 14-20 MALE NON-	81,483.94	198,980.19	109,178.50	212,727.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		602,370.12		
1015	TANF 14-20 FEMALE N O	25,303.51	119,152.30	148,991.49	109,631.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403,078.47		
1016	TANF 21-44 MALE NON-	180,616.91	142,894.03	150,910.06	204,896.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		679,317.09		
1017	TANF 21-44 FEMALE N O	454,160.18	326,646.13	492,410.41	224,211.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,497,427.92		
1018	TANF 45-64 M & F NON	37,034.63	198,804.51	125,576.39	301,998.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		663,413.67		
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	8,489.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,146.42		
2110	SSI AGED NON-MEDICA
R	112,670.07	397,755.12	277,933.20	166,896.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		955,254.90		
2200	SSI DISABLED WITH M E	130,347.89	55,514.79	4,376.07	612,910.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		803,148.82		
2210	SSI DISABLED NON-ME
D	5,846,572.17	6,706,943.88	8,305,555.80	9,619,339.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,478,410.91		
2310	SSI BLIND NON-MEDIC A	11,949.45	9,724.98	13,371.35	31,461.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,506.87		
4311	SOBRA CHILD <1 M & F	2,735,784.55	1,807,996.36	2,408,428.56	3,212,152.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,164,361.63		
4312	SOBRA CHILD 01-05 M	811,967.95	925,721.48	609,324.26	498,970.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,845,984.13		
4313	SOBRA CHILD 06-13 M	1,033,377.89	800,538.20	912,119.74	360,302.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,106,338.10		
4314	SOBRA CHILD 14-20 MA	539,123.31	607,332.68	786,856.62	1,115,558.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,048,871.57		
4315	SOBRA CHILD 14-20 FE	253,541.95	1,134,418.78	573,956.65	384,409.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,346,326.72		
5015	SOBRA PREG 14-20 FE M	1,806.25	0.00	0.00	360.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,166.49		
5017	SOBRA PREG 21-44 FE
M	13,329.82	114,984.27	27,660.93	18,853.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,828.83		
SUBTOTAL:	13,360,776.0	9 15,197,920.09	16,585,151.6	5 19,162,523.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,306,370.90		

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	277,211.54	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	92,412.69	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	83,768.51	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	-26,848.18	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	27,684.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,639.38	
37.87	
922,307.47	
787,303.65	
672,306.36	
3,522.55	
36,411.80	
99,225.34	

3100	TRANSPLANT OPTION 1	0.00	3,395.06	0.00	4,368.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	3,395.06	0.00	4,368.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,763.49

7,763.49

ACC REINSURANCE
For The Period Ending October 31, 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	51,542.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		481,353.91		
SUBTOTAL:	967,764.70	854,007.18	676,565.54	505,770.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,004,108.33		

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	

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	3,250.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	540,308.95	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	358,990.58	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	204,293.21	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	452,563.68	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	1,559,407.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,250.78	
5,076.33	
649,728.48	
16,701.76	
1,358,063.63	
531,040.47	
1,786,864.94	
4,350,726.39	

4413	SOBRA 100-133% M&F
6	241,947.24	262,349.92	95,062.65	115,604.65	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	160,544.26	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	12,853.75	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	289,002.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

714,964.46	
780,539.54	
39,082.31	
1,534,586.31	

3,356.87

882.41

3506	ADULT 40-100% MALE 2	368.52	0.00	0.00	1,532.93	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	15,258.27	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	5,386.04	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	229,040.46	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	97,022.50	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	707,077.66	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	12,522.20	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	140,017.36	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	38,594.18	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	1,444,892.96	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	650,059.70	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	2,003,850.24	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	5,345,254.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,901.45	
10,336.97	
1,256,492.10	
27,679.70	
964,074.31	
231,098.50	
2,854,795.72	
19,414.37	
-12,921.17	
136,611.10	
377,026.51	
225,974.79	
7,171,697.82	
1,833,086.26	
9,512,389.30	
879.78	
24,610,537.51	

4,239.28

ACC REINSURANCE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		
8710	SSI DISABLED FREEDO
M	6,949.00	14,106.75	4,741.37	182.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,979.79		
SUBTOTAL:	6,949.00	17,661.88	6,980.35	182.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,773.90		

97,850,106.11

20,934,675.20	23,395,635.93	26,653,285.54	26,866,509.44	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	24,561.23	-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	222,547.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		899,229.85		
2110	SSI AGED NON-MEDICA
R	69,649.07	75,558.87	47,319.07	3,027.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,554.29		
2200	SSI DISABLED WITH M E	314,831.72	463,347.96	539,913.45	476,106.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,794,199.90		
2210	SSI DISABLED NON-ME
D	6,285,457.34	4,503,314.71	5,531,672.90	4,480,303.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,800,748.33		
2310	SSI BLIND NON-MEDIC A	1,504.99	5,274.08	0.00	330.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,109.27		
SUBTOTAL:	6,807,585.18	5,361,381.84	6,418,046.04	5,182,314.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,769,327.96		

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	5,182,314.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,805,494.96		

