Douglas A. Ducey, Governor Jami Snyder, Director

December 27, 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 November30, 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 November 30, 2019.

Status Summary – AHCCCS has submitted its Fiscal Year 2021 budget request to the Governor’s Office of Strategic Planning and Budgeting pursuant to A.R.S. § 35-113. 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 – November 2019 enrollment is 1,895,254 members, a 6,157 member decrease over the prior month. Enrollment for December 2019 decreased to 1,892,514 members, a 2,740 member change.

Major December 2019 changes by eligibility category include: 1931 for Families and Children/SOBRA – decrease of 3,126, Supplemental Security Income – increase of 434; Prop 204 Restoration - decrease of 117; Adult Expansion – decrease of 321 Medicare Cost Sharing – increase of 778; KidsCare – increase of 114; and Federal Emergency Services – decrease of 317.

Tobacco Funds Revenue Update - Tobacco tax collections through November 2019 are $2.3 million more than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2020 appropriations.

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 December 27, 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 November 30, 2019

Prepared by: Division of Business and Finance

Appropriation Status Report
Table of Contents
APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 2020…	2
Appropriated Expenditures by Funding Source…	3
Appropriated Revenue Received Detail Schedule…	5
FOOTNOTES	7
CASELOAD AND EXPENDITURES BY RATE CODE	10

Appropriation Status Report
Appropriated Sources and Uses of Funds

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

APPROPRIATIONS:									
ADMINISTRATION									
AHCCCS Operating Lump Sum	$	88,542,300	$	36,016,942	$	36,016,942	$		-	$	88,542,300	$	-	
AHCCCS Prop 204 Administration	14,182,800	8,881,437	8,881,437			-	14,182,800		-	
Information Technology	9,878,000	-	-		-	9,878,000	-	
DES Eligibility	91,874,500		25,071,001		25,071,001		-		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		10,577,402		10,577,402		-		44,358,700		-		
ADOA Data Center	19,325,800		4,569,733		4,569,733		-		19,325,800		-		
School District Suicide Prevention Coordinator	100,000		51,865		51,865		-		100,000		-		
TOTAL ADMINISTRATION	 	268,262,100 		 	85,168,378 		 	85,168,378 		 	-			 	268,262,100 		 	-			

Traditional Medicaid Services	5,178,162,100	2,218,062,543	2,218,062,543		5,178,162,100	-	
Proposition 204 Services	4,168,410,500	1,720,155,601	1,720,155,601		4,168,410,500	-	
ACA Adult Expansion	527,018,800	187,317,617	187,317,617		527,018,800	-	
KidsCare Services	106,516,300	32,176,894	32,176,894		106,516,300	-	
ALTCS Services	1,796,913,800	742,594,197	742,594,197		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	15,966,464	15,966,464		345,281,700	-	
CMDP	180,729,500	78,479,965	78,479,965		180,729,500	-	
Behavioral Health Services - in Schools	9,990,000	4,162,500	4,162,500		9,990,000	-	
Targeted Investment Program	90,000,000	-	-		90,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		31,933,729		31,933,729		-		77,646,900		-	
Supported Housing	5,324,800		2,445,128		2,445,128		-		5,324,800		-	
Crisis Services	16,391,300		6,773,458		6,773,458		-		16,391,300		-	
TOTAL PROGRAMMATIC	 	12,536,085,200 		 	5,040,068,095 		 	5,040,068,095 		 	-			 	12,536,085,200 		 	-		

-
-
-
-
-

-
-
-
-

TOTAL EXPENDITURES

  $	12,804,347,300 

-

$	5,125,236,473

$	5,125,236,473	$

-	$   12,804,347,300	$	-

2

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		

Administrative Expenditures	
$	
60,044,200	
$	21,078,183	
$	21,078,183	
-	$	60,044,200	
$	
-	
Proposition 204 - Administrative Expenditures		21,538,900	7,176,055	7,176,055	-	21,538,900		-	
Programmatic Expenditures
Traditional Medicaid Services	
1,170,113,300	
525,679,827	
525,679,827		
-	1,170,113,300	
-	
Proposition 204 Services	95,088,500	39,620,208	39,620,208		-	95,088,500	-	
ACA Adult Expansion	5,393,400	2,246,907	2,246,907		-	5,393,400	-	
KidsCare Services	7,523,800	1,343,994	1,343,994		-	7,523,800	-	
ALTCS Services	234,042,300	97,517,625	97,517,625		-	234,042,300	-	
DSH and Rural Hospitals	8,843,300	-	-	-	8,843,300	-	
CMDP	54,297,600	23,641,799	23,641,799	-	54,297,600	-	
Behavior Health Services - in Schools	3,000,000	1,250,000	1,250,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	31,933,729	31,933,729	-	77,646,900	-	
Supported Housing	5,324,800	2,445,128	2,445,128	-	5,324,800	-	
Crisis Services	14,141,100	5,835,875	5,835,875	-	14,141,100	-	
Voluntary Political Subdivision Programs	 	3,750,000 	 	- 	 	- 	 	- 	 	3,750,000 	 	- 	
TOTAL GF EXPENDITURES	1,760,748,100	759,769,329	759,769,329	-	1,760,748,100	-	
	FEDERAL		
Administrative Expenditures	146,947,600	44,501,478	44,501,478		-	146,947,600	-	
Proposition 204 - Administrative Expenditures	33,035,300	12,282,783	12,282,783		-	33,035,300	-	
Programmatic Expenditures
Traditional Medicaid Services	
3,176,462,800	
1,295,615,325	
1,295,615,325		
-	3,176,462,800	
-	
Proposition 204 Services	3,615,003,800	1,517,780,918	1,517,780,918		-	3,615,003,800	-	
ACA Adult Expansion	484,056,500	174,153,977	174,153,977		-	484,056,500	-	
KidsCare Services	86,764,900	27,025,909	27,025,909		-	86,764,900	-	
ALTCS Services and Nursing Facility Assessment	1,144,403,700	454,649,543	454,649,543		-	1,144,403,700	-	
DSH and Rural Hospitals	24,856,200	-	-	-	24,856,200	-	
CMDP	126,431,900	54,838,166	54,838,166		-	126,431,900	-	
Behavior Health Services - in Schools	6,990,000	2,912,500	2,912,500		-	6,990,000	-	
Targeted Investment Program	61,937,600	-	-	-	61,937,600	-	
Voluntary Political Subdivision Programs	 	240,664,300 	 	10,896,874 	 	10,896,874 	 	- 	 	240,664,300 	 	- 	
TOTAL FEDERAL EXPENDITURES	9,147,554,600	3,594,657,473	3,594,657,473	-	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	
19,234,042	
19,234,042	
-	
46,512,900	
-	
ALTCS Services	 	268,554,800 	 	113,535,144 	 	113,535,144 	 	- 	 	268,554,800 	 	- 	
TOTAL COUNTY EXPENDITURES	318,974,100	132,769,186	132,769,186	-	318,974,100	-	

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

TOBACCO FUNDS		

Programmatic Expenditures							
Traditional Medicaid Services - Medically Needy	61,752,600	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	129,879	129,879	-	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	58,399,417	58,399,417	-	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	294,552,271	294,552,271	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	3,157,667	3,157,667	-	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	15,026,664	15,026,664	-	36,422,000	-	
Proposition 204 Services - Hospital Assessment	303,482,900	144,269,667	144,269,667	-	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	10,871,758	10,871,758	-	37,389,000	-	
ACA Adult Expansion - IGA Fund	179,900	44,975	44,975	-	179,900	-	
Traditional Medicaid Services - TPL	194,700	1,014,734	1,014,734	-	194,700	-	
ALTCS Services - TPL	-	724,963	724,963	-	-	-	
ALTCS Services - Nursing Facility Assessment	105,912,600	57,982,591	57,982,591	-	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	3,806,990	3,806,990	-	12,151,300	-	
Freedom to Work Premiums	31,200	48,372	48,372	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	937,583	937,583	-	2,250,200	-	
Voluntary Political Subdivision Programs	 	100,867,400 	 	5,069,590 	 	5,069,590 	 	- 	 	100,867,400 	 	- 	
TOTAL OTHER EXPENDITURES	1,363,047,300	599,252,721	599,252,721	-	1,363,047,300	-	
	TOTAL		
Administrative Expenditures	268,262,100	85,168,378	85,168,378	-	268,262,100	-	
Acute Care	10,739,171,400	4,297,473,898	4,297,473,898	-	10,739,171,400	-	
Long Term Care	 	1,796,913,800 	 	742,594,197 	 	742,594,197 	 	- 	 	1,796,913,800 	 	- 	
TOTAL EXPENDITURES	  $	12,804,347,300 	  $	5,125,236,473 	  $	5,125,236,473 	  $	- 	  $	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 November 30, 2019

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,251,144,200	$	550,254,916	$	548,008,009	
Proposition 204 Services & Administrative	116,627,400	46,796,264	47,437,439	
KidsCare Services	7,523,800.00	1,343,994.19	1,343,994	
ALTCS Services	234,042,300	97,517,625	97,517,625	
Behavioral Health Traditional Medicaid Services	 	151,410,400 	 	63,856,530 	 	63,856,530 	
TOTAL	1,760,748,100	759,769,329	758,163,597	

FEDERAL:
Acute & Administrative	7,789,954,100	3,058,143,855	3,052,380,520	
KidsCare Services	86,764,900	27,025,909	28,893,880	
ALTCS Services	1,144,403,700	454,649,543	508,864,584	
Behavioral Health Traditional Medicaid Services	 	126,431,900 	 	54,838,166 	 	57,789,970 	
TOTAL	9,147,554,600	3,594,657,473	3,647,928,954	

COUNTY:				
Acute & Administrative	50,419,300		19,234,042		19,815,943	
ALTCS Services	 	268,554,800 		 	113,535,144 		 	145,138,056 	
TOTAL	318,974,100		132,769,186		164,953,999	

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	129,879	129,879	
Traditional Medicaid Services - IGA Fund	10,297,700	2,574,425	2,574,425	
Acute Care - Prescription Drug Rebate Program	712,796,900	352,951,688	352,951,688	
Long Term Care - Prescription Drug Rebate Program	44,000,400	18,184,330	18,184,330	
Hospital Assessment	343,616,500	155,827,576	165,648,539	
ALTCS - Nursing Facility Assessment	105,912,600	57,982,591	138,713	
Acute TPL - Note 1	194,700	1,014,734	1,014,734	
LTC TPL - Note 1	-	724,963	724,963	
KidsCare Services - IGA Fund	76,300	-	-	
KidsCare TPL - Note 1	-	-	(311.00)	
Member Premiums - CHIP	12,151,300	3,806,990	3,806,990	
Member Premiums - Freedom to Work	31,200	48,372	48,372	
Targeted Investment Program	28,062,400	-	12,731,149	
Behavioral Health Traditional Medicaid Services	2,250,200	937,583	651,881	
Voluntary Political Subdivision - State Match	 	100,867,400 	 	5,069,590 	 	7,760,875 	
TOTAL	1,363,047,300	599,252,721	566,366,227	

TOTAL REVENUE

$	12,804,347,300

$	5,125,236,473

$	5,176,200,541

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2019	
Note 1:	Third Party Liability Collections:	November 2019		November 2018		July 1, 2019		July 1, 2018	
	Gross Collections:					November 30, 2019		November 30, 2018	
	Acute	$	1,847,909		$	1,395,213		$	8,060,099		$	6,796,604	
	LTC	729,831		560,640		3,704,266		2,559,730	
	KidsCare	19,435		89		66,614		1,890	
	Total TPL Collections	  $	2,597,175 		$	1,955,942		$	11,830,979		$	9,358,224	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	189,873	$	134,266	$	1,014,734	$	724,367	
LTC		153,712	118,786	724,963	681,091	
KidsCare		(803)	(4)	(311)	(37)	
Total Expenditure Offsets	  $	342,782 		$	253,048		$	1,739,386		$	1,405,421		

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

`

FY 20 Total

1,188.0
1,113.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2019	$ 5,258,991	
	Revenues	5,587,207	
	Transfers-In	 	243,084 	
	Total Revenues	 	5,830,290 	
	Expenditures	4,521,665	
	Transfers-out	 	924,350 	
	Total Expenditures	 	5,446,015 	
	Ending Balance November 30, 2019	  $ 5,643,267 	

Of the $5,643,267 ending balance, $3,311,822 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through December 2019.

Note 4:

Summary of Voluntary Political Subdivision Contribution Expenditures:

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

DSH Voluntary	$	40,980,200	$	4,694,590	$	10,896,874	$	15,591,464	
GME Voluntary	304,301,500	375,000	-	375,000	
Total Voluntary Political Subdivision Program Expenditures	$	345,281,700		$	5,069,590		$	10,896,874		$	15,966,464	

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	332,295,970	0	0	0	0	0	0	0	1,642,436,933	
CAPITATION - AIMHS	292,639	307,037	323,631	334,345	346,743	0	0	0	0	0	0	0	1,604,395	
CAPITATION - LTC	250,917,794	252,209,107	253,136,674	286,967,455	287,233,146	0	0	0	0	0	0	0	1,330,464,175	
MENTAL HEALTH - CHILD	865	2,317	-1,031	-270	1,084	0	0	0	0	0	0	0	2,965	
MENTAL HEALTH - ADULT	340,947	351,310	462,496	348,822	395,190	0	0	0	0	0	0	0	1,898,764	
MENTAL HEALTH - GENERAL	755	1,398	-2,562	3,511	1,243	0	0	0	0	0	0	0	4,344	
MENTAL HEALTH - CMDP	11,210,666	11,149,954	11,526,705	12,227,439	12,150,542	0	0	0	0	0	0	0	58,265,305	
MENTAL HEALTH - DD	7,458,766	7,517,688	7,570,387	6,293	-134	0	0	0	0	0	0	0	22,553,000	
MENTAL HEALTH - RBHA CRISIS	3,210,728	3,227,109	3,238,920	4,390,161	4,391,106	0	0	0	0	0	0	0	18,458,024	
FEE FOR SERVICE - ACUTE	48,820,855	49,681,027	42,280,433	52,930,957	68,773,323	0	0	0	0	0	0	0	262,486,595	
FFS - PRIOR QUARTER COVERAGE	953,544	609,982	539,248	471,399	289,234	0	0	0	0	0	0	0	2,863,407	
EMERGENCY SERVICES - FEDERAL	4,491,141	3,725,509	4,435,620	4,558,207	3,754,689	0	0	0	0	0	0	0	20,965,166	
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	730,589	0	0	0	0	0	0	0	3,772,683	
STATE ONLY TRBHA FFS	158,244	111,819	158,545	188,541	161,000	0	0	0	0	0	0	0	778,149	
INPATIENT INMATES FFS	244,004	235,027	245,518	346,036	345,038	0	0	0	0	0	0	0	1,415,624	
FFS TRBHA FEE FOR SERVICE	12,287,430	11,525,809	8,927,578	12,220,179	11,423,941	0	0	0	0	0	0	0	56,384,937	
QMB - FEE FOR SERVICE	660,278	490,123	440,696	367,062	187,136	0	0	0	0	0	0	0	2,145,296	
PIMA COUNTY INMATES FFS	4,917	34,617	15,870	30,493	13,876	0	0	0	0	0	0	0	99,772	
MARICOPA CTY INMATES FFS	19,819	22,216	24,325	1,088	12,263	0	0	0	0	0	0	0	79,711	
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	
FEE FOR SERVICE - LTC	14,641,720	12,577,411	12,175,076	14,560,491	13,493,550	0	0	0	0	0	0	0	67,448,249	
LFFS - PRIOR QUARTER COVERAGE	72,181	86,245	50,352	44,819	4,812	0	0	0	0	0	0	0	258,408	
COCONINO COUNTY INMATES LTC F	415	4,825	220	0	0	0	0	0	0	0	0	0	5,460	
MARICOPA CTY INMATES LTC FFS	0	419	0	3,723	65	0	0	0	0	0	0	0	4,207	
INPATIENT INMATES LTC FFS	27,260	0	0	0	123	0	0	0	0	0	0	0	27,383	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,557,681	884,889	830,814	1,915,460	1,235,420	0	0	0	0	0	0	0	6,424,264	
REINSURANCE - ACC	13,954,921	15,652,135	16,821,600	19,456,077	19,517,983	0	0	0	0	0	0	0	85,402,717	
REINSURANCE - LTC	6,843,752	5,361,382	6,418,046	5,182,315	6,610,870	0	0	0	0	0	0	0	30,416,365	
SMIB - ACC	15,867,509	15,869,518	16,032,517	16,042,978	16,063,831	0	0	0	0	0	0	0	79,876,352	
HIB - ACC	775,609	843,035	893,679	881,950	862,191	0	0	0	0	0	0	0	4,256,465	
Q1	2,951,192	2,997,689	3,029,726	3,060,005	3,046,073	0	0	0	0	0	0	0	15,084,685	
SMIB - LTC	4,094,296	4,092,510	4,109,180	4,112,907	4,143,919	0	0	0	0	0	0	0	20,552,811	
HIB - LTC	381,353	383,342	394,397	388,191	386,272	0	0	0	0	0	0	0	1,933,554	
SUBTOTAL	728,338,191	726,618,665	718,813,286	776,751,337	787,871,089	0	0	0	0	0	0	0	3,738,392,569	

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	290,460,683	0	0	0	0	0	0	0	1,420,171,867	
CAPITATION - AIMHS	134,306	142,743	148,769	156,410	162,917	0	0	0	0	0	0	0	745,145	
MENTAL HEALTH - ADULT	414,838	404,766	357,960	339,574	346,048	0	0	0	0	0	0	0	1,863,185	
MENTAL HEALTH - GENERAL	-2,350	-4,545	-6,979	-1,026	-2,248	0	0	0	0	0	0	0	-17,148	
MENTAL HEALTH - CMDP	0	393	762	818	1,922	0	0	0	0	0	0	0	3,895	
MENTAL HEALTH - RBHA CRISIS	3,634,857	3,668,731	3,689,681	4,433,299	4,430,127	0	0	0	0	0	0	0	19,856,695	
FEE FOR SERVICE - ACUTE	37,859,959	38,790,683	33,207,024	40,310,956	56,196,515	0	0	0	0	0	0	0	206,365,138	
FFS - PRIOR QUARTER COVERAGE	1,204,975	590,575	350,539	247,496	159,052	0	0	0	0	0	0	0	2,552,637	
EMERGENCY SERVICES - FEDERAL	3,246,745	2,798,913	3,488,929	3,312,152	2,963,400	0	0	0	0	0	0	0	15,810,139	
FFS MEDICAID IN PUBLIC SCHOOLS	723	218	330	768	520	0	0	0	0	0	0	0	2,560	
INPATIENT INMATES FFS	889,101	645,173	765,595	723,663	1,110,236	0	0	0	0	0	0	0	4,133,767	
FFS TRBHA FEE FOR SERVICE	7,885,916	6,336,072	6,757,819	9,050,014	7,775,195	0	0	0	0	0	0	0	37,805,017	
STATE ONLY TRBHA FFS	399,387	372,201	456,058	565,497	378,481	0	0	0	0	0	0	0	2,171,623	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	13,813	0	0	0	0	0	0	0	13,813	
PINAL COUNTY INMATES FFS	415	59	3,076	244	12,960	0	0	0	0	0	0	0	16,755	
PIMA COUNTY INMATES FFS	44,460	29,912	57,917	22,647	78,415	0	0	0	0	0	0	0	233,350	
MOHAVE COUNTY INMATES FFS	3,409	15,944	0	0	0	0	0	0	0	0	0	0	19,353	
MARICOPA CTY INMATES FFS	214,579	207,410	203,431	152,268	191,138	0	0	0	0	0	0	0	968,826	
COCONINO COUNTY INMATES FFS	302	3,171	0	165	80	0	0	0	0	0	0	0	3,718	
REINSURANCE - ACC	6,253,343	6,750,467	8,759,810	5,851,025	9,109,166	0	0	0	0	0	0	0	36,723,812	
SMIB - ACC	7,097,119	7,165,395	7,230,656	7,256,687	7,251,712	0	0	0	0	0	0	0	36,001,569	
HIB - ACC	6,248	4,850	4,894	4,894	4,413	0	0	0	0	0	0	0	25,299	
SUBTOTAL	347,582,951	348,190,644	344,620,338	364,432,537	380,644,543	0	0	0	0	0	0	0	1,785,471,014	

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	34,942,684	0	0	0	0	0	0	0	171,449,634	
CAPITATION - AIMHS	12,254	13,041	13,411	13,456	13,792	0	0	0	0	0	0	0	65,954	
MENTAL HEALTH - ADULT	12,078	12,834	13,307	10,299	9,656	0	0	0	0	0	0	0	58,174	
MENTAL HEALTH - GENERAL	399	-806	497	0	-1,538	0	0	0	0	0	0	0	-1,449	
MENTAL HEALTH - CMDP	0	762	762	818	818	0	0	0	0	0	0	0	3,160	
MENTAL HEALTH - RBHA CRISIS	575,493	582,267	581,810	696,263	690,179	0	0	0	0	0	0	0	3,126,013	
FEE FOR SERVICE - ACUTE	2,872,751	3,384,201	2,596,379	3,610,161	4,963,978	0	0	0	0	0	0	0	17,427,471	
FFS - PRIOR QUARTER COVERAGE	200,446	340,753	89,570	110,297	27,989	0	0	0	0	0	0	0	769,054	
EMERGENCY SERVICES - FEDERAL	5,151,773	4,521,846	4,307,602	4,739,519	4,142,469	0	0	0	0	0	0	0	22,863,209	
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	150,059	0	0	0	0	0	0	0	887,835	
STATE ONLY TRBHA FFS	39,350	9,279	10,091	52,331	11,941	0	0	0	0	0	0	0	122,992	
INPATIENT INMATES FFS	61,395	5,936	718	18,994	90,712	0	0	0	0	0	0	0	177,755	
MARICOPA CTY INMATES FFS	8,779	2,632	4,840	20,343	660	0	0	0	0	0	0	0	37,255	
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	1,139,871	0	0	0	0	0	0	0	5,490,598	
SMIB - ACC	271	136	0	0	271	0	0	0	0	0	0	0	678	
	43,548,708	43,869,597	42,267,781	46,608,827	46,183,539	0	0	0	0	0	0	0	222,478,452	
	1,119,469,850	1,118,678,906	1,105,701,405	1,187,792,702	1,214,699,171	0	0	0	0	0	0	0	5,746,342,034	

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	10	0	0	0	0	0	0	0	62	
KidsCare - CAPITATION	6,102,844	6,193,197	6,245,205	6,672,896	6,665,471	0	0	0	0	0	0	0	31,879,613	
KidsCare - FEE FOR SERVICE	124,559	240,555	141,881	280,744	380,853	0	0	0	0	0	0	0	1,168,592	
KidsCare - MENTAL HEALTH	59,368	60,012	61,651	79,894	73,520	0	0	0	0	0	0	0	334,446	
KidsCare - REINSURANCE	200,701	116,470	178,310	68,995	201,596	0	0	0	0	0	0	0	766,072	

6,487,491	6,610,278	6,629,190	7,105,104	7,321,449	0	0	0	0	0	0	0	34,153,513	

TOTAL TITLE XXI

1,125,957,341	1,125,289,184	1,112,330,595	1,194,897,806	1,222,020,621	0	0	0	0	0	0	0	5,780,495,547	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	42,054.34	48,959.09	44,661.46	42,858.20	42,323.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,856.58		
1007	TANF 21-44 FEMALE WI	45,256.87	48,452.58	37,289.55	36,573.35	40,432.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,004.77		
1008	TANF 45-64 M & F WIT	58,324.80	51,372.72	55,455.73	59,288.73	62,781.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287,223.00		
1009	TANF 65+ M & F WITH	16,091.48	14,740.77	12,841.93	10,830.21	11,819.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,324.37		
100F	TANF 21-44 MALE WITH	40.03	581.66	1,451.87	603.71	578.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,255.68		
100G	TANF 21-44 FEMALE WI	2,488.06	2,248.29	2,866.78	99.61	597.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,300.62		
100H	TANF 45-64 M & F WIT	4,175.05	3,092.89	2,374.57	461.51	341.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,445.86		
100J	TANF 65+ M & F WITH	212.66	202.84	436.85	0.00	359.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,211.74		
1011	TANF <1 M & F NON-ME	5,612,601.91	5,647,107.46	5,662,986.65	5,864,005.96	5,793,927.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,580,629.29		
1012	TANF 01-05 M & F NON	3,457,250.59	3,441,533.14	3,420,435.80	3,663,284.80	3,765,116.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,747,620.37		
1013	TANF 06-13 M & F NON	6,124,074.11	6,152,446.23	6,168,589.18	6,578,134.59	6,771,887.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,795,131.22		
1014	TANF 14-20 MALE NON-	1,914,202.78	1,884,287.16	1,883,566.77	2,025,538.16	2,071,426.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,779,020.98		
1015	TANF 14-20 FEMALE N O	2,353,294.72	2,342,821.82	2,327,116.90	2,475,096.82	2,501,683.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,000,013.33		
1016	TANF 21-44 MALE NON-	9,364,324.51	9,454,366.22	9,451,614.62	9,776,592.84	9,730,339.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,777,237.78		
1017	TANF 21-44 FEMALE N O	32,620,357.05	32,728,554.66	32,775,784.07	33,752,027.12	33,816,267.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,692,990.03		
1018	TANF 45-64 M & F NON	7,767,766.58	7,784,035.25	7,762,785.14	8,000,237.41	8,036,214.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,351,038.65		
1019	TANF 65+ M & F NON-M	31,052.28	29,784.99	31,822.50	32,621.26	32,414.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157,695.74		
101A	TANF < 1 M & F NON-M	352,937.84	334,377.43	295,390.35	340,918.93	316,366.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,639,990.81		
101B	TANF 01-05 M & F NON	31,695.97	27,524.01	22,926.16	34,432.14	22,446.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139,025.11		
101C	TANF 06-13 M & F NON	16,670.28	19,749.31	20,214.14	31,451.20	9,783.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,868.47		
101D	TANF 14-20 MALE NON-	9,808.43	14,845.50	11,848.57	9,602.25	12,556.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,661.06		
101E	TANF 14-20 FEMALE N O	18,630.37	20,897.05	23,373.06	14,812.75	11,908.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,621.94		
101F	TANF 21-44 MALE NON-	246,596.25	255,429.76	194,158.71	213,830.17	206,314.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,116,328.89		
101G	TANF 21-44 FEMALE N O	615,659.33	583,850.07	465,507.37	483,973.96	473,022.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,622,013.07		
101H	TANF 44-64 M & F NON	131,317.46	152,039.59	104,634.71	127,378.55	129,042.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		644,412.55		
101J	TANF 65+ N & F NON-M	198.84	566.38	1,210.63	1,307.79	510.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,794.14		
1024	TANF 14-20 MALE WITH	1,991.65	1,834.56	1,834.56	1,768.75	1,768.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,198.27		
1026	TANF 21-44 MALE WITH	30,833.82	25,161.04	23,949.90	20,548.44	15,048.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,541.93		
1027	TANF 21-44 FEMALE WI	33,845.08	29,934.75	39,393.39	30,840.59	29,261.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163,275.24		
1028	TANF 45-64 M & F WIT	32,482.04	30,194.61	33,485.88	38,169.75	31,879.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,212.18		
1029	TANF 65+ M & F WITH	9,312.30	9,417.77	6,856.06	8,190.14	7,732.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,508.36		
102F	TANF 21-44 MALE WITH	0.00	77.29	129.25	15.42	3.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.94		
102G	TANF 21-44 FEMALE WI	0.00	67.86	0.00	200.16	65.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		333.16		
102H	TANF 44-64 M & F WIT	0.00	0.00	38.22	581.36	6,681.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,300.70		
102J	TANF 65+ M & F WITH	0.00	258.92	0.00	56.69	20.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		336.22		
2100	SSI AGED WITH MEDIC A	712,678.64	703,164.71	703,123.48	667,339.40	650,196.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,436,503.10		

