Arizona Health Care Cost Containment System

Douglas A. Ducey, Governor Jami Snyder, Director

·· ·····································································.···

January 30, 2020

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 December 31, 2019

Dear President Fann and Speaker Bowers:

Pursuant to A.R.S. §'s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System's (AHCCCS) Appropriation Status Report (ASR) for the period ended December 31, 2019.

Status Summary - AHCCCS is currently forecasting a FY 2020 Total Fund shortfall of $337.1 million Total Fund ($24.5 million General Fund). The primary drivers for the estimated shortfall, which represents a 2.6% Total Fund variance and a 1.4% General Fund variance to the appropriation, are caseload growth, medical service expenditure growth, and increases to locally funded provider rate initiatives.

There are several issues this fiscal year that have the potential to affect the projected shortfall. They include:
Continued volatility in caseload growth.
Expenditure flows in fee-for-service and reinsurance payments.
Finalization of prior year reconciliations.

Enrollment Update - December 2019 enrollment is 1,892,514 members, a 2,740 member decrease over the prior month. Enrollment for January 2020 decreased to 1,880,915 members, a 11,599 member change.

Major January 2020 changes by eligibility category include: 1931 for  Families  and Children/SOBRA- decrease of 7,315, Supplemental Security Income - increase of 511; Prop 204 Restoration - decrease of 606; Adult Expansion - decrease of 1,331 Medicare Cost Sharing - decrease of 2,361; KidsCare - decrease of 73; and Federal Emergency  Services -  decrease  of 510.

• • Ill • • ■ II OI e II • ■ e • ■ • ■ Ill a • • . ■ • • • ■ • • • • Ill • • ■ a ■ ■ ■ a ■ Ill ■ ■ ■ ■ ■ ■ ■ Ill a• a Ill • ■ .A ■ ■ • ■ Ill• ■ ■ ■ ■• ■ ■ ■ • ■ a a ■ ■ ■ ' a ■ ■ ■ ■ Ill f • ■ I, ■ Ill ■ ■ Ill ■ 9 II p ■ ■ a Ill ■ a II ■ a ■ Ill ■ e ■ Ill Ill ■ •
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 January 30, 2020
Page 2

Tobacco Funds Revenue Update - Tobacco tax collections through November 2019 are $3.0 million more than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2020 appropriations.

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

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 December 31, 2019

Prepared by: Division of Business and Finance

Appropriation Status Report
Table of Contents
APPROPRIATED SOURCES AND USES OF FUNDS	Page
Summary of Appropriated Expenditures for SFY 2020…	2
Appropriated Expenditures by Funding Source…	3
Appropriated Revenue Received Detail Schedule…	5
FOOTNOTES	7
CASELOAD AND EXPENDITURES BY RATE CODE	11

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending December 31, 2019
SUMMARY OF APPROPRIATED EXPENDITURES	
		(A)	(B)	(A) - (B)				
		EXPENDITURE			PROJECTED			
	ANNUAL	PLAN	EXPENDITURES	VARIANCE	ANNUAL		ANNUALIZED	
	APPROPRIATION	YTD	YTD	YTD	EXPENDITURES		VARIANCE	

APPROPRIATIONS:								
ADMINISTRATION								
AHCCCS Operating Lump Sum	$	88,542,300	$	51,433,400	$	43,601,460	$	7,831,940	$	88,542,300	$	-	
AHCCCS Prop 204 Administration	14,182,800	7,188,200	9,544,130	(2,355,930)	14,182,800		-	
Information Technology	9,878,000	-	-	-	9,878,000		-	
DES Eligibility	91,874,500		48,133,000		32,376,759		15,756,241		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		22,179,500		18,109,726		4,069,774		44,358,700		-		
ADOA Data Center	19,325,800		9,662,700		6,115,191		3,547,509		19,325,800		-		
School District Suicide Prevention Coordinator	100,000		28,200		(13,723)		41,923		100,000		-		
TOTAL ADMINISTRATION	 	268,262,100 		 	138,625,000 		 	109,733,543 		 	28,891,457 		 	268,262,100 		 	-			

Traditional Medicaid Services	5,178,162,100	2,686,665,600	2,558,593,966	128,071,634	5,178,162,100	-	
Proposition 204 Services	4,168,410,500	2,024,731,200	1,973,045,665	51,685,535	4,168,410,500	-	
ACA Adult Expansion	527,018,800	260,757,600	211,286,062	49,471,538	527,018,800	-	
KidsCare Services	106,516,300	52,255,600	36,935,699	15,319,901	106,516,300	-	
ALTCS Services	1,796,913,800	861,452,000	884,398,030	(22,946,030)	1,796,913,800	-	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	28,612,400	8,227,200	8,227,150	50	28,612,400	-	
Voluntary Political Subdivision Programs	345,281,700	15,966,464	15,966,464	-	345,281,700	-	
CMDP	180,729,500	89,034,800	89,892,899	(858,099)	180,729,500	-	
Behavioral Health Services - in Schools	9,990,000	4,995,000	4,995,000	-	9,990,000	-	
Targeted Investment Program	90,000,000	-	-	-	90,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		38,823,600		38,299,488		524,112		77,646,900		-	
Supported Housing	5,324,800		2,662,200		2,657,280		4,920		5,324,800		-	
Crisis Services	16,391,300		8,195,400		8,128,150		67,250		16,391,300		-	
TOTAL PROGRAMMATIC	 	12,536,085,200 		 	6,053,766,664 		 	5,832,425,853 		 	221,340,811 		 	12,536,085,200 		 	-		

TOTAL EXPENDITURES

  $	12,804,347,300 

-

$	6,192,391,664

$	5,942,159,396

$	250,232,267

$   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	
$	32,802,400	
$	26,230,200	
6,572,200	
$	60,044,200	
$	
-	
Proposition 204 - Administrative Expenditures		21,538,900	10,718,700	9,335,621	1,383,079	21,538,900		-	

Programmatic Expenditures Traditional Medicaid Services		

1,170,113,300	

606,482,600	

632,615,249	

(26,132,649)	

1,170,113,300		

-	
Proposition 204 Services		95,088,500	43,391,800	47,544,250	(4,152,450)	95,088,500		-	
ACA Adult Expansion		5,393,400	2,199,700	2,696,700	(497,000)	5,393,400		-	
KidsCare Services		7,523,800	2,517,300	1,978,838	538,462	7,523,800		-	
ALTCS Services		234,042,300	113,869,000	117,021,150	(3,152,150)	234,042,300		-	
DSH and Rural Hospitals		8,843,300	2,483,800	2,466,500	17,300	8,843,300		-	
CMDP		54,297,600	26,794,700	27,034,137	(239,437)	54,297,600		-	
Behavior Health Services - in Schools		3,000,000	1,500,000	1,500,000	-	3,000,000		-	
Non Medicaid Seriously Mentally Ill Services		77,646,900	38,823,600	38,299,488	524,112	77,646,900		-	
Supported Housing		5,324,800	2,662,200	2,657,280	4,920	5,324,800		-	
Crisis Services		14,141,100	7,070,400	7,003,050	67,350	14,141,100		-	
Voluntary Political Subdivision Programs	 	3,750,000 	 	- 	 	- 	 	- 	 	3,750,000 	 	- 	
TOTAL GF EXPENDITURES	1,760,748,100	891,316,200	916,382,463	(25,066,263)	1,760,748,100	-	
	FEDERAL		
Administrative Expenditures	146,947,600	76,092,200	55,678,211	20,413,989	146,947,600	-	
Proposition 204 - Administrative Expenditures	33,035,300	16,695,900	18,318,235	(1,622,335)	33,035,300	-	
Programmatic Expenditures
Traditional Medicaid Services	
3,176,462,800	
1,642,736,900	
1,450,449,936	
192,286,964	
3,176,462,800	
-	
Proposition 204 Services	3,615,003,800	1,797,813,200	1,743,613,436	54,199,764	3,615,003,800	-	
ACA Adult Expansion	484,056,500	243,308,200	194,979,938	48,328,262	484,056,500	-	
KidsCare Services	86,764,900	44,354,300	30,377,127	13,977,173	86,764,900	-	
ALTCS Services and Nursing Facility Assessment	1,144,403,700	537,311,300	560,850,635	(23,539,335)	1,144,403,700	-	
DSH and Rural Hospitals	24,856,200	5,743,400	5,760,650	(17,250)	24,856,200	-	
CMDP	126,431,900	62,240,100	62,858,762	(618,662)	126,431,900	-	
Behavior Health Services - in Schools	6,990,000	3,495,000	3,495,000	-	6,990,000	-	
Targeted Investment Program	61,937,600	-	-	-	61,937,600	-	
Voluntary Political Subdivision Programs	 	240,664,300 	 	10,896,874 	 	10,896,874 	 	- 	 	240,664,300 	 	- 	
TOTAL FEDERAL EXPENDITURES	9,147,554,600	4,440,687,374	4,137,278,804	303,408,571	9,147,554,600	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF Programmatic Expenditures
Traditional Medicaid Services Acute Care	3,906,400

46,512,900	1,953,100

24,185,000	-

24,185,000	1,953,100

-	3,906,400

46,512,900	-

-	
ALTCS Services	 	268,554,800 	 	141,228,700 	 	126,328,187 	 	14,900,513 	 	268,554,800 	 	- 	
TOTAL COUNTY EXPENDITURES	318,974,100	167,366,800	150,513,187	16,853,613	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	32,353,500	30,876,300	1,477,200	61,752,600	-	
Proposition 204 Services - Emergency Health Services	16,216,300	7,393,600	8,108,150	(714,550)	16,216,300	-	
Proposition 204 Services - Proposition 204 Protection	34,054,300	15,526,500	17,027,150	(1,500,650)	34,054,300	-	
Proposition 204 Services - ATLSF	 	102,000,000 	 	- 	 	- 	 	- 	 	102,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	214,023,200	55,273,600	56,011,600	(738,000)	214,023,200	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program	2,789,700	362,700	171,276	191,424	2,789,700	-	
Programmatic Expenditures							
Traditional Medicaid Services - IGA Fund	10,297,700	5,395,200	2,575,135	2,820,065	10,297,700	-	
Acute Care - Prescription Drug Rebate Program State Match	140,158,600	73,431,800	70,079,300	3,352,500	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	301,978,600	346,668,409	(44,689,809)	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	3,686,900	3,789,200	(102,300)	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	17,492,800	17,600,000	(107,200)	36,422,000	-	
Proposition 204 Services - Hospital Assessment	303,482,900	159,436,800	156,111,504	3,325,296	303,482,900	-	
Proposition 204 Services - IGA Fund	2,564,700	1,169,300	641,175	528,125	2,564,700	-	
ACA Adult Expansion - Hospital Assessment	37,389,000	15,249,700	13,564,449	1,685,251	37,389,000	-	
ACA Adult Expansion - IGA Fund	179,900	-	44,975	(44,975)	179,900	-	
Traditional Medicaid Services - TPL	194,700	102,000	1,085,069	(983,069)	194,700	-	
ALTCS Services - TPL	-	-	826,267	(826,267)	-	-	
ALTCS Services - Nursing Facility Assessment	105,912,600	47,863,300	57,982,591	(10,119,291)	105,912,600	-	
Targeted Investment Program	28,062,400	-	-	-	28,062,400	-	
KidsCare Services - IGA Fund	76,300	47,700	-	47,700	76,300	-	
KidsCare Services Premiums	12,151,300	5,336,300	4,579,733	756,567	12,151,300	-	
Freedom to Work Premiums	31,200	-	59,568	(59,568)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	1,125,000	1,125,100	(100)	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	637,747,690	681,973,342	(44,225,653)	1,363,047,300	-	
	TOTAL		
Administrative Expenditures	268,262,100	138,625,000	109,733,543	28,891,457	268,262,100	-	
Acute Care	10,739,171,400	5,192,314,664	4,948,027,823	244,286,841	10,739,171,400	-	
Long Term Care	 	1,796,913,800 	 	861,452,000 	 	884,398,030 	 	(22,946,030)	 	1,796,913,800 	 	- 	
TOTAL EXPENDITURES	  $	12,804,347,300 	  $	6,192,391,664 	  $	5,942,159,396 	  $	250,232,268 	  $	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 December 31, 2019

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,251,144,200	$	645,468,500	$	662,811,949	
Proposition 204 Services & Administrative	116,627,400	54,110,500	57,521,046	
KidsCare Services	7,523,800.00	2,517,300.00	1,978,838	
ALTCS Services	234,042,300	113,869,000	117,021,150	
Behavioral Health Traditional Medicaid Services	 	151,410,400 	 	75,350,900 	 	74,993,955 	
TOTAL	1,760,748,100	891,316,200	914,326,938	

FEDERAL:
Acute & Administrative	7,789,954,100	3,796,781,674	3,684,879,602	
KidsCare Services	86,764,900	44,354,300	34,894,909	
ALTCS Services	1,144,403,700	537,311,300	615,220,940	
Behavioral Health Traditional Medicaid Services	 	126,431,900 	 	62,240,100 	 	66,385,243 	
TOTAL	9,147,554,600	4,440,687,374	4,401,380,694	

COUNTY:				
Acute & Administrative	50,419,300		26,138,100		25,138,152	
ALTCS Services	 	268,554,800 		 	141,228,700 		 	145,138,056 	
TOTAL	318,974,100		167,366,800		170,276,208	

TOBACCO FUNDS:						
Traditional Medicaid Services	61,752,600		32,353,500		30,876,300	
Proposition 204 Services	 	152,270,600 		 	22,920,100 		 	25,135,300 	
TOTAL	214,023,200		55,273,600		56,011,600	

OTHER:

Administrative	2,789,700	362,700	171,276	
Traditional Medicaid Services - IGA Fund	10,297,700	5,395,200	2,575,135	
Acute Care - Prescription Drug Rebate Program	712,796,900	375,410,400	416,747,709	
Long Term Care - Prescription Drug Rebate Program	44,000,400	21,179,700	21,389,200	
Hospital Assessment	343,616,500	175,855,800	165,671,094	
ALTCS - Nursing Facility Assessment	105,912,600	47,863,300	140,281	
Acute TPL - Note 1	194,700	102,000	1,085,069	
LTC TPL - Note 1	-	-	826,267	
KidsCare Services - IGA Fund	76,300	47,700	-	
KidsCare TPL - Note 1	-	-	(360.00)	
Member Premiums - CHIP	12,151,300	5,336,300	4,579,733	
Member Premiums - Freedom to Work	31,200	-	59,568	
Targeted Investment Program	28,062,400	-	12,731,149	
Behavioral Health Traditional Medicaid Services	2,250,200	1,125,000	793,462	
Voluntary Political Subdivision - State Match	 	100,867,400 	 	5,069,590 	 	7,760,875 	
TOTAL	1,363,047,300	637,747,690	634,530,459	

TOTAL REVENUE

$	12,804,347,300

$	6,192,391,664

$	6,176,525,899

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending December 31, 2019	
Note 1:	Third Party Liability Collections:		December 2019		December 2018		July 1, 2019		July 1, 2018	
	Gross Collections:						December 31, 2019		December 31, 2018	
	Acute	$	910,522		$	817,212		$	8,970,621		$	7,613,816	
	LTC		484,960		276,197		4,189,225		2,835,927	
	KidsCare		1,076		1,392		67,690		3,282	
Total TPL Collections	 $	1,396,558	$	1,094,801	$	13,227,536	$	10,453,025

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	70,335	$	51,478	$	1,085,069	$	775,845	
LTC		101,304		50,600	826,267	731,691	
KidsCare		(49)		50	(360)	13	
Total Expenditure Offsets	  $	171,590 		$	102,128		$	1,910,976		$	1,507,549		

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2019	$ 5,258,991	
	Revenues	5,664,367	
	Transfers-In	 	285,336 	
	Total Revenues	 	5,949,703 	
	Expenditures	6,092,035	
	Transfers-out	 	2,424,350 	
	Total Expenditures	 	8,516,385 	
	Ending Balance December 31, 2019	  $ 2,692,310 	

Of the $2,692,310 ending balance, $1,744,987 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through January 2020.

Note 4:

Summary of Voluntary Political Subdivision Contribution Expenditures:

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

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

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

Note 5:

The following is a summary of $227,671,109 Total Fund ($8,238,846 Hospital Assessment Fund) administrative adjustment transactions for medical service claims processed through December 2019 that either pay for or transfer expenditures with dates of service prior to June 30, 2019.

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

Traditional Medicaid Services	
$	
-	$	
133,575,650	
$	
-	$	
133,575,650	
Proposition 204 Services		7,081,194	49,729,561		-	56,810,755	
ACA Adult Expansion		1,157,653	19,446,616		-	20,604,268	
KidsCare - Children Services		-	1,404,339		-	1,404,339	
Long Term Care		-	-		15,276,098	15,276,098	
Total	$	8,238,846		$	204,156,165		$	15,276,098		$	227,671,109	

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	333,445,321	0	0	0	0	0	0	1,975,882,255	
CAPITATION - AIMHS	292,639	307,037	323,631	334,345	346,743	364,401	0	0	0	0	0	0	1,968,795	
CAPITATION - LTC	250,917,794	252,209,107	253,136,674	286,967,455	287,233,146	287,802,351	0	0	0	0	0	0	1,618,266,526	
MENTAL HEALTH - CHILD	865	2,317	-1,031	-270	1,084	-2,908	0	0	0	0	0	0	57	
MENTAL HEALTH - ADULT	340,947	351,310	462,496	348,822	395,190	350,261	0	0	0	0	0	0	2,249,025	
MENTAL HEALTH - GENERAL	755	1,398	-2,562	3,511	1,243	1,875	0	0	0	0	0	0	6,218	
MENTAL HEALTH - CMDP	11,210,666	11,149,954	11,526,705	12,227,439	12,150,542	12,426,514	0	0	0	0	0	0	70,691,819	
MENTAL HEALTH - DD	7,458,766	7,517,688	7,570,387	6,293	-134	11	0	0	0	0	0	0	22,553,010	
MENTAL HEALTH - RBHA CRISIS	3,210,728	3,227,109	3,238,920	4,390,161	4,391,106	4,399,660	0	0	0	0	0	0	22,857,683	
FEE FOR SERVICE - ACUTE	48,820,855	49,681,027	42,280,433	52,930,957	68,773,323	49,769,243	0	0	0	0	0	0	312,255,838	
FFS - PRIOR QUARTER COVERAGE	953,544	609,982	539,248	471,399	289,234	322,445	0	0	0	0	0	0	3,185,852	
EMERGENCY SERVICES - FEDERAL	4,491,141	3,725,509	4,435,620	4,558,207	3,754,689	3,823,350	0	0	0	0	0	0	24,788,516	
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	1,455,484	0	0	0	0	0	0	5,228,167	
STATE ONLY TRBHA FFS	158,244	111,819	158,545	188,541	161,000	116,304	0	0	0	0	0	0	894,454	
INPATIENT INMATES FFS	244,004	235,027	245,518	346,036	345,038	387,696	0	0	0	0	0	0	1,803,320	
FFS TRBHA FEE FOR SERVICE	12,287,430	11,525,809	8,927,578	12,220,179	11,423,941	11,050,947	0	0	0	0	0	0	67,435,885	
QMB - FEE FOR SERVICE	660,278	490,123	440,696	367,062	187,136	361,483	0	0	0	0	0	0	2,506,778	
PIMA COUNTY INMATES FFS	4,917	34,617	15,870	30,493	13,876	1,835	0	0	0	0	0	0	101,607	
MARICOPA CTY INMATES FFS	19,819	22,216	24,325	1,088	12,263	11,231	0	0	0	0	0	0	90,942	
COCONINO COUNTY INMATES FFS	3,561	3,210	464	0	0	52	0	0	0	0	0	0	7,287	
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	13,627,408	0	0	0	0	0	0	81,075,657	
LFFS - PRIOR QUARTER COVERAGE	72,181	86,245	50,352	44,819	4,812	2,409	0	0	0	0	0	0	260,818	
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	685	0	0	0	0	0	0	28,068	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,557,681	884,889	830,814	1,915,460	1,235,420	2,608,989	0	0	0	0	0	0	9,033,252	
REINSURANCE - ACC	13,954,921	15,652,135	16,821,600	19,456,077	19,517,983	12,784,925	0	0	0	0	0	0	98,187,642	
REINSURANCE - LTC	6,843,752	5,361,382	6,418,046	5,182,315	6,610,870	4,886,014	0	0	0	0	0	0	35,302,379	
SMIB - ACC	15,867,509	15,869,518	16,032,517	16,042,978	16,063,831	16,031,103	0	0	0	0	0	0	95,907,455	
HIB - ACC	775,609	843,035	893,679	881,950	862,191	876,720	0	0	0	0	0	0	5,133,185	
Q1	2,951,192	2,997,689	3,029,726	3,060,005	3,046,073	3,086,791	0	0	0	0	0	0	18,171,476	
SMIB - LTC	4,094,296	4,092,510	4,109,180	4,112,907	4,143,919	4,170,089	0	0	0	0	0	0	24,722,900	
HIB - LTC	381,353	383,342	394,397	388,191	386,272	382,641	0	0	0	0	0	0	2,316,194	
SUBTOTAL	728,338,191	726,618,665	718,813,286	776,751,337	787,871,089	764,545,328	0	0	0	0	0	0	4,502,937,896	