ACC SMIB
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	49,447.00	52,667.50	49,591.50	45,730.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		197,436.30		
1010	TANF NON-MEDICARE	677.50	406.50	406.50	406.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,897.00		
1020	TANF WITH QMB	44,961.50	39,964.50	37,916.00	37,653.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,495.00		
2100	SSI AGED WITH MEDIC A	31,102.20	35,121.60	38,203.50	32,389.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,816.30		
2110	SSI AGED NON-MEDICA
R	539,823.00	550,536.20	542,519.50	535,106.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,167,984.70		
2120	SSI AGED WITH QMB	4,358,353.50	4,430,488.50	4,459,947.40	4,469,349.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,718,139.10		
2200	SSI DISABLED WITH M E	79,390.30	75,152.80	78,504.30	81,050.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314,098.00		
2210	SSI DISABLED NON-ME
D	457,985.50	459,066.50	459,745.50	464,882.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,841,680.00		
2220	SSI DISABLED WITH Q M	3,875,518.60	3,899,421.50	3,898,474.00	3,868,672.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,542,086.10		
2300	SSI BLIND WITH MEDIC	135.50	135.50	135.50	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		542.00		
2310	SSI BLIND NON-MEDIC A	4,607.00	4,200.50	4,336.00	3,794.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,937.50		
2320	SSI BLIND WITH QMB	38,872.00	35,636.50	36,178.50	37,669.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148,356.00		
4320	SOBRA CHILD WITH Q MB	271.00	271.00	1,626.00	542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,710.00		
5000	SOBRA PREGNANT WO
MAN	0.00	0.00	0.00	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.50		
5020	SOBRA PREGNANT WO MAN	3,658.50	4,739.50	4,200.50	5,555.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,154.00		
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	816,375.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,236,082.40		
8040	SLMB	5,415,089.00	5,424,721.20	5,454,262.10	5,451,776.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,745,848.50		
8888	SMIB ONLY NOT ELIGIB	-40,718.50	-27,017.20	-34,454.20	-22,677.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-124,867.10		
9999	SMIB ONLY NOT ELIGIB	159,459.10	25,881.20	152,852.80	169,311.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507,504.20		
SUBTOTAL:	15,822,251.7	0 15,824,261.10	15,987,395.5	0 15,997,856.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,631,764.50		

3520	ADULT 40-100% FOR FI	0.00	271.00	542.00	271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	135.50	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	406.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	406.50	677.5	0	813.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,084.00	
135.50	
677.50	
1,897.00	

1100	TANF EXPANDED FPR FI	200,075.30	203,897.00	200,246.00	208,634.00	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	271.00	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	935,560.60	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	12,466.00	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	135.50	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	3,733,600.70	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	135.50	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	12,872.50	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	2,352,198.00	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	7,255,873.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
812,852.30	
1,219.50	
3,682,825.40	
52,947.00	
271.00	
14,777,229.00	
542.00	
54,323.50	
9,365,749.80	
28,747,959.50	

ACC SMIB
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		
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	45,121.50	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	45,121.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
135.50	
180,621.50	
180,757.00	

92,562,784.50

23,263,172.60	23,299,664.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

22,964,898.60

23,035,048.80

ACC HIB
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1020	TANF WITH QMB	1,311.00	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		5,244.00		
2100	SSI AGED WITH MEDIC A	917.70	2,665.70	1,704.30	3,059.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,346.70		
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	603,322.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,312,414.70		
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	273,008.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,053,443.40		
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	1,551.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,767.00		
8020	QMB ONLY	4,259.70	4,259.70	5,613.70	4,571.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,704.80		
9999	SMIB ONLY NOT ELIGIB	-7,682.70	-11,273.20	-3,735.30	-4,872.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-27,564.10		
SUBTOTAL:	775,609.2	0	843,035.00	893,679.2	0	881,950.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,394,273.50		

1120	TANF EXPANDED FOR FI	1,551.00	240.00	240.00	240.00	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	4,653.70	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	4,893.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,271.00	
18,614.80	
20,885.80	

TOTAL:	781,857.60	847,885.00	898,572.90	886,843.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,415,159.30		

Q1
For The Period Ending October 31, 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	3,063,352.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,060,651.80		
9999	SMIB ONLY NOT ELIGIB	-11,850.50	-8,842.50	2,000.50	-3,347.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-22,040.00		
SUBTOTAL:	2,951,192.00	2,997,689.00	3,029,726.00	3,060,004.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,038,611.80		

12,038,611.80

2,951,192.00	2,997,689.00	3,029,726.00	3,060,004.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC SMIB
For The Period Ending October 31, 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	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,084.00		
1020	TANF WITH QMB	677.50	677.50	677.50	542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,574.50		
2100	SSI AGED WITH MEDIC A	1,149,367.50	1,145,754.60	1,146,101.70	1,140,429.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,581,653.20		
2110	SSI AGED NON-MEDICA
R	224,638.00	229,025.80	228,886.30	217,342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		899,892.10		
2120	SSI AGED WITH QMB	1,237,088.50	1,251,357.50	1,255,583.80	1,270,715.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,014,744.80		
2200	SSI DISABLED WITH M E	399,084.90	384,519.80	388,578.30	387,535.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,559,718.80		
2210	SSI DISABLED NON-ME
D	14,092.00	14,769.50	16,937.50	18,563.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,362.50		
2220	SSI DISABLED WITH Q M	1,066,637.10	1,062,882.00	1,069,433.50	1,074,934.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,273,886.60		
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	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		542.00		
2320	SSI BLIND WITH QMB	813.00	948.50	542.00	406.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,710.00		
SUBTOTAL:	4,092,940.50	4,090,748.20	4,107,418.10	4,110,739.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,401,846.00		

8720	SSI DISABLED FREEDO M	1,355.00	1,761.50	1,761.50	2,168.00	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	2,168.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,046.00

7,046.00

TOTAL:	4,094,295.50	4,092,509.70	4,109,179.60	4,112,907.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,408,892.00		