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	52,660.57	41,774.04	32,514.74	42,682.27	33,049.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202,680.74		
2110	SSI AGED NON-MEDIC
AR	8,462,181.12	8,547,064.99	8,567,191.18	8,623,372.18	8,699,929.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,899,739.43		
211Z	SSI AGED NON-MEDIC AR	216,958.62	161,562.33	135,278.37	170,335.07	191,280.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		875,414.96		
2120	SSI AGED WITH QMB	5,479,950.99	5,524,156.46	5,564,371.66	5,231,743.96	5,256,928.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,057,151.30		
212Z	SSI AGED WITH QMB P P	4,799.26	6,473.36	9,408.43	3,946.39	4,822.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,449.99		
2200	SSI DISABLED WITH M
E	1,774,556.51	1,758,603.98	1,757,956.93	1,793,548.74	1,774,074.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,858,740.39		
220Z	SSI DISABLED WITH M E	96,386.79	59,787.78	85,084.80	74,882.47	52,442.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368,584.25		
2210	SSI DISABLED NON-ME
D	70,901,267.74	70,892,010.70	70,871,863.55	71,601,739.66	71,584,855.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355,851,737.05		
221Z	SSI DISABLED NON-ME D	942,051.13	933,821.38	825,347.66	868,410.05	930,105.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,499,735.91		
2220	SSI DISABLED WITH Q
M	14,966,350.81	14,971,834.15	14,896,450.44	15,280,370.49	15,232,817.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,347,823.02		
222Z	SSI DISABLED WITH Q M	31,562.80	38,109.67	39,444.48	60,437.56	39,111.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,666.19		
2300	SSI BLIND WITH MEDIC	7,894.62	8,025.40	7,600.96	7,717.09	7,721.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,959.83		
2310	SSI BLIND NON-MEDIC A	633,695.19	633,652.52	642,091.43	647,172.16	639,301.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,195,912.82		
231Z	SSI BLIND NON-MEDIC
A	5,251.90	10,051.71	22,411.45	23,240.84	2,465.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,421.43		
2320	SSI BLIND WITH QMB	47,291.74	47,835.53	47,975.47	45,708.70	48,382.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237,193.82		
232Z	SSI BLIND WITH QMB P	0.00	84.17	0.00	0.00	85.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170.00		
4302	SOBRA CHILD 01-05 M	384.93	668.23	677.67	625.97	550.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,906.96		
4303	SOBRA CHILD 06-13 M	671.85	839.07	526.79	627.08	627.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,291.87		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	119.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119.47		
4305	SOBRA CHILD 14-20 FE	598.98	472.87	136.70	127.40	127.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,463.35		
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	20,289,176.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,398,602.10		
4312	SOBRA CHILD 01-05 M	30,346,403.53	30,479,033.09	30,485,312.35	31,804,708.22	31,466,105.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,581,562.85		
4313	SOBRA CHILD 06-13 M	39,139,381.16	39,428,777.53	39,455,204.32	41,184,424.08	40,838,668.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200,046,455.20		
4314	SOBRA CHILD 14-20 MA	10,797,911.21	10,918,285.83	10,979,617.38	11,498,504.44	11,447,776.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,642,095.27		
4315	SOBRA CHILD 14-20 FE	10,814,438.27	10,921,113.04	10,946,037.68	11,446,085.19	11,396,963.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,524,637.99		
431A	SOBRA CHILD < 1 M &	255,349.52	216,051.62	182,881.71	205,334.74	189,022.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,048,639.69		
431B	SOBRA CHILD 01-05 M	734,288.72	672,792.26	556,972.69	630,508.19	606,921.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,201,483.66		
431C	SOBRA CHILD 6-13 M& F	698,553.25	730,808.98	551,793.26	609,387.25	588,657.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,179,199.97		
431D	SOBRA CHILD 14-20 MA	203,649.34	208,008.27	168,887.99	169,048.28	179,621.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		929,214.92		
431E	SOBRA CHILD 14-20 FE	210,973.01	203,192.73	181,516.56	172,528.36	178,270.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		946,481.42		
4322	SOBRA CHILD 01-05 M	191.11	191.11	191.11	168.64	168.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		910.61		
4323	SOBRA CHILD 06-13 M	0.00	0.00	145.06	136.09	136.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417.24		
4325	SOBRA CHILD 14-20 FE	194.52	400.68	400.68	370.94	370.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,737.76		
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		

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5007	SOBRA PREG 21-44 FE M	21,876.18	18,676.51	18,335.66	21,167.20	12,544.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,599.94		
5008	SOBRA PREG 45-64 FE
M	253.60	253.60	253.60	350.90	726.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,837.91		
500G	SOBRA PREG 21-44 FE M	3,420.46	2,107.63	794.66	0.00	293.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,616.07		
500H	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	1,154.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,154.50		
5013	SOBRA PREG 09-13 FE M	370.17	851.31	672.01	164.48	556.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,614.69		
5015	SOBRA PREG 14-20 FE
M	530,163.48	543,226.36	547,975.79	575,638.49	549,458.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,746,462.51		
5017	SOBRA PREG 21-44 FE M	5,865,449.13	5,991,687.07	6,062,054.68	6,276,120.33	6,131,242.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,326,553.56		
5018	SOBRA PREG 45-64 FE
M	17,581.17	19,841.48	22,726.54	27,536.00	27,334.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,019.73		
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	38,594.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202,197.60		
501G	SOBRA PREG 21-44 FE M	403,573.06	413,507.29	339,988.21	336,778.20	326,375.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,820,221.97		
501H	SOBRA PREG 45-64 FE
M	54.35	1,725.17	6,412.35	1,312.28	4,770.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,275.06		
5027	SOBRA PREG 21-44 FE M	14,542.79	19,007.23	29,474.11	31,109.80	34,192.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128,326.07		
5028	SOBRA PREG 45-64 FE
M	2,368.16	2,368.16	2,368.16	168.64	288.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,561.23		
SUBTOTAL:	295,696,553.19	296,536,345.61	295,713,370.81	304,392,294.28	303,411,307.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,495,749,871.49		

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

198.00

198.00

9910	TANF & SOBRA CHILDR E	1,876,376.98	1,947,736.11	1,669,626.73	1,696,043.77	1,418,031.80	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 KI C	110,362.96	112,169.53	93,219.96	81,102.59	136,510.54	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	12,965,445.20	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	14,519,987.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,607,815.39	
125,192.71	
533,365.58	
65,485,890.59	
74,752,264.27	

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	70,918.64	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	169,911.55	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	365,683.06	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	86,519.17	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	637.55	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	5,942.06	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	8,327.09	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	3,610.18	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	1,122.19	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	41,498.84	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	281,371.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
145.06	
334,735.40	
919,575.41	
1,935,103.60	
467,708.42	
28,621.29	
47,484.60	
58,484.89	
21,763.24	
186.83	
5,823.63	
198,495.60	
1,390,685.87	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	9,859,718.71	9,828,241.10	9,777,971.60	9,925,394.92	9,813,649.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,204,976.30		
1117	TANF EXPANDED 21-44	26,992,566.22	27,093,093.80	27,010,065.69	27,682,271.54	27,328,871.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,106,868.40		
1118	TANF EXPANDED 45-64	9,163,569.86	9,196,300.84	9,258,902.24	9,429,506.82	9,388,248.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,436,528.10		
1119	TANF EXPANDED 65+
M&	30,255.92	28,131.96	28,000.75	28,862.78	32,142.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,393.84		
111D	TANF EXPANDED 14-20	2,490.39	1,152.78	1,523.21	3,036.33	1,816.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,019.63		
111E	TANF EXPANDED 14-20	7,437.73	5,473.69	3,147.13	10,374.18	5,003.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,435.88		
111F	TANF EXPANDED 21-44	267,373.80	262,773.96	215,068.24	235,644.82	208,690.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,189,551.43		
111G	TANF EXPANDED 21-44	525,020.23	509,660.72	400,174.61	489,416.42	444,516.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,368,788.22		
111H	TANF EXPANDED 45-64	178,932.04	172,494.14	159,074.75	150,035.45	153,058.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		813,595.16		
111J	TANF EXPANDED 65+
M&	592.01	928.69	367.98	904.28	3,138.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,931.41		
1126	TANF EXPANDED 21-44	297,942.68	293,773.27	291,620.59	306,418.42	301,144.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,490,899.10		
1127	TANF EXPANDED 21-44	790,701.02	789,295.29	779,113.14	789,198.37	790,964.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,939,272.00		
1128	TANF EXPANDED 45-64	900,768.88	921,413.73	924,623.19	928,434.52	927,852.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,603,092.95		
1129	TANF EXPANDED 65+
M&	256,772.30	259,581.62	263,961.29	248,104.89	248,988.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,277,408.41		
112F	TANF EXPANDED 21-44	0.00	2,931.30	4,191.82	114.25	988.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,226.29		
112G	TANF EXPANDED 21-44	2,213.20	5,170.00	2,450.40	1,114.75	3,714.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,662.75		
112H	TANF EXPANDED 45-64	6,227.67	1,063.02	540.07	7,528.30	1,670.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,029.70		
112J	TANF EXPANDED 65+
M&	3,111.80	878.74	906.87	814.40	34.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,746.63		
2400	SSI AGED EXPANDED WI	40,745.64	49,658.35	38,234.62	42,281.47	37,211.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,131.44		
240Z	SSI AGED EXPANDED
WI	26,984.10	40,705.46	35,897.94	27,426.39	50,793.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,807.59		
2410	SSI AGED EXPANDED NO	116,302.77	124,836.95	115,780.95	113,521.05	114,817.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		585,259.41		
241Z	SSI AGED EXPANDED
NO	15,686.56	0.00	2,707.35	12,150.89	5,497.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,042.32		
2420	SSI AGED EXPANDED WI	5,409,424.18	5,439,222.61	5,476,481.46	5,251,359.12	5,279,081.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,855,569.09		
242Z	SSI AGED EXPANDED
WI	10,566.52	4,568.42	7,433.00	9,127.29	8,761.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,456.55		
2520	SSI BLIND EXPANDED W	191.11	191.11	191.11	168.64	288.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,030.08		
2600	SSI DISABLED EXPAND
E	95,669.32	118,092.54	108,033.75	124,095.05	114,799.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		560,690.20		
260Z	SSI DISABLED EXPAND E	60,164.41	59,191.60	53,022.25	48,257.79	46,863.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267,499.94		
2610	SSI DISABLED EXPAND
E	1,902,019.15	1,915,769.99	1,925,963.03	1,963,514.67	2,016,274.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,723,541.24		
261Z	SSI DISABLED EXPAND E	41,560.30	39,967.68	26,817.13	29,654.10	36,640.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,639.49		
2620	SSI DISABLED EXPAND
E	10,627,342.37	10,666,934.37	10,681,274.26	10,916,058.37	10,967,913.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,859,522.57		
262Z	SSI DISABLED EXPAND E	24,786.63	13,062.99	25,997.02	38,102.49	8,699.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,648.20		
SUBTOTAL:	68,743,011.0	7 68,940,363.76	68,696,349.0	5 69,927,676.36	69,377,677.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345,685,078.16		

9911	SB PAYMENT FOR TAN F	1,192,225.73	1,197,905.14	1,182,328.27	976,597.96	999,126.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	0.00	0.00	0.00	0.00	6,109.98	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	1,005,236.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,548,183.84	
6,109.98	
5,554,293.82	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3506	ADULT 40-100% MALE 2	5,764.11	5,307.37	5,088.93	7,318.11	4,692.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,170.67		
3507	ADULT 40-100% FEMAL E	2,241.00	10,614.95	5,047.64	5,979.70	6,499.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,382.84		
3508	ADULT 40-100% M&F 45	52,917.78	53,388.43	56,444.93	53,201.28	39,809.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,761.78		
3509	ADULT 40-100% M&F 65	4,596.56	10,268.05	12,020.33	15,029.38	6,926.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,841.27		
350F	ADULT 40-100% MALE 2	0.00	2,062.59	763.78	53.20	728.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,607.92		
350G	ADULT 40-100% FEMAL E	4,201.57	6,234.75	255.24	1,524.01	233.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,449.21		
350H	ADULT 40-100% M&F 45	8,724.34	4,663.08	738.24	589.11	2,009.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,724.60		
3514	ADULT 40-100% MALE 1	3,584,131.94	3,587,963.14	3,598,856.23	3,826,030.33	3,805,604.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,402,585.72		
3515	ADULT 40-100% FEMAL E	3,935,913.21	4,002,324.39	3,958,410.67	4,148,105.87	4,137,259.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,182,013.23		
3516	ADULT 40-100% MALE 2	12,328,492.47	12,442,821.52	12,405,190.10	13,075,156.47	12,942,564.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,194,225.55		
3517	ADULT 40-100% FEMAL E	10,396,684.34	10,406,343.92	10,410,485.60	10,920,791.81	10,905,437.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,039,743.24		
3518	ADULT 40-100% M&F 45	24,233,844.77	24,325,890.22	24,129,566.46	25,165,183.68	24,906,203.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,760,688.22		
3519	ADULT 40-100% M&F 65	4,796.70	2,957.31	3,486.22	3,624.66	2,984.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,849.29		
351D	ADULT 40-100% MALE 1	69,871.09	58,513.99	62,621.06	62,052.90	65,261.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318,320.11		
351E	ADULT 40-100% FEMAL E	96,620.75	91,285.70	76,978.92	72,929.40	87,157.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		424,971.94		
351F	ADULT 40-100% MALE 2	378,306.71	316,217.93	260,303.87	284,982.56	268,566.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,508,377.28		
351G	ADULT 40-100% FEMAL E	314,532.51	292,594.59	213,966.75	241,271.33	233,602.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,295,968.01		
351H	ADULT 40-100% M&F 45	571,004.41	500,509.79	406,418.38	452,726.14	413,199.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,343,857.74		
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	240.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,356.46		
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	5,253.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,253.95		
3528	ADULT 40-100% M&F 45	1,367.52	642.20	984.40	1,899.76	583.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,477.29		
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	560.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,790.97		
352G	ADULT 40-100% FEMAL E	0.00	0.00	696.12	0.00	1,888.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,584.28		
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	39,844.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192,231.04		
3707	ADULT <40% EXP FEM AL	3,910.19	8,759.02	9,934.25	10,776.00	19,252.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,632.17		
3708	ADULT <40% EXP M&F
4	57,244.70	70,221.48	68,023.40	77,774.04	70,086.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		343,350.30		
3709	ADULT <40% EXP M&F 6	3,342.45	6,220.57	8,040.20	9,598.58	6,289.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,490.88		
370F	ADULT <40% EXP MALE	10,732.30	5,515.81	10,662.39	4,379.14	1,950.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,240.29		
370G	ADULT <40% EXP FEM AL	497.19	1,324.21	2,550.57	29,039.02	4,360.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,771.47		
370H	ADULT <40% EXP M&F
4	9,493.54	14,470.80	7,660.76	7,614.14	10,704.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,943.97		
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	7,009,645.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,888,389.91		

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM AL	5,936,403.04	6,019,300.20	6,069,309.64	6,350,497.26	6,296,868.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,672,379.10		
3716	ADULT <40% EXP MALE	48,789,421.85	49,743,271.72	49,815,793.81	53,042,463.71	52,986,149.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		254,377,100.99		
3717	ADULT <40% EXP FEM AL	29,124,659.29	29,572,690.93	29,617,599.15	31,388,885.35	31,363,101.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151,066,936.68		
3718	ADULT <40% EXP M&F
4	56,709,300.26	57,223,557.83	57,236,759.90	60,235,140.58	60,159,804.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		291,564,562.78		
3719	ADULT <40% EXP M&F 6	4,322.81	5,789.39	5,237.33	6,191.72	7,303.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,845.00		
371D	ADULT <40% EXP MALE	173,398.88	166,910.98	142,642.92	149,675.54	149,602.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		782,230.52		
371E	ADULT <40% EXP FEM AL	170,863.21	142,486.87	112,122.69	121,004.92	130,024.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		676,502.30		
371F	ADULT <40% EXP MALE	1,729,093.63	1,542,732.32	1,328,885.56	1,459,959.59	1,384,728.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,445,399.65		
371G	ADULT <40% EXP FEM AL	1,025,917.09	813,958.12	707,195.63	877,496.51	716,944.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,141,511.46		
371H	ADULT <40% EXP M&F
4	1,427,011.49	1,300,300.84	1,052,563.00	1,236,360.48	1,190,254.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,206,490.53		
371J	ADULT <40% EXP M&F 6	0.00	0.00	762.31	0.00	38.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		801.25		
3726	ADULT <40% EXP MALE	1,897.66	3,045.53	1,010.32	4,101.68	3,295.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,350.72		
3727	ADULT <40% EXP FEM AL	1,521.58	1,175.63	1,175.63	3,047.26	946.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,866.61		
3728	ADULT <40% EXP M&F
4	0.00	3,480.51	1,898.98	2,527.06	6,484.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,391.21		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	570.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		570.17		
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 FEM AL	327.59	540.92	0.00	467.84	292.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,628.40		
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	219,395,810.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,065,555,421.84		

3906	NEWLY ELIGIBLE MALE	9,297.77	14,217.05	12,452.76	15,498.83	16,317.22	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	5,820.16	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	30,014.01	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	7,907.64	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	600.20	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	2,814.99	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	889.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	2,594.88	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	1,432,020.80	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	1,584,741.35	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	7,576,758.56	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	11,395,020.64	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	11,727,905.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

67,783.63	
11,644.99	
169,042.91	
57,455.37	
2,044.19	
3,760.39	
24,258.68	
2,594.88	
6,773,112.33	
7,660,436.84	
37,458,259.94	
55,815,747.47	
57,031,088.74	

9935	BIRTH SUPP PAYMENT A	151,291.91	252,079.35	221,179.92	136,085.21	217,101.77	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	464,855.64	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	681,957.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
977,738.16	
2,399,335.04	
3,377,073.20	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3919	NEWLY ELIGIBLE M&F 6	475.27	376.91	749.95	409.28	1,239.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,250.60		
391D	NEWLY ELIGIBLE MALE	35,162.36	25,533.98	27,119.68	23,581.76	22,180.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133,577.93		
391E	NEWLY ELIGIBLE FEMA L	45,902.91	40,350.46	37,851.72	32,289.49	27,676.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		184,071.37		
391F	NEWLY ELIGIBLE MALE	276,730.87	235,207.91	218,621.78	242,758.31	213,094.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,186,413.66		
391G	NEWLY ELIGIBLE FEMA L	424,973.22	387,794.23	305,099.35	342,030.80	321,120.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,781,018.20		
391H	NEWLY ELIGIBLE M&F
4	330,872.11	269,795.17	240,089.92	291,740.21	283,965.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,416,463.32		
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	547.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,226.72		
3928	NEWLY ELIGIBLE M&F
4	0.00	384.57	384.57	852.61	1,800.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,422.31		
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		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	2,651.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,651.91		
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	34,657,683.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,800,852.34		

9939

BIRTH SUPP PAYMENT N

1,648,781.24

1,648,781.24

287,755.48	369,407.99	310,122.63	396,494.47	285,000.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
287,755.48	369,407.99	310,122.63	396,494.47	285,000.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	138.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	7,453,485.41	7,433,353.84	7,295,647.88	7,542,742.30	7,382,321.25	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	2,129,761.41	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	2,080,784.55	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	151,824.75	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	41,572.39	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	43,052.50	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	11,829,316.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

138.81	
37,107,550.68	
10,660,927.23	
10,337,967.46	
40.49	
851,290.24	
242,064.36	
225,620.76	
59,425,600.03	

9944	BIRTH SUPP PAYMENT S	11,882.90	58,943.98	23,471.72	24,770.76	18,450.92	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	18,450.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

137,520.28

137,520.28

4517	BC PATIENT FEMALE 2 1	10,376.74	10,793.95	10,912.09	10,415.24	9,325.23	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	49,270.42	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	489.25	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	1,159.45	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	5,094.73	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	3,797.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
51,823.25	
239,220.21	
245.28	
4,643.75	
12,626.01	
23,954.25	
15,676.48	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		2,792.25		
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		1,336.37		
SUBTOTAL:	71,912.51	67,163.00	67,332.1	6	76,773.50	69,136.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		352,317.85		

6,170.47

9945	SB KICK PAYMENT FO R	0.00	0.00	0.00	0.00	6,170.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	6,170.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,170.47

8600	SSI BLIND FREEDOM/W O	2,514.53	2,514.53	146.37	133.78	133.78	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	127.40	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	1,624,090.67	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	59,847.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	503,485.23	482,840.23	465,242.51	478,632.10	487,623.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	29,729.13	31,884.99	36,076.70	15,507.05	21,677.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	234,348.44	222,168.42	214,558.44	237,099.54	243,132.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	6,655.98	453.87	22,093.47	7,454.95	4,949.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,375,150.96	2,388,363.87	2,400,477.38	2,407,415.55	2,441,583.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,442.99	
664.90	
7,935,115.51	
326,152.98	
2,417,823.39	
134,875.53	
1,151,307.45	
41,608.10	
12,012,990.85	

6015

KIDS 14-19 FEMALE NO

4,706.10

4,706.10

3,234,063,139.94

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	
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	

637,039,184.43	640,246,228.62	636,844,407.74	662,233,982.47	657,699,336.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL: TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	89.69	89.86	94.05	83.11	86.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		443.33		
1007	TANF 21-44 FEMALE WI	106.74	102.58	84.56	88.37	79.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		462.07		
1008	TANF 45-64 M & F WIT	178.61	170.54	178.92	199.62	207.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		934.95		
1009	TANF 65+ M & F WITH	99.53	90.51	78.92	84.48	91.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		444.78		
100F	TANF 21-44 MALE WITH	0.29	4.11	6.65	4.51	4.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.01		
100G	TANF 21-44 FEMALE WI	2.91	6.29	2.43	0.60	0.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.53		
100H	TANF 45-64 M & F WIT	14.60	3.52	2.06	3.33	2.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.24		
100J	TANF 65+ M & F WITH	1.43	1.47	2.63	0.00	2.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.98		
1011	TANF <1 M & F NON-ME	9,979.28	10,037.99	10,057.99	10,140.42	10,014.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,229.90		
1012	TANF 01-05 M & F NON	18,993.92	18,921.51	18,927.54	19,412.07	20,023.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,278.42		
1013	TANF 06-13 M & F NON	34,139.11	34,275.13	34,370.72	35,161.72	36,257.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,203.77		
1014	TANF 14-20 MALE NON-	9,849.08	9,736.84	9,761.39	10,065.68	10,310.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,723.21		
1015	TANF 14-20 FEMALE N O	12,309.27	12,300.27	12,271.12	12,577.25	12,686.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,144.80		
1016	TANF 21-44 MALE NON-	24,304.85	24,468.54	24,434.66	24,611.48	24,513.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,332.86		
1017	TANF 21-44 FEMALE N O	83,159.05	83,428.43	83,491.23	83,874.29	84,068.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		418,021.32		
1018	TANF 45-64 M & F NON	19,720.09	19,730.33	19,681.74	19,798.75	19,925.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,856.33		
1019	TANF 65+ M & F NON-M	78.99	75.92	80.81	80.60	79.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		396.31		
101A	TANF < 1 M & F NON-M	622.00	588.68	516.55	592.34	544.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,864.39		
101B	TANF 01-05 M & F NON	200.41	160.77	137.33	188.42	120.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		807.86		
101C	TANF 06-13 M & F NON	91.26	107.35	109.58	170.91	48.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		527.66		
101D	TANF 14-20 MALE NON-	54.36	79.67	69.03	51.72	46.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		301.59		
101E	TANF 14-20 FEMALE N O	99.54	114.09	110.49	79.17	62.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		466.09		
101F	TANF 21-44 MALE NON-	653.45	692.46	519.54	565.94	544.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,976.30		
101G	TANF 21-44 FEMALE N O	1,627.34	1,538.61	1,238.06	1,261.30	1,216.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,882.04		
101H	TANF 44-64 M & F NON	355.51	400.40	291.08	312.37	337.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,697.24		
101J	TANF 65+ N & F NON-M	0.64	1.67	3.15	3.37	1.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.29		
1024	TANF 14-20 MALE WITH	3.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
1026	TANF 21-44 MALE WITH	60.00	53.27	54.63	53.40	43.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		265.22		
1027	TANF 21-44 FEMALE WI	95.99	92.13	93.99	86.07	77.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		446.10		
1028	TANF 45-64 M & F WIT	108.90	105.00	101.16	90.88	84.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		490.39		
1029	TANF 65+ M & F WITH	47.70	48.38	47.00	49.54	46.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239.45		
102F	TANF 21-44 MALE WITH	0.00	0.61	1.00	0.12	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.76		
102G	TANF 21-44 FEMALE WI	0.00	0.41	0.00	1.06	0.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.27		
102H	TANF 44-64 M & F WIT	0.00	0.00	0.20	3.31	3.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.03		
102J	TANF 65+ M & F WITH	0.00	1.35	0.00	0.44	0.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.95		
2100	SSI AGED WITH MEDIC A	4,122.71	4,063.81	4,030.59	4,108.10	4,048.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,373.48		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	283.43	232.59	193.04	276.87	247.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,233.06		
2110	SSI AGED NON-MEDIC
AR	6,783.06	6,849.40	6,866.93	6,935.45	6,998.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,433.07		
211Z	SSI AGED NON-MEDIC AR	187.29	129.52	110.45	137.39	154.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		718.70		
2120	SSI AGED WITH QMB	31,783.16	31,989.36	32,152.27	32,229.28	32,346.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,500.89		
212Z	SSI AGED WITH QMB P P	32.92	44.99	61.94	25.29	34.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.27		
2200	SSI DISABLED WITH M
E	3,555.63	3,532.68	3,532.88	3,539.90	3,505.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,667.01		
220Z	SSI DISABLED WITH M E	164.92	159.53	143.29	159.73	135.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		763.42		
2210	SSI DISABLED NON-ME
D	51,491.33	51,464.64	51,465.03	51,603.90	51,642.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		257,667.77		
221Z	SSI DISABLED NON-ME D	759.58	802.25	717.53	700.50	733.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,713.43		
2220	SSI DISABLED WITH Q
M	26,441.87	26,456.91	26,414.26	26,455.17	26,448.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,217.12		
222Z	SSI DISABLED WITH Q M	37.02	44.89	66.85	48.70	31.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		229.32		
2300	SSI BLIND WITH MEDIC	28.00	28.99	26.00	28.00	28.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.49		
2310	SSI BLIND NON-MEDIC A	499.60	500.08	506.73	512.86	505.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,525.19		
231Z	SSI BLIND NON-MEDIC
A	4.50	8.28	24.78	19.76	2.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59.38		
2320	SSI BLIND WITH QMB	225.80	229.88	231.00	229.92	235.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,152.49		
232Z	SSI BLIND WITH QMB P	0.00	0.64	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.67		
4302	SOBRA CHILD 01-05 M	3.00	4.93	5.00	5.00	4.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.36		
4303	SOBRA CHILD 06-13 M	5.00	6.06	4.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.06		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4305	SOBRA CHILD 14-20 FE	4.00	3.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
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	34,969.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,739.34		
4312	SOBRA CHILD 01-05 M	166,797.05	167,404.10	167,216.79	167,017.16	165,079.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		833,514.56		
4313	SOBRA CHILD 06-13 M	215,941.09	217,553.86	217,670.05	217,534.97	215,638.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,084,338.92		
4314	SOBRA CHILD 14-20 MA	58,666.27	59,328.82	59,632.71	59,750.19	59,498.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		296,876.02		
4315	SOBRA CHILD 14-20 FE	58,655.28	59,190.73	59,306.71	59,371.69	59,098.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295,622.58		
431A	SOBRA CHILD < 1 M &	446.25	383.74	320.66	352.09	321.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,824.68		
431B	SOBRA CHILD 01-05 M	4,091.48	3,709.51	3,111.72	3,350.73	3,149.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,412.96		
431C	SOBRA CHILD 6-13 M& F	3,855.59	4,029.36	3,035.26	3,207.58	3,026.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,153.92		
431D	SOBRA CHILD 14-20 MA	1,094.86	1,112.84	911.48	886.86	878.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,884.81		
431E	SOBRA CHILD 14-20 FE	1,138.00	1,088.17	967.04	896.29	902.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,991.93		
4322	SOBRA CHILD 01-05 M	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4323	SOBRA CHILD 06-13 M	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4325	SOBRA CHILD 14-20 FE	1.41	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.41		
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		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5007	SOBRA PREG 21-44 FE M	28.29	29.30	34.12	34.00	26.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151.90		
5008	SOBRA PREG 45-64 FE
M	2.00	2.00	2.00	3.00	2.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.30		
500G	SOBRA PREG 21-44 FE M	3.59	4.76	0.86	0.00	1.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.97		
500H	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.70		
5013	SOBRA PREG 09-13 FE M	2.06	5.00	4.00	1.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.06		
5015	SOBRA PREG 14-20 FE
M	2,792.94	2,852.61	2,886.25	2,885.61	2,777.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,194.43		
5017	SOBRA PREG 21-44 FE M	15,577.98	15,919.95	16,021.94	16,183.65	15,819.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,523.38		
5018	SOBRA PREG 45-64 FE
M	38.47	49.97	52.57	61.04	57.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259.77		
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	197.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,044.87		
501G	SOBRA PREG 21-44 FE M	1,105.01	1,101.06	926.53	904.10	855.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,892.24		
501H	SOBRA PREG 45-64 FE
M	0.16	4.86	13.38	3.91	3.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.57		
5027	SOBRA PREG 21-44 FE M	32.00	37.00	37.40	36.98	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180.38		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
SUBTOTAL:	909,956.0	5	913,841.68	911,256.6	1	914,835.20	911,002.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,560,891.69		