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	290,096,362	0	0	0	0	0	0	1,710,268,229	
CAPITATION - AIMHS	134,306	142,743	148,769	156,410	162,917	170,739	0	0	0	0	0	0	915,884	
MENTAL HEALTH - ADULT	414,838	404,766	357,960	339,574	346,048	314,392	0	0	0	0	0	0	2,177,577	
MENTAL HEALTH - GENERAL	-2,350	-4,545	-6,979	-1,026	-2,248	-1,867	0	0	0	0	0	0	-19,014	
MENTAL HEALTH - CMDP	0	393	762	818	1,922	2,291	0	0	0	0	0	0	6,186	
MENTAL HEALTH - RBHA CRISIS	3,634,857	3,668,731	3,689,681	4,433,299	4,430,127	4,407,033	0	0	0	0	0	0	24,263,728	
FEE FOR SERVICE - ACUTE	37,859,959	38,790,683	33,207,024	40,310,956	56,196,515	39,554,153	0	0	0	0	0	0	245,919,291	
FFS - PRIOR QUARTER COVERAGE	1,204,975	590,575	350,539	247,496	159,052	55,456	0	0	0	0	0	0	2,608,093	
EMERGENCY SERVICES - FEDERAL	3,246,745	2,798,913	3,488,929	3,312,152	2,963,400	2,750,306	0	0	0	0	0	0	18,560,445	
FFS MEDICAID IN PUBLIC SCHOOLS	723	218	330	768	520	983	0	0	0	0	0	0	3,543	
INPATIENT INMATES FFS	889,101	645,173	765,595	723,663	1,110,236	603,533	0	0	0	0	0	0	4,737,300	
FFS TRBHA FEE FOR SERVICE	7,885,916	6,336,072	6,757,819	9,050,014	7,775,195	7,147,186	0	0	0	0	0	0	44,952,203	
STATE ONLY TRBHA FFS	399,387	372,201	456,058	565,497	378,481	440,746	0	0	0	0	0	0	2,612,369	
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	1,254	0	0	0	0	0	0	18,010	
PIMA COUNTY INMATES FFS	44,460	29,912	57,917	22,647	78,415	60,335	0	0	0	0	0	0	293,685	
MOHAVE COUNTY INMATES FFS	3,409	15,944	0	0	0	17,050	0	0	0	0	0	0	36,403	
MARICOPA CTY INMATES FFS	214,579	207,410	203,431	152,268	191,138	115,750	0	0	0	0	0	0	1,084,576	
COCONINO COUNTY INMATES FFS	302	3,171	0	165	80	4,062	0	0	0	0	0	0	7,780	
REINSURANCE - ACC	6,253,343	6,750,467	8,759,810	5,851,025	9,109,166	5,954,985	0	0	0	0	0	0	42,678,797	
SMIB - ACC	7,097,119	7,165,395	7,230,656	7,256,687	7,251,712	7,263,705	0	0	0	0	0	0	43,265,274	
HIB - ACC	6,248	4,850	4,894	4,894	4,413	4,173	0	0	0	0	0	0	29,472	
SUBTOTAL	347,582,951	348,190,644	344,620,338	364,432,537	380,644,543	358,962,627	0	0	0	0	0	0	2,144,433,640	

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	34,753,309	0	0	0	0	0	0	206,202,942	
CAPITATION - AIMHS	12,254	13,041	13,411	13,456	13,792	14,397	0	0	0	0	0	0	80,351	
MENTAL HEALTH - ADULT	12,078	12,834	13,307	10,299	9,656	28,879	0	0	0	0	0	0	87,052	
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	818	0	0	0	0	0	0	3,978	
MENTAL HEALTH - RBHA CRISIS	575,493	582,267	581,810	696,263	690,179	686,110	0	0	0	0	0	0	3,812,123	
FEE FOR SERVICE - ACUTE	2,872,751	3,384,201	2,596,379	3,610,161	4,963,978	2,932,703	0	0	0	0	0	0	20,360,174	
FFS - PRIOR QUARTER COVERAGE	200,446	340,753	89,570	110,297	27,989	10,047	0	0	0	0	0	0	779,101	
EMERGENCY SERVICES - FEDERAL	5,151,773	4,521,846	4,307,602	4,739,519	4,142,469	4,038,005	0	0	0	0	0	0	26,901,214	
FFS MEDICAID IN PUBLIC SCHOOLS	66	0	0	34	0	15	0	0	0	0	0	0	115	
FFS TRBHA FEE FOR SERVICE	279,336	136,082	159,112	163,246	150,059	186,733	0	0	0	0	0	0	1,074,569	
STATE ONLY TRBHA FFS	39,350	9,279	10,091	52,331	11,941	33,648	0	0	0	0	0	0	156,639	
INPATIENT INMATES FFS	61,395	5,936	718	18,994	90,712	25,029	0	0	0	0	0	0	202,784	
MARICOPA CTY INMATES FFS	8,779	2,632	4,840	20,343	660	5,792	0	0	0	0	0	0	43,048	
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	1,021,967	0	0	0	0	0	0	6,512,565	
SMIB - ACC	271	136	0	0	271	271	0	0	0	0	0	0	949	
	43,548,708	43,869,597	42,267,781	46,608,827	46,183,539	43,737,723	0	0	0	0	0	0	266,216,175	
	1,119,469,850	1,118,678,906	1,105,701,405	1,187,792,702	1,214,699,171	1,167,245,677	0	0	0	0	0	0	6,913,587,711	

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	6,631,335	0	0	0	0	0	0	38,510,949	
KidsCare - FEE FOR SERVICE	124,559	240,555	141,881	280,744	380,853	260,684	0	0	0	0	0	0	1,429,275	
KidsCare - MENTAL HEALTH	59,368	60,012	61,651	79,894	73,520	75,274	0	0	0	0	0	0	409,719	
KidsCare - REINSURANCE	200,701	116,470	178,310	68,995	201,596	571,913	0	0	0	0	0	0	1,337,985	

6,487,491	6,610,278	6,629,190	7,105,104	7,321,449	7,539,206	0	0	0	0	0	0	41,692,718	

TOTAL TITLE XXI

1,125,957,341	1,125,289,184	1,112,330,595	1,194,897,806	1,222,020,621	1,174,784,883	0	0	0	0	0	0	6,955,280,430	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	123.63	0.00	0.00	0.00	0.00	0.00	0.00		123.63		
1006	TANF 21-44 MALE WITH	42,054.34	48,959.09	44,661.46	42,858.20	42,323.49	37,287.90	0.00	0.00	0.00	0.00	0.00	0.00		258,144.48		
1007	TANF 21-44 FEMALE WI	45,256.87	48,452.58	37,289.55	36,573.35	40,432.42	33,375.17	0.00	0.00	0.00	0.00	0.00	0.00		241,379.94		
1008	TANF 45-64 M & F WIT	58,324.80	51,372.72	55,455.73	59,288.73	62,781.02	65,562.66	0.00	0.00	0.00	0.00	0.00	0.00		352,785.66		
1009	TANF 65+ M & F WITH	16,091.48	14,740.77	12,841.93	10,830.21	11,819.98	12,341.56	0.00	0.00	0.00	0.00	0.00	0.00		78,665.93		
100F	TANF 21-44 MALE WITH	40.03	581.66	1,451.87	603.71	578.41	22.10	0.00	0.00	0.00	0.00	0.00	0.00		3,277.78		
100G	TANF 21-44 FEMALE WI	2,488.06	2,248.29	2,866.78	99.61	597.88	407.73	0.00	0.00	0.00	0.00	0.00	0.00		8,708.35		
100H	TANF 45-64 M & F WIT	4,175.05	3,092.89	2,374.57	461.51	341.84	33.15	0.00	0.00	0.00	0.00	0.00	0.00		10,479.01		
100J	TANF 65+ M & F WITH	212.66	202.84	436.85	0.00	359.39	345.28	0.00	0.00	0.00	0.00	0.00	0.00		1,557.02		
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	5,847,486.08	0.00	0.00	0.00	0.00	0.00	0.00		34,428,115.37		
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	4,048,139.73	0.00	0.00	0.00	0.00	0.00	0.00		21,795,760.10		
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	7,238,680.62	0.00	0.00	0.00	0.00	0.00	0.00		39,033,811.84		
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	2,195,682.05	0.00	0.00	0.00	0.00	0.00	0.00		11,974,703.03		
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	2,625,813.85	0.00	0.00	0.00	0.00	0.00	0.00		14,625,827.18		
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	9,964,864.54	0.00	0.00	0.00	0.00	0.00	0.00		57,742,102.32		
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	34,111,539.68	0.00	0.00	0.00	0.00	0.00	0.00		199,804,529.71		
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	8,178,867.42	0.00	0.00	0.00	0.00	0.00	0.00		47,529,906.07		
1019	TANF 65+ M & F NON-M	31,052.28	29,784.99	31,822.50	32,621.26	32,414.71	36,259.53	0.00	0.00	0.00	0.00	0.00	0.00		193,955.27		
101A	TANF < 1 M & F NON-M	352,937.84	334,377.43	295,390.35	340,918.93	316,366.26	192,943.98	0.00	0.00	0.00	0.00	0.00	0.00		1,832,934.79		
101B	TANF 01-05 M & F NON	31,695.97	27,524.01	22,926.16	34,432.14	22,446.83	34,831.40	0.00	0.00	0.00	0.00	0.00	0.00		173,856.51		
101C	TANF 06-13 M & F NON	16,670.28	19,749.31	20,214.14	31,451.20	9,783.54	26,778.35	0.00	0.00	0.00	0.00	0.00	0.00		124,646.82		
101D	TANF 14-20 MALE NON-	9,808.43	14,845.50	11,848.57	9,602.25	12,556.31	5,869.26	0.00	0.00	0.00	0.00	0.00	0.00		64,530.32		
101E	TANF 14-20 FEMALE N O	18,630.37	20,897.05	23,373.06	14,812.75	11,908.71	14,765.59	0.00	0.00	0.00	0.00	0.00	0.00		104,387.53		
101F	TANF 21-44 MALE NON-	246,596.25	255,429.76	194,158.71	213,830.17	206,314.00	182,598.28	0.00	0.00	0.00	0.00	0.00	0.00		1,298,927.17		
101G	TANF 21-44 FEMALE N O	615,659.33	583,850.07	465,507.37	483,973.96	473,022.34	439,188.43	0.00	0.00	0.00	0.00	0.00	0.00		3,061,201.50		
101H	TANF 44-64 M & F NON	131,317.46	152,039.59	104,634.71	127,378.55	129,042.24	139,855.15	0.00	0.00	0.00	0.00	0.00	0.00		784,267.70		
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	1,768.75	0.00	0.00	0.00	0.00	0.00	0.00		10,967.02		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	1,649.28	0.00	0.00	0.00	0.00	0.00	0.00		1,649.28		
1026	TANF 21-44 MALE WITH	30,833.82	25,161.04	23,949.90	20,548.44	15,048.73	13,459.81	0.00	0.00	0.00	0.00	0.00	0.00		129,001.74		
1027	TANF 21-44 FEMALE WI	33,845.08	29,934.75	39,393.39	30,840.59	29,261.43	35,954.66	0.00	0.00	0.00	0.00	0.00	0.00		199,229.90		
1028	TANF 45-64 M & F WIT	32,482.04	30,194.61	33,485.88	38,169.75	31,879.90	28,830.47	0.00	0.00	0.00	0.00	0.00	0.00		195,042.65		
1029	TANF 65+ M & F WITH	9,312.30	9,417.77	6,856.06	8,190.14	7,732.09	8,277.59	0.00	0.00	0.00	0.00	0.00	0.00		49,785.95		
102F	TANF 21-44 MALE WITH	0.00	77.29	129.25	15.42	3.98	220.10	0.00	0.00	0.00	0.00	0.00	0.00		446.04		
102G	TANF 21-44 FEMALE WI	0.00	67.86	0.00	200.16	65.14	38.54	0.00	0.00	0.00	0.00	0.00	0.00		371.70		
102H	TANF 44-64 M & F WIT	0.00	0.00	38.22	581.36	6,681.12	2,242.53	0.00	0.00	0.00	0.00	0.00	0.00		9,543.23		

ACC CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	657,181.14	0.00	0.00	0.00	0.00	0.00	0.00		4,093,684.24		
210Z	SSI AGED WITH MEDIC
A	52,660.57	41,774.04	32,514.74	42,682.27	33,049.12	44,752.44	0.00	0.00	0.00	0.00	0.00	0.00		247,433.18		
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	8,724,391.57	0.00	0.00	0.00	0.00	0.00	0.00		51,624,131.00		
211Z	SSI AGED NON-MEDIC
AR	216,958.62	161,562.33	135,278.37	170,335.07	191,280.57	135,826.02	0.00	0.00	0.00	0.00	0.00	0.00		1,011,240.98		
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	5,261,789.65	0.00	0.00	0.00	0.00	0.00	0.00		32,318,940.95		
212Z	SSI AGED WITH QMB P P	4,799.26	6,473.36	9,408.43	3,946.39	4,822.55	8,358.60	0.00	0.00	0.00	0.00	0.00	0.00		37,808.59		
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	1,759,854.56	0.00	0.00	0.00	0.00	0.00	0.00		10,618,594.95		
220Z	SSI DISABLED WITH M E	96,386.79	59,787.78	85,084.80	74,882.47	52,442.41	72,487.17	0.00	0.00	0.00	0.00	0.00	0.00		441,071.42		
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	71,853,056.44	0.00	0.00	0.00	0.00	0.00	0.00		427,704,793.49		
221Z	SSI DISABLED NON-ME D	942,051.13	933,821.38	825,347.66	868,410.05	930,105.69	909,560.48	0.00	0.00	0.00	0.00	0.00	0.00		5,409,296.39		
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	15,272,371.07	0.00	0.00	0.00	0.00	0.00	0.00		90,620,194.09		
222Z	SSI DISABLED WITH Q M	31,562.80	38,109.67	39,444.48	60,437.56	39,111.68	41,092.31	0.00	0.00	0.00	0.00	0.00	0.00		249,758.50		
2300	SSI BLIND WITH MEDIC	7,894.62	8,025.40	7,600.96	7,717.09	7,721.76	7,800.88	0.00	0.00	0.00	0.00	0.00	0.00		46,760.71		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	18.06	0.00	0.00	0.00	0.00	0.00	0.00		18.06		
2310	SSI BLIND NON-MEDIC A	633,695.19	633,652.52	642,091.43	647,172.16	639,301.52	639,411.85	0.00	0.00	0.00	0.00	0.00	0.00		3,835,324.67		
231Z	SSI BLIND NON-MEDIC
A	5,251.90	10,051.71	22,411.45	23,240.84	2,465.53	18,241.02	0.00	0.00	0.00	0.00	0.00	0.00		81,662.45		
2320	SSI BLIND WITH QMB	47,291.74	47,835.53	47,975.47	45,708.70	48,382.38	50,070.52	0.00	0.00	0.00	0.00	0.00	0.00		287,264.34		
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		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	133.78	0.00	0.00	0.00	0.00	0.00	0.00		133.78		
4302	SOBRA CHILD 01-05 M	384.93	668.23	677.67	625.97	550.16	358.41	0.00	0.00	0.00	0.00	0.00	0.00		3,265.37		
4303	SOBRA CHILD 06-13 M	671.85	839.07	526.79	627.08	627.08	627.08	0.00	0.00	0.00	0.00	0.00	0.00		3,918.95		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	119.47	119.47	0.00	0.00	0.00	0.00	0.00	0.00		238.94		
4305	SOBRA CHILD 14-20 FE	598.98	472.87	136.70	127.40	127.40	127.40	0.00	0.00	0.00	0.00	0.00	0.00		1,590.75		
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	20,315,889.75	0.00	0.00	0.00	0.00	0.00	0.00		121,714,491.85		
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	31,027,447.32	0.00	0.00	0.00	0.00	0.00	0.00		185,609,010.17		
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	40,373,653.66	0.00	0.00	0.00	0.00	0.00	0.00		240,420,108.86		
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	11,383,678.78	0.00	0.00	0.00	0.00	0.00	0.00		67,025,774.05		
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	11,295,733.89	0.00	0.00	0.00	0.00	0.00	0.00		66,820,371.88		
431A	SOBRA CHILD < 1 M &	255,349.52	216,051.62	182,881.71	205,334.74	189,022.10	152,376.43	0.00	0.00	0.00	0.00	0.00	0.00		1,201,016.12		
431B	SOBRA CHILD 01-05 M	734,288.72	672,792.26	556,972.69	630,508.19	606,921.80	588,207.67	0.00	0.00	0.00	0.00	0.00	0.00		3,789,691.33		
431C	SOBRA CHILD 6-13 M& F	698,553.25	730,808.98	551,793.26	609,387.25	588,657.23	586,656.86	0.00	0.00	0.00	0.00	0.00	0.00		3,765,856.83		
431D	SOBRA CHILD 14-20 MA	203,649.34	208,008.27	168,887.99	169,048.28	179,621.04	184,605.07	0.00	0.00	0.00	0.00	0.00	0.00		1,113,819.99		
431E	SOBRA CHILD 14-20 FE	210,973.01	203,192.73	181,516.56	172,528.36	178,270.76	164,598.61	0.00	0.00	0.00	0.00	0.00	0.00		1,111,080.03		

ACC CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4322	SOBRA CHILD 01-05 M	191.11	191.11	191.11	168.64	168.64	168.64	0.00	0.00	0.00	0.00	0.00	0.00		1,079.25		
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	243.05	0.00	0.00	0.00	0.00	0.00	0.00		1,980.81		
432E	SOBRA CHILD 14-20 FE	80.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80.05		
5007	SOBRA PREG 21-44 FE M	21,876.18	18,676.51	18,335.66	21,167.20	12,544.39	10,269.91	0.00	0.00	0.00	0.00	0.00	0.00		102,869.85		
5008	SOBRA PREG 45-64 FE
M	253.60	253.60	253.60	350.90	726.21	1,880.71	0.00	0.00	0.00	0.00	0.00	0.00		3,718.62		
500G	SOBRA PREG 21-44 FE M	3,420.46	2,107.63	794.66	0.00	293.32	273.77	0.00	0.00	0.00	0.00	0.00	0.00		6,889.84		
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	1,429.12	0.00	0.00	0.00	0.00	0.00	0.00		4,043.81		
5015	SOBRA PREG 14-20 FE
M	530,163.48	543,226.36	547,975.79	575,638.49	549,458.39	546,596.48	0.00	0.00	0.00	0.00	0.00	0.00		3,293,058.99		
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	5,965,315.11	0.00	0.00	0.00	0.00	0.00	0.00		36,291,868.67		
5018	SOBRA PREG 45-64 FE
M	17,581.17	19,841.48	22,726.54	27,536.00	27,334.54	26,327.42	0.00	0.00	0.00	0.00	0.00	0.00		141,347.15		
501C	SOBRA PREG 09-13 FE M	167.73	0.00	0.00	0.00	0.00	73.24	0.00	0.00	0.00	0.00	0.00	0.00		240.97		
501E	SOBRA PREG 14-20 FE
M	46,644.18	38,879.61	39,907.67	38,171.15	38,594.99	30,030.51	0.00	0.00	0.00	0.00	0.00	0.00		232,228.11		
501G	SOBRA PREG 21-44 FE M	403,573.06	413,507.29	339,988.21	336,778.20	326,375.21	322,632.22	0.00	0.00	0.00	0.00	0.00	0.00		2,142,854.19		
501H	SOBRA PREG 45-64 FE
M	54.35	1,725.17	6,412.35	1,312.28	4,770.91	1,216.81	0.00	0.00	0.00	0.00	0.00	0.00		15,491.87		
5027	SOBRA PREG 21-44 FE M	14,542.79	19,007.23	29,474.11	31,109.80	34,192.14	32,355.42	0.00	0.00	0.00	0.00	0.00	0.00		160,681.49		
5028	SOBRA PREG 45-64 FE
M	2,368.16	2,368.16	2,368.16	168.64	288.11	168.64	0.00	0.00	0.00	0.00	0.00	0.00		7,729.87		
SUBTOTAL:	295,696,553.19	296,536,345.61	295,713,370.81	304,392,294.28	303,411,307.60	303,995,563.86	0.00	0.00	0.00	0.00	0.00	0.00		1,799,745,435.35		