LTC HIB
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	0.00	-874.00	0.00	437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-437.00		
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	369,532.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,483,109.80		
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	17,741.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,938.60		
2320	SSI BLIND WITH QMB	480.70	480.70	480.70	480.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,922.80		
SUBTOTAL:	381,352.5	0	383,341.90	394,396.6	0	388,191.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,547,282.20		

1,547,282.20

381,352.50	383,341.90	394,396.60	388,191.20	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,459.38	2,376.85	536.00	1,132.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,504.86		
1007	TANF 21-44 FEMALE WI	1,844.01	2,435.65	604.00	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,964.66		
1008	TANF 45-64 M & F WIT	8,360.17	6,104.83	4,135.71	4,922.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,523.49		
1009	TANF 65+ M & F WITH	6,203.96	2,264.15	1,795.13	3,544.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,807.45		
1011	TANF <1 M & F NON-ME	1,069,634.86	501,655.84	518,233.37	524,144.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,613,668.90		
1012	TANF 01-05 M & F NON	371,200.65	232,647.74	216,168.38	291,939.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,111,955.89		
1013	TANF 06-13 M & F NON	550,058.56	373,315.59	287,418.12	412,270.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,623,062.68		
1014	TANF 14-20 MALE NON-	193,092.30	113,486.70	79,186.08	108,004.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		493,769.38		
1015	TANF 14-20 FEMALE N O	384,301.30	284,458.81	191,867.85	233,145.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,093,773.91		
1016	TANF 21-44 MALE NON-	1,656,199.06	1,433,662.24	1,024,544.40	1,046,770.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,161,175.70		
1017	TANF 21-44 FEMALE N O	5,602,026.93	4,465,727.95	3,632,886.69	4,067,631.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,768,273.32		
1018	TANF 45-64 M & F NON	2,596,861.71	2,027,518.49	1,553,121.75	1,738,239.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,915,741.70		
1019	TANF 65+ M & F NON-M	4,301.94	11,634.33	2,923.99	2,043.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,903.92		
1026	TANF 21-44 MALE WITH	379.83	0.00	15.75	617.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,012.58		
1027	TANF 21-44 FEMALE WI	8,469.49	1,464.04	1,280.01	997.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,211.47		
1028	TANF 45-64 M & F WIT	3,753.41	3,189.89	3,548.81	2,054.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,546.80		
1029	TANF 65+ M & F WITH	3,340.01	1,770.48	5,504.70	1,264.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,880.11		
2100	SSI AGED WITH MEDIC A	112,980.76	60,316.34	46,750.16	54,355.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,402.28		
2110	SSI AGED NON-MEDICA
R	181,290.38	92,702.15	72,010.14	93,986.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		439,988.78		
2120	SSI AGED WITH QMB	409,253.22	316,117.24	254,509.28	267,835.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,247,714.93		
2200	SSI DISABLED WITH M E	264,684.94	158,980.48	165,849.59	168,145.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		757,660.08		
2210	SSI DISABLED NON-ME
D	6,718,110.37	5,424,125.36	3,919,293.62	4,783,703.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,845,232.77		
2220	SSI DISABLED WITH Q M	768,151.66	555,419.51	446,900.87	460,923.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,231,395.59		
2300	SSI BLIND WITH MEDIC	2,403.28	1,253.88	1,539.79	2,094.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,291.06		
2310	SSI BLIND NON-MEDIC A	115,995.95	93,912.22	52,379.85	46,167.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308,455.95		
2320	SSI BLIND WITH QMB	10,555.01	6,761.49	4,295.24	5,940.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,551.74		
4311	SOBRA CHILD <1 M & F	2,800,114.73	1,259,315.50	1,415,197.95	1,498,953.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,973,581.42		
4312	SOBRA CHILD 01-05 M	4,665,875.72	3,219,933.46	2,727,788.10	3,500,214.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,113,811.75		
4313	SOBRA CHILD 06-13 M	6,595,816.61	5,325,072.19	3,862,761.20	5,330,386.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,114,036.12		
4314	SOBRA CHILD 14-20 MA	1,460,742.34	1,340,303.97	1,028,941.33	1,241,190.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,071,177.83		
4315	SOBRA CHILD 14-20 FE	2,086,542.45	1,869,853.40	1,314,627.46	1,807,968.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,078,992.17		
5007	SOBRA PREG 21-44 FE M	93.41	904.06	96.75	746.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,840.55		
5013	SOBRA PREG 09-13 FE
M	0.00	455.00	1,820.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,730.00		
5015	SOBRA PREG 14-20 FE M	517,147.34	253,118.58	308,182.52	262,843.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,341,292.36		
5017	SOBRA PREG 21-44 FE
M	2,680,800.23	1,488,299.21	1,648,387.93	1,617,563.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,435,050.45		
5018	SOBRA PREG 45-64 FE M	3,229.98	455.00	2,730.00	910.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,324.98		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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	414.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		446.95		
SUBTOTAL:	41,855,275.95	30,931,012.62	24,797,865.37	29,583,600.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,167,754.58		

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

0.00

0.00

1106	TANF EXPANDED 21-44	3,391.33	1,198.94	1,322.27	3,291.41	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	1,838.95	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	12,428.37	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	18,636.77	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	455.00	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	2,872.61	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	34,935.08	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	471,192.59	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	1,864,618.59	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	1,101,634.44	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	5,013.44	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	9,294.87	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	10,512.56	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	44,329.74	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	26,534.47	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	11,781.23	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	7,519.22	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	267,021.80	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	3,833.53	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	97,786.88	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	127,230.10	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	4,122,761.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,203.95	
11,561.71	
74,185.63	
108,002.73	
1,160.00	
18,803.98	
121,051.10	
2,031,927.34	
8,253,845.65	
5,159,941.78	
16,052.96	
48,573.87	
70,209.30	
200,522.07	
143,228.61	
30,381.35	
71,585.74	
1,202,066.15	
13,842.08	
430,730.77	
654,218.50	
18,671,095.27	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY 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	
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	-660.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-10,230.00	-660.00	-660.00	0.00	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	
-3,300.00	
-11,550.00	