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

12.00

12.00

9910	TANF & SOBRA CHILDR E	320.00	331.00	284.00	274.00	229.00	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 KI C	19.00	19.00	16.00	13.00	22.00	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	2,088.00	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	2,339.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,438.00	
21.00	
89.00	
10,923.00	
12,471.00	

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	219.58	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	394.32	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	1,239.13	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	632.13	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	4.30	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	17.68	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	40.49	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	26.51	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	6.00	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	221.31	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	1,453.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
1,100.08	
2,087.04	
6,158.71	
3,187.79	
75.98	
113.51	
206.05	
146.76	
1.00	
32.00	
1,077.02	
7,346.48	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	26,425.77	26,359.12	26,183.36	26,015.22	25,721.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,704.81		
1117	TANF EXPANDED 21-44	70,866.22	71,178.63	70,984.18	71,016.34	70,119.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		354,164.66		
1118	TANF EXPANDED 45-64	24,281.16	24,369.33	24,474.90	24,379.75	24,193.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,698.38		
1119	TANF EXPANDED 65+
M&	83.32	77.45	77.00	78.15	86.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		402.34		
111D	TANF EXPANDED 14-20	13.79	6.07	8.58	17.10	9.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.18		
111E	TANF EXPANDED 14-20	41.42	29.93	17.44	33.68	25.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147.68		
111F	TANF EXPANDED 21-44	718.90	716.67	595.02	637.68	567.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,236.00		
111G	TANF EXPANDED 21-44	1,419.51	1,364.36	1,077.59	1,259.01	1,148.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,269.08		
111H	TANF EXPANDED 45-64	496.90	473.74	431.96	405.14	400.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,207.93		
111J	TANF EXPANDED 65+
M&	1.67	2.70	1.00	2.33	9.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.02		
1126	TANF EXPANDED 21-44	763.98	778.79	773.55	785.42	763.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,865.31		
1127	TANF EXPANDED 21-44	1,658.56	1,669.60	1,651.91	1,644.04	1,629.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,253.61		
1128	TANF EXPANDED 45-64	2,534.08	2,564.62	2,606.17	2,585.02	2,556.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,846.10		
1129	TANF EXPANDED 65+
M&	1,524.12	1,537.88	1,571.53	1,601.56	1,608.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,843.55		
112F	TANF EXPANDED 21-44	0.00	2.84	7.71	0.89	4.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.66		
112G	TANF EXPANDED 21-44	4.97	5.84	5.17	7.62	5.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.90		
112H	TANF EXPANDED 45-64	16.91	7.39	3.87	12.72	4.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.57		
112J	TANF EXPANDED 65+
M&	4.82	6.37	6.85	6.23	0.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.56		
2400	SSI AGED EXPANDED WI	227.17	239.12	215.13	247.18	221.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,149.89		
240Z	SSI AGED EXPANDED
WI	188.57	198.61	194.67	205.44	211.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		999.15		
2410	SSI AGED EXPANDED NO	95.13	101.60	93.82	91.90	93.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		475.50		
241Z	SSI AGED EXPANDED
NO	12.57	0.00	2.16	9.64	4.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.83		
2420	SSI AGED EXPANDED WI	26,237.74	26,428.76	26,615.69	26,756.08	26,883.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,922.21		
242Z	SSI AGED EXPANDED
WI	50.54	25.46	32.72	52.19	30.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191.30		
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2600	SSI DISABLED EXPAND
E	203.51	221.75	186.24	232.74	231.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,075.44		
260Z	SSI DISABLED EXPAND E	139.05	119.04	107.14	120.94	124.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		610.60		
2610	SSI DISABLED EXPAND
E	1,467.82	1,478.74	1,490.86	1,530.40	1,572.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,540.18		
261Z	SSI DISABLED EXPAND E	33.02	32.33	22.08	23.16	29.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140.12		
2620	SSI DISABLED EXPAND
E	16,996.27	17,035.00	17,062.79	17,051.98	17,095.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,241.23		
262Z	SSI DISABLED EXPAND E	41.28	27.03	37.78	40.53	17.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.31		
SUBTOTAL:	180,908.2	8	181,437.38	180,791.1	7	181,142.54	179,625.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		903,904.52		

1.00

927.00

9911	SB PAYMENT FOR TAN F	203.00	204.00	201.00	158.00	161.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	203.00	204.00	201.0	0	158.00	162.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

928.00

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3506	ADULT 40-100% MALE 2	6.00	5.12	6.53	7.41	5.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.82		
3507	ADULT 40-100% FEMAL E	1.22	6.09	4.63	5.51	5.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.21		
3508	ADULT 40-100% M&F 45	72.34	67.89	75.89	71.70	53.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		341.24		
3509	ADULT 40-100% M&F 65	7.00	16.00	20.00	24.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.00		
350F	ADULT 40-100% MALE 2	0.00	0.87	0.86	0.03	1.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.99		
350G	ADULT 40-100% FEMAL E	1.77	2.89	0.36	1.47	0.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.89		
350H	ADULT 40-100% M&F 45	4.62	4.08	1.10	1.06	1.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.41		
3514	ADULT 40-100% MALE 1	5,628.35	5,645.27	5,650.26	5,745.37	5,727.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,397.16		
3515	ADULT 40-100% FEMAL E	6,154.09	6,255.84	6,190.88	6,225.51	6,225.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,051.59		
3516	ADULT 40-100% MALE 2	18,543.88	18,724.72	18,647.61	18,854.70	18,643.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93,414.82		
3517	ADULT 40-100% FEMAL E	15,666.52	15,700.84	15,719.62	15,856.09	15,813.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,756.13		
3518	ADULT 40-100% M&F 45	37,448.72	37,572.65	37,317.67	37,391.38	37,022.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186,753.35		
3519	ADULT 40-100% M&F 65	8.00	5.00	6.00	6.00	5.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.03		
351D	ADULT 40-100% MALE 1	107.37	91.34	100.12	93.04	104.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		496.10		
351E	ADULT 40-100% FEMAL E	151.90	141.38	122.28	109.35	131.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		656.28		
351F	ADULT 40-100% MALE 2	592.51	485.14	409.98	420.94	399.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,308.14		
351G	ADULT 40-100% FEMAL E	497.72	447.95	333.43	358.98	354.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,992.75		
351H	ADULT 40-100% M&F 45	894.72	807.69	643.72	707.79	624.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,678.43		
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	0.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.61		
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	2.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.39		
3528	ADULT 40-100% M&F 45	1.80	1.00	1.23	2.74	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.77		
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	0.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.37		
352G	ADULT 40-100% FEMAL E	0.00	0.00	1.00	0.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.73		
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	30.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.05		
3707	ADULT <40% EXP FEM AL	3.22	7.07	12.16	12.92	15.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.85		
3708	ADULT <40% EXP M&F
4	69.28	82.50	84.64	87.86	78.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		402.92		
3709	ADULT <40% EXP M&F 6	5.00	9.32	12.00	14.35	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.67		
370F	ADULT <40% EXP MALE	6.31	6.24	9.97	4.50	2.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.93		
370G	ADULT <40% EXP FEM AL	0.77	1.90	1.82	14.40	1.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.57		
370H	ADULT <40% EXP M&F
4	10.17	19.09	6.71	4.26	9.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.28		
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	10,355.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,343.50		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM AL	9,173.98	9,315.29	9,393.59	9,445.92	9,365.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,694.75		
3716	ADULT <40% EXP MALE	69,372.63	70,752.32	70,889.00	72,351.04	72,311.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355,676.96		
3717	ADULT <40% EXP FEM AL	40,598.88	41,281.54	41,336.24	41,987.49	41,972.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,176.78		
3718	ADULT <40% EXP M&F
4	82,032.08	82,785.12	82,884.26	83,686.47	83,524.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414,912.87		
3719	ADULT <40% EXP M&F 6	7.00	8.00	7.00	8.00	9.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.53		
371D	ADULT <40% EXP MALE	267.37	258.29	210.76	235.94	225.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,197.95		
371E	ADULT <40% EXP FEM AL	271.22	220.41	179.21	181.69	198.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,050.79		
371F	ADULT <40% EXP MALE	2,522.08	2,263.41	1,955.44	2,106.14	1,960.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,807.46		
371G	ADULT <40% EXP FEM AL	1,522.51	1,206.36	1,033.63	1,184.49	1,041.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,988.10		
371H	ADULT <40% EXP M&F
4	2,167.78	1,988.52	1,594.08	1,806.86	1,747.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,304.62		
371J	ADULT <40% EXP M&F 6	0.00	0.00	1.00	0.00	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.06		
3726	ADULT <40% EXP MALE	3.18	5.00	1.60	4.35	2.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.12		
3727	ADULT <40% EXP FEM AL	2.48	2.00	2.00	3.64	1.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.62		
3728	ADULT <40% EXP M&F
4	0.00	3.00	3.20	3.93	5.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.89		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
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 FEM AL	0.51	1.00	0.00	0.31	0.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.32		
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	308,009.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,533,087.01		

3906	NEWLY ELIGIBLE MALE	13.21	15.49	16.06	16.36	17.53	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	5.60	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	60.92	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	12.99	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	1.46	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	3.40	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	1.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	1.99	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	3,248.67	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	3,623.17	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	16,625.63	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	25,201.52	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	25,578.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

78.65	
20.21	
352.25	
120.99	
4.93	
5.78	
47.98	
1.99	
15,813.35	
18,092.95	
84,727.54	
127,484.41	
128,591.61	

9935	BIRTH SUPP PAYMENT A	26.00	43.00	38.00	22.00	35.00	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	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	106.00	120.00	121.0	0	107.00	110.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
164.00	
400.00	
564.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3919	NEWLY ELIGIBLE M&F 6	1.00	1.00	2.00	1.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
391D	NEWLY ELIGIBLE MALE	83.05	62.33	67.48	56.10	48.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		317.37		
391E	NEWLY ELIGIBLE FEMA L	112.21	100.13	92.64	77.04	64.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		446.67		
391F	NEWLY ELIGIBLE MALE	668.38	562.71	524.11	550.66	477.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,783.76		
391G	NEWLY ELIGIBLE FEMA L	1,005.22	908.94	726.00	786.17	726.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,152.97		
391H	NEWLY ELIGIBLE M&F
4	791.17	652.01	570.18	625.85	639.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,279.06		
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	0.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.36		
3928	NEWLY ELIGIBLE M&F
4	0.00	1.00	1.00	1.93	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.93		
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		
392G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	1.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.63		
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	76,350.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		386,350.43		

9939

BIRTH SUPP PAYMENT N

275.00

275.00

49.00	63.00	53.00	64.00	46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
49.00	63.00	53.00	64.00	46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4412	SOBRA 100-133% M&F
1	0.00	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	41,633.68	41,477.67	40,700.23	40,304.10	39,435.87	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	11,318.35	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	11,040.76	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	783.02	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	210.27	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	216.24	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	63,004.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.77	
203,551.55	
58,082.90	
56,402.03	
0.22	
4,622.76	
1,299.79	
1,208.97	
325,168.99	

9944	BIRTH SUPP PAYMENT S	2.00	10.00	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	10.00	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

23.00

23.00

4517	BC PATIENT FEMALE 2 1	22.89	24.00	24.36	27.70	24.66	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	127.75	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	1.33	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	3.25	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	8.00	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	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
123.61	
634.60	
0.58	
12.32	
35.12	
38.41	
41.26	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		7.58		
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		3.73		
SUBTOTAL:	184.49	170.89	169.9	7	196.87	174.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		897.21		

1.00

9945	SB KICK PAYMENT FO R	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00

8600	SSI BLIND FREEDOM/W O	2.00	2.00	1.00	1.00	1.00	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	1.00	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	2,091.29	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	82.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	376.44	361.22	348.08	354.76	365.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	21.21	26.48	28.40	13.15	16.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	342.00	333.87	331.87	341.79	343.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	4.53	3.47	11.18	10.30	2.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,904.59	2,912.52	2,920.98	2,894.24	2,903.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.00	
5.00	
10,415.80	
471.53	
1,805.79	
105.91	
1,692.61	
32.44	
14,536.08	

6015

KIDS 14-19 FEMALE NO

1.90

1.90

0.00	0.00	0.90	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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:

TOTAL:	1,544,822.48	1,552,043.21	1,545,129.35	1,553,385.02	1,543,731.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,739,111.83		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	33.40	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	33.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.40		
1009	TANF 65+ M & F WITH	0.00	33.40	33.40	33.40	50.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150.30		
1011	TANF <1 M & F NON-ME	1,753.50	1,803.60	1,820.30	1,870.40	2,087.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,335.30		
1012	TANF 01-05 M & F NON	1,402.80	1,469.60	1,786.90	1,803.60	1,970.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,433.50		
1013	TANF 06-13 M & F NON	1,285.90	1,369.40	1,603.20	1,670.00	1,887.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,815.60		
1014	TANF 14-20 MALE NON-	334.00	450.90	467.60	484.30	551.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,287.90		
1015	TANF 14-20 FEMALE N O	484.30	467.60	467.60	534.40	567.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,521.70		
1016	TANF 21-44 MALE NON-	1,419.50	1,553.10	1,937.20	2,271.20	2,404.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,585.80		
1017	TANF 21-44 FEMALE N O	5,761.50	6,496.30	7,565.10	8,249.80	9,519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,591.70		
1018	TANF 45-64 M & F NON	2,638.60	2,772.20	3,056.10	3,189.70	3,507.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,163.60		
1019	TANF 65+ M & F NON-M	0.00	0.00	16.70	16.70	33.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
1026	TANF 21-44 MALE WITH	0.00	16.70	16.70	33.40	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.50		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.40		
2100	SSI AGED WITH MEDIC A	83.50	133.60	133.60	133.60	167.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		651.30		
2110	SSI AGED NON-MEDIC
AR	116.90	116.90	200.40	267.20	233.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		935.20		
2120	SSI AGED WITH QMB	1,035.40	1,169.00	1,269.20	1,402.80	1,536.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,412.80		
2200	SSI DISABLED WITH M E	400.80	467.60	517.70	567.80	651.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,605.20		
2210	SSI DISABLED NON-ME
D	6,379.40	7,047.40	7,849.00	8,750.80	9,802.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,829.50		
2220	SSI DISABLED WITH Q M	2,271.20	2,338.00	2,538.40	2,738.80	3,189.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,076.10		
2310	SSI BLIND NON-MEDIC
A	66.80	66.80	83.50	100.20	100.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417.50		
2320	SSI BLIND WITH QMB	16.70	16.70	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.50		
4311	SOBRA CHILD <1 M & F	4,876.40	4,809.60	5,160.30	5,394.10	5,410.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,651.20		
4312	SOBRA CHILD 01-05 M	14,762.80	16,416.10	18,169.60	19,505.60	21,376.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,230.10		
4313	SOBRA CHILD 06-13 M	14,094.80	16,132.20	17,985.90	19,438.80	21,643.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,294.90		
4314	SOBRA CHILD 14-20 MA	2,822.30	3,039.40	3,573.80	3,757.50	4,308.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,501.60		
4315	SOBRA CHILD 14-20 FE	2,922.50	3,306.60	4,024.70	4,408.80	4,909.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,572.40		
5015	SOBRA PREG 14-20 FE M	116.90	116.90	100.20	83.50	116.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		534.40		
5017	SOBRA PREG 21-44 FE
M	751.50	651.30	718.10	651.30	684.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,456.90		
5018	SOBRA PREG 45-64 FE M	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.10		
SUBTOTAL:	65,848.10	72,294.30	81,145.3	0	87,391.10	96,793.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403,472.00		

1108	TANF EXPANDED 45-64	33.40	33.40	50.10	83.50	66.80	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	217.10	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	33.40	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	133.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
267.20	
835.00	
167.00	
450.90	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	885.10	1,135.60	1,369.40	1,603.20	1,820.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,813.60		
1117	TANF EXPANDED 21-44	3,306.60	3,774.20	4,024.70	4,759.50	5,243.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,108.80		
1118	TANF EXPANDED 45-64	1,987.30	2,271.20	2,404.80	2,638.60	2,972.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,274.50		
1119	TANF EXPANDED 65+
M&	16.70	16.70	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.50		
1126	TANF EXPANDED 21-44	50.10	50.10	66.80	83.50	100.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350.70		
1127	TANF EXPANDED 21-44	66.80	66.80	83.50	66.80	66.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350.70		
1128	TANF EXPANDED 45-64	350.70	334.00	317.30	367.40	434.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,803.60		
1129	TANF EXPANDED 65+
M&	250.50	233.80	233.80	250.50	283.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,252.50		
2420	SSI AGED EXPANDED WI	1,452.90	1,753.50	1,920.50	1,987.30	2,204.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,318.60		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.40		
2610	SSI DISABLED EXPAND E	133.60	150.30	200.40	183.70	250.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		918.50		
2620	SSI DISABLED EXPAND
E	751.50	768.20	784.90	851.70	951.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,108.20		
SUBTOTAL:	9,519.00	10,838.30	11,756.8	0	13,209.70	14,812.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,136.70		

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	50.10	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	233.80	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	584.50	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	1,018.70	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	2,020.70	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	3,907.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16.70	
300.60	
718.10	
2,605.20	
4,625.90	
9,418.80	
17,685.30	

3514	ADULT 40-100% MALE 1	83.50	133.60	150.30	150.30	183.70	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	233.80	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	1,002.00	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	868.40	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	3,473.60	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	16.70	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	617.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	367.40	551.10	567.80	634.60	684.70	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	7,815.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	3,122.90	3,456.90	3,941.20	4,475.60	4,926.50	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	10,804.90	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	16.70	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	30,644.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
701.40	
951.90	
4,158.30	
3,957.90	
15,430.80	
16.70	
33.40	
50.10	
2,321.30	
2,805.60	
32,214.30	
19,923.10	
47,511.50	
16.70	
130,093.00	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	1,786.90	1,887.10	2,271.20	2,204.40	2,237.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,387.40		
4414	SOBRA 100-133% MALE	317.30	417.50	467.60	534.40	601.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,338.00		
4415	SOBRA 100-133% FEMA L	334.00	400.80	450.90	417.50	484.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,087.50		
SUBTOTAL:	2,438.20	2,705.40	3,189.70	3,156.30	3,323.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,812.90		

4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16.70	
50.10	
66.80	

8700	SSI DISABLED FREEDO M	50.10	83.50	83.50	50.10	50.10	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	16.70	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	66.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
317.30	
66.80	
33.40	
417.50	

626,684.20

102,037.00	113,059.00	126,085.00	135,938.00	149,565.20	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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1009	TANF 65+ M & F WITH	0.00	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1011	TANF <1 M & F NON-ME	105.00	108.00	109.00	112.00	125.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		559.00		
1012	TANF 01-05 M & F NON	84.00	88.00	107.00	108.00	118.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		505.00		
1013	TANF 06-13 M & F NON	77.00	82.00	96.00	100.00	113.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		468.00		
1014	TANF 14-20 MALE NON-	20.00	27.00	28.00	29.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137.00		
1015	TANF 14-20 FEMALE N O	29.00	28.00	28.00	32.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151.00		
1016	TANF 21-44 MALE NON-	85.00	93.00	116.00	136.00	144.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		574.00		
1017	TANF 21-44 FEMALE N O	345.00	389.00	453.00	494.00	570.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,251.00		
1018	TANF 45-64 M & F NON	158.00	166.00	183.00	191.00	210.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		908.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1026	TANF 21-44 MALE WITH	0.00	1.00	1.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2100	SSI AGED WITH MEDIC A	5.00	8.00	8.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.00		
2110	SSI AGED NON-MEDIC
AR	7.00	7.00	12.00	16.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.00		
2120	SSI AGED WITH QMB	62.00	70.00	76.00	84.00	92.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.00		
2200	SSI DISABLED WITH M E	24.00	28.00	31.00	34.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156.00		
2210	SSI DISABLED NON-ME
D	382.00	422.00	470.00	524.00	587.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,385.00		
2220	SSI DISABLED WITH Q M	136.00	140.00	152.00	164.00	191.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		783.00		
2310	SSI BLIND NON-MEDIC
A	4.00	4.00	5.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4311	SOBRA CHILD <1 M & F	292.00	288.00	309.00	323.00	324.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,536.00		
4312	SOBRA CHILD 01-05 M	884.00	983.00	1,088.00	1,168.00	1,280.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,403.00		
4313	SOBRA CHILD 06-13 M	844.00	966.00	1,077.00	1,164.00	1,296.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,347.00		
4314	SOBRA CHILD 14-20 MA	169.00	182.00	214.00	225.00	258.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,048.00		
4315	SOBRA CHILD 14-20 FE	175.00	198.00	241.00	264.00	294.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,172.00		
5015	SOBRA PREG 14-20 FE M	7.00	7.00	6.00	5.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.00		
5017	SOBRA PREG 21-44 FE
M	45.00	39.00	43.00	39.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207.00		
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	5,796.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,160.00		

1108	TANF EXPANDED 45-64	2.00	2.00	3.00	5.00	4.00	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	13.00	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	2.00	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	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16.00	
50.00	
10.00	
27.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	53.00	68.00	82.00	96.00	109.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408.00		
1117	TANF EXPANDED 21-44	198.00	226.00	241.00	285.00	314.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,264.00		
1118	TANF EXPANDED 45-64	119.00	136.00	144.00	158.00	178.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		735.00		
1119	TANF EXPANDED 65+
M&	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1126	TANF EXPANDED 21-44	3.00	3.00	4.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
1127	TANF EXPANDED 21-44	4.00	4.00	5.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
1128	TANF EXPANDED 45-64	21.00	20.00	19.00	22.00	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108.00		
1129	TANF EXPANDED 65+
M&	15.00	14.00	14.00	15.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.00		
2420	SSI AGED EXPANDED WI	87.00	105.00	115.00	119.00	132.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		558.00		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2610	SSI DISABLED EXPAND E	8.00	9.00	12.00	11.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.00		
2620	SSI DISABLED EXPAND
E	45.00	46.00	47.00	51.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246.00		
SUBTOTAL:	570.00	649.00	704.0	0	791.00	887.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,601.00		

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	3.00	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	14.00	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	35.00	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	61.00	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	121.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	177.00	201.00	219.0	0	228.00	234.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
18.00	
43.00	
156.00	
277.00	
564.00	
1,059.00	

3514	ADULT 40-100% MALE 1	5.00	8.00	9.00	9.00	11.00	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	14.00	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	60.00	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	52.00	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	208.00	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	1.00	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	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	22.00	33.00	34.00	38.00	41.00	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	468.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	187.00	207.00	236.00	268.00	295.00	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	647.00	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	1.00	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	1,835.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
42.00	
57.00	
249.00	
237.00	
924.00	
1.00	
2.00	
3.00	
139.00	
168.00	
1,929.00	
1,193.00	
2,845.00	
1.00	
7,790.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	107.00	113.00	136.00	132.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		622.00		
4414	SOBRA 100-133% MALE	19.00	25.00	28.00	32.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140.00		
4415	SOBRA 100-133% FEMA L	20.00	24.00	27.00	25.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125.00		
SUBTOTAL:	146.00	162.00	191.0	0	189.00	199.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		887.00		

8700	SSI DISABLED FREEDO M	3.00	5.00	5.00	3.00	3.00	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	1.00	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	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

19.00	
4.00	
2.00	
25.00	

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

 
1.00	
3.00	
4.00	

TOTAL:	6,110.00	6,770.00	7,550.00	8,140.00	8,956.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,526.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	22.71	22.71	0.00	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.84		
1008	TANF 45-64 M & F WIT	22.71	45.42	45.42	45.42	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.68		
1009	TANF 65+ M & F WITH	22.71	22.71	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.55		
1011	TANF <1 M & F NON-ME	204.39	204.39	181.68	181.68	181.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		953.82		
1012	TANF 01-05 M & F NON	431.49	545.04	499.62	522.33	567.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,566.23		
1013	TANF 06-13 M & F NON	408.78	431.49	408.78	522.33	635.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,407.26		
1014	TANF 14-20 MALE NON-	22.71	45.42	68.13	136.26	136.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408.78		
1015	TANF 14-20 FEMALE N O	181.68	295.23	363.36	363.36	340.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,544.28		
1016	TANF 21-44 MALE NON-	567.75	681.30	681.30	681.30	885.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,497.34		
1017	TANF 21-44 FEMALE N O	4,428.45	4,791.81	4,905.36	5,155.17	5,541.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,822.03		
1018	TANF 45-64 M & F NON	1,544.28	1,612.41	1,748.67	1,703.25	1,771.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,379.99		
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	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.42		
2100	SSI AGED WITH MEDIC A	181.68	181.68	204.39	204.39	227.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		999.24		
2110	SSI AGED NON-MEDIC
AR	45.42	45.42	68.13	68.13	68.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295.23		
2120	SSI AGED WITH QMB	1,975.77	2,112.03	2,157.45	2,429.97	2,475.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,150.61		
2200	SSI DISABLED WITH M E	681.30	704.01	749.43	749.43	794.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,679.02		
2210	SSI DISABLED NON-ME
D	4,110.51	4,428.45	4,610.13	4,950.78	4,996.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,096.07		
2220	SSI DISABLED WITH Q M	2,861.46	3,020.43	3,156.69	3,292.95	3,451.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,783.45		
2310	SSI BLIND NON-MEDIC
A	22.71	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204.39		
2320	SSI BLIND WITH QMB	45.42	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		227.10		
4311	SOBRA CHILD <1 M & F	908.40	953.82	749.43	749.43	840.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,201.35		
4312	SOBRA CHILD 01-05 M	5,473.11	5,813.76	6,358.80	6,608.61	6,926.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,180.83		
4313	SOBRA CHILD 06-13 M	4,678.26	5,518.53	5,904.60	6,313.38	6,903.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,318.61		
4314	SOBRA CHILD 14-20 MA	976.53	1,226.34	1,294.47	1,317.18	1,408.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,222.54		
4315	SOBRA CHILD 14-20 FE	1,657.83	1,725.96	1,907.64	2,021.19	2,225.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,538.20		
5015	SOBRA PREG 14-20 FE M	113.55	113.55	90.84	90.84	204.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		613.17		
5017	SOBRA PREG 21-44 FE
M	1,021.95	1,135.50	1,317.18	1,385.31	1,226.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,086.28		
SUBTOTAL:	32,611.56	35,768.25	37,607.7	6	39,651.66	41,990.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		187,630.02		