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	1,575,442.44	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	24,767.21	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	118,263.69	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	13,661,872.28	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	15,380,345.62	0.00	0.00	0.00	0.00	0.00	0.00	

 
10,183,257.83	
149,959.92	
651,629.27	
79,147,762.87	
90,132,609.89	

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	74,953.93	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	156,628.07	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	358,025.00	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	88,163.62	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	2,041.08	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	4,450.94	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	6,888.80	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	2,684.33	0.00	0.00	0.00	0.00	0.00	0.00	

 
145.06	
409,689.33	
1,076,203.48	
2,293,128.60	
555,872.04	
30,662.37	
51,935.54	
65,373.69	
24,447.57	

ACC CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		186.83		
1113	TANF EXPANDED 06-13	1,252.85	1,252.85	1,073.55	1,122.19	1,122.19	873.92	0.00	0.00	0.00	0.00	0.00	0.00		6,697.55		
1114	TANF EXPANDED 14-20	38,415.06	38,413.55	38,265.78	41,902.37	41,498.84	41,767.22	0.00	0.00	0.00	0.00	0.00	0.00		240,262.82		
1115	TANF EXPANDED 14-20	275,091.63	277,526.66	267,373.68	289,322.19	281,371.71	274,968.78	0.00	0.00	0.00	0.00	0.00	0.00		1,665,654.65		
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	9,550,325.98	0.00	0.00	0.00	0.00	0.00	0.00		58,755,302.28		
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	26,960,089.61	0.00	0.00	0.00	0.00	0.00	0.00		163,066,958.01		
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	9,227,896.02	0.00	0.00	0.00	0.00	0.00	0.00		55,664,424.12		
1119	TANF EXPANDED 65+
M&	30,255.92	28,131.96	28,000.75	28,862.78	32,142.43	32,001.01	0.00	0.00	0.00	0.00	0.00	0.00		179,394.85		
111C	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	73.27	0.00	0.00	0.00	0.00	0.00	0.00		73.27		
111D	TANF EXPANDED 14-20	2,490.39	1,152.78	1,523.21	3,036.33	1,816.92	1,641.25	0.00	0.00	0.00	0.00	0.00	0.00		11,660.88		
111E	TANF EXPANDED 14-20	7,437.73	5,473.69	3,147.13	10,374.18	5,003.15	4,747.54	0.00	0.00	0.00	0.00	0.00	0.00		36,183.42		
111F	TANF EXPANDED 21-44	267,373.80	262,773.96	215,068.24	235,644.82	208,690.61	216,054.62	0.00	0.00	0.00	0.00	0.00	0.00		1,405,606.05		
111G	TANF EXPANDED 21-44	525,020.23	509,660.72	400,174.61	489,416.42	444,516.24	401,643.71	0.00	0.00	0.00	0.00	0.00	0.00		2,770,431.93		
111H	TANF EXPANDED 45-64	178,932.04	172,494.14	159,074.75	150,035.45	153,058.78	156,082.57	0.00	0.00	0.00	0.00	0.00	0.00		969,677.73		
111J	TANF EXPANDED 65+
M&	592.01	928.69	367.98	904.28	3,138.45	1,269.53	0.00	0.00	0.00	0.00	0.00	0.00		7,200.94		
1126	TANF EXPANDED 21-44	297,942.68	293,773.27	291,620.59	306,418.42	301,144.14	295,722.12	0.00	0.00	0.00	0.00	0.00	0.00		1,786,621.22		
1127	TANF EXPANDED 21-44	790,701.02	789,295.29	779,113.14	789,198.37	790,964.18	796,613.51	0.00	0.00	0.00	0.00	0.00	0.00		4,735,885.51		
1128	TANF EXPANDED 45-64	900,768.88	921,413.73	924,623.19	928,434.52	927,852.63	939,397.80	0.00	0.00	0.00	0.00	0.00	0.00		5,542,490.75		
1129	TANF EXPANDED 65+
M&	256,772.30	259,581.62	263,961.29	248,104.89	248,988.31	250,537.88	0.00	0.00	0.00	0.00	0.00	0.00		1,527,946.29		
112F	TANF EXPANDED 21-44	0.00	2,931.30	4,191.82	114.25	988.92	5,468.45	0.00	0.00	0.00	0.00	0.00	0.00		13,694.74		
112G	TANF EXPANDED 21-44	2,213.20	5,170.00	2,450.40	1,114.75	3,714.40	171.88	0.00	0.00	0.00	0.00	0.00	0.00		14,834.63		
112H	TANF EXPANDED 45-64	6,227.67	1,063.02	540.07	7,528.30	1,670.64	609.93	0.00	0.00	0.00	0.00	0.00	0.00		17,639.63		
112J	TANF EXPANDED 65+
M&	3,111.80	878.74	906.87	814.40	34.82	526.87	0.00	0.00	0.00	0.00	0.00	0.00		6,273.50		
2400	SSI AGED EXPANDED WI	40,745.64	49,658.35	38,234.62	42,281.47	37,211.36	35,322.07	0.00	0.00	0.00	0.00	0.00	0.00		243,453.51		
240Z	SSI AGED EXPANDED
WI	26,984.10	40,705.46	35,897.94	27,426.39	50,793.70	18,708.07	0.00	0.00	0.00	0.00	0.00	0.00		200,515.66		
2410	SSI AGED EXPANDED NO	116,302.77	124,836.95	115,780.95	113,521.05	114,817.69	113,632.17	0.00	0.00	0.00	0.00	0.00	0.00		698,891.58		
241Z	SSI AGED EXPANDED
NO	15,686.56	0.00	2,707.35	12,150.89	5,497.52	3,538.97	0.00	0.00	0.00	0.00	0.00	0.00		39,581.29		
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	5,311,230.72	0.00	0.00	0.00	0.00	0.00	0.00		32,166,799.81		
242Z	SSI AGED EXPANDED
WI	10,566.52	4,568.42	7,433.00	9,127.29	8,761.32	7,137.93	0.00	0.00	0.00	0.00	0.00	0.00		47,594.48		
2520	SSI BLIND EXPANDED W	191.11	191.11	191.11	168.64	288.11	288.11	0.00	0.00	0.00	0.00	0.00	0.00		1,318.19		
2600	SSI DISABLED EXPAND
E	95,669.32	118,092.54	108,033.75	124,095.05	114,799.54	133,457.04	0.00	0.00	0.00	0.00	0.00	0.00		694,147.24		
260Z	SSI DISABLED EXPAND E	60,164.41	59,191.60	53,022.25	48,257.79	46,863.89	51,512.21	0.00	0.00	0.00	0.00	0.00	0.00		319,012.15		
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	2,052,299.41	0.00	0.00	0.00	0.00	0.00	0.00		11,775,840.65		
261Z	SSI DISABLED EXPAND E	41,560.30	39,967.68	26,817.13	29,654.10	36,640.28	47,277.72	0.00	0.00	0.00	0.00	0.00	0.00		221,917.21		
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	10,981,036.60	0.00	0.00	0.00	0.00	0.00	0.00		64,840,559.17		
262Z	SSI DISABLED EXPAND E	24,786.63	13,062.99	25,997.02	38,102.49	8,699.07	14,396.81	0.00	0.00	0.00	0.00	0.00	0.00		125,045.01		

ACC CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	68,743,011.07	68,940,363.76	68,696,349.05	69,927,676.36	69,377,677.92	68,622,157.07	0.00	0.00	0.00	0.00	0.00	0.00		414,307,235.23		

3506	ADULT 40-100% MALE 2	5,764.11	5,307.37	5,088.93	7,318.11	4,692.15	4,968.15	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	2,241.00	10,614.95	5,047.64	5,979.70	6,499.55	8,350.98	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	52,917.78	53,388.43	56,444.93	53,201.28	39,809.36	38,057.14	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	4,596.56	10,268.05	12,020.33	15,029.38	6,926.95	4,879.09	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
350H	ADULT 40-100% M&F 45	8,724.34	4,663.08	738.24	589.11	2,009.83	9,577.04	0.00	0.00	0.00	0.00	0.00	0.00	
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	3,797,873.56	0.00	0.00	0.00	0.00	0.00	0.00	
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	4,152,534.22	0.00	0.00	0.00	0.00	0.00	0.00	
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	12,970,277.84	0.00	0.00	0.00	0.00	0.00	0.00	
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	11,032,383.65	0.00	0.00	0.00	0.00	0.00	0.00	
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	25,070,172.50	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	4,796.70	2,957.31	3,486.22	3,624.66	2,984.40	3,823.28	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	69,871.09	58,513.99	62,621.06	62,052.90	65,261.07	47,006.04	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	96,620.75	91,285.70	76,978.92	72,929.40	87,157.17	73,015.46	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	378,306.71	316,217.93	260,303.87	284,982.56	268,566.21	257,061.67	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	314,532.51	292,594.59	213,966.75	241,271.33	233,602.83	261,647.41	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	571,004.41	500,509.79	406,418.38	452,726.14	413,199.02	466,571.75	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	1,126.81	546.10	1,825.01	2,864.69	0.00	11,988.09	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	512.80	1,005.43	0.00	598.08	240.15	1,462.81	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	5,253.95	2,405.87	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	1,367.52	642.20	984.40	1,899.76	583.41	386.24	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
352G	ADULT 40-100% FEMAL E	0.00	0.00	696.12	0.00	1,888.16	83.06	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	2,899.38	0.00	1,124.38	152.40	0.00	183.93	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3706	ADULT <40% EXP MALE	27,591.56	35,651.38	38,300.27	50,842.90	39,844.93	39,177.75	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	3,910.19	8,759.02	9,934.25	10,776.00	19,252.71	16,415.28	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	57,244.70	70,221.48	68,023.40	77,774.04	70,086.68	76,330.51	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	3,342.45	6,220.57	8,040.20	9,598.58	6,289.08	6,268.70	0.00	0.00	0.00	0.00	0.00	0.00	

33,138.82	
38,733.82	
293,818.92	
53,720.36	
3,607.92	
12,449.21	
26,301.64	
22,200,459.28	
24,334,547.45	
76,164,503.39	
64,072,126.89	
147,830,860.72	
21,672.57	
365,326.15	
497,987.40	
1,765,438.95	
1,557,615.42	
2,810,429.49	
18,350.70	
3,819.27	
7,659.82	
5,863.53	
4,428.87	
3,790.97	
2,667.34	
4,360.09	
636.94	
231,408.79	
69,047.45	
419,680.81	
39,759.58	

9911	SB PAYMENT FOR TAN F	1,192,225.73	1,197,905.14	1,182,328.27	976,597.96	999,126.74	1,129,093.42	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	1,129,093.42	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,677,277.26	
6,109.98	
6,683,387.24	

ACC CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
370F	ADULT <40% EXP MALE	10,732.30	5,515.81	10,662.39	4,379.14	1,950.65	1,869.14	0.00	0.00	0.00	0.00	0.00	0.00		35,109.43		
370G	ADULT <40% EXP FEM AL	497.19	1,324.21	2,550.57	29,039.02	4,360.48	3,081.65	0.00	0.00	0.00	0.00	0.00	0.00		40,853.12		
370H	ADULT <40% EXP M&F
4	9,493.54	14,470.80	7,660.76	7,614.14	10,704.73	8,141.82	0.00	0.00	0.00	0.00	0.00	0.00		58,085.79		
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	6,901,559.02	0.00	0.00	0.00	0.00	0.00	0.00		40,789,948.93		
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	6,205,007.20	0.00	0.00	0.00	0.00	0.00	0.00		36,877,386.30		
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	53,166,341.70	0.00	0.00	0.00	0.00	0.00	0.00		307,543,442.69		
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	31,306,922.65	0.00	0.00	0.00	0.00	0.00	0.00		182,373,859.33		
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	60,237,103.48	0.00	0.00	0.00	0.00	0.00	0.00		351,801,666.26		
3719	ADULT <40% EXP M&F 6	4,322.81	5,789.39	5,237.33	6,191.72	7,303.75	7,773.31	0.00	0.00	0.00	0.00	0.00	0.00		36,618.31		
371D	ADULT <40% EXP MALE	173,398.88	166,910.98	142,642.92	149,675.54	149,602.20	123,554.04	0.00	0.00	0.00	0.00	0.00	0.00		905,784.56		
371E	ADULT <40% EXP FEM AL	170,863.21	142,486.87	112,122.69	121,004.92	130,024.61	116,777.74	0.00	0.00	0.00	0.00	0.00	0.00		793,280.04		
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	1,327,246.80	0.00	0.00	0.00	0.00	0.00	0.00		8,772,646.45		
371G	ADULT <40% EXP FEM AL	1,025,917.09	813,958.12	707,195.63	877,496.51	716,944.11	751,986.62	0.00	0.00	0.00	0.00	0.00	0.00		4,893,498.08		
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	1,141,534.32	0.00	0.00	0.00	0.00	0.00	0.00		7,348,024.85		
371J	ADULT <40% EXP M&F 6	0.00	0.00	762.31	0.00	38.94	1,388.82	0.00	0.00	0.00	0.00	0.00	0.00		2,190.07		
3726	ADULT <40% EXP MALE	1,897.66	3,045.53	1,010.32	4,101.68	3,295.53	3,122.16	0.00	0.00	0.00	0.00	0.00	0.00		16,472.88		
3727	ADULT <40% EXP FEM AL	1,521.58	1,175.63	1,175.63	3,047.26	946.51	953.56	0.00	0.00	0.00	0.00	0.00	0.00		8,820.17		
3728	ADULT <40% EXP M&F
4	0.00	3,480.51	1,898.98	2,527.06	6,484.66	6,335.40	0.00	0.00	0.00	0.00	0.00	0.00		20,726.61		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	570.17	570.17	0.00	0.00	0.00	0.00	0.00	0.00		1,140.34		
372F	ADULT <40% EXP MALE	1,485.99	0.00	0.00	1,682.22	0.00	320.47	0.00	0.00	0.00	0.00	0.00	0.00		3,488.68		
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	7,503.68	0.00	0.00	0.00	0.00	0.00	0.00		8,017.36		
SUBTOTAL:	207,740,499.54	209,424,624.92	208,557,027.17	220,437,459.25	219,395,810.96	219,671,995.77	0.00	0.00	0.00	0.00	0.00	0.00		1,285,227,417.61		

3906	NEWLY ELIGIBLE MALE	9,297.77	14,217.05	12,452.76	15,498.83	16,317.22	18,103.54	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	2,739.82	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	33,998.91	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	5,723.30	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	269.33	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	1,412.31	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	6,382.58	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	

85,887.17	
14,384.81	
203,041.82	
63,178.67	
2,313.52	
5,172.70	
30,641.26	
2,594.88	

9935	BIRTH SUPP PAYMENT A	151,291.91	252,079.35	221,179.92	136,085.21	217,101.77	168,953.67	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	504,161.67	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	673,115.34	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,146,691.83	
2,903,496.71	
4,050,188.54	

ACC CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	1,284,259.95	1,307,972.39	1,305,516.72	1,443,342.47	1,432,020.80	1,458,397.15	0.00	0.00	0.00	0.00	0.00	0.00		8,231,509.48		
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	1,611,711.03	0.00	0.00	0.00	0.00	0.00	0.00		9,272,147.87		
3916	NEWLY ELIGIBLE MALE	7,364,904.93	7,430,921.64	7,329,980.30	7,755,694.51	7,576,758.56	7,505,127.47	0.00	0.00	0.00	0.00	0.00	0.00		44,963,387.41		
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	11,240,452.58	0.00	0.00	0.00	0.00	0.00	0.00		67,056,200.05		
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	11,767,804.16	0.00	0.00	0.00	0.00	0.00	0.00		68,798,892.90		
3919	NEWLY ELIGIBLE M&F 6	475.27	376.91	749.95	409.28	1,239.19	792.02	0.00	0.00	0.00	0.00	0.00	0.00		4,042.62		
391D	NEWLY ELIGIBLE MALE	35,162.36	25,533.98	27,119.68	23,581.76	22,180.15	26,647.21	0.00	0.00	0.00	0.00	0.00	0.00		160,225.14		
391E	NEWLY ELIGIBLE FEMA L	45,902.91	40,350.46	37,851.72	32,289.49	27,676.79	31,657.62	0.00	0.00	0.00	0.00	0.00	0.00		215,728.99		
391F	NEWLY ELIGIBLE MALE	276,730.87	235,207.91	218,621.78	242,758.31	213,094.79	214,885.93	0.00	0.00	0.00	0.00	0.00	0.00		1,401,299.59		
391G	NEWLY ELIGIBLE FEMA L	424,973.22	387,794.23	305,099.35	342,030.80	321,120.60	265,597.58	0.00	0.00	0.00	0.00	0.00	0.00		2,046,615.78		
391H	NEWLY ELIGIBLE M&F
4	330,872.11	269,795.17	240,089.92	291,740.21	283,965.91	236,422.95	0.00	0.00	0.00	0.00	0.00	0.00		1,652,886.27		
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	1,884.40	0.00	0.00	0.00	0.00	0.00	0.00		12,111.12		
3928	NEWLY ELIGIBLE M&F
4	0.00	384.57	384.57	852.61	1,800.56	493.17	0.00	0.00	0.00	0.00	0.00	0.00		3,915.48		
3929	NEWLY ELIGIBLE M&F 6	764.22	0.00	0.00	0.00	0.00	493.17	0.00	0.00	0.00	0.00	0.00	0.00		1,257.39		
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	34,430,996.23	0.00	0.00	0.00	0.00	0.00	0.00		204,231,848.57		

9939	BIRTH SUPP PAYMENT N	287,755.48	369,407.99	310,122.63	396,494.47	285,000.67	322,312.46	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	287,755.48	369,407.99	310,122.63	396,494.47	285,000.67	322,312.46	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,971,093.70

1,971,093.70

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	7,225,521.25	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	2,089,930.01	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	2,052,675.78	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	124,085.75	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	36,319.31	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	37,156.65	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	11,565,688.75	0.00	0.00	0.00	0.00	0.00	0.00	

 
138.81	
44,333,071.93	
12,750,857.24	
12,390,643.24	
40.49	
975,375.99	
278,383.67	
262,777.41	
70,991,288.78	

9944	BIRTH SUPP PAYMENT S	11,882.90	58,943.98	23,471.72	24,770.76	18,450.92	49,784.74	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	49,784.74	0.00	0.00	0.00	0.00	0.00	0.00	

 
187,305.02

187,305.02

60,916.93

4517	BC PATIENT FEMALE 2 1	10,376.74	10,793.95	10,912.09	10,415.24	9,325.23	9,093.68	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	47,402.20	0.00	0.00	0.00	0.00	0.00	0.00	