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

1,351.17

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3508	ADULT 40-100% M&F 45	0.00	91.00	0.00	625.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		716.93		
3509	ADULT 40-100% M&F 65	81.00	0.00	43.40	193.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		317.98		
3514	ADULT 40-100% MALE 1	62,409.69	50,399.74	38,081.34	59,185.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210,076.12		
3515	ADULT 40-100% FEMAL E	126,223.47	102,765.83	67,081.04	110,495.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406,565.81		
3516	ADULT 40-100% MALE 2	727,935.76	485,813.77	396,851.80	404,408.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,015,009.41		
3517	ADULT 40-100% FEMAL E	667,579.54	460,943.19	314,517.42	383,245.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,826,285.57		
3518	ADULT 40-100% M&F 45	2,280,931.12	1,866,834.84	1,194,937.11	1,416,993.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,759,696.50		
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	3,200.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,665.55		
3707	ADULT <40% EXP FEMA L	910.00	1,023.38	3,655.57	1,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,408.95		
3708	ADULT <40% EXP M&F
4	5,022.91	7,067.77	5,582.80	8,786.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,460.07		
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	231,621.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		997,633.46		
3715	ADULT <40% EXP FEMA L	489,450.66	370,107.48	272,561.22	323,903.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,456,022.67		
3716	ADULT <40% EXP MALE	5,578,819.17	4,600,936.70	3,846,127.28	4,096,201.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,122,084.95		
3717	ADULT <40% EXP FEMA L	3,643,354.41	2,910,869.26	2,243,667.36	2,583,972.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,381,863.40		
3718	ADULT <40% EXP M&F
4	8,545,612.25	7,023,601.87	5,412,793.44	6,021,584.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,003,591.61		
3719	ADULT <40% EXP M&F 6	455.00	21,292.98	455.00	3,665.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,868.67		
3727	ADULT <40% EXP FEMA
L	0.00	0.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455.00		
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:	22,463,419.3	3 18,154,543.07	13,980,062.5	8 15,650,357.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,248,382.82		

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	390,359.63	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	135,189.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

910.00	
1,760,492.69	
625,537.03	

3906	NEWLY ELIGIBLE MALE	0.00	455.00	1,473.15	1,376.41	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	93.41	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	2,363.28	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	148.72	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	13,916.00	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	28,726.02	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	298,943.60	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	508,095.57	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	847,097.63	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	910.00	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	1,701,670.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,304.56	
93.41	
4,296.05	
705.70	
57,390.23	
156,930.91	
1,454,030.93	
2,341,117.98	
4,360,060.77	
910.00	
8,378,840.54	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	237,463.81	175,607.59	149,384.42	159,032.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		721,488.67		
SUBTOTAL:	1,013,023.62	761,388.60	649,434.45	684,581.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,108,428.39		

8700	SSI DISABLED FREEDO M	12,901.78	6,600.67	1,644.15	10,536.85	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	24,978.66	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	1,104.03	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	36,619.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

31,683.45	
95,820.67	
1,997.06	
129,501.18	

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

4517	BC PATIENT FEMALE 2 1	0.00	0.00	910.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	4,984.51	6,853.69	7,700.14	3,185.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	455.00	455.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	2,275.00	2,730.00	1,820.00	8,572.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,259.51	10,038.69	10,885.1	4	12,667.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,365.00	
22,723.34	
1,365.00	
15,397.24	
40,850.58	

TOTAL:	74,111,672.71	56,982,751.98	44,847,279.40	51,791,599.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227,733,303.36		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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	-37,884.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,366.93		
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	-37,884.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,366.93		

0.00

0.00

0.00

-37,884.57

TOTAL:

42,607.07

41,818.90

47,825.53

0.00

0.00

0.00

0.00

0.00

94,366.93

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	7,031.94	2,402.11	8,987.48	2,175.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,596.63		
1012	TANF 01-05 M & F NON	777.88	2,632.04	96.35	168.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,674.33		
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	1,765.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,973.47		
1016	TANF 21-44 MALE NON-	5,642.36	1,117.64	5,118.38	5,301.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,179.61		
1017	TANF 21-44 FEMALE N O	38,709.06	5,112.40	66,186.01	2,817.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,824.77		
1018	TANF 45-64 M & F NON	3,220.37	9,395.06	5,423.50	1,020.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,059.89		
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	5,032.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,205.40		
2110	SSI AGED NON-MEDICA
R	4,535.42	5,494.64	3,476.23	8,172.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,678.78		
2120	SSI AGED WITH QMB	-5.22	718.26	13,438.47	-162.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,988.52		
2200	SSI DISABLED WITH M E	828.88	4,440.65	346.64	599.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,215.54		
2210	SSI DISABLED NON-ME
D	46,209.75	8,576.13	356,427.07	96,324.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507,537.15		
2220	SSI DISABLED WITH Q M	6,575.10	48.79	92,736.81	2,768.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,129.14		
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	16,241.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,189.38		
4312	SOBRA CHILD 01-05 M	8,047.58	7,985.21	39,028.64	7,716.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,777.83		
4313	SOBRA CHILD 06-13 M	11,969.38	4,816.54	6,351.37	9,105.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,242.40		
4314	SOBRA CHILD 14-20 MA	1,518.14	858.50	2,084.57	11,953.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,415.12		
4315	SOBRA CHILD 14-20 FE	1,126.11	886.24	3,376.06	583.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,972.15		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	359.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		359.89		
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	1,033.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,152.32		
5017	SOBRA PREG 21-44 FE
M	25,861.76	19,139.00	21,533.20	34,999.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,533.88		
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 October 31, 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	207,976.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,111,106.21		