1108	TANF EXPANDED 45-64	45.42	45.42	45.42	45.42	45.42	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	45.42	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	249.81	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	3,474.63	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	1,771.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
227.10	
90.84	
113.55	
1,294.47	
15,965.13	
8,039.34	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending November 30, 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	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.55		
1128	TANF EXPANDED 45-64	90.84	113.55	158.97	181.68	158.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		704.01		
1129	TANF EXPANDED 65+
M&	249.81	295.23	295.23	295.23	340.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,476.15		
2410	SSI AGED EXPANDED NO	22.71	22.71	22.71	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.97		
2420	SSI AGED EXPANDED
WI	1,703.25	1,884.93	1,930.35	2,021.19	2,112.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,651.75		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.71		
2610	SSI DISABLED EXPAND
E	68.13	45.42	22.71	90.84	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272.52		
2620	SSI DISABLED EXPAND E	567.75	567.75	613.17	613.17	635.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,997.72		
SUBTOTAL:	7,448.88	7,903.08	8,243.73	8,561.67	8,970.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,127.81		

3514	ADULT 40-100% MALE 1	136.26	113.55	113.55	68.13	68.13	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	295.23	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	408.78	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	545.04	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	1,725.96	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	340.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	317.94	317.94	340.65	431.49	408.78	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	2,225.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,657.83	1,725.96	1,680.54	1,771.38	1,839.51	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	6,608.61	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	14,466.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
499.62	
1,476.15	
1,975.77	
2,112.03	
8,561.67	
90.84	
1,226.34	
1,816.80	
10,514.73	
8,675.22	
31,725.87	
68,675.04	

3908	NEWLY ELIGIBLE M&F 4	22.71	45.42	22.71	22.71	22.71	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	45.42	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	22.71	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	113.55	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	862.98	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	1,271.76	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	2,339.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
136.26	
45.42	
272.52	
90.84	
726.72	
3,656.31	
5,791.05	
10,719.12	

4413	SOBRA 100-133% M&F
6	386.07	363.36	476.91	545.04	567.75	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	158.97	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	204.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	635.88	681.30	862.9	8	931.11	931.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,339.13	
817.56	
885.69	
4,042.38	

4518

BC PATIENT FEMALE 4 5

22.71

22.71

22.71

22.71

22.71

0.00

0.00	0.00

0.00

0.00

0.00

0.00

113.55

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	22.71	22.71	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.55		

8700	SSI DISABLED FREEDO M	45.42	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	45.42	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	90.84	90.84	90.84	90.84	90.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
227.10	
227.10	
454.20	

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

 
22.71

22.71

312,784.83

54,821.94	60,022.53	63,042.96	66,086.10	68,811.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	1.00	1.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1008	TANF 45-64 M & F WIT	1.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1009	TANF 65+ M & F WITH	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1011	TANF <1 M & F NON-ME	9.00	9.00	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.00		
1012	TANF 01-05 M & F NON	19.00	24.00	22.00	23.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.00		
1013	TANF 06-13 M & F NON	18.00	19.00	18.00	23.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.00		
1014	TANF 14-20 MALE NON-	1.00	2.00	3.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
1015	TANF 14-20 FEMALE N O	8.00	13.00	16.00	16.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.00		
1016	TANF 21-44 MALE NON-	25.00	30.00	30.00	30.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154.00		
1017	TANF 21-44 FEMALE N O	195.00	211.00	216.00	227.00	244.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,093.00		
1018	TANF 45-64 M & F NON	68.00	71.00	77.00	75.00	78.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		369.00		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2100	SSI AGED WITH MEDIC A	8.00	8.00	9.00	9.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.00		
2110	SSI AGED NON-MEDIC
AR	2.00	2.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
2120	SSI AGED WITH QMB	87.00	93.00	95.00	107.00	109.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		491.00		
2200	SSI DISABLED WITH M E	30.00	31.00	33.00	33.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.00		
2210	SSI DISABLED NON-ME
D	181.00	195.00	203.00	218.00	220.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,017.00		
2220	SSI DISABLED WITH Q M	126.00	133.00	139.00	145.00	152.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		695.00		
2310	SSI BLIND NON-MEDIC
A	1.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
2320	SSI BLIND WITH QMB	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
4311	SOBRA CHILD <1 M & F	40.00	42.00	33.00	33.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185.00		
4312	SOBRA CHILD 01-05 M	241.00	256.00	280.00	291.00	305.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,373.00		
4313	SOBRA CHILD 06-13 M	206.00	243.00	260.00	278.00	304.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,291.00		
4314	SOBRA CHILD 14-20 MA	43.00	54.00	57.00	58.00	62.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274.00		
4315	SOBRA CHILD 14-20 FE	73.00	76.00	84.00	89.00	98.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		420.00		
5015	SOBRA PREG 14-20 FE M	5.00	5.00	4.00	4.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.00		
5017	SOBRA PREG 21-44 FE
M	45.00	50.00	58.00	61.00	54.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268.00		
SUBTOTAL:	1,436.00	1,575.00	1,656.00	1,746.00	1,849.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,262.00		

1108	TANF EXPANDED 45-64	2.00	2.00	2.00	2.00	2.00	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	2.00	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	11.00	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	153.00	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	78.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10.00	
4.00	
5.00	
57.00	
703.00	
354.00	

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending November 30, 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1128	TANF EXPANDED 45-64	4.00	5.00	7.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.00		
1129	TANF EXPANDED 65+
M&	11.00	13.00	13.00	13.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65.00		
2410	SSI AGED EXPANDED NO	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2420	SSI AGED EXPANDED
WI	75.00	83.00	85.00	89.00	93.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425.00		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2610	SSI DISABLED EXPAND
E	3.00	2.00	1.00	4.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
2620	SSI DISABLED EXPAND E	25.00	25.00	27.00	27.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132.00		
SUBTOTAL:	328.00	348.00	363.0	0	377.00	395.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,811.00		

3514	ADULT 40-100% MALE 1	6.00	5.00	5.00	3.00	3.00	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	13.00	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	18.00	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	24.00	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	76.00	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	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	14.00	14.00	15.00	19.00	18.00	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	98.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	73.00	76.00	74.00	78.00	81.00	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	291.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	531.00	592.00	620.0	0	644.00	637.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22.00	
65.00	
87.00	
93.00	
377.00	
4.00	
54.00	
80.00	
463.00	
382.00	
1,397.00	
3,024.00	

3908	NEWLY ELIGIBLE M&F 4	1.00	2.00	1.00	1.00	1.00	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	2.00	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	1.00	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	5.00	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	38.00	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	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	86.00	92.00	94.00	97.00	103.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
2.00	
12.00	
4.00	
32.00	
161.00	
255.00	
472.00	

4413	SOBRA 100-133% M&F
6	17.00	16.00	21.00	24.00	25.00	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	7.00	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	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28.00	30.00	38.00	41.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
103.00	
36.00	
39.00	
178.00	

4518

BC PATIENT FEMALE 4 5

1.00

1.00

1.00

1.00

1.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

5.00

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		

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

1.00

1.00

8700	SSI DISABLED FREEDO M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10.00	
10.00	
20.00	

TOTAL:	2,414.00	2,643.00	2,776.00	2,910.00	3,030.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,773.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	49.80	49.80	49.80	74.70	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		273.90		
1009	TANF 65+ M & F WITH	49.80	49.80	74.70	74.70	74.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323.70		
1011	TANF <1 M & F NON-ME	1,045.80	946.20	1,045.80	1,095.60	1,020.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,154.30		
1012	TANF 01-05 M & F NON	2,191.20	1,992.00	2,116.50	2,365.50	2,490.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,155.20		
1013	TANF 06-13 M & F NON	2,340.60	2,539.80	2,714.10	2,838.60	3,062.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,495.80		
1014	TANF 14-20 MALE NON-	423.30	597.60	771.90	821.70	921.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,535.80		
1015	TANF 14-20 FEMALE N O	1,767.90	1,767.90	1,992.00	2,041.80	1,942.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,511.80		
1016	TANF 21-44 MALE NON-	6,474.00	6,548.70	6,648.30	6,623.40	6,498.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,793.30		
1017	TANF 21-44 FEMALE N O	23,904.00	24,053.40	24,800.40	24,974.70	25,323.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,055.80		
1018	TANF 45-64 M & F NON	7,519.80	7,445.10	7,569.60	7,768.80	7,968.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,271.30		
1019	TANF 65+ M & F NON-M	24.90	24.90	49.80	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.20		
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	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.20		
1029	TANF 65+ M & F WITH	24.90	24.90	0.00	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
2100	SSI AGED WITH MEDIC A	1,444.20	1,469.10	1,444.20	1,494.00	1,543.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,395.30		
2110	SSI AGED NON-MEDIC
AR	199.20	174.30	199.20	149.40	149.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		871.50		
2120	SSI AGED WITH QMB	5,229.00	5,453.10	5,453.10	5,577.60	5,577.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,290.40		
2200	SSI DISABLED WITH M E	3,336.60	3,560.70	3,635.40	3,685.20	3,710.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,928.00		
2210	SSI DISABLED NON-ME
D	18,077.40	18,351.30	18,525.60	18,774.60	18,874.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,603.10		
2220	SSI DISABLED WITH Q M	8,341.50	8,490.90	8,715.00	8,839.50	8,964.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,350.90		
2300	SSI BLIND WITH MEDIC	49.80	49.80	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.30		
2310	SSI BLIND NON-MEDIC A	273.90	298.80	298.80	323.70	348.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,543.80		
2320	SSI BLIND WITH QMB	99.60	99.60	124.50	124.50	124.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572.70		
4311	SOBRA CHILD <1 M & F	3,884.40	3,610.50	3,411.30	3,311.70	3,062.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,280.60		
4312	SOBRA CHILD 01-05 M	31,847.10	32,046.30	32,768.40	32,793.30	32,768.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162,223.50		
4313	SOBRA CHILD 06-13 M	42,330.00	44,421.60	45,865.80	46,363.80	46,388.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225,369.90		
4314	SOBRA CHILD 14-20 MA	10,034.70	10,308.60	11,080.50	11,329.50	11,454.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,207.30		
4315	SOBRA CHILD 14-20 FE	11,727.90	12,300.60	12,450.00	12,798.60	12,549.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,826.70		
5007	SOBRA PREG 21-44 FE M	0.00	24.90	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
5013	SOBRA PREG 09-13 FE
M	24.90	24.90	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.50		
5015	SOBRA PREG 14-20 FE M	473.10	522.90	572.70	597.60	398.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,564.70		
5017	SOBRA PREG 21-44 FE
M	2,838.60	2,888.40	2,863.50	2,863.50	2,689.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,143.20		
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	198,129.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		967,813.20		

1106

TANF EXPANDED 21-44

24.90

24.90

24.90

24.90

49.80

0.00

0.00	0.00

0.00

0.00

0.00

0.00

149.40

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	249.00	249.00	224.10	224.10	224.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,170.30		
1109	TANF EXPANDED 65+
M&	174.30	199.20	174.30	174.30	199.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		921.30		
1113	TANF EXPANDED 06-13	0.00	0.00	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.70		
1115	TANF EXPANDED 14-20	249.00	224.10	174.30	174.30	124.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		946.20		
1116	TANF EXPANDED 21-44	3,237.00	3,212.10	3,361.50	3,436.20	3,486.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,732.80		
1117	TANF EXPANDED 21-44	9,935.10	10,134.30	10,308.60	10,731.90	11,030.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,140.60		
1118	TANF EXPANDED 45-64	5,004.90	4,955.10	4,880.40	5,004.90	5,204.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,049.40		
1119	TANF EXPANDED 65+
M&	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
1126	TANF EXPANDED 21-44	99.60	99.60	99.60	99.60	124.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		522.90		
1127	TANF EXPANDED 21-44	249.00	224.10	224.10	224.10	224.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,145.40		
1128	TANF EXPANDED 45-64	498.00	547.80	597.60	547.80	522.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,714.10		
1129	TANF EXPANDED 65+
M&	498.00	498.00	522.90	547.80	498.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,564.70		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
2410	SSI AGED EXPANDED
NO	99.60	99.60	99.60	99.60	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.00		
2420	SSI AGED EXPANDED WI	3,311.70	3,486.00	3,436.20	3,535.80	3,610.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,380.20		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
2610	SSI DISABLED EXPAND E	124.50	174.30	149.40	149.40	174.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		771.90		
2620	SSI DISABLED EXPAND
E	1,593.60	1,643.40	1,718.10	1,718.10	1,743.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,416.20		
SUBTOTAL:	25,373.10	25,796.40	26,020.5	0	26,742.60	27,390.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,322.60		

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	249.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

49.80	
24.90	
1,245.00	

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	622.50	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	771.90	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	1,344.60	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	1,095.60	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	4,108.50	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	2,838.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	2,664.30	2,913.30	2,888.40	3,037.80	3,212.10	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	21,140.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	9,163.20	9,636.30	9,785.70	10,034.70	10,408.20	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	21,090.30	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	66,632.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
49.80	
2,340.60	
3,535.80	
6,698.10	
5,577.60	
19,944.90	
99.60	
13,296.60	
14,715.90	
98,031.30	
49,028.10	
100,471.50	
313,789.80	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	298.80	348.60	323.70	249.00	273.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,494.00		
3916	NEWLY ELIGIBLE MALE	1,269.90	1,369.50	1,394.40	1,294.80	1,245.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,573.60		
3917	NEWLY ELIGIBLE FEMA L	2,589.60	2,639.40	2,465.10	2,365.50	2,415.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,474.90		
3918	NEWLY ELIGIBLE M&F
4	2,913.30	2,963.10	3,187.20	3,261.90	3,361.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,687.00		
SUBTOTAL:	7,345.50	7,594.50	7,619.40	7,445.10	7,544.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,549.20		

4413	SOBRA 100-133% M&F
6	2,813.70	2,938.20	2,913.30	2,963.10	3,087.60	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	1,020.90	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	1,170.30	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	5,278.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14,715.90	
5,328.60	
5,204.10	
25,248.60	

8710	SSI DISABLED FREEDO M	49.80	49.80	49.80	74.70	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.80	49.80	49.80	74.70	99.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
323.70

323.70

1,476,047.10

282,341.10	289,761.30	296,683.50	302,186.40	305,074.80	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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	2.00	2.00	2.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
1009	TANF 65+ M & F WITH	2.00	2.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1011	TANF <1 M & F NON-ME	42.00	38.00	42.00	44.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207.00		
1012	TANF 01-05 M & F NON	88.00	80.00	85.00	95.00	100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		448.00		
1013	TANF 06-13 M & F NON	94.00	102.00	109.00	114.00	123.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		542.00		
1014	TANF 14-20 MALE NON-	17.00	24.00	31.00	33.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.00		
1015	TANF 14-20 FEMALE N O	71.00	71.00	80.00	82.00	78.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382.00		
1016	TANF 21-44 MALE NON-	260.00	263.00	267.00	266.00	261.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,317.00		
1017	TANF 21-44 FEMALE N O	960.00	966.00	996.00	1,003.00	1,017.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,942.00		
1018	TANF 45-64 M & F NON	302.00	299.00	304.00	312.00	320.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,537.00		
1019	TANF 65+ M & F NON-M	1.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1029	TANF 65+ M & F WITH	1.00	1.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2100	SSI AGED WITH MEDIC A	58.00	59.00	58.00	60.00	62.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		297.00		
2110	SSI AGED NON-MEDIC
AR	8.00	7.00	8.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.00		
2120	SSI AGED WITH QMB	210.00	219.00	219.00	224.00	224.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,096.00		
2200	SSI DISABLED WITH M E	134.00	143.00	146.00	148.00	149.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		720.00		
2210	SSI DISABLED NON-ME
D	726.00	737.00	744.00	754.00	758.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,719.00		
2220	SSI DISABLED WITH Q M	335.00	341.00	350.00	355.00	360.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,741.00		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2310	SSI BLIND NON-MEDIC A	11.00	12.00	12.00	13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.00		
2320	SSI BLIND WITH QMB	4.00	4.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.00		
4311	SOBRA CHILD <1 M & F	156.00	145.00	137.00	133.00	123.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		694.00		
4312	SOBRA CHILD 01-05 M	1,279.00	1,287.00	1,316.00	1,317.00	1,316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,515.00		
4313	SOBRA CHILD 06-13 M	1,700.00	1,784.00	1,842.00	1,862.00	1,863.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,051.00		
4314	SOBRA CHILD 14-20 MA	403.00	414.00	445.00	455.00	460.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,177.00		
4315	SOBRA CHILD 14-20 FE	471.00	494.00	500.00	514.00	504.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,483.00		
5007	SOBRA PREG 21-44 FE M	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
5013	SOBRA PREG 09-13 FE
M	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
5015	SOBRA PREG 14-20 FE M	19.00	21.00	23.00	24.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103.00		
5017	SOBRA PREG 21-44 FE
M	114.00	116.00	115.00	115.00	108.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		568.00		
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	7,957.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,868.00		

1106

TANF EXPANDED 21-44

1.00

1.00

1.00

1.00

2.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

6.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	10.00	10.00	9.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.00		
1109	TANF EXPANDED 65+
M&	7.00	8.00	7.00	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.00		
1113	TANF EXPANDED 06-13	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1115	TANF EXPANDED 14-20	10.00	9.00	7.00	7.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.00		
1116	TANF EXPANDED 21-44	130.00	129.00	135.00	138.00	140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		672.00		
1117	TANF EXPANDED 21-44	399.00	407.00	414.00	431.00	443.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,094.00		
1118	TANF EXPANDED 45-64	201.00	199.00	196.00	201.00	209.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,006.00		
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	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
1127	TANF EXPANDED 21-44	10.00	9.00	9.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46.00		
1128	TANF EXPANDED 45-64	20.00	22.00	24.00	22.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109.00		
1129	TANF EXPANDED 65+
M&	20.00	20.00	21.00	22.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103.00		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2410	SSI AGED EXPANDED
NO	4.00	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
2420	SSI AGED EXPANDED WI	133.00	140.00	138.00	142.00	145.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		698.00		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2610	SSI DISABLED EXPAND E	5.00	7.00	6.00	6.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.00		
2620	SSI DISABLED EXPAND
E	64.00	66.00	69.00	69.00	70.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338.00		
SUBTOTAL:	1,019.00	1,036.00	1,045.00	1,074.00	1,100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,274.00		

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	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
1.00	
50.00	

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	25.00	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	31.00	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	54.00	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	44.00	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	165.00	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	114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	107.00	117.00	116.00	122.00	129.00	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	849.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	368.00	387.00	393.00	403.00	418.00	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	847.00	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	2,676.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
94.00	
142.00	
269.00	
224.00	
801.00	
4.00	
534.00	
591.00	
3,937.00	
1,969.00	
4,035.00	
12,602.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA L	12.00	14.00	13.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.00		
3916	NEWLY ELIGIBLE MALE	51.00	55.00	56.00	52.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264.00		
3917	NEWLY ELIGIBLE FEMA L	104.00	106.00	99.00	95.00	97.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		501.00		
3918	NEWLY ELIGIBLE M&F
4	117.00	119.00	128.00	131.00	135.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		630.00		
SUBTOTAL:	295.00	305.00	306.0	0	299.00	303.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,508.00		

8710	SSI DISABLED FREEDO M	2.00	2.00	2.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	2.00	2.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13.00

13.00

4413	SOBRA 100-133% M&F
6	113.00	118.00	117.00	119.00	124.00	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	41.00	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	47.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	191.00	203.00	205.0	0	203.00	212.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
591.00	
214.00	
209.00	
1,014.00	

TOTAL:	11,339.00	11,637.00	11,915.00	12,136.00	12,252.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,279.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	8,388.64	12,582.96	8,388.64	19,010.52	19,010.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,381.28		
1010	TANF NON-MEDICARE	1,661,849.71	1,910,910.01	2,172,000.39	2,518,290.98	2,691,857.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,954,908.50		
1020	TANF WITH QMB	20,971.60	20,971.60	20,971.60	19,010.52	19,010.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,935.84		
2100	SSI AGED WITH MEDIC A	35,053,635.97	35,173,656.27	35,192,043.97	39,134,738.02	39,070,350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183,624,424.23		
210Z	SSI AGED WITH MEDIC
A	1,732,093.67	1,894,450.16	1,631,535.03	2,025,571.72	1,871,063.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,154,714.31		
2110	SSI AGED NON-MEDIC AR	3,603,820.94	3,588,951.22	3,571,776.99	4,155,910.91	4,093,524.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,013,984.87		
211Z	SSI AGED NON-MEDIC
AR	101,176.43	20,587.31	54,593.15	170,167.44	79,886.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		426,411.18		
2120	SSI AGED WITH QMB	26,288,894.99	26,531,693.06	26,919,643.96	29,858,898.87	29,944,297.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139,543,428.06		
212Z	SSI AGED WITH QMB P P	53,559.58	52,446.69	41,429.50	22,115.27	58,475.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228,026.95		
2200	SSI DISABLED WITH M
E	15,658,939.46	15,620,560.12	15,526,866.46	17,415,845.01	17,412,058.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,634,269.78		
220Z	SSI DISABLED WITH M E	241,491.30	210,523.92	148,685.65	226,958.11	161,194.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		988,853.22		
2210	SSI DISABLED NON-ME
D	136,360,868.15	136,890,501.12	137,407,556.47	156,969,550.24	157,202,622.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		724,831,098.74		
221Z	SSI DISABLED NON-ME D	220,330.68	212,099.65	164,951.73	216,450.20	303,719.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,117,551.58		
2220	SSI DISABLED WITH Q
M	29,326,623.98	29,529,057.68	29,688,987.13	33,510,873.21	33,622,119.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,677,661.92		
222Z	SSI DISABLED WITH Q M	36,101.66	3,297.05	17,224.42	15,278.93	27,610.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,512.25		
2300	SSI BLIND WITH MEDIC	2,719.44	2,719.44	212.67	165.00	6,728.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,545.46		
2310	SSI BLIND NON-MEDIC A	108,525.41	110,540.42	91,578.43	100,852.27	134,721.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		546,218.39		
2320	SSI BLIND WITH QMB	20,374.22	15,937.16	9,369.05	12,502.85	14,831.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,014.47		
SUBTOTAL:	250,500,365.83	251,801,485.84	252,667,815.24	286,392,190.07	286,733,084.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,328,094,941.03		

8700	SSI DISABLED FREEDO M	155,943.28	136,803.98	166,698.11	213,746.58	177,649.55	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	-9,760.07	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	244,483.33	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	87,490.97	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	197.74	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	500,061.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
850,841.50	
7,864.81	
1,115,449.89	
24,777.45	
369,812.40	
488.15	
2,369,234.20	

1,330,464,175.23

250,917,794.02	252,209,106.88	253,136,673.96	286,967,454.80	287,233,145.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	3.00	2.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
1010	TANF NON-MEDICARE	393.91	454.32	516.92	526.58	561.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,453.56		
1020	TANF WITH QMB	5.00	5.00	5.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.00		
2100	SSI AGED WITH MEDIC A	11,901.36	11,949.18	11,925.57	12,001.32	11,967.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,744.66		
210Z	SSI AGED WITH MEDIC
A	562.03	623.08	527.53	634.91	558.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,906.27		
2110	SSI AGED NON-MEDIC AR	611.47	610.68	604.51	598.67	590.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,015.42		
211Z	SSI AGED NON-MEDIC
AR	16.60	3.70	9.02	26.02	10.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.20		
2120	SSI AGED WITH QMB	9,350.65	9,436.56	9,532.55	9,570.71	9,598.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,489.18		
212Z	SSI AGED WITH QMB P P	17.29	17.74	14.71	7.74	17.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.37		
2200	SSI DISABLED WITH M
E	4,466.83	4,466.23	4,430.22	4,447.90	4,441.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,252.19		
220Z	SSI DISABLED WITH M E	78.72	70.28	48.18	70.48	48.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315.71		
2210	SSI DISABLED NON-ME
D	30,896.55	31,019.03	31,105.49	31,176.95	31,215.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,413.82		
221Z	SSI DISABLED NON-ME D	35.96	35.18	26.20	33.83	43.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.14		
2220	SSI DISABLED WITH Q
M	7,937.60	7,999.85	8,044.45	8,080.55	8,115.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,177.82		
222Z	SSI DISABLED WITH Q M	11.96	1.08	5.01	4.72	8.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.75		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	1.00	2.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.50		
2310	SSI BLIND NON-MEDIC A	24.00	24.64	22.40	21.32	27.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119.69		
2320	SSI BLIND WITH QMB	6.00	4.99	3.00	4.63	3.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.63		
SUBTOTAL:	66,319.93	66,726.54	66,823.7	6	67,215.33	67,219.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334,304.91		

8700	SSI DISABLED FREEDO M	42.00	36.25	45.99	51.93	42.87	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	-2.93	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	36.00	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	20.93	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	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	91.98	87.97	104.9	9	114.88	96.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
219.04	
2.80	
176.49	
3.48	
94.78	
0.16	
496.75	

TOTAL:	66,411.91	66,814.51	66,928.75	67,330.21	67,316.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334,801.66		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	360.61	0.00	368.93	21.43	29.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		780.03		
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	676.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228.97		
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	196.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,768.21		
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	182.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		238.35		
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	1,084.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,559.00		

4415

SOBRA 100-133% FEMA L

405.96

405.96

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

SUBTOTAL:

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

-0.07

-0.07

2,964.89

864.84	2,316.93	-1,030.86	-270.07	1,084.05	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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431C	SOBRA CHILD 6-13 M& F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

4415

SOBRA 100-133% FEMA L

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:

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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	27,128.70	27,368.37	30,877.78	30,079.04	34,303.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,756.97		
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		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	4,820.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,820.14		
1017	TANF 21-44 FEMALE N O	8,755.69	0.00	473.63	913.62	47,771.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,913.96		
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-MEDIC AR	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-MEDIC
AR	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	8,135.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,825.47		
2200	SSI DISABLED WITH M E	6,705.80	6,218.03	9,375.73	5,561.04	5,561.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,421.64		
220Z	SSI DISABLED WITH M
E	1,230.03	0.00	1,706.25	2,617.33	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,128.37		
2210	SSI DISABLED NON-ME D	191,817.13	229,386.03	284,569.91	201,387.94	201,591.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,108,752.33		
221Z	SSI DISABLED NON-ME
D	4,176.42	1,262.61	0.00	1,777.83	5,372.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,588.91		
2220	SSI DISABLED WITH Q M	70,948.72	70,948.72	97,309.03	75,572.44	75,515.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390,294.47		
222Z	SSI DISABLED WITH Q
M	880.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		880.65		
2310	SSI BLIND NON-MEDIC A	1,706.25	1,706.25	1,706.25	1,649.28	1,649.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,417.31		
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	171.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,243.16		
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	5,149.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,035.36		
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	392,615.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,884,064.83		