286,622.41

ACC CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4519	BC PATIENT FEMALE 6 5	0.00	245.28	0.00	0.00	0.00	805.63	0.00	0.00	0.00	0.00	0.00	0.00		1,050.91		
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		4,643.75		
451H	BC PATIENT FEMALE 4 5	6,761.14	474.81	281.62	3,948.99	1,159.45	5,906.73	0.00	0.00	0.00	0.00	0.00	0.00		18,532.74		
4617	CC PATIENT FEMALE 2
1	4,771.12	4,771.12	4,440.56	4,876.72	5,094.73	4,719.27	0.00	0.00	0.00	0.00	0.00	0.00		28,673.52		
4618	CC PATIENT FEMALE 4 5	2,661.05	2,661.05	2,759.18	3,797.60	3,797.60	4,173.06	0.00	0.00	0.00	0.00	0.00	0.00		19,849.54		
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	72,100.57	0.00	0.00	0.00	0.00	0.00	0.00		424,418.42		

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

6,170.47

8600	SSI BLIND FREEDOM/W O	2,514.53	2,514.53	146.37	133.78	133.78	133.78	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	127.40	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	1,609,018.36	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	33,767.97	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	458,369.77	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	32,039.83	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	242,333.44	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	6,047.39	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	2,381,837.94	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,576.77	
792.30	
9,544,133.87	
359,920.95	
2,876,193.16	
166,915.36	
1,393,640.89	
47,655.49	
14,394,828.79	

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

 
4,706.10

4,706.10

3,892,358,131.71

637,039,184.43	640,246,228.62	636,844,407.74	662,233,982.47	657,699,336.68	658,294,991.77	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1006	TANF 21-44 MALE WITH	89.69	89.86	94.05	83.11	86.62	79.25	0.00	0.00	0.00	0.00	0.00	0.00		522.58		
1007	TANF 21-44 FEMALE WI	106.74	102.58	84.56	88.37	79.82	87.81	0.00	0.00	0.00	0.00	0.00	0.00		549.88		
1008	TANF 45-64 M & F WIT	178.61	170.54	178.92	199.62	207.26	207.76	0.00	0.00	0.00	0.00	0.00	0.00		1,142.71		
1009	TANF 65+ M & F WITH	99.53	90.51	78.92	84.48	91.34	95.56	0.00	0.00	0.00	0.00	0.00	0.00		540.34		
100F	TANF 21-44 MALE WITH	0.29	4.11	6.65	4.51	4.45	0.19	0.00	0.00	0.00	0.00	0.00	0.00		20.20		
100G	TANF 21-44 FEMALE WI	2.91	6.29	2.43	0.60	0.30	2.14	0.00	0.00	0.00	0.00	0.00	0.00		14.67		
100H	TANF 45-64 M & F WIT	14.60	3.52	2.06	3.33	2.73	0.29	0.00	0.00	0.00	0.00	0.00	0.00		26.53		
100J	TANF 65+ M & F WITH	1.43	1.47	2.63	0.00	2.45	2.41	0.00	0.00	0.00	0.00	0.00	0.00		10.39		
1011	TANF <1 M & F NON-ME	9,979.28	10,037.99	10,057.99	10,140.42	10,014.22	10,108.73	0.00	0.00	0.00	0.00	0.00	0.00		60,338.63		
1012	TANF 01-05 M & F NON	18,993.92	18,921.51	18,927.54	19,412.07	20,023.38	21,489.42	0.00	0.00	0.00	0.00	0.00	0.00		117,767.84		
1013	TANF 06-13 M & F NON	34,139.11	34,275.13	34,370.72	35,161.72	36,257.09	38,617.53	0.00	0.00	0.00	0.00	0.00	0.00		212,821.30		
1014	TANF 14-20 MALE NON-	9,849.08	9,736.84	9,761.39	10,065.68	10,310.22	10,952.57	0.00	0.00	0.00	0.00	0.00	0.00		60,675.78		
1015	TANF 14-20 FEMALE N O	12,309.27	12,300.27	12,271.12	12,577.25	12,686.89	13,282.49	0.00	0.00	0.00	0.00	0.00	0.00		75,427.29		
1016	TANF 21-44 MALE NON-	24,304.85	24,468.54	24,434.66	24,611.48	24,513.33	25,120.03	0.00	0.00	0.00	0.00	0.00	0.00		147,452.89		
1017	TANF 21-44 FEMALE N O	83,159.05	83,428.43	83,491.23	83,874.29	84,068.32	84,900.88	0.00	0.00	0.00	0.00	0.00	0.00		502,922.20		
1018	TANF 45-64 M & F NON	19,720.09	19,730.33	19,681.74	19,798.75	19,925.42	20,310.25	0.00	0.00	0.00	0.00	0.00	0.00		119,166.58		
1019	TANF 65+ M & F NON-M	78.99	75.92	80.81	80.60	79.99	90.99	0.00	0.00	0.00	0.00	0.00	0.00		487.30		
101A	TANF < 1 M & F NON-M	622.00	588.68	516.55	592.34	544.82	327.21	0.00	0.00	0.00	0.00	0.00	0.00		3,191.60		
101B	TANF 01-05 M & F NON	200.41	160.77	137.33	188.42	120.93	185.25	0.00	0.00	0.00	0.00	0.00	0.00		993.11		
101C	TANF 06-13 M & F NON	91.26	107.35	109.58	170.91	48.56	138.19	0.00	0.00	0.00	0.00	0.00	0.00		665.85		
101D	TANF 14-20 MALE NON-	54.36	79.67	69.03	51.72	46.81	28.76	0.00	0.00	0.00	0.00	0.00	0.00		330.35		
101E	TANF 14-20 FEMALE N O	99.54	114.09	110.49	79.17	62.80	77.48	0.00	0.00	0.00	0.00	0.00	0.00		543.57		
101F	TANF 21-44 MALE NON-	653.45	692.46	519.54	565.94	544.91	477.85	0.00	0.00	0.00	0.00	0.00	0.00		3,454.15		
101G	TANF 21-44 FEMALE N O	1,627.34	1,538.61	1,238.06	1,261.30	1,216.73	1,142.03	0.00	0.00	0.00	0.00	0.00	0.00		8,024.07		
101H	TANF 44-64 M & F NON	355.51	400.40	291.08	312.37	337.88	281.50	0.00	0.00	0.00	0.00	0.00	0.00		1,978.74		
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	2.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1026	TANF 21-44 MALE WITH	60.00	53.27	54.63	53.40	43.92	48.93	0.00	0.00	0.00	0.00	0.00	0.00		314.15		
1027	TANF 21-44 FEMALE WI	95.99	92.13	93.99	86.07	77.92	93.67	0.00	0.00	0.00	0.00	0.00	0.00		539.77		
1028	TANF 45-64 M & F WIT	108.90	105.00	101.16	90.88	84.45	96.12	0.00	0.00	0.00	0.00	0.00	0.00		586.51		
1029	TANF 65+ M & F WITH	47.70	48.38	47.00	49.54	46.83	50.00	0.00	0.00	0.00	0.00	0.00	0.00		289.45		
102F	TANF 21-44 MALE WITH	0.00	0.61	1.00	0.12	0.03	1.48	0.00	0.00	0.00	0.00	0.00	0.00		3.24		
102G	TANF 21-44 FEMALE WI	0.00	0.41	0.00	1.06	0.80	0.32	0.00	0.00	0.00	0.00	0.00	0.00		2.59		
102H	TANF 44-64 M & F WIT	0.00	0.00	0.20	3.31	3.52	0.87	0.00	0.00	0.00	0.00	0.00	0.00		7.90		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	4,062.77	0.00	0.00	0.00	0.00	0.00	0.00		24,436.25		
210Z	SSI AGED WITH MEDIC
A	283.43	232.59	193.04	276.87	247.13	229.28	0.00	0.00	0.00	0.00	0.00	0.00		1,462.34		
2110	SSI AGED NON-MEDIC AR	6,783.06	6,849.40	6,866.93	6,935.45	6,998.23	7,016.51	0.00	0.00	0.00	0.00	0.00	0.00		41,449.58		
211Z	SSI AGED NON-MEDIC
AR	187.29	129.52	110.45	137.39	154.05	111.03	0.00	0.00	0.00	0.00	0.00	0.00		829.73		
2120	SSI AGED WITH QMB	31,783.16	31,989.36	32,152.27	32,229.28	32,346.82	32,412.95	0.00	0.00	0.00	0.00	0.00	0.00		192,913.84		
212Z	SSI AGED WITH QMB P P	32.92	44.99	61.94	25.29	34.13	58.11	0.00	0.00	0.00	0.00	0.00	0.00		257.38		
2200	SSI DISABLED WITH M
E	3,555.63	3,532.68	3,532.88	3,539.90	3,505.92	3,521.40	0.00	0.00	0.00	0.00	0.00	0.00		21,188.41		
220Z	SSI DISABLED WITH M E	164.92	159.53	143.29	159.73	135.95	170.42	0.00	0.00	0.00	0.00	0.00	0.00		933.84		
2210	SSI DISABLED NON-ME
D	51,491.33	51,464.64	51,465.03	51,603.90	51,642.87	51,806.36	0.00	0.00	0.00	0.00	0.00	0.00		309,474.13		
221Z	SSI DISABLED NON-ME D	759.58	802.25	717.53	700.50	733.57	703.10	0.00	0.00	0.00	0.00	0.00	0.00		4,416.53		
2220	SSI DISABLED WITH Q
M	26,441.87	26,456.91	26,414.26	26,455.17	26,448.91	26,447.26	0.00	0.00	0.00	0.00	0.00	0.00		158,664.38		
222Z	SSI DISABLED WITH Q M	37.02	44.89	66.85	48.70	31.86	58.93	0.00	0.00	0.00	0.00	0.00	0.00		288.25		
2300	SSI BLIND WITH MEDIC	28.00	28.99	26.00	28.00	28.50	29.22	0.00	0.00	0.00	0.00	0.00	0.00		168.71		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.16	0.00	0.00	0.00	0.00	0.00	0.00		0.16		
2310	SSI BLIND NON-MEDIC A	499.60	500.08	506.73	512.86	505.92	505.99	0.00	0.00	0.00	0.00	0.00	0.00		3,031.18		
231Z	SSI BLIND NON-MEDIC
A	4.50	8.28	24.78	19.76	2.06	15.60	0.00	0.00	0.00	0.00	0.00	0.00		74.98		
2320	SSI BLIND WITH QMB	225.80	229.88	231.00	229.92	235.89	233.00	0.00	0.00	0.00	0.00	0.00	0.00		1,385.49		
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		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
4302	SOBRA CHILD 01-05 M	3.00	4.93	5.00	5.00	4.43	3.00	0.00	0.00	0.00	0.00	0.00	0.00		25.36		
4303	SOBRA CHILD 06-13 M	5.00	6.06	4.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00		30.06		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4305	SOBRA CHILD 14-20 FE	4.00	3.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
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	35,018.57	0.00	0.00	0.00	0.00	0.00	0.00		212,757.91		
4312	SOBRA CHILD 01-05 M	166,797.05	167,404.10	167,216.79	167,017.16	165,079.46	162,596.55	0.00	0.00	0.00	0.00	0.00	0.00		996,111.11		
4313	SOBRA CHILD 06-13 M	215,941.09	217,553.86	217,670.05	217,534.97	215,638.95	213,001.62	0.00	0.00	0.00	0.00	0.00	0.00		1,297,340.54		
4314	SOBRA CHILD 14-20 MA	58,666.27	59,328.82	59,632.71	59,750.19	59,498.03	59,135.44	0.00	0.00	0.00	0.00	0.00	0.00		356,011.46		
4315	SOBRA CHILD 14-20 FE	58,655.28	59,190.73	59,306.71	59,371.69	59,098.17	58,468.91	0.00	0.00	0.00	0.00	0.00	0.00		354,091.49		
431A	SOBRA CHILD < 1 M &	446.25	383.74	320.66	352.09	321.94	256.30	0.00	0.00	0.00	0.00	0.00	0.00		2,080.98		
431B	SOBRA CHILD 01-05 M	4,091.48	3,709.51	3,111.72	3,350.73	3,149.52	3,001.99	0.00	0.00	0.00	0.00	0.00	0.00		20,414.95		
431C	SOBRA CHILD 6-13 M& F	3,855.59	4,029.36	3,035.26	3,207.58	3,026.13	3,013.38	0.00	0.00	0.00	0.00	0.00	0.00		20,167.30		
431D	SOBRA CHILD 14-20 MA	1,094.86	1,112.84	911.48	886.86	878.77	882.91	0.00	0.00	0.00	0.00	0.00	0.00		5,767.72		
431E	SOBRA CHILD 14-20 FE	1,138.00	1,088.17	967.04	896.29	902.43	833.72	0.00	0.00	0.00	0.00	0.00	0.00		5,825.65		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4322	SOBRA CHILD 01-05 M	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
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	2.00	0.00	0.00	0.00	0.00	0.00	0.00		15.41		
432E	SOBRA CHILD 14-20 FE	0.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.58		
5007	SOBRA PREG 21-44 FE M	28.29	29.30	34.12	34.00	26.19	28.13	0.00	0.00	0.00	0.00	0.00	0.00		180.03		
5008	SOBRA PREG 45-64 FE
M	2.00	2.00	2.00	3.00	2.30	3.00	0.00	0.00	0.00	0.00	0.00	0.00		14.30		
500G	SOBRA PREG 21-44 FE M	3.59	4.76	0.86	0.00	1.76	1.77	0.00	0.00	0.00	0.00	0.00	0.00		12.74		
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	7.61	0.00	0.00	0.00	0.00	0.00	0.00		22.67		
5015	SOBRA PREG 14-20 FE
M	2,792.94	2,852.61	2,886.25	2,885.61	2,777.02	2,758.51	0.00	0.00	0.00	0.00	0.00	0.00		16,952.94		
5017	SOBRA PREG 21-44 FE M	15,577.98	15,919.95	16,021.94	16,183.65	15,819.86	15,370.66	0.00	0.00	0.00	0.00	0.00	0.00		94,894.04		
5018	SOBRA PREG 45-64 FE
M	38.47	49.97	52.57	61.04	57.72	57.95	0.00	0.00	0.00	0.00	0.00	0.00		317.72		
501C	SOBRA PREG 09-13 FE M	0.93	0.00	0.00	0.00	0.00	0.38	0.00	0.00	0.00	0.00	0.00	0.00		1.31		
501E	SOBRA PREG 14-20 FE
M	242.99	207.98	196.51	199.53	197.86	150.93	0.00	0.00	0.00	0.00	0.00	0.00		1,195.80		
501G	SOBRA PREG 21-44 FE M	1,105.01	1,101.06	926.53	904.10	855.54	849.97	0.00	0.00	0.00	0.00	0.00	0.00		5,742.21		
501H	SOBRA PREG 45-64 FE
M	0.16	4.86	13.38	3.91	3.26	1.03	0.00	0.00	0.00	0.00	0.00	0.00		26.60		
5027	SOBRA PREG 21-44 FE M	32.00	37.00	37.40	36.98	37.00	41.96	0.00	0.00	0.00	0.00	0.00	0.00		222.34		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	1.00	1.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
SUBTOTAL:	909,956.0	5	913,841.68	911,256.6	1	914,835.20	911,002.15	911,180.34	0.00	0.00	0.00	0.00	0.00	0.00		5,472,072.03		

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	254.00	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	4.00	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	19.00	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	2,200.00	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	2,477.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,692.00	
25.00	
108.00	
13,123.00	
14,948.00	

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	222.04	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	387.35	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	1,203.29	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	640.42	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	11.92	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	19.33	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	31.50	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	13.72	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
1,322.12	
2,474.39	
7,362.00	
3,828.21	
87.90	
132.84	
237.55	
160.48	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		1.00		
1113	TANF EXPANDED 06-13	7.00	7.00	6.00	6.00	6.00	4.61	0.00	0.00	0.00	0.00	0.00	0.00		36.61		
1114	TANF EXPANDED 14-20	211.02	210.83	211.15	222.71	221.31	222.23	0.00	0.00	0.00	0.00	0.00	0.00		1,299.25		
1115	TANF EXPANDED 14-20	1,488.06	1,490.04	1,445.15	1,470.14	1,453.09	1,425.02	0.00	0.00	0.00	0.00	0.00	0.00		8,771.50		
1116	TANF EXPANDED 21-44	26,425.77	26,359.12	26,183.36	26,015.22	25,721.34	25,007.63	0.00	0.00	0.00	0.00	0.00	0.00		155,712.44		
1117	TANF EXPANDED 21-44	70,866.22	71,178.63	70,984.18	71,016.34	70,119.29	69,222.39	0.00	0.00	0.00	0.00	0.00	0.00		423,387.05		
1118	TANF EXPANDED 45-64	24,281.16	24,369.33	24,474.90	24,379.75	24,193.24	23,751.33	0.00	0.00	0.00	0.00	0.00	0.00		145,449.71		
1119	TANF EXPANDED 65+
M&	83.32	77.45	77.00	78.15	86.42	85.62	0.00	0.00	0.00	0.00	0.00	0.00		487.96		
111C	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.38	0.00	0.00	0.00	0.00	0.00	0.00		0.38		
111D	TANF EXPANDED 14-20	13.79	6.07	8.58	17.10	9.64	8.64	0.00	0.00	0.00	0.00	0.00	0.00		63.82		
111E	TANF EXPANDED 14-20	41.42	29.93	17.44	33.68	25.21	20.43	0.00	0.00	0.00	0.00	0.00	0.00		168.11		
111F	TANF EXPANDED 21-44	718.90	716.67	595.02	637.68	567.73	573.91	0.00	0.00	0.00	0.00	0.00	0.00		3,809.91		
111G	TANF EXPANDED 21-44	1,419.51	1,364.36	1,077.59	1,259.01	1,148.61	1,050.60	0.00	0.00	0.00	0.00	0.00	0.00		7,319.68		
111H	TANF EXPANDED 45-64	496.90	473.74	431.96	405.14	400.19	412.66	0.00	0.00	0.00	0.00	0.00	0.00		2,620.59		
111J	TANF EXPANDED 65+
M&	1.67	2.70	1.00	2.33	9.32	3.34	0.00	0.00	0.00	0.00	0.00	0.00		20.36		
1126	TANF EXPANDED 21-44	763.98	778.79	773.55	785.42	763.57	751.94	0.00	0.00	0.00	0.00	0.00	0.00		4,617.25		
1127	TANF EXPANDED 21-44	1,658.56	1,669.60	1,651.91	1,644.04	1,629.50	1,618.75	0.00	0.00	0.00	0.00	0.00	0.00		9,872.36		
1128	TANF EXPANDED 45-64	2,534.08	2,564.62	2,606.17	2,585.02	2,556.21	2,565.54	0.00	0.00	0.00	0.00	0.00	0.00		15,411.64		
1129	TANF EXPANDED 65+
M&	1,524.12	1,537.88	1,571.53	1,601.56	1,608.46	1,618.35	0.00	0.00	0.00	0.00	0.00	0.00		9,461.90		
112F	TANF EXPANDED 21-44	0.00	2.84	7.71	0.89	4.22	3.22	0.00	0.00	0.00	0.00	0.00	0.00		18.88		
112G	TANF EXPANDED 21-44	4.97	5.84	5.17	7.62	5.30	1.34	0.00	0.00	0.00	0.00	0.00	0.00		30.24		
112H	TANF EXPANDED 45-64	16.91	7.39	3.87	12.72	4.68	3.55	0.00	0.00	0.00	0.00	0.00	0.00		49.12		
112J	TANF EXPANDED 65+
M&	4.82	6.37	6.85	6.23	0.29	4.34	0.00	0.00	0.00	0.00	0.00	0.00		28.90		
2400	SSI AGED EXPANDED WI	227.17	239.12	215.13	247.18	221.29	218.75	0.00	0.00	0.00	0.00	0.00	0.00		1,368.64		
240Z	SSI AGED EXPANDED
WI	188.57	198.61	194.67	205.44	211.86	143.50	0.00	0.00	0.00	0.00	0.00	0.00		1,142.65		
2410	SSI AGED EXPANDED NO	95.13	101.60	93.82	91.90	93.05	93.89	0.00	0.00	0.00	0.00	0.00	0.00		569.39		
241Z	SSI AGED EXPANDED
NO	12.57	0.00	2.16	9.64	4.46	2.95	0.00	0.00	0.00	0.00	0.00	0.00		31.78		
2420	SSI AGED EXPANDED WI	26,237.74	26,428.76	26,615.69	26,756.08	26,883.94	27,117.23	0.00	0.00	0.00	0.00	0.00	0.00		160,039.44		
242Z	SSI AGED EXPANDED
WI	50.54	25.46	32.72	52.19	30.39	37.49	0.00	0.00	0.00	0.00	0.00	0.00		228.79		
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2600	SSI DISABLED EXPAND
E	203.51	221.75	186.24	232.74	231.20	267.61	0.00	0.00	0.00	0.00	0.00	0.00		1,343.05		
260Z	SSI DISABLED EXPAND E	139.05	119.04	107.14	120.94	124.43	107.35	0.00	0.00	0.00	0.00	0.00	0.00		717.95		
2610	SSI DISABLED EXPAND
E	1,467.82	1,478.74	1,490.86	1,530.40	1,572.36	1,602.38	0.00	0.00	0.00	0.00	0.00	0.00		9,142.56		
261Z	SSI DISABLED EXPAND E	33.02	32.33	22.08	23.16	29.53	37.79	0.00	0.00	0.00	0.00	0.00	0.00		177.91		
2620	SSI DISABLED EXPAND
E	16,996.27	17,035.00	17,062.79	17,051.98	17,095.19	17,074.84	0.00	0.00	0.00	0.00	0.00	0.00		102,316.07		
262Z	SSI DISABLED EXPAND E	41.28	27.03	37.78	40.53	17.69	21.97	0.00	0.00	0.00	0.00	0.00	0.00		186.28		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	180,908.28	181,437.38	180,791.17	181,142.54	179,625.15	177,613.14	0.00	0.00	0.00	0.00	0.00	0.00		1,081,517.66		