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

0.00

0.00

1106	TANF EXPANDED 21-44	46.16	0.00	0.00	18.39	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	2,770.51	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	1,382.56	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	42,075.88	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	56.92	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	140.16	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	106.36	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	184.97	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	46,735.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
64.55	
6.60	
274.49	
0.00	
0.00	
1,920.91	
0.00	
67,632.74	
34,668.16	
47,988.88	
0.00	
0.00	
108.16	
748.08	
0.00	
2,672.15	
1,055.47	
0.00	
543.83	
2,154.19	
24.82	
159,863.03	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY 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	
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

103.16

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

103.16

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		
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	9,335.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,002.48		
3517	ADULT 40-100% FEMAL E	3,335.31	6,034.54	665.68	1,659.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,694.70		
3518	ADULT 40-100% M&F 45	119,068.49	118,784.75	153,724.03	19,853.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		411,430.78		
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	2,380.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,803.21		
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	2,618.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,873.68		
3715	ADULT <40% EXP FEMA L	462.06	1,931.76	1,739.85	2,414.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,547.72		
3716	ADULT <40% EXP MALE	365,435.81	51,493.65	58,404.37	83,378.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		558,712.05		
3717	ADULT <40% EXP FEMA L	28,305.36	19,951.64	62,170.84	56,367.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,795.57		
3718	ADULT <40% EXP M&F
4	250,841.33	74,155.25	56,080.07	78,701.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		459,777.84		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	0.00	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	256,811.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,706,125.06		

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	377.58	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	378.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
3,459.43	
486.84	

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	9.46	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	268.82	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	8,430.22	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	1,411.17	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	23,743.67	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	47.55	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	33,910.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
9.46	
0.00	
530.04	
488.57	
136,385.14	
19,147.36	
331,467.47	
47.55	
488,075.59	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	171.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.36		
SUBTOTAL:	100.51	2,095.60	993.76	927.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,117.63		

8700	SSI DISABLED FREEDO M	57.08	79.22	0.00	993.52	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	993.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,129.82	
0.00	
0.00	
1,129.82	

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

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	22,572.76	13,720.73	3,192.13	20.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	22,572.76	13,720.73	3,192.13	20.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
39,506.40	
0.00	
0.00	
39,506.40	

TOTAL:	1,206,055.14	560,583.24	1,194,018.97	547,376.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,508,034.14		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 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	404,946.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,863,286.02		
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	404,946.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,863,688.53		

0.00

0.00

0.00

404,946.54

TOTAL:

617,587.71

448,283.68

392,870.60

0.00

0.00

0.00

0.00

0.00

1,863,688.53

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,365.00	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	161,043.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		812,530.52		
2110	SSI AGED NON-MEDICA
R	62,182.20	66,431.52	41,317.62	34,066.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,997.80		
2120	SSI AGED WITH QMB	359,948.35	251,228.84	236,600.09	249,357.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,097,134.81		
2200	SSI DISABLED WITH M E	64,376.04	44,880.45	44,560.73	41,946.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,763.49		
2210	SSI DISABLED NON-ME
D	1,137,487.58	1,052,503.74	822,964.63	856,226.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,869,182.75		
2220	SSI DISABLED WITH Q M	153,160.28	111,134.47	98,763.76	108,290.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471,348.68		
2300	SSI BLIND WITH MEDIC	0.00	608.28	239.12	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		928.40		
2310	SSI BLIND NON-MEDIC A	8,478.78	5,005.00	4,989.14	5,488.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,961.08		
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	1,456,500.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,678,537.08		

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	1,456,500.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,678,537.08		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	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	25,620.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,055.94		
2110	SSI AGED NON-MEDICA
R	25,720.01	775.26	473.84	4,116.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,085.15		
2120	SSI AGED WITH QMB	11,865.96	23,336.47	4,003.90	4,412.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,618.64		
2200	SSI DISABLED WITH M E	11,704.99	147.31	163.48	395.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,411.13		
2210	SSI DISABLED NON-ME
D	73,355.72	69,642.29	33,336.99	50,764.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227,099.47		
2220	SSI DISABLED WITH Q M	2,493.77	1,494.83	26,114.02	5,892.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,995.06		
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	-306.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-306.34		
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	90,894.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		432,980.04		