1100	TANF EXPANDED FPR FI	5,780.66	5,780.66	5,780.66	5,873.32	5,873.32	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	24,518.00	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	4,068.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
29,088.62	
1,680.63	
625.63	
137,120.33	
12,526.71	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	1,604.24	0.00	0.00	-1,589.47	686.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		701.37		
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	1,493.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,386.02		
240Z	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	2,231.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,231.46		
2420	SSI AGED EXPANDED WI	10,037.64	10,037.64	10,037.64	10,710.56	8,479.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,302.58		
260Z	SSI DISABLED EXPAND
E	440.32	1,772.15	534.75	0.00	355.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,102.80		
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	32,413.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,101.36		
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	80,119.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		417,480.19		

3910	NEWLY ELIGIBLE FOR F	11,840.80	11,840.80	13,307.38	10,299.04	9,373.56	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	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	83.06	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	199.09	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	9,655.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

56,661.58	
236.82	
83.06	
1,192.19	
58,173.65	

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	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,574.76

7,938.08

3510	ADULT 40-100% FOR FI	49,075.49	46,707.33	45,143.84	49,294.58	57,018.86	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	2,231.46	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	189,450.84	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	5,998.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	38,663.11	4,447.86	-455.00	3,838.82	1,224.49	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	5,197.60	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	1,871.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEM AL	13,048.25	0.00	1,308.13	83.06	1,630.68	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	1,304.40	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	265,927.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
247,240.10	
4,902.33	
1,816.33	
7,091.43	
3,122.83	
988,899.93	
2,902.91	
75,273.40	
47,719.28	
6,883.26	
28,947.09	
16,070.12	
14,835.73	
1,445,704.74	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	5,118.75	2,819.33	0.00	0.00	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,512.84		

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

0.00

0.00

0.00

698,694.23

TOTAL:

767,862.18

768,909.98

833,762.78

750,893.38

0.00

0.00

0.00

0.00

3,820,122.55

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

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

For The Period Ending November 30, 2019

RATE CODE	DESCRIPTION 1010	TANF NON-MEDICARE
1014	TANF 14-20 MALE NON-

1016	TANF 21-44 MALE NON-

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

101D	TANF 14-20 MALE NON-

101F	TANF 21-44 MALE NON-

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

1020	TANF WITH QMB

2100	SSI AGED WITH MEDIC
A
210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDIC
AR
211Z	SSI AGED NON-MEDIC
AR

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

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

2200

220Z

2210

221Z

2220

222Z

2310

4314

4315

431E

5007

5010

5017

501G

SSI DISABLED WITH M E
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

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	

0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		
240Z	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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

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	
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	
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	
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	
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	

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

3517	ADULT 40-100% MALE 2

ADULT 40-100% FEMAL E	Cu0.00rren0.00t an0.0d0	pr0i.00or m0.00	ont0h.00	da0.0t0	a is0.00	und0.00er r0e.00	vis0i.0o0	n. 0.00
0.00	
351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL	0.00
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED	0.00
FO	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 FEM	0.00
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F	0.00
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEM	0.00
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F	0.00
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

 

0.00

0.00

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1013	TANF 06-13 M & F NON	0.00	178.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178.47		
1014	TANF 14-20 MALE NON-	0.00	-0.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.24		
1015	TANF 14-20 FEMALE N O	0.00	0.00	20.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.76		
1016	TANF 21-44 MALE NON-	-1.81	-6.11	0.00	0.00	-120.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-128.50		
1017	TANF 21-44 FEMALE N O	593.22	420.31	329.89	0.00	-1,008.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334.47		
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	-350.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-267.02		
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	950.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,088.69		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	-140.84	0.00	270.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.00		
211Z	SSI AGED NON-MEDIC AR	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		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.53		
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	102.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,108.18		
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	394.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390.48		
SUBTOTAL:	792.76	1,422.27	-2,554.68	3,510.92	309.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,480.41		

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

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	211.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	-182.58	-717.48	0.00	0.00	-239.16	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	51.35	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	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	141.06	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	164.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
211.59	
-1,139.22	
1,244.16	
-1,622.47	
159.44	
141.06	
38.57	
-966.87	

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	-291.22	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	-594.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
209.24	
-532.24	
-3.41	
-748.12	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351H	ADULT 40-100% M&F 45	0.00	-22.67	0.00	0.00	-43.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-66.39		
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		634.77		
3714	ADULT <40% EXP MALE	0.00	797.20	-195.66	0.00	79.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		681.26		
3716	ADULT <40% EXP MALE	-806.04	-3,513.00	-2,336.03	0.00	-508.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,163.49		
3717	ADULT <40% EXP FEM AL	-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	-1,055.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-5,715.60		
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 FEM
AL	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 FEM AL	-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	-2,412.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-16,336.71		

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	-1,460.62	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	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	-77.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	398.60	-805.62	496.7	2	0.00	-1,538.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-441.12	
1,322.57	
-2,207.46	
-44.91	
-77.58	
-1,448.50	

8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	933.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	933.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
933.43

933.43

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

 
-70.00

-70.00

-14,252.51

-1,196.12	-3,952.91	-9,044.75	2,484.98	-2,543.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL

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

For The Period Ending November 30, 2019

RATE CODE	DESCRIPTION 1013	TANF 06-13 M & F NON
1014	TANF 14-20 MALE NON-

1015	TANF 14-20 FEMALE N
O
1016	TANF 21-44 MALE NON-

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

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

2100	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDIC
AR
211Z	SSI AGED NON-MEDIC
AR
2120	SSI AGED WITH QMB

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

Cu0.00rren0.00t

an0.0d0

pr0i.00or

m0.00 ont0h.00

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

r0e.00   vis0i.0o0

n. 0.00	0.00

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

2220

4312

4314

4315

5017

SSI DISABLED WITH Q M
SOBRA CHILD 01-05 M

SOBRA CHILD 14-20 MA SOBRA CHILD 14-20 FE
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:

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	
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	
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	
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	
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	

 
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371E	ADULT <40% EXP FEM
AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371G	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

0.00

0.00

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

391H

NEWLY ELIGIBLE M&F

4
SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE MALE

391F

NEWLY ELIGIBLE M&F 4

3918

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE FEMA L

3917

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE MALE

3916

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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

 
0.00

0.00

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

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	675,910.00	670,888.15	500,674.55	532,532.67	408,990.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,788,996.09		
1011	TANF <1 M & F NON-ME	248.11	953.72	-5,125.27	13,521.89	13,832.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,430.96		
1012	TANF 01-05 M & F NON	-15,379.82	-11,274.85	-15,393.11	-14,326.02	1,219.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-55,154.49		
1013	TANF 06-13 M & F NON	-2,418.26	-7,544.45	3,346.51	2,532.68	-359.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,443.26		
1014	TANF 14-20 MALE NON-	-811.16	-1,806.09	1,478.38	4,248.21	3,277.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,387.04		
1015	TANF 14-20 FEMALE N O	-368.71	-1,388.95	1,344.21	1,730.28	109.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,425.89		
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	52.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.16		
101B	TANF 01-05 M & F NON	-261.17	93.90	0.00	-3,216.83	-3,592.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-6,976.69		
101C	TANF 06-13 M & F NON	1,300.68	-970.35	-792.55	76.20	584.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198.82		
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	304,241.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,387,447.66		
221Z	SSI DISABLED NON-ME D	232.93	-271.78	-3,810.00	1,516.45	862.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,469.85		
2220	SSI DISABLED WITH Q
M	762.00	762.00	762.00	817.98	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,921.96		
2310	SSI BLIND NON-MEDIC A	762.00	762.00	762.00	817.98	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,921.96		
4310	SOBRA CHILD NON-ME
DI	10,445,633.40	10,379,896.70	10,747,274.95	11,347,873.20	11,399,680.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,320,359.07		
4311	SOBRA CHILD <1 M & F	13,625.43	15,714.43	26,374.80	64,140.68	41,219.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,074.54		
4312	SOBRA CHILD 01-05 M	-74,721.61	-78,041.28	-39,438.44	-22,022.88	-20,911.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-235,136.04		
4313	SOBRA CHILD 06-13 M	-105,628.37	-106,985.86	-26,667.13	-38,539.84	-21,900.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-299,721.52		
4314	SOBRA CHILD 14-20 MA	-43,134.77	-38,503.25	2,887.88	-13,089.30	-18,636.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-110,476.29		
4315	SOBRA CHILD 14-20 FE	-40,754.75	-20,963.64	-19,790.76	-8,327.22	-6,843.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-96,680.25		
431A	SOBRA CHILD < 1 M &	1,940.81	16,788.88	6,353.47	1,731.58	3,643.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,458.39		
431B	SOBRA CHILD 01-05 M	12,785.94	9,798.85	10,136.79	6,573.62	-2,311.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,983.43		
431C	SOBRA CHILD 6-13 M& F	25,205.14	21,852.27	12,251.98	22,429.04	1,841.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,579.94		
431D	SOBRA CHILD 14-20 MA	16,781.28	5,724.71	4,846.17	2,208.14	-63.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,497.16		
431E	SOBRA CHILD 14-20 FE	11,745.14	9,190.46	4,671.89	1,089.23	5,678.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,375.47		
5010	SOBRA PREGNANT WO MAN	13,738.15	13,995.75	20,755.25	22,862.96	19,191.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,543.43		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	817.98	-1,746.16	471.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-456.76		
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	12,131,913.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,192,933.49		

3710	AHC CARE EXPANDED FO	0.00	0.00	762.00	817.98	817.98	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	204.21	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	136.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	681.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,397.96	
597.50	
136.33	
681.65	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	81.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81.80		
SUBTOTAL:	0.00	393.29	762.00	817.98	1,921.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,895.24		

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	762.00	817.98	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	589.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL:	0.00	762.00	762.0	0	817.98	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,397.96	
589.94	
172.06	
3,159.96	

4410	SOBRA 100-133% FOR F	12,926.90	12,373.25	10,432.55	10,404.37	11,422.21	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	4,840.50	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	-26.02	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	2,391.38	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	18,628.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
57,559.28	
9,813.82	
2,023.81	
2,928.53	
681.12	
127.00	
73,133.56	

-762.00

58,272,360.25

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	

11,528,229.23	12,229,074.55	12,153,281.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-762.00

TOTAL:

11,210,666.00

11,151,108.99

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

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

For The Period Ending November 30, 2019

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

1012	TANF 01-05 M & F NON

1013	TANF 06-13 M & F NON

1014	TANF 14-20 MALE NON-

1015	TANF 14-20 FEMALE N
O
1017	TANF 21-44 FEMALE N
O
101A	TANF < 1 M & F NON-M

101B	TANF 01-05 M & F NON

101C	TANF 06-13 M & F NON

101D	TANF 14-20 MALE NON-

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

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

4310

4311

4312

4313

4314

4315

431A

431B

431C

431D

431E

5010

5015

501E

SSI BLIND NON-MEDIC A
SOBRA CHILD NON-ME
DI
SOBRA CHILD <1 M & F

SOBRA CHILD 01-05 M SOBRA CHILD 06-13 M SOBRA CHILD 14-20 MA SOBRA CHILD 14-20 FE SOBRA CHILD < 1 M & SOBRA CHILD 01-05 M
SOBRA CHILD 6-13 M& F
SOBRA CHILD 14-20 MA

SOBRA CHILD 14-20 FE

SOBRA PREGNANT WO MAN
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

SUBTOTAL:

3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
371D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL:	0.00	0.0	0	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	

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	

0.00

Cu0.00

0.00

rren0.00

0.00

t an0.00

0.00

d

pr0.00

0.00

ior m0.00 ont0.00

0.00

0.00

h

da

0.00

ta is0.00 und

0.00

0.00

er r

0.00

e

vis

0.00

io

n.0.00

0.00

0.00

0.00

0.00

0.00

STATE-ONLY BHS

S000

SUBTOTAL:	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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	204.75	398.47	398.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,001.69		
1010	TANF NON-MEDICARE	88,390.05	113,571.24	121,494.47	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-MED IC	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-MEDIC
AR	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	-174.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,220.77		
2200	SSI DISABLED WITH M E	391,262.61	392,589.11	387,859.38	273.12	466.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,172,450.25		
2210	SSI DISABLED NON-ME
D	5,853,769.90	5,880,424.06	5,923,149.37	3,563.06	-464.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,660,441.55		
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	38.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,919,878.02		
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	-134.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,528,705.53		

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	

22,552,999.69

7,458,765.69	7,517,688.26	7,570,386.98	6,293.18	-134.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

SUBTOTAL:

Cu0.00rren0.00t an0.0d0

pr0.0i0or m0.00   ont0.0h0

da0.00ta is0.00   und0.00  er r0.0e0     vis0.0i0on.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-MED IC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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 November 30, 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	37.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.90		
1006	TANF 21-44 MALE WITH	572.44	524.04	554.06	610.44	653.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,914.56		
1007	TANF 21-44 FEMALE WI	697.86	633.68	569.00	684.33	704.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,289.18		
1008	TANF 45-64 M & F WIT	1,292.20	1,256.05	1,295.38	1,740.93	1,802.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,386.63		
1009	TANF 65+ M & F WITH	784.65	740.61	658.68	876.87	918.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,979.20		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	1,298.21	1,375.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,674.12		
1011	TANF <1 M & F NON-ME	13,774.43	13,889.53	14,044.68	17,835.20	17,855.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,399.78		
1012	TANF 01-05 M & F NON	26,627.12	26,500.41	26,825.46	34,791.07	36,165.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,909.63		
1013	TANF 06-13 M & F NON	48,891.34	48,999.00	49,380.14	63,910.09	65,933.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277,114.20		
1014	TANF 14-20 MALE NON-	29,752.48	29,183.72	29,422.86	36,763.51	37,072.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162,195.40		
1015	TANF 14-20 FEMALE N O	50,257.49	49,708.32	49,693.38	60,864.17	60,283.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270,806.60		
1016	TANF 21-44 MALE NON-	196,818.83	196,825.88	198,260.40	238,341.36	238,159.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,068,405.91		
1017	TANF 21-44 FEMALE N O	669,123.39	671,878.41	675,375.54	809,952.99	813,363.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,639,694.29		
1018	TANF 45-64 M & F NON	161,187.72	160,988.62	161,431.18	193,858.32	194,773.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		872,239.64		
1019	TANF 65+ M & F NON-M	674.30	651.26	689.40	813.75	820.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,649.66		
1020	TANF WITH QMB	0.00	0.00	0.00	40.74	40.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81.48		
1024	TANF 14-20 MALE WITH	10.41	1.08	1.08	1.36	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.29		
1026	TANF 21-44 MALE WITH	387.68	364.94	366.97	429.87	417.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,966.52		
1027	TANF 21-44 FEMALE WI	653.45	638.63	661.09	729.06	730.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,412.49		
1028	TANF 45-64 M & F WIT	835.76	807.47	773.65	772.59	694.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,884.18		
1029	TANF 65+ M & F WITH	450.07	433.44	423.81	508.56	487.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,303.65		
2100	SSI AGED WITH MEDIC A	32,980.00	32,982.55	33,054.20	141,547.41	142,231.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382,795.30		
2110	SSI AGED NON-MEDIC
AR	53,956.16	54,404.88	54,776.81	70,837.29	71,168.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		305,144.05		
2120	SSI AGED WITH QMB	256,470.33	258,178.50	259,225.39	392,946.39	393,935.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,560,755.77		
2200	SSI DISABLED WITH M E	25,887.66	25,631.83	25,902.25	69,776.70	69,843.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217,042.13		
2210	SSI DISABLED NON-ME
D	277,976.12	277,927.49	278,125.13	480,981.11	482,036.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,797,046.81		
2220	SSI DISABLED WITH Q M	170,604.53	170,784.02	170,828.67	276,883.13	277,277.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,066,378.00		
2300	SSI BLIND WITH MEDIC	235.51	244.84	214.82	270.87	296.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,262.08		
2310	SSI BLIND NON-MEDIC A	3,591.59	3,599.17	3,649.81	4,587.91	4,550.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,979.18		
2320	SSI BLIND WITH QMB	1,900.92	1,912.30	1,925.39	2,370.60	2,435.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,544.52		
4302	SOBRA CHILD 01-05 M	3.24	3.24	5.40	6.80	6.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.48		
4303	SOBRA CHILD 06-13 M	9.76	9.76	10.85	13.70	13.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.77		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.36		
4305	SOBRA CHILD 14-20 FE	20.16	17.99	9.33	11.58	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.64		
4311	SOBRA CHILD <1 M & F	48,698.46	48,704.10	48,220.98	60,494.89	60,162.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		266,281.20		
4312	SOBRA CHILD 01-05 M	236,845.73	238,192.76	238,593.68	299,784.93	297,048.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,310,465.82		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4313	SOBRA CHILD 06-13 M	310,882.77	313,296.50	314,734.87	397,068.44	394,162.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,730,145.26		
4314	SOBRA CHILD 14-20 MA	155,400.15	157,444.43	158,328.17	193,512.39	192,498.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		857,183.98		
4315	SOBRA CHILD 14-20 FE	157,772.95	160,194.90	160,353.44	196,109.27	196,274.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		870,704.97		
4322	SOBRA CHILD 01-05 M	1.08	1.08	1.08	1.36	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.96		
4323	SOBRA CHILD 06-13 M	0.00	0.00	1.08	1.36	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.80		
4325	SOBRA CHILD 14-20 FE	2.17	11.92	11.92	14.27	14.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.55		
5007	SOBRA PREG 21-44 FE M	148.67	173.44	218.64	246.09	218.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,005.36		
5008	SOBRA PREG 45-64 FE
M	11.36	11.36	11.36	13.59	13.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.26		
5013	SOBRA PREG 09-13 FE M	3.32	8.72	6.56	4.30	8.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.30		
5015	SOBRA PREG 14-20 FE
M	18,252.71	19,137.94	19,530.79	23,029.58	22,663.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,614.03		
5017	SOBRA PREG 21-44 FE M	118,643.32	122,268.55	124,930.21	148,505.19	146,902.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		661,250.10		
5018	SOBRA PREG 45-64 FE
M	307.55	390.33	379.25	514.56	486.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,077.90		
5027	SOBRA PREG 21-44 FE M	205.51	237.30	212.81	245.67	246.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,148.16		
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	8.79	17.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.37		
SUBTOTAL:	3,073,603.35	3,089,794.99	3,103,689.65	4,224,649.54	4,226,823.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,718,561.42		

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	1,892.34	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	3,093.69	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	10,680.81	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	6,259.05	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	9.74	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	2,211.62	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	13,881.42	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	242,473.17	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	664,936.08	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	232,420.44	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	838.89	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	6,150.27	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	12,843.99	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	22,318.02	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	16,549.35	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	1,306.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.58	
8,320.84	
14,478.39	
47,410.63	
28,334.38	
2.17	
48.83	
9,568.76	
62,706.98	
1,106,414.62	
3,019,079.87	
1,050,153.09	
3,554.92	
28,228.95	
58,358.70	
101,243.15	
72,380.85	
5,044.23	

3100	TRANSPLANT OPTION 1	30.32	22.74	22.74	8.79	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30.32	22.74	22.74	8.79	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
93.38

93.38

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2410	SSI AGED EXPANDED NO	734.20	842.92	773.27	900.06	912.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,163.29		
2420	SSI AGED EXPANDED
WI	200,778.15	202,142.27	203,515.08	246,928.83	247,840.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,101,204.77		
2520	SSI BLIND EXPANDED W	7.58	7.58	7.58	8.79	17.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.11		
2600	SSI DISABLED EXPAND
E	762.25	849.07	753.42	803.40	1,180.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,348.64		
2610	SSI DISABLED EXPAND E	10,383.49	10,503.92	10,814.11	13,250.58	13,618.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,570.63		
2620	SSI DISABLED EXPAND
E	99,455.39	99,763.22	99,882.81	119,843.46	119,853.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		538,798.78		
SUBTOTAL:	1,353,111.57	1,358,060.90	1,361,578.86	1,628,431.45	1,621,289.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,322,472.16		

3506	ADULT 40-100% MALE 2	39.65	24.49	41.40	58.32	40.74	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	42.75	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	470.58	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	99.87	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	54,484.44	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	58,745.34	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	173,338.86	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	146,083.20	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	340,813.08	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	57.12	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	4.80	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	178.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	15.16	37.90	71.72	93.48	111.06	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	594.03	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	84.69	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	101,394.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	74,646.71	75,409.29	76,563.99	92,135.04	91,599.54	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	685,951.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	311,573.37	317,055.36	320,391.77	386,374.98	387,869.64	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	766,723.32	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	87.48	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 FEM AL	15.16	7.58	16.91	20.37	8.79	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	42.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
204.60	
89.36	
2,557.59	
661.21	
242,551.57	
263,656.37	
781,029.63	
656,428.77	
1,539,701.45	
261.10	
12.38	
52.70	
49.65	
7.58	
786.90	
329.32	
2,775.23	
413.41	
451,671.67	
410,354.57	
3,033,138.01	
1,723,265.12	
3,423,581.58	
365.57	
100.86	
68.81	
96.38	
11.58	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,281,745.11	2,310,670.32	2,328,102.00	2,804,867.64	2,808,837.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,534,222.97		

3906	NEWLY ELIGIBLE MALE	90.34	82.78	88.61	131.82	118.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	22.74	30.32	22.74	35.16	22.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	508.36	559.03	527.84	691.14	574.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	153.92	184.22	242.21	325.17	102.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	23,916.71	24,486.72	24,647.46	30,396.06	30,344.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	27,726.24	28,155.12	28,588.52	34,391.16	34,068.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	130,814.88	132,521.42	131,942.21	156,760.74	154,807.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	195,391.19	198,499.23	198,178.20	236,087.01	233,510.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	196,812.85	197,720.38	197,534.93	237,401.61	236,555.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	16.91	18.66	27.99	23.16	36.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3928	NEWLY ELIGIBLE M&F 4	16.91	9.33	9.33	11.58	37.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL:	575,493.4	9	582,267.21	581,810.0	4	696,263.40	690,178.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
511.78	
133.34	
2,860.81	
1,008.18	
133,791.23	
152,929.43	
706,846.60	
1,061,666.60	
1,066,024.99	
123.47	
18.12	
85.10	
13.11	
3,126,012.76	

4413	SOBRA 100-133% M&F
6	58,543.74	58,461.45	57,600.88	71,698.76	70,643.77	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	36,813.90	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	35,776.08	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	143,233.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
316,948.60	
167,411.50	
163,186.25	
647,546.35	

4517	BC PATIENT FEMALE 2 1	143.38	164.09	156.51	211.74	220.53	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	1,138.14	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	59.13	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	99.06	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	1,516.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
896.25	
5,121.67	
244.23	
384.21	
6,646.36	

8600	SSI BLIND FREEDOM/W O	7.58	7.58	7.58	8.79	8.79	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	11.58	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	13,794.54	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	3,253.26	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	2,454.87	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	19,523.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
40.32	
51.15	
60,926.36	
13,623.47	
10,534.83	
85,176.13	

6015	KIDS 14-19 FEMALE NO	18.76	21.00	12.32	0.00	9.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	18.76	21.00	12.32	0.00	9.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
61.68

61.68

41,440,793.21

7,421,096.76	7,478,127.98	7,510,423.34	9,519,723.30	9,511,421.83	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 November 30, 2019

RATE CODE	DESCRIPTION

JULY

AUGUST	SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

1000

1006

1007

1008

1009

1010

1011

1012

1013

1014

1015

1016

1017

1018

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

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

1019

TANF 65+ M & F NON-M

Cu0.00rren0.00t

an0.0d0

pr0i.00or

m0.00 ont0h.00

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

r0e.00   vis0i.0o0

n. 0.00

0.00

1020

1024

1026

1027

1028

1029

2100

2110

2120

2200

2210

2220

2300

2310

2320

4302

4303

4304

4305

4311

4312

TANF WITH QMB

TANF 14-20 MALE WITH TANF 21-44 MALE WITH TANF 21-44 FEMALE WI TANF 45-64 M & F WIT TANF 65+ M & F WITH
SSI AGED WITH MEDIC A
SSI AGED NON-MEDIC
AR
SSI AGED WITH QMB

SSI DISABLED WITH M E
SSI DISABLED NON-ME
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 MA SOBRA CHILD 14-20 FE SOBRA CHILD <1 M & F 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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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 November 30, 2019

RATE CODE	DESCRIPTION

4313

SOBRA CHILD 06-13 M

4314

SOBRA CHILD 14-20 MA

4315

SOBRA CHILD 14-20 FE

4322

4323

SOBRA CHILD 01-05 M

SOBRA CHILD 06-13 M

4325

SOBRA CHILD 14-20 FE

5007

5008

5013

5015

5017

5018

5027

5028

SOBRA PREG 21-44 FE M
SOBRA PREG 45-64 FE
M
SOBRA PREG 09-13 FE
M
SOBRA PREG 14-20 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE

M
SUBTOTAL:

Cu0.0r0   ren0.0t0

an0.d00

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

n.0.00

0.00

0.00

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

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

0.00

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	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2410	SSI AGED EXPANDED NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2520	SSI BLIND EXPANDED W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	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

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

dat

0.00

a is

0.00

under re

0.00

0.00

0.00

visio

0.00

0.00

n.