3506	ADULT 40-100% MALE 2	6.00	5.12	6.53	7.41	5.76	6.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	1.22	6.09	4.63	5.51	5.76	7.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	72.34	67.89	75.89	71.70	53.42	49.86	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	7.00	16.00	20.00	24.00	11.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
350H	ADULT 40-100% M&F 45	4.62	4.08	1.10	1.06	1.55	15.12	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	5,628.35	5,645.27	5,650.26	5,745.37	5,727.91	5,719.89	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	6,154.09	6,255.84	6,190.88	6,225.51	6,225.27	6,242.12	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	18,543.88	18,724.72	18,647.61	18,854.70	18,643.91	18,691.01	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	15,666.52	15,700.84	15,719.62	15,856.09	15,813.06	15,975.74	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	37,448.72	37,572.65	37,317.67	37,391.38	37,022.93	37,205.77	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	8.00	5.00	6.00	6.00	5.03	6.38	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	107.37	91.34	100.12	93.04	104.23	72.11	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	151.90	141.38	122.28	109.35	131.37	115.28	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	592.51	485.14	409.98	420.94	399.57	390.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	497.72	447.95	333.43	358.98	354.67	409.78	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	894.72	807.69	643.72	707.79	624.51	725.08	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	2.00	1.00	3.00	4.46	0.00	20.61	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.90	1.41	0.00	1.00	0.30	2.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	2.39	0.93	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	1.80	1.00	1.23	2.74	1.00	0.67	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
352G	ADULT 40-100% FEMAL E	0.00	0.00	1.00	0.00	0.73	0.03	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	2.18	0.00	0.76	0.25	0.00	0.32	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3706	ADULT <40% EXP MALE	24.30	33.18	33.65	40.79	30.13	29.85	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	3.22	7.07	12.16	12.92	15.48	12.59	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	69.28	82.50	84.64	87.86	78.64	87.48	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	5.00	9.32	12.00	14.35	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	

36.82	
30.21	
391.10	
86.00	
2.99	
6.89	
27.53	
34,117.05	
37,293.71	
112,105.83	
94,731.87	
223,959.12	
36.41	
568.21	
771.56	
2,698.14	
2,402.53	
4,403.51	
31.07	
5.61	
3.32	
8.44	
6.00	
6.37	
1.76	
3.51	
1.00	
191.90	
63.44	
490.40	
58.67	

9911	SB PAYMENT FOR TAN F	203.00	204.00	201.00	158.00	161.00	182.00	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	182.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,109.00	
1.00	
1,110.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
370F	ADULT <40% EXP MALE	6.31	6.24	9.97	4.50	2.91	0.76	0.00	0.00	0.00	0.00	0.00	0.00		30.69		
370G	ADULT <40% EXP FEM AL	0.77	1.90	1.82	14.40	1.68	2.11	0.00	0.00	0.00	0.00	0.00	0.00		22.68		
370H	ADULT <40% EXP M&F
4	10.17	19.09	6.71	4.26	9.05	5.20	0.00	0.00	0.00	0.00	0.00	0.00		54.48		
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	10,201.78	0.00	0.00	0.00	0.00	0.00	0.00		61,545.28		
3715	ADULT <40% EXP FEM AL	9,173.98	9,315.29	9,393.59	9,445.92	9,365.97	9,237.13	0.00	0.00	0.00	0.00	0.00	0.00		55,931.88		
3716	ADULT <40% EXP MALE	69,372.63	70,752.32	70,889.00	72,351.04	72,311.97	72,514.16	0.00	0.00	0.00	0.00	0.00	0.00		428,191.12		
3717	ADULT <40% EXP FEM AL	40,598.88	41,281.54	41,336.24	41,987.49	41,972.63	41,922.26	0.00	0.00	0.00	0.00	0.00	0.00		249,099.04		
3718	ADULT <40% EXP M&F
4	82,032.08	82,785.12	82,884.26	83,686.47	83,524.94	83,653.36	0.00	0.00	0.00	0.00	0.00	0.00		498,566.23		
3719	ADULT <40% EXP M&F 6	7.00	8.00	7.00	8.00	9.53	7.87	0.00	0.00	0.00	0.00	0.00	0.00		47.40		
371D	ADULT <40% EXP MALE	267.37	258.29	210.76	235.94	225.59	194.54	0.00	0.00	0.00	0.00	0.00	0.00		1,392.49		
371E	ADULT <40% EXP FEM AL	271.22	220.41	179.21	181.69	198.26	181.54	0.00	0.00	0.00	0.00	0.00	0.00		1,232.33		
371F	ADULT <40% EXP MALE	2,522.08	2,263.41	1,955.44	2,106.14	1,960.39	1,904.17	0.00	0.00	0.00	0.00	0.00	0.00		12,711.63		
371G	ADULT <40% EXP FEM AL	1,522.51	1,206.36	1,033.63	1,184.49	1,041.11	1,087.25	0.00	0.00	0.00	0.00	0.00	0.00		7,075.35		
371H	ADULT <40% EXP M&F
4	2,167.78	1,988.52	1,594.08	1,806.86	1,747.38	1,689.36	0.00	0.00	0.00	0.00	0.00	0.00		10,993.98		
371J	ADULT <40% EXP M&F 6	0.00	0.00	1.00	0.00	0.06	2.12	0.00	0.00	0.00	0.00	0.00	0.00		3.18		
3726	ADULT <40% EXP MALE	3.18	5.00	1.60	4.35	2.99	3.35	0.00	0.00	0.00	0.00	0.00	0.00		20.47		
3727	ADULT <40% EXP FEM AL	2.48	2.00	2.00	3.64	1.50	1.45	0.00	0.00	0.00	0.00	0.00	0.00		13.07		
3728	ADULT <40% EXP M&F
4	0.00	3.00	3.20	3.93	5.76	4.77	0.00	0.00	0.00	0.00	0.00	0.00		20.66		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
372F	ADULT <40% EXP MALE	2.46	0.00	0.00	2.64	0.00	0.48	0.00	0.00	0.00	0.00	0.00	0.00		5.58		
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	3.21	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
SUBTOTAL:	303,949.6	1	306,439.32	305,225.7	5	309,463.23	308,009.10	308,420.49	0.00	0.00	0.00	0.00	0.00	0.00		1,841,507.50		

3906	NEWLY ELIGIBLE MALE	13.21	15.49	16.06	16.36	17.53	21.41	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	6.41	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	69.23	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	14.00	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	0.58	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	3.57	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	15.73	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	

100.06	
26.62	
421.48	
134.99	
5.51	
9.35	
63.71	
1.99	

9935	BIRTH SUPP PAYMENT A	26.00	43.00	38.00	22.00	35.00	27.00	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	81.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	106.00	120.00	121.0	0	107.00	110.00	108.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
191.00	
481.00	
672.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	3,064.23	3,121.58	3,122.24	3,256.63	3,248.67	3,293.79	0.00	0.00	0.00	0.00	0.00	0.00		19,107.14		
3915	NEWLY ELIGIBLE FEMA L	3,540.91	3,604.90	3,646.42	3,677.55	3,623.17	3,676.08	0.00	0.00	0.00	0.00	0.00	0.00		21,769.03		
3916	NEWLY ELIGIBLE MALE	16,984.12	17,133.92	16,970.49	17,013.38	16,625.63	16,487.97	0.00	0.00	0.00	0.00	0.00	0.00		101,215.51		
3917	NEWLY ELIGIBLE FEMA L	25,383.25	25,775.37	25,504.82	25,619.45	25,201.52	24,851.26	0.00	0.00	0.00	0.00	0.00	0.00		152,335.67		
3918	NEWLY ELIGIBLE M&F
4	25,738.62	25,803.75	25,652.50	25,817.83	25,578.91	25,629.81	0.00	0.00	0.00	0.00	0.00	0.00		154,221.42		
3919	NEWLY ELIGIBLE M&F 6	1.00	1.00	2.00	1.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
391D	NEWLY ELIGIBLE MALE	83.05	62.33	67.48	56.10	48.41	58.21	0.00	0.00	0.00	0.00	0.00	0.00		375.58		
391E	NEWLY ELIGIBLE FEMA L	112.21	100.13	92.64	77.04	64.65	73.71	0.00	0.00	0.00	0.00	0.00	0.00		520.38		
391F	NEWLY ELIGIBLE MALE	668.38	562.71	524.11	550.66	477.90	465.01	0.00	0.00	0.00	0.00	0.00	0.00		3,248.77		
391G	NEWLY ELIGIBLE FEMA L	1,005.22	908.94	726.00	786.17	726.64	608.75	0.00	0.00	0.00	0.00	0.00	0.00		4,761.72		
391H	NEWLY ELIGIBLE M&F
4	791.17	652.01	570.18	625.85	639.85	537.10	0.00	0.00	0.00	0.00	0.00	0.00		3,816.16		
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	2.00	0.00	0.00	0.00	0.00	0.00	0.00		6.36		
3928	NEWLY ELIGIBLE M&F
4	0.00	1.00	1.00	1.93	4.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		8.93		
3929	NEWLY ELIGIBLE M&F 6	2.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
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	75,818.62	0.00	0.00	0.00	0.00	0.00	0.00		462,169.05		

9939	BIRTH SUPP PAYMENT N	49.00	63.00	53.00	64.00	46.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.00	63.00	53.00	64.00	46.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
327.00

327.00

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	38,581.32	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	11,092.83	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	10,847.44	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	637.42	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	187.97	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	191.41	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	61,538.39	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.77	
242,132.87	
69,175.73	
67,249.47	
0.22	
5,260.18	
1,487.76	
1,400.38	
386,707.38	

9944	BIRTH SUPP PAYMENT S	2.00	10.00	4.00	4.00	3.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	10.00	4.00	4.00	3.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
31.00

31.00

147.61

4517	BC PATIENT FEMALE 2 1	22.89	24.00	24.36	27.70	24.66	24.00	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	126.15	0.00	0.00	0.00	0.00	0.00	0.00	

760.75

ACC CAPITATION - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4519	BC PATIENT FEMALE 6 5	0.00	0.58	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		2.58		
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		12.32		
451H	BC PATIENT FEMALE 4 5	19.22	1.28	0.66	10.71	3.25	17.82	0.00	0.00	0.00	0.00	0.00	0.00		52.94		
4617	CC PATIENT FEMALE 2
1	8.00	8.00	7.00	7.41	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00		45.41		
4618	CC PATIENT FEMALE 4 5	7.00	7.00	7.26	10.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00		52.26		
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	187.97	0.00	0.00	0.00	0.00	0.00	0.00		1,085.18		

8600	SSI BLIND FREEDOM/W O	2.00	2.00	1.00	1.00	1.00	1.00	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	1.00	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	2,078.15	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	62.49	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	345.04	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	24.83	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	357.49	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	11.81	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	2,881.81	0.00	0.00	0.00	0.00	0.00	0.00	

8.00	
6.00	
12,493.95	
534.02	
2,150.83	
130.74	
2,050.10	
44.25	
17,417.89	

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

1.90

1.90

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

1.00

TOTAL:	1,544,822.48	1,552,043.21	1,545,129.35	1,553,385.02	1,543,731.77	1,540,467.76	0.00	0.00	0.00	0.00	0.00	0.00		9,279,579.59		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	33.40	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.80		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	33.40	16.70	0.00	0.00	0.00	0.00	0.00	0.00		50.10		
1009	TANF 65+ M & F WITH	0.00	33.40	33.40	33.40	50.10	66.80	0.00	0.00	0.00	0.00	0.00	0.00		217.10		
1011	TANF <1 M & F NON-ME	1,753.50	1,803.60	1,820.30	1,870.40	2,087.50	1,870.40	0.00	0.00	0.00	0.00	0.00	0.00		11,205.70		
1012	TANF 01-05 M & F NON	1,402.80	1,469.60	1,786.90	1,803.60	1,970.60	2,054.10	0.00	0.00	0.00	0.00	0.00	0.00		10,487.60		
1013	TANF 06-13 M & F NON	1,285.90	1,369.40	1,603.20	1,670.00	1,887.10	2,087.50	0.00	0.00	0.00	0.00	0.00	0.00		9,903.10		
1014	TANF 14-20 MALE NON-	334.00	450.90	467.60	484.30	551.10	534.40	0.00	0.00	0.00	0.00	0.00	0.00		2,822.30		
1015	TANF 14-20 FEMALE N O	484.30	467.60	467.60	534.40	567.80	818.30	0.00	0.00	0.00	0.00	0.00	0.00		3,340.00		
1016	TANF 21-44 MALE NON-	1,419.50	1,553.10	1,937.20	2,271.20	2,404.80	2,471.60	0.00	0.00	0.00	0.00	0.00	0.00		12,057.40		
1017	TANF 21-44 FEMALE N O	5,761.50	6,496.30	7,565.10	8,249.80	9,519.00	8,817.60	0.00	0.00	0.00	0.00	0.00	0.00		46,409.30		
1018	TANF 45-64 M & F NON	2,638.60	2,772.20	3,056.10	3,189.70	3,507.00	3,256.50	0.00	0.00	0.00	0.00	0.00	0.00		18,420.10		
1019	TANF 65+ M & F NON-M	0.00	0.00	16.70	16.70	33.40	16.70	0.00	0.00	0.00	0.00	0.00	0.00		83.50		
1026	TANF 21-44 MALE WITH	0.00	16.70	16.70	33.40	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00		100.20		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00		50.10		
2100	SSI AGED WITH MEDIC A	83.50	133.60	133.60	133.60	167.00	150.30	0.00	0.00	0.00	0.00	0.00	0.00		801.60		
2110	SSI AGED NON-MEDIC
AR	116.90	116.90	200.40	267.20	233.80	150.30	0.00	0.00	0.00	0.00	0.00	0.00		1,085.50		
2120	SSI AGED WITH QMB	1,035.40	1,169.00	1,269.20	1,402.80	1,536.40	1,352.70	0.00	0.00	0.00	0.00	0.00	0.00		7,765.50		
2200	SSI DISABLED WITH M E	400.80	467.60	517.70	567.80	651.30	534.40	0.00	0.00	0.00	0.00	0.00	0.00		3,139.60		
2210	SSI DISABLED NON-ME
D	6,379.40	7,047.40	7,849.00	8,750.80	9,802.90	8,550.40	0.00	0.00	0.00	0.00	0.00	0.00		48,379.90		
2220	SSI DISABLED WITH Q M	2,271.20	2,338.00	2,538.40	2,738.80	3,189.70	2,905.80	0.00	0.00	0.00	0.00	0.00	0.00		15,981.90		
2310	SSI BLIND NON-MEDIC
A	66.80	66.80	83.50	100.20	100.20	66.80	0.00	0.00	0.00	0.00	0.00	0.00		484.30		
2320	SSI BLIND WITH QMB	16.70	16.70	16.70	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00		100.20		
4311	SOBRA CHILD <1 M & F	4,876.40	4,809.60	5,160.30	5,394.10	5,410.80	5,193.70	0.00	0.00	0.00	0.00	0.00	0.00		30,844.90		
4312	SOBRA CHILD 01-05 M	14,762.80	16,416.10	18,169.60	19,505.60	21,376.00	20,641.20	0.00	0.00	0.00	0.00	0.00	0.00		110,871.30		
4313	SOBRA CHILD 06-13 M	14,094.80	16,132.20	17,985.90	19,438.80	21,643.20	20,574.40	0.00	0.00	0.00	0.00	0.00	0.00		109,869.30		
4314	SOBRA CHILD 14-20 MA	2,822.30	3,039.40	3,573.80	3,757.50	4,308.60	4,241.80	0.00	0.00	0.00	0.00	0.00	0.00		21,743.40		
4315	SOBRA CHILD 14-20 FE	2,922.50	3,306.60	4,024.70	4,408.80	4,909.80	4,625.90	0.00	0.00	0.00	0.00	0.00	0.00		24,198.30		
5015	SOBRA PREG 14-20 FE M	116.90	116.90	100.20	83.50	116.90	150.30	0.00	0.00	0.00	0.00	0.00	0.00		684.70		
5017	SOBRA PREG 21-44 FE
M	751.50	651.30	718.10	651.30	684.70	801.60	0.00	0.00	0.00	0.00	0.00	0.00		4,258.50		
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	92,000.30	0.00	0.00	0.00	0.00	0.00	0.00		495,472.30		

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	16.70	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	33.40	33.40	50.10	83.50	66.80	100.20	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	150.30	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	33.40	0.00	0.00	0.00	0.00	0.00	0.00	

 
16.70	
367.40	
985.30	
200.40	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	83.50	83.50	66.80	83.50	133.60	100.20	0.00	0.00	0.00	0.00	0.00	0.00		551.10		
1116	TANF EXPANDED 21-44	885.10	1,135.60	1,369.40	1,603.20	1,820.30	1,720.10	0.00	0.00	0.00	0.00	0.00	0.00		8,533.70		
1117	TANF EXPANDED 21-44	3,306.60	3,774.20	4,024.70	4,759.50	5,243.80	5,060.10	0.00	0.00	0.00	0.00	0.00	0.00		26,168.90		
1118	TANF EXPANDED 45-64	1,987.30	2,271.20	2,404.80	2,638.60	2,972.60	2,939.20	0.00	0.00	0.00	0.00	0.00	0.00		15,213.70		
1119	TANF EXPANDED 65+
M&	16.70	16.70	16.70	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00		100.20		
1126	TANF EXPANDED 21-44	50.10	50.10	66.80	83.50	100.20	100.20	0.00	0.00	0.00	0.00	0.00	0.00		450.90		
1127	TANF EXPANDED 21-44	66.80	66.80	83.50	66.80	66.80	50.10	0.00	0.00	0.00	0.00	0.00	0.00		400.80		
1128	TANF EXPANDED 45-64	350.70	334.00	317.30	367.40	434.20	400.80	0.00	0.00	0.00	0.00	0.00	0.00		2,204.40		
1129	TANF EXPANDED 65+
M&	250.50	233.80	233.80	250.50	283.90	283.90	0.00	0.00	0.00	0.00	0.00	0.00		1,536.40		
2420	SSI AGED EXPANDED WI	1,452.90	1,753.50	1,920.50	1,987.30	2,204.40	2,237.80	0.00	0.00	0.00	0.00	0.00	0.00		11,556.40		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	16.70	16.70	16.70	0.00	0.00	0.00	0.00	0.00	0.00		50.10		
2610	SSI DISABLED EXPAND E	133.60	150.30	200.40	183.70	250.50	283.90	0.00	0.00	0.00	0.00	0.00	0.00		1,202.40		
2620	SSI DISABLED EXPAND
E	751.50	768.20	784.90	851.70	951.90	851.70	0.00	0.00	0.00	0.00	0.00	0.00		4,959.90		
SUBTOTAL:	9,519.00	10,838.30	11,756.8	0	13,209.70	14,812.90	14,362.00	0.00	0.00	0.00	0.00	0.00	0.00		74,498.70		