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

432,980.04

131,554.40	123,114.60	87,416.10	90,894.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	5,720.54	2,465.16	4,020.71	6,395.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,601.46		
1007	TANF 21-44 FEMALE WI	3,816.12	5,879.47	3,052.17	5,354.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,102.54		
1008	TANF 45-64 M & F WIT	5,162.62	6,679.62	8,917.62	7,499.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,258.92		
1009	TANF 65+ M & F WITH	1,369.44	4,783.88	4,100.16	5,212.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,465.94		
1011	TANF <1 M & F NON-ME	628,082.08	711,492.30	296,466.98	645,951.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,281,992.99		
1012	TANF 01-05 M & F NON	-50,122.75	71,884.03	76,313.07	115,241.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213,315.37		
1013	TANF 06-13 M & F NON	-19,553.65	128,348.20	158,426.17	188,205.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455,426.65		
1014	TANF 14-20 MALE NON-	10,100.26	62,045.38	70,011.32	54,058.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196,215.24		
1015	TANF 14-20 FEMALE N O	6,465.57	126,772.99	103,778.36	159,527.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		396,544.48		
1016	TANF 21-44 MALE NON-	294,900.11	801,287.54	672,377.63	1,067,853.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,836,418.70		
1017	TANF 21-44 FEMALE N O	750,289.28	2,390,887.38	2,393,699.27	2,965,553.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,500,429.29		
1018	TANF 45-64 M & F NON	-33,187.01	951,911.48	737,553.79	1,066,265.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,722,543.45		
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	858.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,391.77		
1027	TANF 21-44 FEMALE WI	-417.22	1,655.20	77.56	944.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,260.46		
1028	TANF 45-64 M & F WIT	3,274.44	3,207.91	2,161.45	3,540.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,184.05		
1029	TANF 65+ M & F WITH	8,541.20	4,679.40	4,543.87	4,349.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,114.19		
2100	SSI AGED WITH MEDIC A	118,534.81	198,886.57	83,623.90	193,229.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		594,274.95		
2110	SSI AGED NON-MEDICA
R	-20,837.80	44,299.09	20,582.28	66,215.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,259.21		
2120	SSI AGED WITH QMB	287,256.68	330,452.18	337,985.49	450,546.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,406,241.14		
2200	SSI DISABLED WITH M E	244,210.75	434,046.24	381,914.80	665,603.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,725,774.89		
2210	SSI DISABLED NON-ME
D	2,585,073.97	4,850,256.22	4,050,436.74	5,262,121.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,747,888.43		
2220	SSI DISABLED WITH Q M	1,024,738.22	919,873.87	907,980.42	1,337,441.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,190,033.95		
2300	SSI BLIND WITH MEDIC	382.84	1,263.66	105.80	2,311.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,064.01		
2310	SSI BLIND NON-MEDIC A	-10,414.70	57,882.15	38,196.51	42,753.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128,417.40		
2320	SSI BLIND WITH QMB	15,251.72	12,243.64	15,483.93	22,990.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,970.20		
4311	SOBRA CHILD <1 M & F	276,758.94	806,294.97	811,636.78	1,159,492.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,054,183.15		
4312	SOBRA CHILD 01-05 M	-529,357.21	815,047.27	908,198.23	1,405,903.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,599,792.17		
4313	SOBRA CHILD 06-13 M	-404,516.16	1,555,596.60	1,745,883.56	2,157,314.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,054,278.72		
4314	SOBRA CHILD 14-20 MA	412,233.42	670,329.89	613,362.34	880,335.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,576,261.57		
4315	SOBRA CHILD 14-20 FE	176,458.66	660,455.78	637,320.79	919,012.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,393,248.14		
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	119,949.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232,159.73		
5017	SOBRA PREG 21-44 FE
M	32,799.46	847,611.96	664,440.78	1,070,291.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,615,144.10		
5018	SOBRA PREG 45-64 FE M	3,309.67	0.00	0.00	26.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,336.02		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending October 31, 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	4,584.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,289.64		
SUBTOTAL:	5,776,029.87	17,576,958.59	15,827,937.98	22,056,937.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,237,863.97		

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

-153.38

-153.38

1106	TANF EXPANDED 21-44	1,673.27	565.51	1,006.98	3,172.13	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	13,851.00	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	24,801.20	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	20,661.60	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	7,497.12	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	12,937.44	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	382,507.12	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	1,101,219.49	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	657,915.28	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	216.50	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	10,423.40	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	34,013.46	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	114,173.25	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	46,479.19	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	2,759.86	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	2,560.32	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	396,286.88	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	4,722.46	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	385,559.98	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	364,578.35	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	3,586,336.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,417.89	
30,548.89	
83,231.83	
48,949.38	
126.96	
19,040.24	
59,896.55	
1,055,244.25	
2,610,644.42	
1,678,889.93	
-496.35	
48,142.99	
111,506.26	
361,780.45	
156,439.84	
12,308.45	
-3,912.31	
1,220,193.34	
22,729.59	
745,894.34	
1,138,296.25	
9,405,873.19	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	-227.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	-133.62	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	-421.38	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	-257.17	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	-1,039.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-227.42	
-133.62	
0.00	
-421.38	
-257.17	
-75.63	
-1,115.22	

3507

ADULT 40-100% FEMAL E

-732.91

0.00

0.00

706.80

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

-26.11

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3508	ADULT 40-100% M&F 45	1,036.20	47.56	673.58	1,641.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,398.71		
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		
3514	ADULT 40-100% MALE 1	19,735.15	21,488.58	23,358.20	23,752.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,334.79		
3515	ADULT 40-100% FEMAL E	7,544.55	46,694.72	44,995.21	35,156.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,390.80		
3516	ADULT 40-100% MALE 2	182,166.05	316,990.28	363,173.76	431,032.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,293,362.10		
3517	ADULT 40-100% FEMAL E	49,024.77	190,927.44	234,561.60	218,475.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		692,989.79		
3518	ADULT 40-100% M&F 45	71,316.53	789,388.68	1,007,444.02	1,196,226.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,064,376.12		
3519	ADULT 40-100% M&F 65	-455.00	0.00	0.00	42.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-412.52		
3706	ADULT <40% EXP MALE	431.73	2,282.38	826.72	124.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,665.03		
3707	ADULT <40% EXP FEMA L	100.67	102.43	48.94	141.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		393.81		
3708	ADULT <40% EXP M&F
4	-450.34	1,622.11	2,005.33	2,429.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,606.31		
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	361,014.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		843,587.08		
3715	ADULT <40% EXP FEMA L	25,044.72	246,565.40	181,740.15	280,996.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		734,346.69		
3716	ADULT <40% EXP MALE	3,653,638.18	4,242,514.88	3,995,546.33	5,557,424.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,449,123.55		
3717	ADULT <40% EXP FEMA L	1,007,616.94	2,103,959.39	2,032,422.59	2,450,655.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,594,654.30		
3718	ADULT <40% EXP M&F
4	2,576,297.05	4,745,543.78	4,665,651.27	6,088,460.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,075,952.78		
3719	ADULT <40% EXP M&F 6	-455.00	5,271.31	411.02	1,371.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,598.72		
3727	ADULT <40% EXP FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	7,728,753.96	12,865,269.19	12,746,425.7	1 16,649,652.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,990,101.51		