0.00

3518

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

3706

3707

ADULT <40% EXP MALE ADULT <40% EXP MALE
ADULT <40% EXP FEM AL
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6
ADULT <40% EXP MALE

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3708

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

3714

3715

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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

3718

3719

ADULT <40% EXP FEM AL
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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

3728

3729

ADULT <40% EXP FEM AL
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

Cu0.0r0   ren0.0t0      an0.d00

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE M&F 6

3929

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE M&F 4

3928

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE MALE

3926

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE M&F 6

3919

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE M&F 4

3918

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE FEMA L

3917

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE MALE

3916

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE FEMA L

3915

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE MALE

3914

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE M&F 6

3909

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE M&F 4

3908

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE FEMA L

3907

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

NEWLY ELIGIBLE MALE

3906

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

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

0.00	
0.00	
0.00	
0.00	

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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	7,179.92	4,842.01	4,556.71	7,527.68	5,436.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,543.16		
1007	TANF 21-44 FEMALE WI	5,660.13	8,315.12	3,656.17	5,435.78	2,517.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,584.43		
1008	TANF 45-64 M & F WIT	13,522.79	12,784.45	13,053.33	12,421.84	22,109.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,891.84		
1009	TANF 65+ M & F WITH	7,573.40	7,048.03	5,895.29	8,756.67	14,657.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,930.95		
1011	TANF <1 M & F NON-ME	1,704,748.88	1,215,550.25	823,687.83	1,172,271.56	1,201,371.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,117,630.21		
1012	TANF 01-05 M & F NON	321,855.78	307,163.81	292,577.80	407,348.20	543,346.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,872,291.87		
1013	TANF 06-13 M & F NON	530,515.76	501,663.79	446,044.70	600,476.34	775,465.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,854,166.57		
1014	TANF 14-20 MALE NON-	203,236.61	175,532.08	149,342.10	162,062.58	211,886.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		902,059.67		
1015	TANF 14-20 FEMALE N O	393,263.47	411,573.01	297,015.96	394,439.42	504,458.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,000,750.37		
1016	TANF 21-44 MALE NON-	1,956,741.53	2,236,067.42	1,702,040.41	2,119,924.65	2,720,179.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,734,953.94		
1017	TANF 21-44 FEMALE N O	6,391,025.27	6,861,727.73	6,092,771.97	7,036,002.41	9,884,559.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,266,087.08		
1018	TANF 45-64 M & F NON	2,566,895.07	2,988,825.03	2,296,099.04	2,805,525.90	4,279,329.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,936,674.04		
1019	TANF 65+ M & F NON-M	3,082.12	11,634.33	3,047.76	2,043.66	9,366.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,174.56		
1026	TANF 21-44 MALE WITH	5,452.82	2,600.75	875.03	1,475.75	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,859.35		
1027	TANF 21-44 FEMALE WI	8,052.27	3,119.24	1,357.57	1,942.85	3,864.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,336.69		
1028	TANF 45-64 M & F WIT	7,027.85	6,397.80	5,710.26	5,594.94	4,290.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,021.14		
1029	TANF 65+ M & F WITH	11,881.21	6,449.88	10,048.57	5,614.64	7,235.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,229.73		
2100	SSI AGED WITH MEDIC A	231,952.74	259,830.87	132,481.39	252,617.63	276,656.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,153,539.32		
2110	SSI AGED NON-MEDIC
AR	164,988.00	142,495.88	96,068.65	168,374.24	260,998.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		832,924.96		
2120	SSI AGED WITH QMB	696,504.68	647,287.68	605,933.24	718,218.99	1,059,551.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,727,496.29		
2200	SSI DISABLED WITH M E	509,724.57	597,467.37	548,111.03	834,347.54	1,004,039.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,493,689.68		
2210	SSI DISABLED NON-ME
D	9,349,394.09	10,282,957.71	8,326,157.43	10,142,149.12	14,837,360.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,938,019.28		
2220	SSI DISABLED WITH Q M	1,799,464.98	1,475,342.17	1,447,618.10	1,801,133.43	2,128,044.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,651,603.39		
2300	SSI BLIND WITH MEDIC	2,786.12	2,517.54	1,645.59	4,405.82	6,481.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,836.80		
2310	SSI BLIND NON-MEDIC A	105,581.25	151,794.37	90,576.36	88,921.37	174,467.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611,340.87		
2320	SSI BLIND WITH QMB	25,806.73	19,005.13	19,779.17	28,930.91	31,467.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,989.81		
4311	SOBRA CHILD <1 M & F	3,079,674.40	2,071,093.53	2,246,499.03	2,674,686.99	3,025,879.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,097,833.11		
4312	SOBRA CHILD 01-05 M	4,144,566.09	4,042,965.94	3,675,014.97	4,913,834.75	6,054,953.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,831,335.45		
4313	SOBRA CHILD 06-13 M	6,203,269.83	6,885,485.33	5,614,996.13	7,496,805.95	9,255,075.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,455,632.89		
4314	SOBRA CHILD 14-20 MA	1,874,493.90	2,011,492.36	1,644,388.24	2,133,480.02	2,680,149.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,344,004.34		
4315	SOBRA CHILD 14-20 FE	2,264,127.22	2,531,195.42	1,955,324.31	2,727,565.51	3,251,992.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,730,204.82		
5007	SOBRA PREG 21-44 FE M	1,468.11	1,067.27	1,508.98	1,106.22	266.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,417.18		
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	392,651.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,974,255.42		
5017	SOBRA PREG 21-44 FE
M	2,739,461.45	2,355,050.17	2,334,361.91	2,722,854.90	2,810,234.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,961,962.75		
5018	SOBRA PREG 45-64 FE M	6,539.65	455.00	2,730.00	936.35	1,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,481.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	50.00	0.00	687.71	4,998.88	3,136.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,873.24		
SUBTOTAL:	47,800,049.38	48,593,680.36	41,274,480.48	51,848,514.54	67,445,758.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256,962,483.16		

1106	TANF EXPANDED 21-44	5,110.76	1,764.45	2,329.25	6,481.93	7,114.30	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	11,065.25	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	51,246.64	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	55,728.09	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	42,544.80	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	61,168.91	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	1,339,040.05	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	4,325,064.33	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	2,932,292.05	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	11,977.06	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	24,379.84	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	50,825.37	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	181,567.28	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	130,553.45	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	19,850.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	11,659.69	34,342.19	12,647.48	10,079.54	25,715.32	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	1,031,568.87	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	16,050.28	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	506,168.94	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	570,776.51	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	11,394,697.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
22,800.69	
53,182.45	
208,938.59	
212,680.20	
1,286.96	
82,309.93	
242,116.56	
4,493,844.38	
15,224,222.56	
9,819,112.64	
27,533.67	
121,096.70	
232,649.09	
744,617.88	
430,221.90	
65,212.18	
94,444.22	
3,453,828.36	
53,165.78	
1,684,948.24	
2,363,316.08	
39,631,529.06	

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

 
-153.38

-153.38

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 November 30, 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	2,653.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,769.62		
3509	ADULT 40-100% M&F 65	107.15	0.00	43.40	193.58	272.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		616.86		
3514	ADULT 40-100% MALE 1	82,193.78	72,082.38	61,562.64	82,938.21	90,272.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		389,049.14		
3515	ADULT 40-100% FEMAL E	133,768.02	149,460.55	112,076.25	145,651.79	180,110.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		721,066.94		
3516	ADULT 40-100% MALE 2	929,328.88	812,103.33	787,166.18	844,775.60	1,276,235.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,649,609.32		
3517	ADULT 40-100% FEMAL E	719,939.62	657,905.17	549,744.70	603,380.57	1,078,217.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,609,187.11		
3518	ADULT 40-100% M&F 45	2,471,316.14	2,775,008.27	2,356,105.16	2,633,073.83	4,204,167.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,439,670.45		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	42.48	603.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		646.34		
3706	ADULT <40% EXP MALE	684.21	6,334.49	1,409.66	5,705.43	2,437.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,571.39		
3707	ADULT <40% EXP FEM AL	3,777.08	1,125.81	3,880.63	1,961.77	711.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,457.00		
3708	ADULT <40% EXP M&F
4	4,674.03	12,630.88	7,588.13	11,215.80	19,967.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,076.81		
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	657,972.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,513,066.99		
3715	ADULT <40% EXP FEM AL	514,957.44	618,604.64	456,041.22	607,313.78	764,561.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,961,478.90		
3716	ADULT <40% EXP MALE	9,597,893.16	8,894,945.23	7,900,077.98	9,737,004.18	12,187,936.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,317,856.77		
3717	ADULT <40% EXP FEM AL	4,679,276.71	5,034,780.29	4,338,260.79	5,090,995.48	6,781,810.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,925,123.75		
3718	ADULT <40% EXP M&F
4	11,372,750.63	11,843,300.90	10,134,524.78	12,188,745.92	17,548,238.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,087,560.81		
3719	ADULT <40% EXP M&F 6	0.00	26,564.29	866.02	5,037.08	4,738.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,205.61		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	455.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		910.00		
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	44,801,817.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,746,427.22		

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	666,288.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,716,458.66

455.00

3906	NEWLY ELIGIBLE MALE	390.09	1,220.96	1,870.06	13,333.02	81.00	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	215.21	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	3,995.64	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	985.74	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	37,603.39	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	59,467.12	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	773,482.17	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	1,439,690.43	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	2,647,231.07	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	1,226.67	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	4,963,978.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,895.13	
6,801.45	
16,301.45	
6,122.52	
149,194.30	
300,335.27	
3,890,623.96	
4,368,249.38	
8,668,198.07	
4,749.22	
17,427,470.75	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4414	SOBRA 100-133% MALE	190,200.70	184,917.01	233,700.68	185,130.04	263,069.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,057,018.36		
4415	SOBRA 100-133% FEMA L	228,920.72	243,977.81	263,975.40	261,842.64	327,941.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,326,658.26		
SUBTOTAL:	904,642.2	2	1,005,919.81	946,429.7	7	986,298.01	1,257,300.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,100,590.28		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	910.00	455.00	1,365.00	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	8,330.95	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	1,820.00	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	11,515.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,730.00	
108,769.35	
3,185.00	
14,032.24	
128,716.59	

8700	SSI DISABLED FREEDO M	18,707.10	13,486.58	11,826.59	23,094.07	19,236.20	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	35,818.11	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	3,693.84	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	58,748.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
86,350.54	
186,923.00	
23,421.15	
296,694.69	

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

486,279,203.55

89,553,565.50	91,855,910.80	78,083,835.78	96,852,074.66	129,933,816.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	41.58	81.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.23		
1008	TANF 45-64 M & F WIT	250.37	0.00	136.24	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	940.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,312.72		
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	360.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,354.11		
1014	TANF 14-20 MALE NON-	696.15	2,503.24	3,247.65	5,629.39	926.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,002.82		
1015	TANF 14-20 FEMALE N O	3,945.81	579.34	6,069.05	4,082.89	454.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,131.93		
1016	TANF 21-44 MALE NON-	42,364.00	16,517.72	2,089.15	5,485.58	2,831.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,287.49		
1017	TANF 21-44 FEMALE N O	99,491.18	25,376.76	38,133.79	23,054.07	22,025.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,081.03		
1018	TANF 45-64 M & F NON	43,845.13	11,730.98	-5,418.24	1,206.07	341.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,705.49		
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	1,675.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,514.71		
2110	SSI AGED NON-MEDIC
AR	37,219.25	24,330.99	5,813.58	11,051.99	16.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,432.19		
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	6,790.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,007.95		
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	18,621.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253,633.84		
4312	SOBRA CHILD 01-05 M	171,883.85	118,793.66	52,409.54	33,938.23	31,230.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408,255.78		
4313	SOBRA CHILD 06-13 M	39,579.36	92,454.57	127,080.50	57,433.95	24,484.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		341,032.69		
4314	SOBRA CHILD 14-20 MA	60,862.64	16,699.62	13,097.54	40,879.42	6,956.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138,496.14		
4315	SOBRA CHILD 14-20 FE	39,098.46	12,346.02	27,377.62	56,688.03	14,027.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,538.07		
5007	SOBRA PREG 21-44 FE M	0.00	196.52	579.22	267.63	14.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,058.13		
5015	SOBRA PREG 14-20 FE
M	36,367.09	15,253.89	33,521.26	33,931.60	12,754.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,828.12		
5017	SOBRA PREG 21-44 FE M	145,231.52	116,182.97	137,749.55	145,267.58	107,510.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		651,942.20		
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	251,963.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,650,731.04		

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	75.95	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	574.47	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	2,085.69	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	5,283.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
697.46	
1,368.75	
4,996.82	
1,437.37	
2,713.51	
113,450.05	
114,785.73	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	23,861.92	7,741.48	8,059.52	1,234.47	10,219.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,117.37		
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	2,194.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,432.67		
2420	SSI AGED EXPANDED
WI	791.45	260.86	0.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,507.31		
2600	SSI DISABLED EXPAND E	1,295.64	5,019.32	2,677.00	785.92	275.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,053.43		
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	22.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,527.36		
SUBTOTAL:	158,581.4	5	65,862.36	37,923.5	1	54,989.49	21,187.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338,544.44		

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	534.20	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	-773.05	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	1,362.17	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	8,619.32	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	16,446.45	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	-1,805.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	26,859.93	13,005.35	9,045.42	2,151.36	8,247.55	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	58,757.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	120,559.81	62,701.51	28,974.08	17,765.00	16,044.33	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	30,432.01	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	137,864.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,407.26	
23,299.88	
8,212.43	
133,991.39	
71,671.37	
251,247.23	
48,503.27	
59,309.61	
683,412.33	
246,044.73	
686,992.72	
2,214,092.22	

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	4,218.19	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	6,466.39	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	6,484.37	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	10,820.03	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	27,988.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
106.30	
2,253.29	
10,132.04	
6,542.94	
137,731.89	
192,550.75	
419,736.88	
769,054.09	

4413	SOBRA 100-133% M&F
6	97,572.50	14,475.99	11,390.95	8,926.66	20,752.05	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	13,453.66	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	2,956.99	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	37,162.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
153,118.15	
26,467.55	
25,401.89	
204,987.59	

8700

SSI DISABLED FREEDO M

144.13

203.30

1,545.39

0.00

108.16

0.00

0.00	0.00

0.00

0.00

0.00

0.00

2,000.98

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	0.00	5,206.52	0.00	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	108.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,687.88		

TOTAL:	2,358,964.61	1,541,309.62	979,357.24	829,190.89	476,274.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,185,097.26		

FEDERAL EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	2,216.23	3,492.52	29,766.20	3,922.02	22,945.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,342.06		
1012	TANF 01-05 M & F NON	77,421.94	71,881.43	120,924.31	163,993.83	20,887.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455,109.32		
1013	TANF 06-13 M & F NON	67,181.43	79,607.43	75,624.93	49,537.63	89,698.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361,650.33		
1014	TANF 14-20 MALE NON-	44,070.56	156,398.57	56,041.71	49,472.44	51,130.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		357,114.27		
1015	TANF 14-20 FEMALE N O	346,405.17	185,300.28	245,335.08	327,590.52	186,380.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,291,011.54		
1016	TANF 21-44 MALE NON-	573.09	-107.55	0.00	553.78	92.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,112.17		
1017	TANF 21-44 FEMALE N O	2,136,707.54	1,669,785.38	1,971,352.20	2,264,596.62	1,702,134.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,744,575.81		
1018	TANF 45-64 M & F NON	9,102.32	9,101.37	7,812.93	9,840.98	269.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,127.13		
2100	SSI AGED WITH MEDIC A	22,518.78	19,427.61	17,554.57	10,826.93	28,454.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,782.39		
2110	SSI AGED NON-MEDIC
AR	1,723,508.17	1,475,976.91	1,832,508.02	1,630,520.22	1,588,365.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,250,878.79		
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	9,853.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,581.66		
2210	SSI DISABLED NON-ME
D	52,112.74	40,196.05	75,208.50	38,646.07	54,475.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		260,639.02		
SUBTOTAL:	4,491,141.36	3,725,508.87	4,435,619.96	4,558,207.08	3,754,689.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,965,166.46		

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	7,997.62	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	-7,469.44	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	29,476.39	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	947,488.04	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	435,938.67	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	2,727,823.65	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	1,213.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

154.26	
27,763.20	
166,331.97	
168,712.17	
4,603,776.13	
2,420,327.42	
15,457,608.42	
18,535.48	

1107	TANF EXPANDED 21-44	0.00	1,521.24	1,510.13	775.83	18.39	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	1,323.62	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	136.78	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	5,990.33	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	705,012.88	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	1,355,066.64	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	830,164.90	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	44,026.77	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	70.62	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	6.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	1,355.53	2,926.42	15,402.26	18,337.64	17,952.31	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	3,629.47	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	2,963,399.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,825.59	
44,900.55	
8,730.74	
113,860.26	
3,723,011.59	
7,551,863.88	
4,120,707.36	
163,084.78	
4,575.31	
2,711.39	
55,974.16	
16,893.39	
15,810,139.00	

FEDERAL EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	5,151,773.36	4,521,846.40	4,307,601.76	4,739,518.88	4,142,468.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,863,209.05		

59,638,514.51

12,889,659.55	11,046,268.49	12,232,150.82	12,609,878.11	10,860,557.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

FEDERAL ESP CHRONIC SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1014	TANF 14-20 MALE NON-	4,719.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,719.36		
SUBTOTAL:	4,719.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,719.36		

TOTAL:	4,719.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,719.36		

QMB - FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	660,202.07	490,087.07	440,384.81	367,061.97	187,136.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,144,872.38		
8040	SLMB	75.68	15.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.19		
8050	QI1	0.00	20.66	311.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		331.98		
SUBTOTAL:	660,277.7	5	490,123.24	440,696.1	3	367,061.97	187,136.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,145,295.55		

0.00

0.00

0.00

367,061.97

TOTAL:

660,277.75

490,123.24

440,696.13

187,136.46

0.00

0.00

0.00

0.00

2,145,295.55

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	335.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		335.08		
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	3,555.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,620.23		
1012	TANF 01-05 M & F NON	7,865.88	6,230.65	3,847.53	16,600.15	25,389.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,933.81		
1013	TANF 06-13 M & F NON	307,867.77	285,146.24	121,253.04	191,932.51	183,233.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,089,432.80		
1014	TANF 14-20 MALE NON-	72,162.55	27,686.96	22,237.41	54,500.62	24,988.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,576.20		
1015	TANF 14-20 FEMALE N O	109,108.33	104,274.36	91,303.97	148,372.80	116,514.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		569,574.12		
1016	TANF 21-44 MALE NON-	482,746.26	346,671.53	408,164.25	508,526.75	458,634.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,204,743.18		
1017	TANF 21-44 FEMALE N O	1,459,385.50	1,078,950.83	1,248,877.02	1,908,670.88	1,572,968.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,268,852.39		
1018	TANF 45-64 M & F NON	285,431.75	240,088.50	276,977.66	260,726.04	299,518.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,362,742.45		
1028	TANF 45-64 M & F WIT	184.73	173.16	1,730.03	2,588.94	828.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,505.38		
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	14,709.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,209.19		
2110	SSI AGED NON-MEDIC
AR	3,423.10	2,391.21	7,023.46	3,567.70	2,992.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,398.25		
2120	SSI AGED WITH QMB	66,532.03	48,594.38	50,139.30	42,216.05	47,939.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,421.53		
2200	SSI DISABLED WITH M E	63,339.72	50,009.45	55,104.31	57,799.84	52,251.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		278,505.17		
2210	SSI DISABLED NON-ME
D	2,142,025.20	1,716,824.90	1,550,850.31	2,058,806.20	1,738,356.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,206,862.88		
2220	SSI DISABLED WITH Q M	388,879.11	342,330.15	328,681.88	351,532.78	352,022.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,763,445.96		
2310	SSI BLIND NON-MEDIC
A	36,358.35	59,301.51	24,367.36	15,444.33	13,764.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,236.37		
2320	SSI BLIND WITH QMB	5,271.02	1,918.97	1,852.18	1,952.66	2,400.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,395.42		
4311	SOBRA CHILD <1 M & F	6,460.61	6,068.40	6,860.01	8,565.44	20,779.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,734.16		
4312	SOBRA CHILD 01-05 M	239,174.74	187,542.33	207,568.43	288,173.03	246,312.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,168,770.83		
4313	SOBRA CHILD 06-13 M	3,963,253.67	4,322,269.98	2,531,999.44	3,877,188.33	3,725,669.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,420,381.35		
4314	SOBRA CHILD 14-20 MA	974,878.74	1,029,423.72	690,182.62	862,224.33	899,977.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,456,686.85		
4315	SOBRA CHILD 14-20 FE	1,157,053.84	1,207,668.34	895,132.65	1,075,681.12	1,125,511.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,461,046.97		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81.00		
5013	SOBRA PREG 09-13 FE
M	0.00	910.00	3,640.00	13,195.00	3,185.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,930.00		
5015	SOBRA PREG 14-20 FE M	14,079.10	20,092.68	21,250.32	19,914.07	6,818.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,154.87		
5017	SOBRA PREG 21-44 FE
M	146,024.25	157,851.29	176,250.02	173,453.52	199,370.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		852,949.77		
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	11,138,109.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,067,567.47		

11,360.26

218.26

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	1,144.93	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	

1,273.92

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1114	TANF EXPANDED 14-20	3,045.00	0.00	455.00	2,275.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,230.00		
1115	TANF EXPANDED 14-20	8,599.02	7,220.23	6,005.61	1,805.65	16,259.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,889.51		
1116	TANF EXPANDED 21-44	167,952.92	117,356.15	142,575.60	227,334.13	150,169.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		805,388.23		
1117	TANF EXPANDED 21-44	457,969.90	350,831.66	341,891.81	530,864.00	592,930.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,274,487.59		
1118	TANF EXPANDED 45-64	151,584.86	119,327.65	157,762.76	340,355.24	259,292.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,028,323.34		
1126	TANF EXPANDED 21-44	5,497.39	1,646.16	1,878.64	5,708.07	2,011.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,741.46		
1127	TANF EXPANDED 21-44	310.16	265.12	710.40	2,088.65	19,813.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,187.91		
1128	TANF EXPANDED 45-64	12,149.05	12,375.62	7,302.92	10,233.30	7,080.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,141.81		
1129	TANF EXPANDED 65+
M&	4,153.95	4,207.54	4,482.68	4,946.55	3,997.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,787.78		
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
NO	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	32,152.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,627.41		
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	7,001.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,293.88		
2620	SSI DISABLED EXPAND
E	85,511.04	31,421.19	54,808.45	81,212.86	79,495.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332,449.44		
SUBTOTAL:	963,690.3	5	700,065.73	768,322.7	2	1,246,725.01	1,171,803.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,850,607.47		

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	4,027.77	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	2,300.31	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	64,080.63	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	37,826.83	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	41,823.29	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	150,058.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

29.55	
17,667.47	
27,592.29	
355,437.16	
188,684.23	
298,424.53	
887,835.23	

3514	ADULT 40-100% MALE 1	10,776.55	6,979.68	14,745.82	14,618.09	21,431.14	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	16,454.76	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	199,735.76	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	124,271.14	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	174,411.98	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	1,535.19	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	248,661.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	121,984.63	90,822.12	102,482.58	122,531.26	96,753.89	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	2,623,103.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	1,686,784.93	1,402,493.82	1,389,894.21	1,735,878.72	1,561,275.52	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	1,535,756.41	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	6,603,391.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
68,551.28	
79,575.41	
894,095.38	
622,566.46	
907,337.27	
6,006.18	
791,480.50	
534,574.48	
13,596,756.27	
7,776,327.20	
7,677,139.32	
32,954,409.75	

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	173,365.54	159,239.19	99,226.38	126,346.38	141,503.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		699,680.87		
4414	SOBRA 100-133% MALE	81,411.72	56,370.35	48,420.00	70,673.88	80,886.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		337,762.60		
4415	SOBRA 100-133% FEMA L	64,610.03	48,795.79	38,281.65	60,718.99	62,479.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,886.19		
SUBTOTAL:	319,387.2	9	264,405.33	185,928.0	3	257,739.25	284,869.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,312,329.66		

4518

BC PATIENT FEMALE 4 5

1,365.00

1,365.00

455.00	455.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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:

8700	SSI DISABLED FREEDO M	444.71	126.96	282.09	322.07	506.65	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	455.00	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	961.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,682.48	
1,820.00	
172.78	
3,675.26	

TOTAL:	20,452,681.91	17,997,963.86	15,844,509.37	21,433,439.88	19,349,194.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,077,789.84		

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	20,058.67	22,328.76	18,380.71	27,455.16	10,458.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,681.88		
1017	TANF 21-44 FEMALE N O	52,130.85	26,691.95	54,079.33	75,587.04	67,172.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		275,661.78		
1018	TANF 45-64 M & F NON	0.00	0.00	19,006.49	5,714.73	5,672.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,394.16		
2210	SSI DISABLED NON-ME D	84,690.30	48,792.04	60,634.16	78,420.21	77,695.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		350,232.64		
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	161,000.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		778,149.34		

1116	TANF EXPANDED 21-44	1,524.14	15,016.02	0.00	0.00	4,204.40	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	8,291.16	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	12,495.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
20,744.56	
70,133.19	
17,658.48	
5,432.00	
113,968.23	

3516	ADULT 40-100% MALE 2	3,699.35	11,299.46	14,172.51	14,360.32	12,703.07	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	11,865.95	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	226,619.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	99,476.60	32,250.19	107,768.46	135,298.62	41,276.71	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	73,520.38	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	365,985.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
56,234.71	
21,228.07	
28,047.05	
1,195,875.48	
416,070.58	
340,198.77	
2,057,654.66	

3916	NEWLY ELIGIBLE MALE	8,408.80	0.00	3,363.52	39,865.17	11,940.86	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	11,940.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
63,578.35	
38,391.51	
21,022.00	
122,991.86	

0.00

0.00

0.00

806,369.12

TOTAL:

596,980.30

493,299.07

624,693.91

551,421.69

0.00

0.00

0.00

0.00

3,072,764.09

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	82,215.38	125,849.80	34,955.01	98,230.33	54,035.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		395,286.34		
2110	SSI AGED NON-MEDIC
AR	76,145.26	43,432.58	94,089.34	170,616.32	178,372.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		562,655.55		
2200	SSI DISABLED WITH M E	43,412.57	37,118.69	31,528.29	42,362.80	66,041.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,463.54		
2210	SSI DISABLED NON-ME
D	6,450.10	54.14	3,268.79	936.25	3,398.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,108.05		
2220	SSI DISABLED WITH Q M	0.00	5,818.84	74,831.29	1,429.31	5,191.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87,270.78		
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	37,999.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129,898.34		
SUBTOTAL:	244,004.3	7	235,026.81	245,517.6	3	346,036.42	345,038.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,415,623.70		

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	35,039.37	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	16,759.28	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	453,371.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	8,831.44	5,563.08	0.00	4,596.23	23,331.14	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	575,707.83	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	1,104,209.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,964.62	
5,113.33	
15,763.58	
119,477.17	
16,759.28	
1,744,131.08	
42,321.89	
2,152,732.72	
1,647.10	
4,105,910.77	

3916	NEWLY ELIGIBLE MALE	57,655.11	4,600.84	464.10	10,899.98	62,999.44	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	27,712.10	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	90,711.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

136,619.47	
41,135.04	
177,754.51	

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	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	6,026.67	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	6,026.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
15,017.82	
5,657.49	
6,026.67	
1,154.46	
27,856.44	

TOTAL:	1,194,500.53	886,135.76	1,011,830.27	1,088,693.11	1,545,985.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,727,145.42		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1017	TANF 21-44 FEMALE N O	3,561.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,561.30		
4314	SOBRA CHILD 14-20 MA	0.00	3,210.12	464.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,674.59		
SUBTOTAL:	3,561.30	3,210.12	464.4	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,235.89		

3716	ADULT <40% EXP MALE	193.90	3,027.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	79.80	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	79.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,221.03	
79.80	
417.33	
3,718.16	

3,863.35

6,381.37

464.47

79.80

0.00

0.00

0.00

0.00

0.00	0.00

0.00

165.06

10,954.05

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	3,026.28	69.19	0.00	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	7,890.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,200.22		
1017	TANF 21-44 FEMALE N O	13,398.03	846.61	57.84	80.06	4,373.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,755.91		
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	12,263.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,711.00		

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	144.04	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	13,533.87	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	120,796.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	21,348.89	807.55	21,060.04	8,305.99	7,746.07	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	48,338.48	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	190,559.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,821.96	
4,470.96	
17,450.94	
587,287.47	
59,268.54	
253,517.29	
938,817.16	

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	221.60	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	438.70	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	660.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

421.95	
26,291.87	
9,558.83	
982.61	
37,255.26	

1116	TANF EXPANDED 21-44	19,096.08	276.04	0.00	218.09	578.78	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	578.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
20,168.99	
9,840.04	
30,009.03	

TOTAL:	243,176.40	232,257.84	232,596.60	173,699.92	204,061.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,085,792.45		

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3717	ADULT <40% EXP FEM AL	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 November 30, 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	2,914.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,757.46		
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	5,152.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,665.92		
5017	SOBRA PREG 21-44 FE
M	120.60	9,182.78	547.22	0.00	5,809.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,660.58		
SUBTOTAL:	4,916.63	34,616.65	15,869.7	1	30,492.56	13,876.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,772.01		

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	3,200.60	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	42,955.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	5,525.63	0.00	16,749.93	843.84	31,840.47	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	418.33	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	78,414.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,283.13	
141,587.15	
54,959.87	
33,519.96	
233,350.11	

TOTAL:	49,387.38	64,539.25	73,786.31	53,139.17	92,291.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		333,143.28		

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1017	TANF 21-44 FEMALE N O	2,189.61	0.00	0.00	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	12,869.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	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	91.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	415.11	59.26	3,076.36	244.13	12,960.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,996.79	
2,109.20	
649.05	
16,755.04	

27,203.68

2,604.72	59.26	3,076.36	8,503.16	12,960.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	13,812.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,812.66		
SUBTOTAL:	0.00	0.00	0.00	0.00	13,812.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,812.66		