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	66.80	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	217.10	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	617.90	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	1,035.40	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	1,903.80	0.00	0.00	0.00	0.00	0.00	0.00	

16.70	
367.40	
935.20	
3,223.10	
5,661.30	
11,322.60	

3514	ADULT 40-100% MALE 1	83.50	133.60	150.30	150.30	183.70	200.40	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	167.00	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	968.60	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	918.50	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	3,373.40	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	16.70	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	601.20	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	668.00	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	7,598.50	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	4,759.50	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	10,170.30	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	29,442.10	0.00	0.00	0.00	0.00	0.00	0.00	

 
901.80	
1,118.90	
5,126.90	
4,876.40	
18,804.20	
16.70	
33.40	
66.80	
2,922.50	
3,473.60	
39,812.80	
24,682.60	
57,681.80	
16.70	
159,535.10	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,955.90	3,356.70	3,657.30	3,807.60	3,907.80	3,841.00	0.00	0.00	0.00	0.00	0.00	0.00		21,526.30		

4413	SOBRA 100-133% M&F
6	1,786.90	1,887.10	2,271.20	2,204.40	2,237.80	2,037.40	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	317.30	417.50	467.60	534.40	601.20	534.40	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	334.00	400.80	450.90	417.50	484.30	367.40	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,438.20	2,705.40	3,189.70	3,156.30	3,323.30	2,939.20	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,424.80	
2,872.40	
2,454.90	
17,752.10	

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	50.10	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	16.70	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	16.70	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	83.50	116.90	100.2	0	50.10	66.80	83.50	0.00	0.00	0.00	0.00	0.00	0.00	

 
367.40	
83.50	
50.10	
501.00	

769,352.30

102,037.00	113,059.00	126,085.00	135,938.00	149,565.20	142,668.10	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1009	TANF 65+ M & F WITH	0.00	2.00	2.00	2.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1011	TANF <1 M & F NON-ME	105.00	108.00	109.00	112.00	125.00	112.00	0.00	0.00	0.00	0.00	0.00	0.00		671.00		
1012	TANF 01-05 M & F NON	84.00	88.00	107.00	108.00	118.00	123.00	0.00	0.00	0.00	0.00	0.00	0.00		628.00		
1013	TANF 06-13 M & F NON	77.00	82.00	96.00	100.00	113.00	125.00	0.00	0.00	0.00	0.00	0.00	0.00		593.00		
1014	TANF 14-20 MALE NON-	20.00	27.00	28.00	29.00	33.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00		169.00		
1015	TANF 14-20 FEMALE N O	29.00	28.00	28.00	32.00	34.00	49.00	0.00	0.00	0.00	0.00	0.00	0.00		200.00		
1016	TANF 21-44 MALE NON-	85.00	93.00	116.00	136.00	144.00	148.00	0.00	0.00	0.00	0.00	0.00	0.00		722.00		
1017	TANF 21-44 FEMALE N O	345.00	389.00	453.00	494.00	570.00	528.00	0.00	0.00	0.00	0.00	0.00	0.00		2,779.00		
1018	TANF 45-64 M & F NON	158.00	166.00	183.00	191.00	210.00	195.00	0.00	0.00	0.00	0.00	0.00	0.00		1,103.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	1.00	1.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1026	TANF 21-44 MALE WITH	0.00	1.00	1.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2100	SSI AGED WITH MEDIC A	5.00	8.00	8.00	8.00	10.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00		48.00		
2110	SSI AGED NON-MEDIC
AR	7.00	7.00	12.00	16.00	14.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00		65.00		
2120	SSI AGED WITH QMB	62.00	70.00	76.00	84.00	92.00	81.00	0.00	0.00	0.00	0.00	0.00	0.00		465.00		
2200	SSI DISABLED WITH M E	24.00	28.00	31.00	34.00	39.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00		188.00		
2210	SSI DISABLED NON-ME
D	382.00	422.00	470.00	524.00	587.00	512.00	0.00	0.00	0.00	0.00	0.00	0.00		2,897.00		
2220	SSI DISABLED WITH Q M	136.00	140.00	152.00	164.00	191.00	174.00	0.00	0.00	0.00	0.00	0.00	0.00		957.00		
2310	SSI BLIND NON-MEDIC
A	4.00	4.00	5.00	6.00	6.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
4311	SOBRA CHILD <1 M & F	292.00	288.00	309.00	323.00	324.00	311.00	0.00	0.00	0.00	0.00	0.00	0.00		1,847.00		
4312	SOBRA CHILD 01-05 M	884.00	983.00	1,088.00	1,168.00	1,280.00	1,236.00	0.00	0.00	0.00	0.00	0.00	0.00		6,639.00		
4313	SOBRA CHILD 06-13 M	844.00	966.00	1,077.00	1,164.00	1,296.00	1,232.00	0.00	0.00	0.00	0.00	0.00	0.00		6,579.00		
4314	SOBRA CHILD 14-20 MA	169.00	182.00	214.00	225.00	258.00	254.00	0.00	0.00	0.00	0.00	0.00	0.00		1,302.00		
4315	SOBRA CHILD 14-20 FE	175.00	198.00	241.00	264.00	294.00	277.00	0.00	0.00	0.00	0.00	0.00	0.00		1,449.00		
5015	SOBRA PREG 14-20 FE M	7.00	7.00	6.00	5.00	7.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
5017	SOBRA PREG 21-44 FE
M	45.00	39.00	43.00	39.00	41.00	48.00	0.00	0.00	0.00	0.00	0.00	0.00		255.00		
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	5,509.00	0.00	0.00	0.00	0.00	0.00	0.00		29,669.00		

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	2.00	2.00	3.00	5.00	4.00	6.00	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	9.00	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.00	
22.00	
59.00	
12.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	5.00	5.00	4.00	5.00	8.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
1116	TANF EXPANDED 21-44	53.00	68.00	82.00	96.00	109.00	103.00	0.00	0.00	0.00	0.00	0.00	0.00		511.00		
1117	TANF EXPANDED 21-44	198.00	226.00	241.00	285.00	314.00	303.00	0.00	0.00	0.00	0.00	0.00	0.00		1,567.00		
1118	TANF EXPANDED 45-64	119.00	136.00	144.00	158.00	178.00	176.00	0.00	0.00	0.00	0.00	0.00	0.00		911.00		
1119	TANF EXPANDED 65+
M&	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1126	TANF EXPANDED 21-44	3.00	3.00	4.00	5.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00		27.00		
1127	TANF EXPANDED 21-44	4.00	4.00	5.00	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00		24.00		
1128	TANF EXPANDED 45-64	21.00	20.00	19.00	22.00	26.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00		132.00		
1129	TANF EXPANDED 65+
M&	15.00	14.00	14.00	15.00	17.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00		92.00		
2420	SSI AGED EXPANDED WI	87.00	105.00	115.00	119.00	132.00	134.00	0.00	0.00	0.00	0.00	0.00	0.00		692.00		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2610	SSI DISABLED EXPAND E	8.00	9.00	12.00	11.00	15.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00		72.00		
2620	SSI DISABLED EXPAND
E	45.00	46.00	47.00	51.00	57.00	51.00	0.00	0.00	0.00	0.00	0.00	0.00		297.00		
SUBTOTAL:	570.00	649.00	704.0	0	791.00	887.00	860.00	0.00	0.00	0.00	0.00	0.00	0.00		4,461.00		

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	4.00	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	13.00	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	37.00	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	62.00	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	114.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
22.00	
56.00	
193.00	
339.00	
678.00	

3514	ADULT 40-100% MALE 1	5.00	8.00	9.00	9.00	11.00	12.00	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	10.00	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	58.00	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	55.00	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	202.00	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	1.00	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	36.00	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	40.00	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	455.00	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	285.00	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	609.00	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	1,763.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
54.00	
67.00	
307.00	
292.00	
1,126.00	
1.00	
2.00	
4.00	
175.00	
208.00	
2,384.00	
1,478.00	
3,454.00	
1.00	
9,553.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	177.00	201.00	219.00	228.00	234.00	230.00	0.00	0.00	0.00	0.00	0.00	0.00		1,289.00		

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	

8700	SSI DISABLED FREEDO M	3.00	5.00	5.00	3.00	3.00	3.00	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	1.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5.00	7.00	6.00	3.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.00	
5.00	
3.00	
30.00	

4413	SOBRA 100-133% M&F
6	107.00	113.00	136.00	132.00	134.00	122.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	19.00	25.00	28.00	32.00	36.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	20.00	24.00	27.00	25.00	29.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	146.00	162.00	191.0	0	189.00	199.00	176.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
744.00	
172.00	
147.00	
1,063.00	

TOTAL:	6,110.00	6,770.00	7,550.00	8,140.00	8,956.00	8,543.00	0.00	0.00	0.00	0.00	0.00	0.00		46,069.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	22.71	22.71	0.00	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00		113.55		
1008	TANF 45-64 M & F WIT	22.71	45.42	45.42	45.42	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00		204.39		
1009	TANF 65+ M & F WITH	22.71	22.71	22.71	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00		136.26		
1011	TANF <1 M & F NON-ME	204.39	204.39	181.68	181.68	181.68	158.97	0.00	0.00	0.00	0.00	0.00	0.00		1,112.79		
1012	TANF 01-05 M & F NON	431.49	545.04	499.62	522.33	567.75	545.04	0.00	0.00	0.00	0.00	0.00	0.00		3,111.27		
1013	TANF 06-13 M & F NON	408.78	431.49	408.78	522.33	635.88	681.30	0.00	0.00	0.00	0.00	0.00	0.00		3,088.56		
1014	TANF 14-20 MALE NON-	22.71	45.42	68.13	136.26	136.26	204.39	0.00	0.00	0.00	0.00	0.00	0.00		613.17		
1015	TANF 14-20 FEMALE N O	181.68	295.23	363.36	363.36	340.65	317.94	0.00	0.00	0.00	0.00	0.00	0.00		1,862.22		
1016	TANF 21-44 MALE NON-	567.75	681.30	681.30	681.30	885.69	862.98	0.00	0.00	0.00	0.00	0.00	0.00		4,360.32		
1017	TANF 21-44 FEMALE N O	4,428.45	4,791.81	4,905.36	5,155.17	5,541.24	5,609.37	0.00	0.00	0.00	0.00	0.00	0.00		30,431.40		
1018	TANF 45-64 M & F NON	1,544.28	1,612.41	1,748.67	1,703.25	1,771.38	1,998.48	0.00	0.00	0.00	0.00	0.00	0.00		10,378.47		
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	22.71	0.00	0.00	0.00	0.00	0.00	0.00		68.13		
2100	SSI AGED WITH MEDIC A	181.68	181.68	204.39	204.39	227.10	249.81	0.00	0.00	0.00	0.00	0.00	0.00		1,249.05		
2110	SSI AGED NON-MEDIC
AR	45.42	45.42	68.13	68.13	68.13	68.13	0.00	0.00	0.00	0.00	0.00	0.00		363.36		
2120	SSI AGED WITH QMB	1,975.77	2,112.03	2,157.45	2,429.97	2,475.39	2,543.52	0.00	0.00	0.00	0.00	0.00	0.00		13,694.13		
2200	SSI DISABLED WITH M E	681.30	704.01	749.43	749.43	794.85	817.56	0.00	0.00	0.00	0.00	0.00	0.00		4,496.58		
2210	SSI DISABLED NON-ME
D	4,110.51	4,428.45	4,610.13	4,950.78	4,996.20	5,018.91	0.00	0.00	0.00	0.00	0.00	0.00		28,114.98		
2220	SSI DISABLED WITH Q M	2,861.46	3,020.43	3,156.69	3,292.95	3,451.92	3,429.21	0.00	0.00	0.00	0.00	0.00	0.00		19,212.66		
2310	SSI BLIND NON-MEDIC
A	22.71	45.42	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00		249.81		
2320	SSI BLIND WITH QMB	45.42	45.42	45.42	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00		272.52		
4311	SOBRA CHILD <1 M & F	908.40	953.82	749.43	749.43	840.27	908.40	0.00	0.00	0.00	0.00	0.00	0.00		5,109.75		
4312	SOBRA CHILD 01-05 M	5,473.11	5,813.76	6,358.80	6,608.61	6,926.55	6,926.55	0.00	0.00	0.00	0.00	0.00	0.00		38,107.38		
4313	SOBRA CHILD 06-13 M	4,678.26	5,518.53	5,904.60	6,313.38	6,903.84	7,176.36	0.00	0.00	0.00	0.00	0.00	0.00		36,494.97		
4314	SOBRA CHILD 14-20 MA	976.53	1,226.34	1,294.47	1,317.18	1,408.02	1,566.99	0.00	0.00	0.00	0.00	0.00	0.00		7,789.53		
4315	SOBRA CHILD 14-20 FE	1,657.83	1,725.96	1,907.64	2,021.19	2,225.58	2,316.42	0.00	0.00	0.00	0.00	0.00	0.00		11,854.62		
5015	SOBRA PREG 14-20 FE M	113.55	113.55	90.84	90.84	204.39	272.52	0.00	0.00	0.00	0.00	0.00	0.00		885.69		
5017	SOBRA PREG 21-44 FE
M	1,021.95	1,135.50	1,317.18	1,385.31	1,226.34	1,294.47	0.00	0.00	0.00	0.00	0.00	0.00		7,380.75		
SUBTOTAL:	32,611.56	35,768.25	37,607.7	6	39,651.66	41,990.79	43,149.00	0.00	0.00	0.00	0.00	0.00	0.00		230,779.02		

1108	TANF EXPANDED 45-64	45.42	45.42	45.42	45.42	45.42	68.13	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	68.13	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	340.65	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	3,406.50	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	1,816.80	0.00	0.00	0.00	0.00	0.00	0.00	

 
295.23	
90.84	
181.68	
1,635.12	
19,371.63	
9,856.14	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	22.71	22.71	22.71	22.71	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00		136.26		
1128	TANF EXPANDED 45-64	90.84	113.55	158.97	181.68	158.97	136.26	0.00	0.00	0.00	0.00	0.00	0.00		840.27		
1129	TANF EXPANDED 65+
M&	249.81	295.23	295.23	295.23	340.65	363.36	0.00	0.00	0.00	0.00	0.00	0.00		1,839.51		
2410	SSI AGED EXPANDED NO	22.71	22.71	22.71	45.42	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00		204.39		
2420	SSI AGED EXPANDED
WI	1,703.25	1,884.93	1,930.35	2,021.19	2,112.03	2,112.03	0.00	0.00	0.00	0.00	0.00	0.00		11,763.78		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	22.71	22.71	0.00	0.00	0.00	0.00	0.00	0.00		45.42		
2610	SSI DISABLED EXPAND
E	68.13	45.42	22.71	90.84	45.42	45.42	0.00	0.00	0.00	0.00	0.00	0.00		317.94		
2620	SSI DISABLED EXPAND E	567.75	567.75	613.17	613.17	635.88	658.59	0.00	0.00	0.00	0.00	0.00	0.00		3,656.31		
SUBTOTAL:	7,448.88	7,903.08	8,243.73	8,561.67	8,970.45	9,106.71	0.00	0.00	0.00	0.00	0.00	0.00		50,234.52		

3514	ADULT 40-100% MALE 1	136.26	113.55	113.55	68.13	68.13	45.42	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	227.10	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	454.20	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	681.30	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	1,862.22	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	363.36	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	454.20	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	2,339.13	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	1,930.35	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	6,608.61	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	14,965.89	0.00	0.00	0.00	0.00	0.00	0.00	

 
545.04	
1,703.25	
2,429.97	
2,793.33	
10,423.89	
90.84	
1,589.70	
2,271.00	
12,853.86	
10,605.57	
38,334.48	
83,640.93	

3908	NEWLY ELIGIBLE M&F 4	22.71	45.42	22.71	22.71	22.71	22.71	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	45.42	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	68.13	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	90.84	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	885.69	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	1,226.34	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	2,339.13	0.00	0.00	0.00	0.00	0.00	0.00	

 
158.97	
45.42	
317.94	
158.97	
817.56	
4,542.00	
7,017.39	
13,058.25	

4413	SOBRA 100-133% M&F
6	386.07	363.36	476.91	545.04	567.75	476.91	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	158.97	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	158.97	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	635.88	681.30	862.9	8	931.11	931.11	794.85	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,816.04	
976.53	
1,044.66	
4,837.23	

4518

BC PATIENT FEMALE 4 5

22.71

22.71

22.71

22.71

22.71

22.71

0.00	0.00

0.00

0.00

0.00

0.00

136.26

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending December 31, 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	22.71	0.00	0.00	0.00	0.00	0.00	0.00		136.26		

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

 
272.52	
272.52	
545.04	

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

383,253.96

54,821.94	60,022.53	63,042.96	66,086.10	68,811.30	70,469.13	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	1.00	1.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1008	TANF 45-64 M & F WIT	1.00	2.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1009	TANF 65+ M & F WITH	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1011	TANF <1 M & F NON-ME	9.00	9.00	8.00	8.00	8.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00		49.00		
1012	TANF 01-05 M & F NON	19.00	24.00	22.00	23.00	25.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00		137.00		
1013	TANF 06-13 M & F NON	18.00	19.00	18.00	23.00	28.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00		136.00		
1014	TANF 14-20 MALE NON-	1.00	2.00	3.00	6.00	6.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00		27.00		
1015	TANF 14-20 FEMALE N O	8.00	13.00	16.00	16.00	15.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00		82.00		
1016	TANF 21-44 MALE NON-	25.00	30.00	30.00	30.00	39.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00		192.00		
1017	TANF 21-44 FEMALE N O	195.00	211.00	216.00	227.00	244.00	247.00	0.00	0.00	0.00	0.00	0.00	0.00		1,340.00		
1018	TANF 45-64 M & F NON	68.00	71.00	77.00	75.00	78.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00		457.00		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2100	SSI AGED WITH MEDIC A	8.00	8.00	9.00	9.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00		55.00		
2110	SSI AGED NON-MEDIC
AR	2.00	2.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
2120	SSI AGED WITH QMB	87.00	93.00	95.00	107.00	109.00	112.00	0.00	0.00	0.00	0.00	0.00	0.00		603.00		
2200	SSI DISABLED WITH M E	30.00	31.00	33.00	33.00	35.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00		198.00		
2210	SSI DISABLED NON-ME
D	181.00	195.00	203.00	218.00	220.00	221.00	0.00	0.00	0.00	0.00	0.00	0.00		1,238.00		
2220	SSI DISABLED WITH Q M	126.00	133.00	139.00	145.00	152.00	151.00	0.00	0.00	0.00	0.00	0.00	0.00		846.00		
2310	SSI BLIND NON-MEDIC
A	1.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
2320	SSI BLIND WITH QMB	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
4311	SOBRA CHILD <1 M & F	40.00	42.00	33.00	33.00	37.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00		225.00		
4312	SOBRA CHILD 01-05 M	241.00	256.00	280.00	291.00	305.00	305.00	0.00	0.00	0.00	0.00	0.00	0.00		1,678.00		
4313	SOBRA CHILD 06-13 M	206.00	243.00	260.00	278.00	304.00	316.00	0.00	0.00	0.00	0.00	0.00	0.00		1,607.00		
4314	SOBRA CHILD 14-20 MA	43.00	54.00	57.00	58.00	62.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00		343.00		
4315	SOBRA CHILD 14-20 FE	73.00	76.00	84.00	89.00	98.00	102.00	0.00	0.00	0.00	0.00	0.00	0.00		522.00		
5015	SOBRA PREG 14-20 FE M	5.00	5.00	4.00	4.00	9.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00		39.00		
5017	SOBRA PREG 21-44 FE
M	45.00	50.00	58.00	61.00	54.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00		325.00		
SUBTOTAL:	1,436.00	1,575.00	1,656.00	1,746.00	1,849.00	1,900.00	0.00	0.00	0.00	0.00	0.00	0.00		10,162.00		