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	148,588.12	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	49,561.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-455.00	
286,217.69	
167,924.56	

3906	NEWLY ELIGIBLE MALE	390.09	765.96	396.91	11,956.61	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	4,158.61	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	5,834.05	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	3,685.96	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	22,545.32	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	35,619.36	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	1,008,276.84	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	220,047.48	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	561,279.73	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	1,175.86	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	1,874,579.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,509.57	
6,492.83	
8,000.30	
4,431.08	
53,670.64	
83,448.67	
1,526,725.72	
568,293.61	
1,329,438.76	
2,565.00	
3,596,576.18	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	-8,543.09	68,370.22	114,590.98	102,638.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277,056.54		
SUBTOTAL:	-108,481.91	242,435.61	296,001.56	300,788.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		730,743.79		

8700	SSI DISABLED FREEDO M	5,748.24	6,806.69	10,182.44	11,563.70	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	28,342.33	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	441.77	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	40,347.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

34,301.07	
55,284.22	
17,730.25	
107,315.54	

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

0.00

0.00

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	10,451.64	11,028.21	11,221.95	5,506.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	-1,365.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,086.64	11,028.21	11,221.9	5	5,506.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
38,208.66	
0.00	
-1,365.00	
36,843.66	

TOTAL:	14,235,837.65	34,312,575.58	32,042,537.41	44,513,098.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125,104,049.24		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	111.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111.55		
2100	SSI AGED WITH MEDIC A	3,141,298.02	2,783,579.05	2,655,926.93	3,278,008.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,858,812.15		
2110	SSI AGED NON-MEDICA
R	182,346.04	132,352.21	128,808.51	146,829.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		590,336.47		
2120	SSI AGED WITH QMB	4,772,976.61	4,078,974.33	3,954,822.95	4,949,020.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,755,794.32		
2200	SSI DISABLED WITH M E	589,027.23	472,720.03	496,572.43	619,033.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,177,352.85		
2210	SSI DISABLED NON-ME
D	2,848,444.87	2,321,363.70	2,518,764.62	2,940,087.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,628,661.00		
2220	SSI DISABLED WITH Q M	928,876.44	954,747.01	838,487.63	1,066,518.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,788,629.39		
2300	SSI BLIND WITH MEDIC	2,008.80	1,636.80	1,350.99	1,956.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,952.59		
2310	SSI BLIND NON-MEDIC A	1,597.02	4,684.37	5,612.65	7,485.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,379.39		
2320	SSI BLIND WITH QMB	4,366.58	1,392.78	0.00	2,694.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,453.73		
SUBTOTAL:	12,471,053.16	10,751,450.28	10,600,346.7	1 13,011,633.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,834,483.44		

8720	SSI DISABLED FREEDO M	2,380.80	2,692.35	2,162.25	1,462.80	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	1,462.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

8,698.20

8,698.20

46,843,181.64

12,473,433.96	10,754,142.63	10,602,508.96	13,013,096.09	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 October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	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		

KidsCare - CAPITATION AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	163,955.19	166,288.57	166,584.01	170,052.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		666,880.39		
6012	KIDS 1-5 M & F NON-M	1,543,957.96	1,565,323.61	1,575,292.00	1,676,794.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,361,368.46		
6013	KIDS 6-13 M & F NON-	2,896,611.35	2,928,471.06	2,946,784.80	3,150,605.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,922,472.97		
6014	KIDS 14-19 MALE NON-	741,190.91	756,932.03	769,166.95	820,270.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,087,560.13		
6015	KIDS 14-19 FEMALE NO	751,128.68	770,184.18	781,392.45	842,956.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,145,661.42		
9960	KIDSCARE KICK PAYME N	6,000.27	5,997.30	5,984.82	12,216.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,198.80		
SUBTOTAL:	6,102,844.36	6,193,196.75	6,245,205.03	6,672,896.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,214,142.17		

25,214,142.17

6,102,844.36	6,193,196.75	6,245,205.03	6,672,896.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	283.84	288.66	289.09	288.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,149.97		
6012	KIDS 1-5 M & F NON-M	8,605.77	8,720.94	8,773.24	8,915.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,015.43		
6013	KIDS 6-13 M & F NON-	16,171.73	16,347.00	16,437.62	16,765.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,721.95		
6014	KIDS 14-19 MALE NON-	4,132.98	4,218.92	4,287.26	4,374.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,014.12		
6015	KIDS 14-19 FEMALE NO	4,170.12	4,274.87	4,336.42	4,469.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,250.99		
9960	KIDSCARE KICK PAYME N	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
SUBTOTAL:	33,365.44	33,851.39	34,124.6	3	34,816.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,157.46		