TOTAL:	0.00	0.00	0.00	0.00	13,812.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,812.66		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,476.55	1,365.00	12,020.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,862.54		
2100	SSI AGED WITH MEDIC A	3,396,841.10	2,978,203.93	2,902,681.05	3,464,672.53	3,061,637.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,804,036.46		
2110	SSI AGED NON-MEDIC
AR	270,248.25	199,558.99	170,599.97	185,012.21	184,709.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,010,128.63		
2120	SSI AGED WITH QMB	5,144,790.92	4,353,539.64	4,195,426.94	5,202,790.27	4,581,640.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,478,188.08		
2200	SSI DISABLED WITH M E	665,108.26	517,747.79	541,296.64	661,374.78	528,583.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,914,110.63		
2210	SSI DISABLED NON-ME
D	4,059,288.17	3,443,509.73	3,375,066.24	3,847,079.08	4,045,270.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,770,214.02		
2220	SSI DISABLED WITH Q M	1,084,530.49	1,067,376.31	963,365.41	1,180,700.92	1,066,554.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,362,527.30		
2300	SSI BLIND WITH MEDIC	2,008.80	2,245.08	1,590.11	2,037.00	1,227.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,108.97		
2310	SSI BLIND NON-MEDIC A	10,075.80	9,689.37	10,601.79	12,667.17	20,147.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,181.24		
2320	SSI BLIND WITH QMB	4,970.93	1,483.22	264.76	2,694.37	352.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,765.75		
SUBTOTAL:	14,639,339.2	7 12,574,719.06	12,172,913.9	0 14,559,028.33	13,490,123.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,436,123.62		

8720	SSI DISABLED FREEDO M	2,380.80	2,692.35	2,162.25	1,462.80	3,427.20	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	3,427.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

12,125.40

12,125.40

67,448,249.02

14,641,720.07	12,577,411.41	12,175,076.15	14,560,491.13	13,493,550.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	61,523.02	81,067.68	60,616.91	27,444.50	4,176.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		234,828.32		
2110	SSI AGED NON-MEDIC
AR	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	470.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,657.39		
2210	SSI DISABLED NON-ME
D	5,636.33	1,595.00	-17,970.22	14,969.70	165.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,396.62		
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	4,812.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258,408.37		

TOTAL:	72,181.04	86,244.99	50,351.64	44,818.59	4,812.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258,408.37		

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	123.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.10		
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	123.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,382.89		

27,382.89

27,259.79	0.00	0.00	0.00	123.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	415.40	4,824.76	219.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,459.94		
SUBTOTAL:	415.40	4,824.76	219.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,459.94		

TOTAL:	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		

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	418.80	0.00	3,722.67	65.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,206.73		
SUBTOTAL:	0.00	418.80	0.00	3,722.67	65.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,206.73		

4,206.73

0.00	418.80	0.00	3,722.67	65.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	37,904.12	18,644.88	18,077.02	41,557.58	23,951.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,134.62		
1013	TANF 06-13 M & F NON	66,306.45	34,537.50	30,933.97	78,081.26	62,985.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,844.44		
1014	TANF 14-20 MALE NON-	8,676.21	4,254.94	4,356.71	9,494.57	4,136.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,919.03		
1015	TANF 14-20 FEMALE N O	4,890.64	2,240.60	3,653.73	5,679.18	2,819.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,283.38		
2210	SSI DISABLED NON-ME
D	274,297.27	169,632.61	140,315.24	309,801.13	179,463.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,073,510.09		
2220	SSI DISABLED WITH Q M	391.92	153.36	40.00	11.48	11.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		608.24		
2310	SSI BLIND NON-MEDIC
A	2,652.31	2,038.76	585.07	3,217.05	2,280.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,774.00		
4312	SOBRA CHILD 01-05 M	170,389.43	100,660.33	74,587.65	204,872.11	137,167.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		687,677.08		
4313	SOBRA CHILD 06-13 M	266,108.81	157,297.68	134,113.69	317,309.08	232,961.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,107,790.77		
4314	SOBRA CHILD 14-20 MA	22,058.21	12,674.72	8,832.55	22,642.46	12,326.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,534.09		
4315	SOBRA CHILD 14-20 FE	10,521.23	4,139.37	3,902.67	11,933.37	9,550.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,046.73		
SUBTOTAL:	864,196.6	0	506,274.75	419,398.3	0	1,004,599.27	667,653.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,462,122.47		

3514	ADULT 40-100% MALE 1	29.06	8.84	0.00	136.98	35.34	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	65.38	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	326.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	288.06	20.10	116.24	217.24	64.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	599.33	156.24	314.9	2	659.80	491.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

210.22	
65.38	
1,240.19	
706.16	
2,221.95	

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	28.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	124.10	62.05	15.18	108.33	28.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
124.10	
67.21	
146.49	
337.80	

4413	SOBRA 100-133% M&F
6	78,148.02	39,845.81	32,383.47	78,247.46	57,642.27	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	4,460.10	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	833.07	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	62,935.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
286,267.03	
19,422.84	
4,871.02	
310,560.89	

TOTAL:	950,558.83	549,098.89	454,090.88	1,090,485.75	731,108.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,775,343.14		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	12,928.83	7,704.40	11,737.08	25,845.92	20,899.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,115.80		
2200	SSI DISABLED WITH M E	2,586.31	606.85	362.12	1,724.42	617.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,897.27		
2210	SSI DISABLED NON-ME
D	1,533,543.66	873,651.18	817,014.12	1,881,520.37	1,209,002.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,314,732.02		
2220	SSI DISABLED WITH Q M	5,358.58	2,675.67	559.32	4,335.90	3,240.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,170.25		
2310	SSI BLIND NON-MEDIC
A	3,264.10	251.23	1,140.95	2,033.05	1,659.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,348.35		
SUBTOTAL:	1,557,681.48	884,889.33	830,813.5	9	1,915,459.66	1,235,419.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,424,263.69		

6,424,263.69

830,813.59	1,915,459.66	1,235,419.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

1,557,681.48

884,889.33

ACC REINSURANCE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	-437.59	0.00	1,517.56	-2,236.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,156.42		
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	1,091,840.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,164,558.59		
1012	TANF 01-05 M & F NON	4,347.40	32,160.78	45,922.59	341,221.48	166,194.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589,846.25		
1013	TANF 06-13 M & F NON	324,791.53	193,449.53	186,177.60	201,887.65	181,031.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,087,337.36		
1014	TANF 14-20 MALE NON-	81,483.94	198,980.19	109,178.50	212,727.49	208,264.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		810,634.48		
1015	TANF 14-20 FEMALE N O	25,303.51	119,152.30	148,991.49	109,631.17	75,994.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		479,072.61		
1016	TANF 21-44 MALE NON-	180,616.91	142,894.03	150,910.06	204,896.09	338,346.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,017,663.45		
1017	TANF 21-44 FEMALE N O	454,160.18	326,646.13	492,410.41	224,211.20	360,502.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,857,930.27		
1018	TANF 45-64 M & F NON	37,034.63	198,804.51	125,576.39	301,998.14	186,652.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		850,066.15		
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	139,072.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,218.94		
2110	SSI AGED NON-MEDIC
AR	112,670.07	397,755.12	277,933.20	166,896.51	161,217.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,116,472.18		
2200	SSI DISABLED WITH M E	130,347.89	55,514.79	4,376.07	612,910.07	86,054.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		889,203.26		
2210	SSI DISABLED NON-ME
D	5,846,572.17	6,706,943.88	8,305,555.80	9,619,339.06	8,223,427.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,701,838.41		
2310	SSI BLIND NON-MEDIC A	11,949.45	9,724.98	13,371.35	31,461.09	36,471.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,978.49		
4311	SOBRA CHILD <1 M & F	2,735,784.55	1,807,996.36	2,408,428.56	3,212,152.16	3,224,940.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,389,302.01		
4312	SOBRA CHILD 01-05 M	811,967.95	925,721.48	609,324.26	498,970.44	629,281.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,475,265.47		
4313	SOBRA CHILD 06-13 M	1,033,377.89	800,538.20	912,119.74	360,302.27	1,862,487.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,968,826.02		
4314	SOBRA CHILD 14-20 MA	539,123.31	607,332.68	786,856.62	1,115,558.96	571,715.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,620,587.35		
4315	SOBRA CHILD 14-20 FE	253,541.95	1,134,418.78	573,956.65	384,409.34	1,168,479.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,514,806.16		
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	210,398.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		385,226.94		
SUBTOTAL:	13,360,776.0	9 15,197,920.09	16,585,151.6	5 19,162,523.07	18,920,135.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,226,506.38		

1106	TANF EXPANDED 21-44	0.00	4,184.74	-2,545.36	0.00	-2,127.97	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	-37.87	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	232,912.38	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	215,265.57	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	384,659.88	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	6,945.62	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	1,824.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-488.59	
0.00	
1,155,219.85	
1,002,569.22	
1,056,966.24	
3,522.55	
43,357.42	
101,049.59	

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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2610	SSI DISABLED EXPAND E	143,236.05	152,119.17	134,456.56	51,542.13	26,484.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507,838.31		
SUBTOTAL:	967,764.70	854,007.18	676,565.54	505,770.91	865,926.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,870,034.59		

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	204,628.44	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	286,761.33	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	68,047.76	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	580,433.59	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	1,139,871.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,250.78	
5,076.33	
854,356.92	
16,701.76	
1,644,824.96	
599,088.23	
2,367,298.53	
5,490,597.51	

4413	SOBRA 100-133% M&F
6	241,947.24	262,349.92	95,062.65	115,604.65	209,009.42	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	226,009.18	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	143,854.23	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	578,872.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

923,973.88	
1,006,548.72	
182,936.54	
2,113,459.14	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	882.41	0.00	1,480.26	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	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	10,978.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,362.67	
3,356.87	
10,978.89	

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	21,576.16	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	10,711.82	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	513,461.47	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	76,083.61	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	1,680,998.38	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 FEM AL	0.00	-490.64	-12,430.53	0.00	19,132.32	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	-10,045.96	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	291,457.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	125,669.32	28,161.24	33,550.05	38,594.18	2,126.99	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	2,097,720.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	54,757.63	203,263.13	925,005.80	650,059.70	640,318.50	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	2,899,697.96	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	8,243,239.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,901.45	
10,336.97	
1,278,068.26	
38,391.52	
1,477,535.78	
307,182.11	
4,535,794.10	
19,414.37	
6,211.15	
126,565.14	
668,484.40	
228,101.78	
9,269,418.16	
2,473,404.76	
12,412,087.26	
879.78	
32,853,776.99	

ACC REINSURANCE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	0.00	4,239.28	0.00	12,459.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,698.43		

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	
8710	SSI DISABLED FREEDO
M	6,949.00	14,106.75	4,741.37	182.67	6,515.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,949.00	17,661.88	6,980.35	182.67	6,515.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,794.11	
32,495.24	
38,289.35	

TOTAL:	20,934,675.20	23,395,635.93	26,653,285.54	26,866,509.44	29,767,019.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,617,125.88		

LONG TERM CARE REINSURANCE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	24,561.23	-15,106.07	63,031.16	0.00	49,711.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,197.99		
2100	SSI AGED WITH MEDIC A	111,580.83	328,992.29	236,109.46	222,547.27	152,904.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,052,134.06		
2110	SSI AGED NON-MEDIC
AR	69,649.07	75,558.87	47,319.07	3,027.28	106,909.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302,463.38		
2200	SSI DISABLED WITH M E	314,831.72	463,347.96	539,913.45	476,106.77	314,740.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,108,940.53		
2210	SSI DISABLED NON-ME
D	6,285,457.34	4,503,314.71	5,531,672.90	4,480,303.38	5,984,555.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,785,303.43		
2310	SSI BLIND NON-MEDIC A	1,504.99	5,274.08	0.00	330.20	2,049.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,158.99		
SUBTOTAL:	6,807,585.18	5,361,381.84	6,418,046.04	5,182,314.90	6,610,870.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,380,198.38		

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

30,416,365.38

6,843,752.18	5,361,381.84	6,418,046.04	5,182,314.90	6,610,870.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC SMIB
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	0.00	0.00	0.00	0.00	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.50		
1000	TANF WITH MEDICARE	49,447.00	52,667.50	49,591.50	45,730.30	54,123.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,560.10		
1010	TANF NON-MEDICARE	677.50	406.50	406.50	406.50	271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,168.00		
1020	TANF WITH QMB	44,961.50	39,964.50	37,916.00	37,653.00	36,433.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196,928.50		
2100	SSI AGED WITH MEDIC A	31,102.20	35,121.60	38,203.50	32,389.00	33,875.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,691.30		
2110	SSI AGED NON-MEDIC
AR	539,823.00	550,536.20	542,519.50	535,106.00	534,008.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,701,993.20		
2120	SSI AGED WITH QMB	4,358,353.50	4,430,488.50	4,459,947.40	4,469,349.70	4,491,576.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,209,715.40		
2200	SSI DISABLED WITH M E	79,390.30	75,152.80	78,504.30	81,050.60	69,228.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		383,326.50		
2210	SSI DISABLED NON-ME
D	457,985.50	459,066.50	459,745.50	464,882.50	459,887.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,301,567.00		
2220	SSI DISABLED WITH Q M	3,875,518.60	3,899,421.50	3,898,474.00	3,868,672.00	3,868,765.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,410,851.80		
2300	SSI BLIND WITH MEDIC	135.50	135.50	135.50	135.50	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		677.50		
2310	SSI BLIND NON-MEDIC A	4,607.00	4,200.50	4,336.00	3,794.00	5,555.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,493.00		
2320	SSI BLIND WITH QMB	38,872.00	35,636.50	36,178.50	37,669.00	36,314.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		184,670.00		
4320	SOBRA CHILD WITH Q MB	271.00	271.00	1,626.00	542.00	542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,252.00		
5000	SOBRA PREGNANT WO
MAN	0.00	0.00	0.00	135.50	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271.00		
5020	SOBRA PREGNANT WO MAN	3,658.50	4,739.50	4,200.50	5,555.50	4,878.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,032.00		
8000	SMIB ONLY NOT ELIGIB	0.00	-271.00	0.00	0.00	-677.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-948.50		
8020	QMB ONLY	803,619.00	813,138.30	802,950.10	816,375.00	804,392.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,040,474.90		
8040	SLMB	5,415,089.00	5,424,721.20	5,454,262.10	5,451,776.20	5,464,976.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,210,824.50		
8888	SMIB ONLY NOT ELIGIB	-40,718.50	-27,017.20	-34,454.20	-22,677.20	-33,932.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-158,799.70		
9999	SMIB ONLY NOT ELIGIB	159,459.10	25,881.20	152,852.80	169,311.10	187,950.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		695,454.20		
SUBTOTAL:	15,822,251.7	0 15,824,261.10	15,987,395.5	0 15,997,856.20	16,018,573.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,650,338.20		

3520	ADULT 40-100% FOR FI	0.00	271.00	542.00	271.00	271.00	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	542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,355.00	
135.50	
1,219.50	

1100	TANF EXPANDED FPR FI	200,075.30	203,897.00	200,246.00	208,634.00	193,151.00	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	406.50	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	926,713.50	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	14,092.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED NO	0.00	0.00	135.50	135.50	271.00	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	3,748,513.00	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	135.50	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	15,176.00	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	2,352,440.60	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	7,250,899.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,006,003.30	
1,626.00	
4,609,538.90	
67,039.00	
542.00	
18,525,742.00	
677.50	
69,499.50	
11,718,190.40	
35,998,858.60	

ACC SMIB
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	0.00	406.50	677.50	813.00	813.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,710.00		

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	45,257.00	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	45,257.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

135.50	
225,878.50	
226,014.00	

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

 

677.50

677.50

TOTAL:	22,964,898.60	23,035,048.80	23,263,172.60	23,299,664.50	23,315,813.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,878,598.30		

ACC HIB
For The Period Ending November 30, 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	437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		437.00		
1020	TANF WITH QMB	1,311.00	1,311.00	1,311.00	1,311.00	874.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,118.00		
2100	SSI AGED WITH MEDIC A	917.70	2,665.70	1,704.30	3,059.00	2,271.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,617.70		
2110	SSI AGED NON-MEDIC
AR	7,866.00	4,807.00	0.00	0.00	1,311.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,984.00		
2120	SSI AGED WITH QMB	516,393.00	581,314.30	611,385.20	603,322.20	590,157.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,902,572.40		
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	267,249.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,320,693.10		
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	1,551.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,318.00		
8020	QMB ONLY	4,259.70	4,259.70	5,613.70	4,571.70	4,523.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,228.50		
9999	SMIB ONLY NOT ELIGIB	-7,682.70	-11,273.20	-3,735.30	-4,872.90	-6,183.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-33,747.80		
SUBTOTAL:	775,609.2	0	843,035.00	893,679.2	0	881,950.10	862,191.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,256,464.90		

1120	TANF EXPANDED FOR FI	1,551.00	240.00	240.00	240.00	240.00	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	4,173.00	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	4,413.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,511.00	
22,787.80	
25,298.80	

4,281,763.70

898,572.90	886,843.80	866,604.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

781,857.60

847,885.00

Q1
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	2,963,042.50	3,006,531.50	3,027,725.50	3,063,352.30	3,047,411.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,108,063.70		
9999	SMIB ONLY NOT ELIGIB	-11,850.50	-8,842.50	2,000.50	-3,347.50	-1,339.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-23,379.00		
SUBTOTAL:	2,951,192.00	2,997,689.00	3,029,726.00	3,060,004.80	3,046,072.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,084,684.70		

TOTAL:	2,951,192.00	2,997,689.00	3,029,726.00	3,060,004.80	3,046,072.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,084,684.70		

LTC SMIB
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	135.50	542.00	271.00	135.50	948.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,032.50		
1020	TANF WITH QMB	677.50	677.50	677.50	542.00	542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,116.50		
2100	SSI AGED WITH MEDIC A	1,149,367.50	1,145,754.60	1,146,101.70	1,140,429.40	1,137,634.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,719,287.20		
2110	SSI AGED NON-MEDIC
AR	224,638.00	229,025.80	228,886.30	217,342.00	218,832.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,118,724.60		
2120	SSI AGED WITH QMB	1,237,088.50	1,251,357.50	1,255,583.80	1,270,715.00	1,275,550.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,290,294.80		
2200	SSI DISABLED WITH M E	399,084.90	384,519.80	388,578.30	387,535.80	383,855.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,943,574.70		
2210	SSI DISABLED NON-ME
D	14,092.00	14,769.50	16,937.50	18,563.50	19,105.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,468.00		
2220	SSI DISABLED WITH Q M	1,066,637.10	1,062,882.00	1,069,433.50	1,074,934.00	1,104,470.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,378,356.60		
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	135.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		677.50		
2320	SSI BLIND WITH QMB	813.00	948.50	542.00	406.50	542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,252.00		
SUBTOTAL:	4,092,940.50	4,090,748.20	4,107,418.10	4,110,739.20	4,141,615.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,543,461.90		

8720	SSI DISABLED FREEDO M	1,355.00	1,761.50	1,761.50	2,168.00	2,303.50	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	2,303.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9,349.50

9,349.50

20,552,811.40

4,094,295.50	4,092,509.70	4,109,179.60	4,112,907.20	4,143,919.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC HIB
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	0.00	-874.00	0.00	437.00	-437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-874.00		
2110	SSI AGED NON-MEDIC
AR	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	369,054.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,852,164.30		
2200	SSI DISABLED WITH M E	1,354.70	-1,354.70	437.00	0.00	-437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q
M	11,405.70	14,901.70	16,889.70	17,741.50	17,610.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,549.00		
2320	SSI BLIND WITH QMB	480.70	480.70	480.70	480.70	480.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,403.50		
SUBTOTAL:	381,352.5	0	383,341.90	394,396.6	0	388,191.20	386,271.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,933,553.80		

TOTAL:	381,352.50	383,341.90	394,396.60	388,191.20	386,271.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,933,553.80		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,459.38	2,376.85	536.00	1,132.63	695.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,200.00		
1007	TANF 21-44 FEMALE WI	1,844.01	2,435.65	604.00	81.00	925.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,890.41		
1008	TANF 45-64 M & F WIT	8,360.17	6,104.83	4,135.71	4,922.78	12,448.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,972.13		
1009	TANF 65+ M & F WITH	6,203.96	2,264.15	1,795.13	3,544.21	7,375.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,182.90		
1011	TANF <1 M & F NON-ME	1,069,634.86	501,655.84	518,233.37	524,144.83	659,731.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,273,400.84		
1012	TANF 01-05 M & F NON	371,200.65	232,647.74	216,168.38	291,939.12	433,104.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,545,060.30		
1013	TANF 06-13 M & F NON	550,058.56	373,315.59	287,418.12	412,270.41	595,520.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,218,583.12		
1014	TANF 14-20 MALE NON-	193,092.30	113,486.70	79,186.08	108,004.30	154,318.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		648,087.67		
1015	TANF 14-20 FEMALE N O	384,301.30	284,458.81	191,867.85	233,145.95	318,019.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,411,793.47		
1016	TANF 21-44 MALE NON-	1,656,199.06	1,433,662.24	1,024,544.40	1,046,770.00	1,677,940.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,839,116.55		
1017	TANF 21-44 FEMALE N O	5,602,026.93	4,465,727.95	3,632,886.69	4,067,631.75	6,759,477.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,527,750.64		
1018	TANF 45-64 M & F NON	2,596,861.71	2,027,518.49	1,553,121.75	1,738,239.75	3,092,238.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,007,980.51		
1019	TANF 65+ M & F NON-M	4,301.94	11,634.33	2,923.99	2,043.66	9,336.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,240.77		
1026	TANF 21-44 MALE WITH	379.83	0.00	15.75	617.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,467.58		
1027	TANF 21-44 FEMALE WI	8,469.49	1,464.04	1,280.01	997.93	2,824.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,036.22		
1028	TANF 45-64 M & F WIT	3,753.41	3,189.89	3,548.81	2,054.69	2,028.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,575.34		
1029	TANF 65+ M & F WITH	3,340.01	1,770.48	5,504.70	1,264.92	2,564.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,444.14		
2100	SSI AGED WITH MEDIC A	112,980.76	60,316.34	46,750.16	54,355.02	136,123.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		410,525.39		
2110	SSI AGED NON-MEDIC
AR	181,290.38	92,702.15	72,010.14	93,986.11	178,925.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		618,914.51		
2120	SSI AGED WITH QMB	409,253.22	316,117.24	254,509.28	267,835.19	704,155.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,951,870.53		
2200	SSI DISABLED WITH M E	264,684.94	158,980.48	165,849.59	168,145.07	453,783.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,211,443.31		
2210	SSI DISABLED NON-ME
D	6,718,110.37	5,424,125.36	3,919,293.62	4,783,703.42	8,133,027.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,978,260.28		
2220	SSI DISABLED WITH Q M	768,151.66	555,419.51	446,900.87	460,923.55	1,142,267.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,373,663.29		
2300	SSI BLIND WITH MEDIC	2,403.28	1,253.88	1,539.79	2,094.11	5,774.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,065.40		
2310	SSI BLIND NON-MEDIC A	115,995.95	93,912.22	52,379.85	46,167.93	103,264.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		411,720.18		
2320	SSI BLIND WITH QMB	10,555.01	6,761.49	4,295.24	5,940.00	13,728.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,279.86		
4311	SOBRA CHILD <1 M & F	2,800,114.73	1,259,315.50	1,415,197.95	1,498,953.24	1,954,163.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,927,744.55		
4312	SOBRA CHILD 01-05 M	4,665,875.72	3,219,933.46	2,727,788.10	3,500,214.47	4,717,665.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,831,477.17		
4313	SOBRA CHILD 06-13 M	6,595,816.61	5,325,072.19	3,862,761.20	5,330,386.12	6,839,773.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,953,809.64		
4314	SOBRA CHILD 14-20 MA	1,460,742.34	1,340,303.97	1,028,941.33	1,241,190.19	1,602,877.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,674,055.06		
4315	SOBRA CHILD 14-20 FE	2,086,542.45	1,869,853.40	1,314,627.46	1,807,968.86	2,227,372.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,306,364.53		
5007	SOBRA PREG 21-44 FE M	93.41	904.06	96.75	746.33	266.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,107.15		
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	322,610.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,663,902.55		
5017	SOBRA PREG 21-44 FE
M	2,680,800.23	1,488,299.21	1,648,387.93	1,617,563.08	1,943,765.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,378,815.91		
5018	SOBRA PREG 45-64 FE M	3,229.98	455.00	2,730.00	910.00	1,820.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,144.98		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	32.85	414.10	467.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		914.05		
SUBTOTAL:	41,855,275.95	30,931,012.62	24,797,865.37	29,583,600.64	44,210,836.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,378,590.93		

1106	TANF EXPANDED 21-44	3,391.33	1,198.94	1,322.27	3,291.41	6,614.19	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	4,491.64	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	38,988.31	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	39,554.33	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	2,730.00	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	53,570.71	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	945,239.25	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	3,068,918.83	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	2,159,853.16	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	11,977.06	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	14,014.19	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	18,688.19	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	110,537.42	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	93,988.04	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	13,906.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	19,508.42	33,062.60	11,495.50	7,519.22	24,873.29	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	693,042.16	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	4,177.88	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	195,800.61	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	282,811.60	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	7,783,777.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
15,818.14	
16,053.35	
113,173.94	
147,557.06	
1,160.00	
21,533.98	
174,621.81	
2,977,166.59	
11,322,764.48	
7,319,794.94	
28,030.02	
62,588.06	
88,897.49	
311,059.49	
237,216.65	
44,287.50	
96,459.03	
1,895,108.31	
18,019.96	
626,531.38	
937,030.10	
26,454,872.28	

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

 
0.00

0.00

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 November 30, 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	1,412.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,129.51		
3509	ADULT 40-100% M&F 65	81.00	0.00	43.40	193.58	272.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		590.71		
3514	ADULT 40-100% MALE 1	62,409.69	50,399.74	38,081.34	59,185.35	62,153.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,229.16		
3515	ADULT 40-100% FEMAL E	126,223.47	102,765.83	67,081.04	110,495.47	144,308.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		550,874.42		
3516	ADULT 40-100% MALE 2	727,935.76	485,813.77	396,851.80	404,408.08	708,364.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,723,373.95		
3517	ADULT 40-100% FEMAL E	667,579.54	460,943.19	314,517.42	383,245.42	714,490.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,540,775.91		
3518	ADULT 40-100% M&F 45	2,280,931.12	1,866,834.84	1,194,937.11	1,416,993.43	2,939,943.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,699,639.78		
3519	ADULT 40-100% M&F 65	455.00	0.00	0.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		910.00		
3706	ADULT <40% EXP MALE	252.48	1,629.66	582.94	3,200.47	161.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,827.39		
3707	ADULT <40% EXP FEM AL	910.00	1,023.38	3,655.57	1,820.00	643.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,052.25		
3708	ADULT <40% EXP M&F
4	5,022.91	7,067.77	5,582.80	8,786.59	13,162.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,622.80		
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	336,939.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,334,573.17		
3715	ADULT <40% EXP FEM AL	489,450.66	370,107.48	272,561.22	323,903.31	508,211.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,964,234.20		
3716	ADULT <40% EXP MALE	5,578,819.17	4,600,936.70	3,846,127.28	4,096,201.80	5,874,883.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,996,968.29		
3717	ADULT <40% EXP FEM AL	3,643,354.41	2,910,869.26	2,243,667.36	2,583,972.37	4,039,439.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,421,302.81		
3718	ADULT <40% EXP M&F
4	8,545,612.25	7,023,601.87	5,412,793.44	6,021,584.05	10,460,029.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,463,620.86		
3719	ADULT <40% EXP M&F 6	455.00	21,292.98	455.00	3,665.69	3,458.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,327.48		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	455.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		910.00		
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	25,809,240.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,057,622.86		