1108	TANF EXPANDED 45-64	2.00	2.00	2.00	2.00	2.00	3.00	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	3.00	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	15.00	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	150.00	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	80.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13.00	
4.00	
8.00	
72.00	
853.00	
434.00	

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1128	TANF EXPANDED 45-64	4.00	5.00	7.00	8.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00		37.00		
1129	TANF EXPANDED 65+
M&	11.00	13.00	13.00	13.00	15.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00		81.00		
2410	SSI AGED EXPANDED NO	1.00	1.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
2420	SSI AGED EXPANDED
WI	75.00	83.00	85.00	89.00	93.00	93.00	0.00	0.00	0.00	0.00	0.00	0.00		518.00		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2610	SSI DISABLED EXPAND
E	3.00	2.00	1.00	4.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
2620	SSI DISABLED EXPAND E	25.00	25.00	27.00	27.00	28.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00		161.00		
SUBTOTAL:	328.00	348.00	363.0	0	377.00	395.00	401.00	0.00	0.00	0.00	0.00	0.00	0.00		2,212.00		

3514	ADULT 40-100% MALE 1	6.00	5.00	5.00	3.00	3.00	2.00	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	10.00	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	20.00	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	30.00	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	82.00	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	16.00	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	20.00	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	103.00	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	85.00	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	291.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	531.00	592.00	620.0	0	644.00	637.00	659.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
24.00	
75.00	
107.00	
123.00	
459.00	
4.00	
70.00	
100.00	
566.00	
467.00	
1,688.00	
3,683.00	

3908	NEWLY ELIGIBLE M&F 4	1.00	2.00	1.00	1.00	1.00	1.00	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	2.00	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	3.00	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	4.00	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	39.00	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	54.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	86.00	92.00	94.00	97.00	103.00	103.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7.00	
2.00	
14.00	
7.00	
36.00	
200.00	
309.00	
575.00	

4413	SOBRA 100-133% M&F
6	17.00	16.00	21.00	24.00	25.00	21.00	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	7.00	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	7.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28.00	30.00	38.00	41.00	41.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
124.00	
43.00	
46.00	
213.00	

4518

BC PATIENT FEMALE 4 5

1.00

1.00

1.00

1.00

1.00

1.00

0.00	0.00

0.00

0.00

0.00

0.00

6.00

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending December 31, 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	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		

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	2.00	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	4.00	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12.00	
12.00	
24.00	

TOTAL:	2,414.00	2,643.00	2,776.00	2,910.00	3,030.00	3,103.00	0.00	0.00	0.00	0.00	0.00	0.00		16,876.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	24.90	0.00	0.00	0.00	0.00	0.00	0.00		24.90		
1008	TANF 45-64 M & F WIT	49.80	49.80	49.80	74.70	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00		323.70		
1009	TANF 65+ M & F WITH	49.80	49.80	74.70	74.70	74.70	49.80	0.00	0.00	0.00	0.00	0.00	0.00		373.50		
1011	TANF <1 M & F NON-ME	1,045.80	946.20	1,045.80	1,095.60	1,020.90	1,369.50	0.00	0.00	0.00	0.00	0.00	0.00		6,523.80		
1012	TANF 01-05 M & F NON	2,191.20	1,992.00	2,116.50	2,365.50	2,490.00	3,012.90	0.00	0.00	0.00	0.00	0.00	0.00		14,168.10		
1013	TANF 06-13 M & F NON	2,340.60	2,539.80	2,714.10	2,838.60	3,062.70	3,535.80	0.00	0.00	0.00	0.00	0.00	0.00		17,031.60		
1014	TANF 14-20 MALE NON-	423.30	597.60	771.90	821.70	921.30	1,195.20	0.00	0.00	0.00	0.00	0.00	0.00		4,731.00		
1015	TANF 14-20 FEMALE N O	1,767.90	1,767.90	1,992.00	2,041.80	1,942.20	2,116.50	0.00	0.00	0.00	0.00	0.00	0.00		11,628.30		
1016	TANF 21-44 MALE NON-	6,474.00	6,548.70	6,648.30	6,623.40	6,498.90	7,171.20	0.00	0.00	0.00	0.00	0.00	0.00		39,964.50		
1017	TANF 21-44 FEMALE N O	23,904.00	24,053.40	24,800.40	24,974.70	25,323.30	28,087.20	0.00	0.00	0.00	0.00	0.00	0.00		151,143.00		
1018	TANF 45-64 M & F NON	7,519.80	7,445.10	7,569.60	7,768.80	7,968.00	9,013.80	0.00	0.00	0.00	0.00	0.00	0.00		47,285.10		
1019	TANF 65+ M & F NON-M	24.90	24.90	49.80	49.80	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00		249.00		
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	24.90	0.00	0.00	0.00	0.00	0.00	0.00		224.10		
1029	TANF 65+ M & F WITH	24.90	24.90	0.00	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00		124.50		
2100	SSI AGED WITH MEDIC A	1,444.20	1,469.10	1,444.20	1,494.00	1,543.80	1,643.40	0.00	0.00	0.00	0.00	0.00	0.00		9,038.70		
2110	SSI AGED NON-MEDIC
AR	199.20	174.30	199.20	149.40	149.40	323.70	0.00	0.00	0.00	0.00	0.00	0.00		1,195.20		
2120	SSI AGED WITH QMB	5,229.00	5,453.10	5,453.10	5,577.60	5,577.60	5,876.40	0.00	0.00	0.00	0.00	0.00	0.00		33,166.80		
2200	SSI DISABLED WITH M E	3,336.60	3,560.70	3,635.40	3,685.20	3,710.10	4,158.30	0.00	0.00	0.00	0.00	0.00	0.00		22,086.30		
2210	SSI DISABLED NON-ME
D	18,077.40	18,351.30	18,525.60	18,774.60	18,874.20	21,588.30	0.00	0.00	0.00	0.00	0.00	0.00		114,191.40		
2220	SSI DISABLED WITH Q M	8,341.50	8,490.90	8,715.00	8,839.50	8,964.00	9,561.60	0.00	0.00	0.00	0.00	0.00	0.00		52,912.50		
2300	SSI BLIND WITH MEDIC	49.80	49.80	24.90	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00		199.20		
2310	SSI BLIND NON-MEDIC A	273.90	298.80	298.80	323.70	348.60	398.40	0.00	0.00	0.00	0.00	0.00	0.00		1,942.20		
2320	SSI BLIND WITH QMB	99.60	99.60	124.50	124.50	124.50	124.50	0.00	0.00	0.00	0.00	0.00	0.00		697.20		
4311	SOBRA CHILD <1 M & F	3,884.40	3,610.50	3,411.30	3,311.70	3,062.70	3,859.50	0.00	0.00	0.00	0.00	0.00	0.00		21,140.10		
4312	SOBRA CHILD 01-05 M	31,847.10	32,046.30	32,768.40	32,793.30	32,768.40	35,681.70	0.00	0.00	0.00	0.00	0.00	0.00		197,905.20		
4313	SOBRA CHILD 06-13 M	42,330.00	44,421.60	45,865.80	46,363.80	46,388.70	51,244.20	0.00	0.00	0.00	0.00	0.00	0.00		276,614.10		
4314	SOBRA CHILD 14-20 MA	10,034.70	10,308.60	11,080.50	11,329.50	11,454.00	12,275.70	0.00	0.00	0.00	0.00	0.00	0.00		66,483.00		
4315	SOBRA CHILD 14-20 FE	11,727.90	12,300.60	12,450.00	12,798.60	12,549.60	13,495.80	0.00	0.00	0.00	0.00	0.00	0.00		75,322.50		
5007	SOBRA PREG 21-44 FE M	0.00	24.90	24.90	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00		124.50		
5013	SOBRA PREG 09-13 FE
M	24.90	24.90	24.90	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00		149.40		
5015	SOBRA PREG 14-20 FE M	473.10	522.90	572.70	597.60	398.40	448.20	0.00	0.00	0.00	0.00	0.00	0.00		3,012.90		
5017	SOBRA PREG 21-44 FE
M	2,838.60	2,888.40	2,863.50	2,863.50	2,689.20	2,689.20	0.00	0.00	0.00	0.00	0.00	0.00		16,832.40		
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	219,169.80	0.00	0.00	0.00	0.00	0.00	0.00		1,186,983.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1106	TANF EXPANDED 21-44	24.90	24.90	24.90	24.90	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00		199.20		
1108	TANF EXPANDED 45-64	249.00	249.00	224.10	224.10	224.10	224.10	0.00	0.00	0.00	0.00	0.00	0.00		1,394.40		
1109	TANF EXPANDED 65+
M&	174.30	199.20	174.30	174.30	199.20	273.90	0.00	0.00	0.00	0.00	0.00	0.00		1,195.20		
1113	TANF EXPANDED 06-13	0.00	0.00	24.90	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
1115	TANF EXPANDED 14-20	249.00	224.10	174.30	174.30	124.50	149.40	0.00	0.00	0.00	0.00	0.00	0.00		1,095.60		
1116	TANF EXPANDED 21-44	3,237.00	3,212.10	3,361.50	3,436.20	3,486.00	3,809.70	0.00	0.00	0.00	0.00	0.00	0.00		20,542.50		
1117	TANF EXPANDED 21-44	9,935.10	10,134.30	10,308.60	10,731.90	11,030.70	11,528.70	0.00	0.00	0.00	0.00	0.00	0.00		63,669.30		
1118	TANF EXPANDED 45-64	5,004.90	4,955.10	4,880.40	5,004.90	5,204.10	5,577.60	0.00	0.00	0.00	0.00	0.00	0.00		30,627.00		
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	124.50	0.00	0.00	0.00	0.00	0.00	0.00		647.40		
1127	TANF EXPANDED 21-44	249.00	224.10	224.10	224.10	224.10	249.00	0.00	0.00	0.00	0.00	0.00	0.00		1,394.40		
1128	TANF EXPANDED 45-64	498.00	547.80	597.60	547.80	522.90	647.40	0.00	0.00	0.00	0.00	0.00	0.00		3,361.50		
1129	TANF EXPANDED 65+
M&	498.00	498.00	522.90	547.80	498.00	572.70	0.00	0.00	0.00	0.00	0.00	0.00		3,137.40		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00		49.80		
2410	SSI AGED EXPANDED
NO	99.60	99.60	99.60	99.60	99.60	124.50	0.00	0.00	0.00	0.00	0.00	0.00		622.50		
2420	SSI AGED EXPANDED WI	3,311.70	3,486.00	3,436.20	3,535.80	3,610.50	3,735.00	0.00	0.00	0.00	0.00	0.00	0.00		21,115.20		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	24.90	24.90	24.90	0.00	0.00	0.00	0.00	0.00	0.00		74.70		
2610	SSI DISABLED EXPAND E	124.50	174.30	149.40	149.40	174.30	249.00	0.00	0.00	0.00	0.00	0.00	0.00		1,020.90		
2620	SSI DISABLED EXPAND
E	1,593.60	1,643.40	1,718.10	1,718.10	1,743.00	1,942.20	0.00	0.00	0.00	0.00	0.00	0.00		10,358.40		
SUBTOTAL:	25,373.10	25,796.40	26,020.5	0	26,742.60	27,390.00	29,332.20	0.00	0.00	0.00	0.00	0.00	0.00		160,654.80		

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	

24.90

49.80

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	647.40	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	871.50	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	1,593.60	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	1,269.90	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	4,556.70	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	3,012.90	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	3,361.50	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	22,858.20	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	11,454.00	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	23,904.00	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	73,529.70	0.00	0.00	0.00	0.00	0.00	0.00	

 
49.80	
2,988.00	
4,407.30	
8,291.70	
6,847.50	
24,501.60	
99.60	
16,309.50	
18,077.40	
120,889.50	
60,482.10	
124,375.50	
387,319.50	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	224.10	249.00	249.00	273.90	249.00	273.90	0.00	0.00	0.00	0.00	0.00	0.00		1,518.90		
3915	NEWLY ELIGIBLE FEMA L	298.80	348.60	323.70	249.00	273.90	398.40	0.00	0.00	0.00	0.00	0.00	0.00		1,892.40		
3916	NEWLY ELIGIBLE MALE	1,269.90	1,369.50	1,394.40	1,294.80	1,245.00	1,294.80	0.00	0.00	0.00	0.00	0.00	0.00		7,868.40		
3917	NEWLY ELIGIBLE FEMA L	2,589.60	2,639.40	2,465.10	2,365.50	2,415.30	2,465.10	0.00	0.00	0.00	0.00	0.00	0.00		14,940.00		
3918	NEWLY ELIGIBLE M&F
4	2,913.30	2,963.10	3,187.20	3,261.90	3,361.50	3,784.80	0.00	0.00	0.00	0.00	0.00	0.00		19,471.80		
SUBTOTAL:	7,345.50	7,594.50	7,619.40	7,445.10	7,544.70	8,217.00	0.00	0.00	0.00	0.00	0.00	0.00		45,766.20		

4413	SOBRA 100-133% M&F
6	2,813.70	2,938.20	2,913.30	2,963.10	3,087.60	3,585.60	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	1,170.30	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	1,294.80	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	6,050.70	0.00	0.00	0.00	0.00	0.00	0.00	

 
18,301.50	
6,498.90	
6,498.90	
31,299.30	

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

 

423.30

423.30

1,812,446.10

282,341.10	289,761.30	296,683.50	302,186.40	305,074.80	336,399.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1008	TANF 45-64 M & F WIT	2.00	2.00	2.00	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1009	TANF 65+ M & F WITH	2.00	2.00	3.00	3.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
1011	TANF <1 M & F NON-ME	42.00	38.00	42.00	44.00	41.00	55.00	0.00	0.00	0.00	0.00	0.00	0.00		262.00		
1012	TANF 01-05 M & F NON	88.00	80.00	85.00	95.00	100.00	121.00	0.00	0.00	0.00	0.00	0.00	0.00		569.00		
1013	TANF 06-13 M & F NON	94.00	102.00	109.00	114.00	123.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00		684.00		
1014	TANF 14-20 MALE NON-	17.00	24.00	31.00	33.00	37.00	48.00	0.00	0.00	0.00	0.00	0.00	0.00		190.00		
1015	TANF 14-20 FEMALE N O	71.00	71.00	80.00	82.00	78.00	85.00	0.00	0.00	0.00	0.00	0.00	0.00		467.00		
1016	TANF 21-44 MALE NON-	260.00	263.00	267.00	266.00	261.00	288.00	0.00	0.00	0.00	0.00	0.00	0.00		1,605.00		
1017	TANF 21-44 FEMALE N O	960.00	966.00	996.00	1,003.00	1,017.00	1,128.00	0.00	0.00	0.00	0.00	0.00	0.00		6,070.00		
1018	TANF 45-64 M & F NON	302.00	299.00	304.00	312.00	320.00	362.00	0.00	0.00	0.00	0.00	0.00	0.00		1,899.00		
1019	TANF 65+ M & F NON-M	1.00	1.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1029	TANF 65+ M & F WITH	1.00	1.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2100	SSI AGED WITH MEDIC A	58.00	59.00	58.00	60.00	62.00	66.00	0.00	0.00	0.00	0.00	0.00	0.00		363.00		
2110	SSI AGED NON-MEDIC
AR	8.00	7.00	8.00	6.00	6.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00		48.00		
2120	SSI AGED WITH QMB	210.00	219.00	219.00	224.00	224.00	236.00	0.00	0.00	0.00	0.00	0.00	0.00		1,332.00		
2200	SSI DISABLED WITH M E	134.00	143.00	146.00	148.00	149.00	167.00	0.00	0.00	0.00	0.00	0.00	0.00		887.00		
2210	SSI DISABLED NON-ME
D	726.00	737.00	744.00	754.00	758.00	867.00	0.00	0.00	0.00	0.00	0.00	0.00		4,586.00		
2220	SSI DISABLED WITH Q M	335.00	341.00	350.00	355.00	360.00	384.00	0.00	0.00	0.00	0.00	0.00	0.00		2,125.00		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
2310	SSI BLIND NON-MEDIC A	11.00	12.00	12.00	13.00	14.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00		78.00		
2320	SSI BLIND WITH QMB	4.00	4.00	5.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00		28.00		
4311	SOBRA CHILD <1 M & F	156.00	145.00	137.00	133.00	123.00	155.00	0.00	0.00	0.00	0.00	0.00	0.00		849.00		
4312	SOBRA CHILD 01-05 M	1,279.00	1,287.00	1,316.00	1,317.00	1,316.00	1,433.00	0.00	0.00	0.00	0.00	0.00	0.00		7,948.00		
4313	SOBRA CHILD 06-13 M	1,700.00	1,784.00	1,842.00	1,862.00	1,863.00	2,058.00	0.00	0.00	0.00	0.00	0.00	0.00		11,109.00		
4314	SOBRA CHILD 14-20 MA	403.00	414.00	445.00	455.00	460.00	493.00	0.00	0.00	0.00	0.00	0.00	0.00		2,670.00		
4315	SOBRA CHILD 14-20 FE	471.00	494.00	500.00	514.00	504.00	542.00	0.00	0.00	0.00	0.00	0.00	0.00		3,025.00		
5007	SOBRA PREG 21-44 FE M	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
5013	SOBRA PREG 09-13 FE
M	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
5015	SOBRA PREG 14-20 FE M	19.00	21.00	23.00	24.00	16.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00		121.00		
5017	SOBRA PREG 21-44 FE
M	114.00	116.00	115.00	115.00	108.00	108.00	0.00	0.00	0.00	0.00	0.00	0.00		676.00		
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	8,802.00	0.00	0.00	0.00	0.00	0.00	0.00		47,670.00		

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1106	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1108	TANF EXPANDED 45-64	10.00	10.00	9.00	9.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00		56.00		
1109	TANF EXPANDED 65+
M&	7.00	8.00	7.00	7.00	8.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00		48.00		
1113	TANF EXPANDED 06-13	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1115	TANF EXPANDED 14-20	10.00	9.00	7.00	7.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00		44.00		
1116	TANF EXPANDED 21-44	130.00	129.00	135.00	138.00	140.00	153.00	0.00	0.00	0.00	0.00	0.00	0.00		825.00		
1117	TANF EXPANDED 21-44	399.00	407.00	414.00	431.00	443.00	463.00	0.00	0.00	0.00	0.00	0.00	0.00		2,557.00		
1118	TANF EXPANDED 45-64	201.00	199.00	196.00	201.00	209.00	224.00	0.00	0.00	0.00	0.00	0.00	0.00		1,230.00		
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	5.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
1127	TANF EXPANDED 21-44	10.00	9.00	9.00	9.00	9.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00		56.00		
1128	TANF EXPANDED 45-64	20.00	22.00	24.00	22.00	21.00	26.00	0.00	0.00	0.00	0.00	0.00	0.00		135.00		
1129	TANF EXPANDED 65+
M&	20.00	20.00	21.00	22.00	20.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00		126.00		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2410	SSI AGED EXPANDED
NO	4.00	4.00	4.00	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
2420	SSI AGED EXPANDED WI	133.00	140.00	138.00	142.00	145.00	150.00	0.00	0.00	0.00	0.00	0.00	0.00		848.00		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2610	SSI DISABLED EXPAND E	5.00	7.00	6.00	6.00	7.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
2620	SSI DISABLED EXPAND
E	64.00	66.00	69.00	69.00	70.00	78.00	0.00	0.00	0.00	0.00	0.00	0.00		416.00		
SUBTOTAL:	1,019.00	1,036.00	1,045.00	1,074.00	1,100.00	1,178.00	0.00	0.00	0.00	0.00	0.00	0.00		6,452.00		

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	

1.00

2.00

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	26.00	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	35.00	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	64.00	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	51.00	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	183.00	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	121.00	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	135.00	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	918.00	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	460.00	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	960.00	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	2,953.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
120.00	
177.00	
333.00	
275.00	
984.00	
4.00	
655.00	
726.00	
4,855.00	
2,429.00	
4,995.00	
15,555.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	9.00	10.00	10.00	11.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00		61.00		
3915	NEWLY ELIGIBLE FEMA L	12.00	14.00	13.00	10.00	11.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00		76.00		
3916	NEWLY ELIGIBLE MALE	51.00	55.00	56.00	52.00	50.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00		316.00		
3917	NEWLY ELIGIBLE FEMA L	104.00	106.00	99.00	95.00	97.00	99.00	0.00	0.00	0.00	0.00	0.00	0.00		600.00		
3918	NEWLY ELIGIBLE M&F
4	117.00	119.00	128.00	131.00	135.00	152.00	0.00	0.00	0.00	0.00	0.00	0.00		782.00		
SUBTOTAL:	295.00	305.00	306.0	0	299.00	303.00	330.00	0.00	0.00	0.00	0.00	0.00	0.00		1,838.00		