TOTAL:	33,365.44	33,851.39	34,124.63	34,816.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,157.46		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	372.22	377.84	377.73	488.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,615.98		
6012	KIDS 1-5 M & F NON-M	14,030.25	13,776.71	13,002.24	17,818.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,627.71		
6013	KIDS 6-13 M & F NON-	24,067.99	24,576.74	26,372.06	34,081.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,098.37		
6014	KIDS 14-19 MALE NON-	10,487.13	10,708.53	10,950.58	13,577.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,723.24		
6015	KIDS 14-19 FEMALE NO	10,410.58	10,572.35	10,948.34	13,929.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,860.30		
SUBTOTAL:	59,368.17	60,012.17	61,650.9	5	79,894.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		260,925.60		

61,650.95

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

79,894.31

260,925.60

TOTAL:

59,368.17

60,012.17

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	289.00	292.00	291.00	300.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,172.00		
6012	KIDS 1-5 M & F NON-M	8,836.06	8,937.06	9,053.03	9,159.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,985.75		
6013	KIDS 6-13 M & F NON-	16,748.06	16,847.06	16,997.12	17,272.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,864.39		
6014	KIDS 14-19 MALE NON-	4,347.00	4,404.00	4,514.00	4,609.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,874.00		
6015	KIDS 14-19 FEMALE NO	4,353.00	4,428.00	4,520.00	4,664.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,965.00		
SUBTOTAL:	34,573.12	34,908.12	35,375.1	5	36,004.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,861.14		

TOTAL:	34,573.12	34,908.12	35,375.15	36,004.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,861.14		

KidsCare - FEE FOR SERVICE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	284.12	1,147.85	637.02	1,114.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,183.91		
6012	KIDS 1-5 M & F NON-M	14,179.76	23,135.73	17,015.05	46,530.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,861.19		
6013	KIDS 6-13 M & F NON-	45,325.01	144,046.96	62,107.36	97,046.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		348,525.61		
6014	KIDS 14-19 MALE NON-	39,303.11	50,503.51	36,039.38	88,935.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		214,781.48		
6015	KIDS 14-19 FEMALE NO	25,467.01	21,720.72	26,081.79	47,116.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,386.47		
SUBTOTAL:	124,559.0	1	240,554.77	141,880.6	0	280,744.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		787,738.66		

141,880.60

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

280,744.28

787,738.66

TOTAL:

124,559.01

240,554.77

KidsCare - REINSURANCE
For The Period Ending October 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	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	33,835.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271,076.77		
6014	KIDS 14-19 MALE NON-	113,827.14	40,260.35	35,353.19	35,159.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224,599.97		
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	68,994.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		564,476.10		

TOTAL:	200,701.01	116,470.46	178,309.64	68,994.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		564,476.10		

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending October 31, 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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.00	
1010	TANF NON-MEDICARE	389.91	450.32	511.92	518.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,871.03	
1020	TANF WITH QMB	5.00	5.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.00	
2100	SSI AGED WITH MEDICA	257.99	261.42	260.66	263.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,043.07	
2110	SSI AGED NON-MEDICAR	11.00	11.00	11.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45.00	
2120	SSI AGED WITH QMB	429.97	429.89	431.22	434.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,725.47	
2200	SSI DISABLED WITH ME	1,924.20	1,920.69	1,910.74	1,907.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,663.11	
2210	SSI DISABLED NON-MED	26,376.88	26,455.14	26,530.06	26,599.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	105,961.49	
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	4,945.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19,635.42	
2310	SSI BLIND NON-MEDICA	13.00	13.48	14.00	12.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	52.80	
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	26.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	92.03	
8710	SSI DISABLED FREEDOM	3.99	5.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.99	
8720	SSI DISABLED FREEDOM	10.99	12.00	14.00	14.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	51.95	
SUBTOTAL:	34,321.39	34,487.62	34,642.03	34,750.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	138,201.93	
TOTAL:	34,321.39	34,487.62	34,642.03	34,750.8	0.00	0.00	0.00	0.00	0.00	0.	0.00	0.00	138,201.93	

9

00

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending October 31, 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	636,779.32	441,164.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,928,167.23	
EPD	106,533,521.90	107,126,210.66	107,209,520.71	121,442,144.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	442,311,398.02	
TOTAL AHCCCS LTC	106,955,990.86	107,553,965.60	107,846,300.03	121,883,308.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	444,239,565.25	
DES/DD	143,961,803.16	144,655,141.28	145,290,373.93	165,084,146.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	598,991,464.41	
TOTAL DES LTC	143,961,803.16	144,655,141.28	145,290,373.93	165,084,146.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	598,991,464.41	
TOTAL LTC - CAP	250,917,794.02	252,209,106.88	253,136,673.96	286,967,454.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,043,231,029.66	

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	14,560,491.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53,954,698.76	
DES/DD	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL DES LTC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
TOTAL LTC - FFS	14,641,720.07	12,577,411.41	12,175,076.15	14,560,491.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53,954,698.76	

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	2,412,067.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11,710,495.01	
DES/DD	4,204,532.65	1,620,152.95	3,500,067.02	2,770,247.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,094,999.95	
TOTAL DES LTC	4,204,532.65	1,620,152.95	3,500,067.02	2,770,247.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,094,999.95	
TOTAL LTC - REIN	6,843,752.18	5,361,381.84	6,418,046.04	5,182,314.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,805,494.96	

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	4,501,098.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,956,274.20	

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.

138

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	1,264,254.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,616,348.69	
Subtotal	203,452.53	932,589.80	216,051.55	1,264,254.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,616,348.69	

206,373.18	932,589.80	216,051.55	1,264,254.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,619,269.34	

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 October 31, 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