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	503,224.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,263,717.12

910.00

3906	NEWLY ELIGIBLE MALE	0.00	455.00	1,473.15	1,376.41	81.00	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	1,736.51	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	779.55	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	25,895.22	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	47,452.40	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	519,583.34	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	911,530.18	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	1,787,183.84	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	8.96	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	3,294,251.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,385.56	
93.41	
6,032.56	
1,485.25	
83,285.45	
204,383.31	
1,973,614.27	
3,252,648.16	
6,147,244.61	
918.96	
11,673,091.54	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4414	SOBRA 100-133% MALE	197,152.96	138,160.37	155,034.46	135,189.24	169,740.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		795,277.87		
4415	SOBRA 100-133% FEMA L	237,463.81	175,607.59	149,384.42	159,032.85	244,863.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		966,351.82		
SUBTOTAL:	1,013,023.62	761,388.60	649,434.4	5	684,581.72	917,828.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,026,256.81		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	910.00	455.00	1,365.00	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	4,740.74	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	1,820.00	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	7,925.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,730.00	
27,464.08	
3,185.00	
15,397.24	
48,776.32	

8700	SSI DISABLED FREEDO M	12,901.78	6,600.67	1,644.15	10,536.85	10,209.34	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	25,968.93	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	2,457.84	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	38,636.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
41,892.79	
121,789.60	
4,454.90	
168,137.29	

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

309,795,798.03

74,111,672.71	56,982,751.98	44,847,279.40	51,791,599.27	82,062,494.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	42,607.07	41,818.90	47,825.53	-37,884.57	-45,916.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,450.08		
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	-45,916.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,450.08		

TOTAL:	42,607.07	41,818.90	47,825.53	-37,884.57	-45,916.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,450.08		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	7,031.94	2,402.11	8,987.48	2,175.10	3,768.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,365.36		
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	59.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271.20		
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	5,045.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,018.75		
1016	TANF 21-44 MALE NON-	5,642.36	1,117.64	5,118.38	5,301.23	9,159.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,339.54		
1017	TANF 21-44 FEMALE N O	38,709.06	5,112.40	66,186.01	2,817.30	16,861.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129,685.90		
1018	TANF 45-64 M & F NON	3,220.37	9,395.06	5,423.50	1,020.96	779.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,839.77		
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	2,989.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,195.29		
2110	SSI AGED NON-MEDIC
AR	4,535.42	5,494.64	3,476.23	8,172.49	13,764.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,443.71		
2120	SSI AGED WITH QMB	-5.22	718.26	13,438.47	-162.99	839.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,828.42		
2200	SSI DISABLED WITH M E	828.88	4,440.65	346.64	599.37	3,442.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,658.49		
2210	SSI DISABLED NON-ME
D	46,209.75	8,576.13	356,427.07	96,324.20	242,923.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		750,460.97		
2220	SSI DISABLED WITH Q M	6,575.10	48.79	92,736.81	2,768.44	1,258.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,387.58		
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	15,055.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,245.15		
4312	SOBRA CHILD 01-05 M	8,047.58	7,985.21	39,028.64	7,716.40	6,509.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,287.52		
4313	SOBRA CHILD 06-13 M	11,969.38	4,816.54	6,351.37	9,105.11	13,559.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,801.42		
4314	SOBRA CHILD 14-20 MA	1,518.14	858.50	2,084.57	11,953.91	3,589.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,004.28		
4315	SOBRA CHILD 14-20 FE	1,126.11	886.24	3,376.06	583.74	1,527.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,499.69		
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	20,098.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,632.37		
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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	168,743.56	85,709.15	648,677.13	207,976.37	361,234.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,472,340.70		

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	374.54	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	528.31	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	3,193.17	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	28,530.40	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	129.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	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	4,122.06	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	481.30	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	37,359.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
64.55	
6.60	
649.03	
0.00	
0.00	
1,920.91	
0.00	
68,161.05	
37,861.33	
76,519.28	
0.00	
0.00	
108.16	
748.08	
0.00	
2,802.05	
1,055.47	
0.00	
4,665.89	
2,635.49	
24.82	
197,222.71	

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

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 November 30, 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	68.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		434.79		
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	368.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368.66		
3516	ADULT 40-100% MALE 2	19,227.07	9,299.28	27,140.62	9,335.51	13,408.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,410.97		
3517	ADULT 40-100% FEMAL E	3,335.31	6,034.54	665.68	1,659.17	11,962.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,657.17		
3518	ADULT 40-100% M&F 45	119,068.49	118,784.75	153,724.03	19,853.51	58,444.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		469,875.53		
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	2,275.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,078.97		
3707	ADULT <40% EXP FEM AL	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	1,190.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,064.25		
3715	ADULT <40% EXP FEM AL	462.06	1,931.76	1,739.85	2,414.05	5,075.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,623.56		
3716	ADULT <40% EXP MALE	365,435.81	51,493.65	58,404.37	83,378.22	76,487.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		635,199.29		
3717	ADULT <40% EXP FEM AL	28,305.36	19,951.64	62,170.84	56,367.73	23,722.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190,518.18		
3718	ADULT <40% EXP M&F
4	250,841.33	74,155.25	56,080.07	78,701.19	84,778.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		544,556.64		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F
4	0.00	0.00	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	277,783.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,983,908.94		

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	544.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,004.34

0.00

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	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	409.23	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	1,708.35	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	186,546.67	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	2,645.44	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	191,309.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
9.46	
0.00	
939.27	
488.57	
138,093.49	
205,694.03	
334,112.91	
47.55	
679,385.28	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4414	SOBRA 100-133% MALE	100.51	0.00	7.51	378.82	221.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		708.62		
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	171.36	635.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		806.68		
SUBTOTAL:	100.51	2,095.60	993.7	6	927.76	1,402.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,519.64		

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	711.55	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	711.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
40,217.95	
0.00	
0.00	
40,217.95	

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	976.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	57.08	79.22	0.00	993.52	976.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,129.82	
0.00	
976.16	
2,105.98	

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

4,378,811.60

1,206,055.14	560,583.24	1,194,018.97	547,376.79	870,777.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	617,512.03	448,268.17	392,559.28	404,946.54	233,053.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,096,339.33		
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	233,053.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,096,741.84		

TOTAL:	617,587.71	448,283.68	392,870.60	404,946.54	233,053.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,096,741.84		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,365.00	1,365.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,730.00		
2100	SSI AGED WITH MEDIC A	249,129.13	166,906.44	235,451.24	161,043.71	353,900.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,166,430.79		
2110	SSI AGED NON-MEDIC
AR	62,182.20	66,431.52	41,317.62	34,066.46	47,965.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		251,963.38		
2120	SSI AGED WITH QMB	359,948.35	251,228.84	236,600.09	249,357.53	578,921.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,676,056.66		
2200	SSI DISABLED WITH M E	64,376.04	44,880.45	44,560.73	41,946.27	108,752.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		304,516.40		
2210	SSI DISABLED NON-ME
D	1,137,487.58	1,052,503.74	822,964.63	856,226.80	1,221,741.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,090,923.91		
2220	SSI DISABLED WITH Q M	153,160.28	111,134.47	98,763.76	108,290.17	217,713.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		689,062.63		
2300	SSI BLIND WITH MEDIC	0.00	608.28	239.12	81.00	15.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		944.38		
2310	SSI BLIND NON-MEDIC A	8,478.78	5,005.00	4,989.14	5,488.16	11,375.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,336.08		
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	2,540,386.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,218,923.78		

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

9,218,923.78

2,036,731.71	1,700,154.18	1,485,151.09	1,456,500.10	2,540,386.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	12,020.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,020.99		
2100	SSI AGED WITH MEDIC A	6,413.95	27,718.44	11,302.88	25,620.67	13,751.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,807.38		
2110	SSI AGED NON-MEDIC
AR	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	611.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,230.62		
2200	SSI DISABLED WITH M E	11,704.99	147.31	163.48	395.35	2,067.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,478.67		
2210	SSI DISABLED NON-ME
D	73,355.72	69,642.29	33,336.99	50,764.47	91,594.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318,693.91		
2220	SSI DISABLED WITH Q M	2,493.77	1,494.83	26,114.02	5,892.44	2,553.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,548.79		
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	110,579.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		543,559.17		

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:	131,554.40	123,114.60	87,416.10	90,894.94	110,579.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		543,559.17		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	5,720.54	2,465.16	4,020.71	6,395.05	4,741.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,343.16		
1007	TANF 21-44 FEMALE WI	3,816.12	5,879.47	3,052.17	5,354.78	1,591.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,694.02		
1008	TANF 45-64 M & F WIT	5,162.62	6,679.62	8,917.62	7,499.06	9,660.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,919.71		
1009	TANF 65+ M & F WITH	1,369.44	4,783.88	4,100.16	5,212.46	7,282.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,748.05		
1011	TANF <1 M & F NON-ME	628,082.08	711,492.30	296,466.98	645,951.63	537,871.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,819,864.01		
1012	TANF 01-05 M & F NON	-50,122.75	71,884.03	76,313.07	115,241.02	110,241.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323,557.24		
1013	TANF 06-13 M & F NON	-19,553.65	128,348.20	158,426.17	188,205.93	179,885.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		635,312.25		
1014	TANF 14-20 MALE NON-	10,100.26	62,045.38	70,011.32	54,058.28	57,568.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253,783.25		
1015	TANF 14-20 FEMALE N O	6,465.57	126,772.99	103,778.36	159,527.56	181,393.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		577,938.15		
1016	TANF 21-44 MALE NON-	294,900.11	801,287.54	672,377.63	1,067,853.42	1,033,079.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,869,497.85		
1017	TANF 21-44 FEMALE N O	750,289.28	2,390,887.38	2,393,699.27	2,965,553.36	3,108,221.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,608,650.54		
1018	TANF 45-64 M & F NON	-33,187.01	951,911.48	737,553.79	1,066,265.19	1,186,310.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,908,853.76		
1019	TANF 65+ M & F NON-M	-1,219.82	0.00	123.77	0.00	29.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,066.21		
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	1,040.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,300.47		
1028	TANF 45-64 M & F WIT	3,274.44	3,207.91	2,161.45	3,540.25	2,261.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,445.80		
1029	TANF 65+ M & F WITH	8,541.20	4,679.40	4,543.87	4,349.72	4,671.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,785.59		
2100	SSI AGED WITH MEDIC A	118,534.81	198,886.57	83,623.90	193,229.67	137,543.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		731,818.64		
2110	SSI AGED NON-MEDIC
AR	-20,837.80	44,299.09	20,582.28	66,215.64	68,307.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178,566.74		
2120	SSI AGED WITH QMB	287,256.68	330,452.18	337,985.49	450,546.79	354,556.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,760,797.34		
2200	SSI DISABLED WITH M E	244,210.75	434,046.24	381,914.80	665,603.10	546,812.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,272,587.88		
2210	SSI DISABLED NON-ME
D	2,585,073.97	4,850,256.22	4,050,436.74	5,262,121.50	6,461,409.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,209,298.03		
2220	SSI DISABLED WITH Q M	1,024,738.22	919,873.87	907,980.42	1,337,441.44	984,518.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,174,552.52		
2300	SSI BLIND WITH MEDIC	382.84	1,263.66	105.80	2,311.71	707.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,771.40		
2310	SSI BLIND NON-MEDIC A	-10,414.70	57,882.15	38,196.51	42,753.44	71,203.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,620.69		
2320	SSI BLIND WITH QMB	15,251.72	12,243.64	15,483.93	22,990.91	17,739.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,709.95		
4311	SOBRA CHILD <1 M & F	276,758.94	806,294.97	811,636.78	1,159,492.46	1,056,660.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,110,843.41		
4312	SOBRA CHILD 01-05 M	-529,357.21	815,047.27	908,198.23	1,405,903.88	1,330,778.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,930,570.76		
4313	SOBRA CHILD 06-13 M	-404,516.16	1,555,596.60	1,745,883.56	2,157,314.72	2,401,743.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,456,021.83		
4314	SOBRA CHILD 14-20 MA	412,233.42	670,329.89	613,362.34	880,335.92	1,073,683.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,649,945.00		
4315	SOBRA CHILD 14-20 FE	176,458.66	660,455.78	637,320.79	919,012.91	1,023,092.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,416,340.60		
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	70,040.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302,200.55		
5017	SOBRA PREG 21-44 FE
M	32,799.46	847,611.96	664,440.78	1,070,291.90	846,370.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,461,514.47		
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 November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	50.00	0.00	654.86	4,584.78	2,669.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,959.19		
SUBTOTAL:	5,776,029.87	17,576,958.59	15,827,937.98	22,056,937.53	22,873,687.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,111,551.53		

1106	TANF EXPANDED 21-44	1,673.27	565.51	1,006.98	3,172.13	500.11	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	6,573.61	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	11,883.79	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	16,173.76	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	39,814.80	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	7,598.20	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	393,272.49	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	1,252,952.33	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	743,908.49	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	10,365.65	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	32,137.18	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	71,029.86	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	36,565.41	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	5,814.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	-8,714.28	1,279.59	962.06	2,560.32	842.03	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	338,526.71	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	7,750.34	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	309,887.03	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	287,964.91	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	3,573,560.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,918.00	
37,122.50	
95,115.62	
65,123.14	
126.96	
58,855.04	
67,494.75	
1,448,516.74	
3,863,596.75	
2,422,798.42	
-496.35	
58,508.64	
143,643.44	
432,810.31	
193,005.25	
18,122.63	
-3,070.28	
1,558,720.05	
30,479.93	
1,055,781.37	
1,426,261.16	
12,979,434.07	

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

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 November 30, 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	1,241.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,640.11		
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	28,050.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116,385.19		
3515	ADULT 40-100% FEMAL E	7,544.55	46,694.72	44,995.21	35,156.32	35,433.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		169,823.86		
3516	ADULT 40-100% MALE 2	182,166.05	316,990.28	363,173.76	431,032.01	554,462.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,847,824.40		
3517	ADULT 40-100% FEMAL E	49,024.77	190,927.44	234,561.60	218,475.98	351,764.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,044,754.03		
3518	ADULT 40-100% M&F 45	71,316.53	789,388.68	1,007,444.02	1,196,226.89	1,205,779.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,270,155.14		
3519	ADULT 40-100% M&F 65	-455.00	0.00	0.00	42.48	148.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-263.66		
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 FEM AL	100.67	102.43	48.94	141.77	68.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		462.22		
3708	ADULT <40% EXP M&F
4	-450.34	1,622.11	2,005.33	2,429.21	6,805.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,411.55		
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	319,842.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,163,429.57		
3715	ADULT <40% EXP FEM AL	25,044.72	246,565.40	181,740.15	280,996.42	251,274.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		985,621.14		
3716	ADULT <40% EXP MALE	3,653,638.18	4,242,514.88	3,995,546.33	5,557,424.16	6,236,565.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,685,689.19		
3717	ADULT <40% EXP FEM AL	1,007,616.94	2,103,959.39	2,032,422.59	2,450,655.38	2,718,648.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,313,302.76		
3718	ADULT <40% EXP M&F
4	2,576,297.05	4,745,543.78	4,665,651.27	6,088,460.68	7,003,430.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,079,383.31		
3719	ADULT <40% EXP M&F 6	-455.00	5,271.31	411.02	1,371.39	1,279.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,878.13		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	7,728,753.96	12,865,269.19	12,746,425.7	1 16,649,652.65	18,714,793.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,704,895.42		

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	162,519.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

448,737.20

-455.00

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	215.21	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	2,259.13	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	206.19	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	11,298.94	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	12,014.72	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	252,190.48	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	341,613.58	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	857,401.79	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	1,217.71	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	1,478,417.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,509.57	
6,708.04	
10,259.43	
4,637.27	
64,969.58	
95,463.39	
1,778,916.20	
909,907.19	
2,186,840.55	
3,782.71	
5,074,993.93	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4414	SOBRA 100-133% MALE	-7,052.77	46,756.64	78,658.71	49,561.98	93,107.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		261,031.87		
4415	SOBRA 100-133% FEMA L	-8,543.09	68,370.22	114,590.98	102,638.43	82,443.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		359,499.76		
SUBTOTAL:	-108,481.91	242,435.61	296,001.5	6	300,788.53	338,070.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,068,813.83		

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	2,878.66	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	2,878.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
41,087.32	
0.00	
-1,365.00	
39,722.32	

8700	SSI DISABLED FREEDO M	5,748.24	6,806.69	10,182.44	11,563.70	9,026.86	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	9,849.18	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	259.84	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	19,135.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
43,327.93	
65,133.40	
17,990.09	
126,451.42	

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

172,104,593.92

14,235,837.65	34,312,575.58	32,042,537.41	44,513,098.60	47,000,544.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	111.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111.55		
2100	SSI AGED WITH MEDIC A	3,141,298.02	2,783,579.05	2,655,926.93	3,278,008.15	2,693,986.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,552,798.29		
2110	SSI AGED NON-MEDIC
AR	182,346.04	132,352.21	128,808.51	146,829.71	136,743.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		727,080.10		
2120	SSI AGED WITH QMB	4,772,976.61	4,078,974.33	3,954,822.95	4,949,020.43	4,002,106.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,757,900.80		
2200	SSI DISABLED WITH M E	589,027.23	472,720.03	496,572.43	619,033.16	417,762.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,595,115.56		
2210	SSI DISABLED NON-ME
D	2,848,444.87	2,321,363.70	2,518,764.62	2,940,087.81	2,731,935.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,360,596.20		
2220	SSI DISABLED WITH Q M	928,876.44	954,747.01	838,487.63	1,066,518.31	846,286.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,634,915.88		
2300	SSI BLIND WITH MEDIC	2,008.80	1,636.80	1,350.99	1,956.00	1,212.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,164.59		
2310	SSI BLIND NON-MEDIC A	1,597.02	4,684.37	5,612.65	7,485.35	8,772.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,151.50		
2320	SSI BLIND WITH QMB	4,366.58	1,392.78	0.00	2,694.37	352.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,806.20		
SUBTOTAL:	12,471,053.16	10,751,450.28	10,600,346.7	1 13,011,633.29	10,839,157.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,673,640.67		

8720	SSI DISABLED FREEDO M	2,380.80	2,692.35	2,162.25	1,462.80	3,427.20	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	3,427.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

12,125.40

12,125.40

TOTAL:	12,473,433.96	10,754,142.63	10,602,508.96	13,013,096.09	10,842,584.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,685,766.07		

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

0.00

0.00

0.00

0.00

TOTAL:

0.00

20.66

0.00

0.00

0.00

0.00

0.00

0.00

20.66

KidsCare - CAPITATION AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	163,955.19	166,288.57	166,584.01	170,052.62	168,594.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		835,475.35		
6012	KIDS 1-5 M & F NON-M	1,543,957.96	1,565,323.61	1,575,292.00	1,676,794.89	1,653,850.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,015,218.79		
6013	KIDS 6-13 M & F NON-	2,896,611.35	2,928,471.06	2,946,784.80	3,150,605.76	3,143,966.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,066,439.71		
6014	KIDS 14-19 MALE NON-	741,190.91	756,932.03	769,166.95	820,270.24	813,103.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,900,664.12		
6015	KIDS 14-19 FEMALE NO	751,128.68	770,184.18	781,392.45	842,956.11	848,685.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,994,346.66		
9960	KIDSCARE KICK PAYM EN	6,000.27	5,997.30	5,984.82	12,216.41	37,269.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,468.66		
SUBTOTAL:	6,102,844.36	6,193,196.75	6,245,205.03	6,672,896.03	6,665,471.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,879,613.29		

TOTAL:	6,102,844.36	6,193,196.75	6,245,205.03	6,672,896.03	6,665,471.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,879,613.29		

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	283.84	288.66	289.09	288.38	286.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,436.54		
6012	KIDS 1-5 M & F NON-M	8,605.77	8,720.94	8,773.24	8,915.48	8,796.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,812.14		
6013	KIDS 6-13 M & F NON-	16,171.73	16,347.00	16,437.62	16,765.60	16,725.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,447.34		
6014	KIDS 14-19 MALE NON-	4,132.98	4,218.92	4,287.26	4,374.96	4,331.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,345.31		
6015	KIDS 14-19 FEMALE NO	4,170.12	4,274.87	4,336.42	4,469.58	4,498.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,749.42		
9960	KIDSCARE KICK PAYM EN	1.00	1.00	1.00	2.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
SUBTOTAL:	33,365.44	33,851.39	34,124.6	3	34,816.00	34,644.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,801.75		

170,801.75

33,365.44	33,851.39	34,124.63	34,816.00	34,644.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	372.22	377.84	377.73	488.19	488.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,104.42		
6012	KIDS 1-5 M & F NON-M	14,030.25	13,776.71	13,002.24	17,818.51	15,470.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,098.15		
6013	KIDS 6-13 M & F NON-	24,067.99	24,576.74	26,372.06	34,081.58	30,348.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139,446.53		
6014	KIDS 14-19 MALE NON-	10,487.13	10,708.53	10,950.58	13,577.00	13,259.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,982.72		
6015	KIDS 14-19 FEMALE NO	10,410.58	10,572.35	10,948.34	13,929.03	13,953.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,813.69		
SUBTOTAL:	59,368.17	60,012.17	61,650.9	5	79,894.31	73,519.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334,445.51		

TOTAL:	59,368.17	60,012.17	61,650.95	79,894.31	73,519.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334,445.51		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	289.00	292.00	291.00	300.00	293.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,465.00		
6012	KIDS 1-5 M & F NON-M	8,836.06	8,937.06	9,053.03	9,159.60	9,046.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,031.75		
6013	KIDS 6-13 M & F NON-	16,748.06	16,847.06	16,997.12	17,272.15	17,171.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,035.42		
6014	KIDS 14-19 MALE NON-	4,347.00	4,404.00	4,514.00	4,609.00	4,531.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,405.00		
6015	KIDS 14-19 FEMALE NO	4,353.00	4,428.00	4,520.00	4,664.00	4,647.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,612.00		
SUBTOTAL:	34,573.12	34,908.12	35,375.1	5	36,004.75	35,688.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,549.17		

35,375.15

35,688.03

0.00

0.00

0.00

0.00

0.00	0.00

0.00

36,004.75

176,549.17

TOTAL:

34,573.12

34,908.12

KidsCare - FEE FOR SERVICE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	284.12	1,147.85	637.02	1,114.92	5,561.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,745.75		
6012	KIDS 1-5 M & F NON-M	14,179.76	23,135.73	17,015.05	46,530.65	75,177.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176,038.59		
6013	KIDS 6-13 M & F NON-	45,325.01	144,046.96	62,107.36	97,046.28	168,312.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		516,838.31		
6014	KIDS 14-19 MALE NON-	39,303.11	50,503.51	36,039.38	88,935.48	51,814.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		266,596.08		
6015	KIDS 14-19 FEMALE NO	25,467.01	21,720.72	26,081.79	47,116.95	79,986.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200,372.78		
SUBTOTAL:	124,559.0	1	240,554.77	141,880.6	0	280,744.28	380,852.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,168,591.51		

TOTAL:	124,559.01	240,554.77	141,880.60	280,744.28	380,852.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,168,591.51		

KidsCare - REINSURANCE
For The Period Ending November 30, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	10,129.35	0.00	0.00	4,746.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,876.05		
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	82,026.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		353,103.22		
6014	KIDS 14-19 MALE NON-	113,827.14	40,260.35	35,353.19	35,159.29	96,771.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321,371.92		
6015	KIDS 14-19 FEMALE NO	1,145.72	0.00	0.00	0.00	18,050.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,196.43		
SUBTOTAL:	200,701.0	1	116,470.46	178,309.6	4	68,994.99	201,595.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		766,071.91		

766,071.91

178,309.64	68,994.99	201,595.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

200,701.01

116,470.46

9

00

15.00

2,424.86

23.00

1,310.80

57.00

2,152.48

9,591.09

132,614.59

2.57

24,596.39

1.00

69.13

3.99

114.96

35.99

66.95

173,079.80

173,079.80

TOTAL

JUNE

MAY

APRIL

MARCH

FEBRUARY

JANUARY

NOVEMBER	DECEMBER

OCTOBER

AUGUST SEPTEMBER

JULY

DESCRIPTION

RATE CODE

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending November 30, 2019

1000	TANF WITH MEDICARE	2.00	3.00	2.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	389.91	450.32	511.92	518.88	553.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	5.00	5.00	5.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2100	SSI AGED WITH MEDICA	257.99	261.42	260.66	263.00	267.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICAR	11.00	11.00	11.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	429.97	429.89	431.22	434.39	427.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH ME	1,924.20	1,920.69	1,910.74	1,907.48	1,927.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2210	SSI DISABLED NON-MED	26,376.88	26,455.14	26,530.06	26,599.41	26,653.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
221Z	SSI DISABLED NON-MED	2.51	0.00	-1.93	0.00	1.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2220	SSI DISABLED WITH QM	4,868.95	4,898.69	4,922.37	4,945.41	4,960.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDICA	13.00	13.48	14.00	12.32	16.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	2.00	0.99	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDOM	23.00	21.00	21.99	26.04	22.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	3.99	5.00	9.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	10.99	12.00	14.00	14.96	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:
TOTAL:	34,321.39	34,487.62	34,642.03	34,750.89	34,877.8	7	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	34,321.39	34,487.62	34,642.03	34,750.	34,877.8	7	0.00	0.00	0.00	0.00	0.	0.00	0.00	

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

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	422,468.96	427,754.94	636,779.32	441,164.01	439,709.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,367,876.88	
EPD	106,533,521.90	107,126,210.66	107,209,520.71	121,442,144.75	121,053,408.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	563,364,806.86	
TOTAL AHCCCS LTC	106,955,990.86	107,553,965.60	107,846,300.03	121,883,308.76	121,493,118.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	565,732,683.74	
DES/DD	143,961,803.16	144,655,141.28	145,290,373.93	165,084,146.04	165,740,027.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	764,731,491.49	
TOTAL DES LTC	143,961,803.16	144,655,141.28	145,290,373.93	165,084,146.04	165,740,027.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	764,731,491.49	
TOTAL LTC - CAP	250,917,794.02	252,209,106.88	253,136,673.96	286,967,454.80	287,233,145.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,330,464,175.23	

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	13,493,550.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,448,249.02	
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	13,493,550.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67,448,249.02	

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	3,940,201.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,650,696.90	
DES/DD	4,204,532.65	1,620,152.95	3,500,067.02	2,770,247.33	2,670,668.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,765,668.48	
TOTAL DES LTC	4,204,532.65	1,620,152.95	3,500,067.02	2,770,247.33	2,670,668.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,765,668.48	
TOTAL LTC - REIN	6,843,752.18	5,361,381.84	6,418,046.04	5,182,314.90	6,610,870.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30,416,365.38	

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	4,530,191.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,486,465.20	

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.

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	518,538.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,134,887.53	
Subtotal	203,452.53	932,589.80	216,051.55	1,264,254.81	518,538.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,134,887.53	

206,373.18	932,589.80	216,051.55	1,264,254.81	518,538.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,137,808.18	

GRAND TOTAL

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

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

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

GRAND TOTAL

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

00010715	HEALTH CHOICE INTEGRATED - CAP	1,289.88	0.00	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 November 30, 2019

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

00010715
00010735
00010795

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

1,289.88

0.00

1,522.60

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,812.48

-7,052.52

0.00

-7,362.34

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-14,414.86

-60,720.16

10,522.46

615.08

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-49,582.62

Subtotal

-66,482.80

10,522.46

-5,224.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-61,185.00

-66,482.80

10,522.46

-5,224.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-61,185.00

GRAND TOTAL