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

17.00

17.00

4413	SOBRA 100-133% M&F
6	113.00	118.00	117.00	119.00	124.00	144.00	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	47.00	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	52.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	191.00	203.00	205.0	0	203.00	212.00	243.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
735.00	
261.00	
261.00	
1,257.00	

TOTAL:	11,339.00	11,637.00	11,915.00	12,136.00	12,252.00	13,510.00	0.00	0.00	0.00	0.00	0.00	0.00		72,789.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	8,388.64	12,582.96	8,388.64	19,010.52	19,010.52	14,257.89	0.00	0.00	0.00	0.00	0.00	0.00		81,639.17		
1010	TANF NON-MEDICARE	1,661,849.71	1,910,910.01	2,172,000.39	2,518,290.98	2,691,857.41	2,799,312.28	0.00	0.00	0.00	0.00	0.00	0.00		13,754,220.78		
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	20,971.60	20,971.60	20,971.60	19,010.52	19,010.52	9,505.26	0.00	0.00	0.00	0.00	0.00	0.00		110,441.10		
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	39,108,038.87	0.00	0.00	0.00	0.00	0.00	0.00		222,732,463.10		
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	1,823,674.54	0.00	0.00	0.00	0.00	0.00	0.00		10,978,388.85		
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	4,078,019.65	0.00	0.00	0.00	0.00	0.00	0.00		23,092,004.52		
211Z	SSI AGED NON-MEDIC
AR	101,176.43	20,587.31	54,593.15	170,167.44	79,886.85	36,165.99	0.00	0.00	0.00	0.00	0.00	0.00		462,577.17		
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	29,925,825.66	0.00	0.00	0.00	0.00	0.00	0.00		169,469,253.72		
212Z	SSI AGED WITH QMB P P	53,559.58	52,446.69	41,429.50	22,115.27	58,475.91	76,799.03	0.00	0.00	0.00	0.00	0.00	0.00		304,825.98		
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	17,196,532.59	0.00	0.00	0.00	0.00	0.00	0.00		98,830,802.37		
220Z	SSI DISABLED WITH M E	241,491.30	210,523.92	148,685.65	226,958.11	161,194.24	193,326.58	0.00	0.00	0.00	0.00	0.00	0.00		1,182,179.80		
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	157,695,091.75	0.00	0.00	0.00	0.00	0.00	0.00		882,526,190.49		
221Z	SSI DISABLED NON-ME D	220,330.68	212,099.65	164,951.73	216,450.20	303,719.32	282,573.62	0.00	0.00	0.00	0.00	0.00	0.00		1,400,125.20		
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	33,801,956.52	0.00	0.00	0.00	0.00	0.00	0.00		189,479,618.44		
222Z	SSI DISABLED WITH Q M	36,101.66	3,297.05	17,224.42	15,278.93	27,610.19	4,358.92	0.00	0.00	0.00	0.00	0.00	0.00		103,871.17		
2300	SSI BLIND WITH MEDIC	2,719.44	2,719.44	212.67	165.00	6,728.91	5,683.06	0.00	0.00	0.00	0.00	0.00	0.00		18,228.52		
2310	SSI BLIND NON-MEDIC A	108,525.41	110,540.42	91,578.43	100,852.27	134,721.86	137,827.34	0.00	0.00	0.00	0.00	0.00	0.00		684,045.73		
2320	SSI BLIND WITH QMB	20,374.22	15,937.16	9,369.05	12,502.85	14,831.19	21,169.01	0.00	0.00	0.00	0.00	0.00	0.00		94,183.48		
SUBTOTAL:	250,500,365.83	251,801,485.84	252,667,815.24	286,392,190.07	286,733,084.05	287,210,118.56	0.00	0.00	0.00	0.00	0.00	0.00		1,615,305,059.59		

8700	SSI DISABLED FREEDO M	155,943.28	136,803.98	166,698.11	213,746.58	177,649.55	220,911.51	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	18,873.27	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	249,782.52	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	10,684.07	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	91,981.30	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	592,232.67	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,071,753.01	
26,738.08	
1,365,232.41	
35,461.52	
461,793.70	
488.15	
2,961,466.87	

1,618,266,526.46

250,917,794.02	252,209,106.88	253,136,673.96	286,967,454.80	287,233,145.57	287,802,351.23	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	3.00	2.00	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
1010	TANF NON-MEDICARE	393.91	454.32	516.92	526.58	561.83	584.76	0.00	0.00	0.00	0.00	0.00	0.00		3,038.32		
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	5.00	5.00	5.00	4.00	4.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
2100	SSI AGED WITH MEDIC A	11,901.36	11,949.18	11,925.57	12,001.32	11,967.23	11,999.05	0.00	0.00	0.00	0.00	0.00	0.00		71,743.71		
210Z	SSI AGED WITH MEDIC
A	562.03	623.08	527.53	634.91	558.72	534.58	0.00	0.00	0.00	0.00	0.00	0.00		3,440.85		
2110	SSI AGED NON-MEDIC AR	611.47	610.68	604.51	598.67	590.09	584.83	0.00	0.00	0.00	0.00	0.00	0.00		3,600.25		
211Z	SSI AGED NON-MEDIC
AR	16.60	3.70	9.02	26.02	10.86	5.20	0.00	0.00	0.00	0.00	0.00	0.00		71.40		
2120	SSI AGED WITH QMB	9,350.65	9,436.56	9,532.55	9,570.71	9,598.71	9,572.84	0.00	0.00	0.00	0.00	0.00	0.00		57,062.02		
212Z	SSI AGED WITH QMB P P	17.29	17.74	14.71	7.74	17.89	25.63	0.00	0.00	0.00	0.00	0.00	0.00		101.00		
2200	SSI DISABLED WITH M
E	4,466.83	4,466.23	4,430.22	4,447.90	4,441.01	4,388.31	0.00	0.00	0.00	0.00	0.00	0.00		26,640.50		
220Z	SSI DISABLED WITH M E	78.72	70.28	48.18	70.48	48.05	56.18	0.00	0.00	0.00	0.00	0.00	0.00		371.89		
2210	SSI DISABLED NON-ME
D	30,896.55	31,019.03	31,105.49	31,176.95	31,215.80	31,304.36	0.00	0.00	0.00	0.00	0.00	0.00		186,718.18		
221Z	SSI DISABLED NON-ME D	35.96	35.18	26.20	33.83	43.97	39.50	0.00	0.00	0.00	0.00	0.00	0.00		214.64		
2220	SSI DISABLED WITH Q
M	7,937.60	7,999.85	8,044.45	8,080.55	8,115.37	8,157.44	0.00	0.00	0.00	0.00	0.00	0.00		48,335.26		
222Z	SSI DISABLED WITH Q M	11.96	1.08	5.01	4.72	8.98	1.21	0.00	0.00	0.00	0.00	0.00	0.00		32.96		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	1.00	2.50	2.25	0.00	0.00	0.00	0.00	0.00	0.00		10.75		
2310	SSI BLIND NON-MEDIC A	24.00	24.64	22.40	21.32	27.33	27.22	0.00	0.00	0.00	0.00	0.00	0.00		146.91		
2320	SSI BLIND WITH QMB	6.00	4.99	3.00	4.63	3.01	5.64	0.00	0.00	0.00	0.00	0.00	0.00		27.27		
SUBTOTAL:	66,319.93	66,726.54	66,823.7	6	67,215.33	67,219.35	67,294.00	0.00	0.00	0.00	0.00	0.00	0.00		401,598.91		

8700	SSI DISABLED FREEDO M	42.00	36.25	45.99	51.93	42.87	52.85	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	5.12	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	37.48	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	1.51	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	21.82	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	118.78	0.00	0.00	0.00	0.00	0.00	0.00	

 
271.89	
7.92	
213.97	
4.99	
116.60	
0.16	
615.53	

TOTAL:	66,411.91	66,814.51	66,928.75	67,330.21	67,316.28	67,412.78	0.00	0.00	0.00	0.00	0.00	0.00		402,214.44		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	360.61	0.00	368.93	21.43	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	1,142.12	0.00	0.00	0.00	0.00	0.00	0.00		1,371.09		
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	-482.70	0.00	0.00	0.00	0.00	0.00	0.00		-2,250.91		
4312	SOBRA CHILD 01-05 M	-100.40	1,427.57	203.97	1,154.33	0.00	-1,788.51	0.00	0.00	0.00	0.00	0.00	0.00		896.96		
4313	SOBRA CHILD 06-13 M	292.16	-195.37	-41.12	0.00	182.68	-1,779.22	0.00	0.00	0.00	0.00	0.00	0.00		-1,540.87		
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		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431C	SOBRA CHILD 6-13 M& F	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	-2,908.31	0.00	0.00	0.00	0.00	0.00	0.00		-349.31		

4415	SOBRA 100-133% FEMA L	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:	0.00	405.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
405.96

405.96

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

56.58

864.84	2,316.93	-1,030.86	-270.07	1,084.05	-2,908.31	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

0.00

0.00

0.00

SOBRA CHILD 6-13 M& F

431C

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA CHILD 01-05 M

431B

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA CHILD 14-20 FE

4315

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA CHILD 14-20 MA

4314

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA CHILD 06-13 M

4313

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA CHILD 01-05 M

4312

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SOBRA CHILD <1 M & F

4311

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SSI DISABLED NON-ME D

221Z

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

SSI DISABLED NON-ME D

2210

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

TANF 14-20 FEMALE N O

1015

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

TANF 14-20 MALE NON-

1014

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

TANF 06-13 M & F NON

1013

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

TANF 01-05 M & F NON

1012

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

TANF <1 M & F NON-ME

1011

TOTAL

JUNE

MAY

APRIL

MARCH

FEBRUARY

JANUARY

DECEMBER

OCTOBER	NOVEMBER

AUGUST	SEPTEMBER

JULY

RATE CODE	DESCRIPTION

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

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

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	27,128.70	27,368.37	30,877.78	30,079.04	34,303.08	26,470.83	0.00	0.00	0.00	0.00	0.00	0.00		176,227.80		
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		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	106.41	0.00	0.00	0.00	0.00	0.00	0.00		106.41		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	4,820.14	1,630.68	0.00	0.00	0.00	0.00	0.00	0.00		6,450.82		
1017	TANF 21-44 FEMALE N O	8,755.69	0.00	473.63	913.62	47,771.02	5,923.22	0.00	0.00	0.00	0.00	0.00	0.00		63,837.18		
1018	TANF 45-64 M & F NON	0.00	0.00	20,190.63	1,223.66	0.00	2,076.42	0.00	0.00	0.00	0.00	0.00	0.00		23,490.71		
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	1,578.08	0.00	0.00	0.00	0.00	0.00	0.00		5,633.54		
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	798.04	0.00	0.00	0.00	0.00	0.00	0.00		2,358.37		
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	6,806.89	0.00	0.00	0.00	0.00	0.00	0.00		45,632.36		
2200	SSI DISABLED WITH M E	6,705.80	6,218.03	9,375.73	5,561.04	5,561.04	10,710.56	0.00	0.00	0.00	0.00	0.00	0.00		44,132.20		
220Z	SSI DISABLED WITH M
E	1,230.03	0.00	1,706.25	2,617.33	2,574.76	2,368.16	0.00	0.00	0.00	0.00	0.00	0.00		10,496.53		
2210	SSI DISABLED NON-ME D	191,817.13	229,386.03	284,569.91	201,387.94	201,591.32	203,320.03	0.00	0.00	0.00	0.00	0.00	0.00		1,312,072.36		
221Z	SSI DISABLED NON-ME
D	4,176.42	1,262.61	0.00	1,777.83	5,372.05	2,956.83	0.00	0.00	0.00	0.00	0.00	0.00		15,545.74		
2220	SSI DISABLED WITH Q M	70,948.72	70,948.72	97,309.03	75,572.44	75,515.56	76,193.83	0.00	0.00	0.00	0.00	0.00	0.00		466,488.30		
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	1,649.28	0.00	0.00	0.00	0.00	0.00	0.00		10,066.59		
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	242.67	0.00	0.00	0.00	0.00	0.00	0.00		1,485.83		
431E	SOBRA CHILD 14-20 FE	0.00	2,036.49	0.00	0.00	0.00	257.48	0.00	0.00	0.00	0.00	0.00	0.00		2,293.97		
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	9,373.56	0.00	0.00	0.00	0.00	0.00	0.00		24,408.92		
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	352,462.97	0.00	0.00	0.00	0.00	0.00	0.00		2,236,527.80		

1100	TANF EXPANDED FPR FI	5,780.66	5,780.66	5,780.66	5,873.32	5,873.32	5,873.32	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	18,800.82	0.00	0.00	0.00	0.00	0.00	0.00	

 
34,961.94	
1,680.63	
625.63	
155,921.15	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		12,526.71		
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		
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	6,478.43	0.00	0.00	0.00	0.00	0.00	0.00		6,478.43		
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	1,493.14	0.00	0.00	0.00	0.00	0.00	0.00		8,879.16		
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	8,135.80	0.00	0.00	0.00	0.00	0.00	0.00		57,438.38		
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	29,312.68	0.00	0.00	0.00	0.00	0.00	0.00		178,414.04		
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	70,094.19	0.00	0.00	0.00	0.00	0.00	0.00		487,574.38		

3910	NEWLY ELIGIBLE FOR F	11,840.80	11,840.80	13,307.38	10,299.04	9,373.56	14,321.40	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	1,011.48	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	4,036.56	0.00	0.00	0.00	0.00	0.00	0.00	

70,982.98	
1,248.30	
4,119.62	

3510	ADULT 40-100% FOR FI	49,075.49	46,707.33	45,143.84	49,294.58	57,018.86	52,383.30	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	-4,806.22	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	664.45	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	
370G	ADULT <40% EXP FEM
AL	0.00	0.00	0.00	0.00	0.00	266.01	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	167,405.16	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	1,059.65	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	16,088.58	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	7,647.57	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	-1,362.58	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	426.36	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	1,162.79	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	2,491.70	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	498.34	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	372.42	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	328,562.8	311,125.74	278,672.9	261,415.39	265,927.83	244,297.53	0.00	0.00	0.00	0.00	0.00	0.00	

 
299,623.40	
96.11	
2,480.78	
7,091.43	
3,122.83	
266.01	
1,156,305.09	
3,962.56	
91,361.98	
55,366.85	
5,520.68	
426.36	
1,162.79	
31,438.79	
16,568.46	
15,208.15	
1,690,002.27	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	9,509.12	0.00	0.00	0.00	0.00	0.00	0.00		9,509.12		
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		1,192.19		
SUBTOTAL:	12,077.62	12,833.90	13,307.3	8	10,299.04	9,655.71	28,878.56	0.00	0.00	0.00	0.00	0.00	0.00		87,052.21		

166.11

4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	166.11	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	166.11	0.00	0.00	0.00	0.00	0.00	0.00	

166.11

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	
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	

7,938.08	
2,574.76	
10,512.84	

S000	STATE-ONLY BHS	4,186.30	0.00	0.00	0.00	0.00	-2,368.16	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,186.30	0.00	0.00	0.00	0.00	-2,368.16	0.00	0.00	0.00	0.00	0.00	0.00	

1,818.14

1,818.14

4,513,653.75

767,862.18	768,909.98	833,762.78	698,694.23	750,893.38	693,531.20	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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 December 31, 2019

RATE CODE	DESCRIPTION 1010	TANF NON-MEDICARE
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

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

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	

2120

2200

220Z

2210

221Z

2220

222Z

2310

4314

4315

431E

5007

5010

5017

501G

SSI AGED WITH QMB

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	

0.00	
0.00	
0.00	
0.00	

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

RATE CODE	DESCRIPTION

1116

TANF EXPANDED 21-44

1117

TANF EXPANDED 21-44

1118

TANF EXPANDED 45-64

111F

111G

TANF EXPANDED 21-44

TANF EXPANDED 21-44

111H

TANF EXPANDED 45-64

1120

240Z

2420

260Z

2610

261Z

2620

262Z

TANF EXPANDED FOR FI
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

E
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

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	

3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	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	
370G	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	
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	
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371E	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEM AL	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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

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

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	
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	

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	

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.

0.00

0.00	
0.00	
0.00	

0.00

0.00

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1013	TANF 06-13 M & F NON	0.00	178.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		178.47		
1014	TANF 14-20 MALE NON-	0.00	-0.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.24		
1015	TANF 14-20 FEMALE N O	0.00	0.00	20.76	0.00	0.00	-252.10	0.00	0.00	0.00	0.00	0.00	0.00		-231.34		
1016	TANF 21-44 MALE NON-	-1.81	-6.11	0.00	0.00	-120.58	-186.56	0.00	0.00	0.00	0.00	0.00	0.00		-315.06		
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	2,181.12	0.00	0.00	0.00	0.00	0.00	0.00		3,289.30		
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	-206.43	0.00	0.00	0.00	0.00	0.00	0.00		-135.90		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	338.54	0.00	0.00	0.00	0.00	0.00	0.00		338.54		
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	1,874.57	0.00	0.00	0.00	0.00	0.00	0.00		5,354.98		

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	-1,460.62	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	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	45.50	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	564.24	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	-850.88	0.00	0.00	0.00	0.00	0.00	0.00	

 
211.59	
-1,139.22	
-216.46	
-1,622.47	
159.44	
141.06	
45.50	
564.24	
38.57	
-1,817.75	

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

 

155.73

155.73

3514

ADULT 40-100% MALE 1

209.24

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

209.24

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3515	ADULT 40-100% FEMAL E	0.00	0.00	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		-532.24		
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		-3.41		
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		-748.12		
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		
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	-1,002.09	0.00	0.00	0.00	0.00	0.00	0.00		-1,002.09		
3716	ADULT <40% EXP MALE	-806.04	-3,513.00	-2,336.03	0.00	-508.42	-6.85	0.00	0.00	0.00	0.00	0.00	0.00		-7,170.34		
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	-6.77	0.00	0.00	0.00	0.00	0.00	0.00		-5,722.37		
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	-1,015.71	0.00	0.00	0.00	0.00	0.00	0.00		-17,352.42		

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

-14,244.53

-1,196.12	-3,952.91	-9,044.75	2,484.98	-2,543.71	7.98	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 December 31, 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	
0.00	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

5015

5017

SSI DISABLED WITH Q M
SOBRA CHILD 01-05 M

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

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	
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	
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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

0.00

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

RATE CODE	DESCRIPTION

3515

3516

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

3517

3518

351H

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

ADULT 40-100% M&F 45

3709

3714

ADULT <40% EXP M&F 6
ADULT <40% EXP MALE

3715

3716

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

3717

3718

3719

371E

371F

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

371G

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

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

371H

0.00

0.00

0.00

0.00

4
SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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	

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

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	675,910.00	670,888.15	500,674.55	532,532.67	408,990.72	438,613.29	0.00	0.00	0.00	0.00	0.00	0.00		3,227,609.38		
1011	TANF <1 M & F NON-ME	248.11	953.72	-5,125.27	13,521.89	13,832.51	15,769.15	0.00	0.00	0.00	0.00	0.00	0.00		39,200.11		
1012	TANF 01-05 M & F NON	-15,379.82	-11,274.85	-15,393.11	-14,326.02	1,219.31	-1,002.96	0.00	0.00	0.00	0.00	0.00	0.00		-56,157.45		
1013	TANF 06-13 M & F NON	-2,418.26	-7,544.45	3,346.51	2,532.68	-359.74	13,098.70	0.00	0.00	0.00	0.00	0.00	0.00		8,655.44		
1014	TANF 14-20 MALE NON-	-811.16	-1,806.09	1,478.38	4,248.21	3,277.70	2,891.87	0.00	0.00	0.00	0.00	0.00	0.00		9,278.91		
1015	TANF 14-20 FEMALE N O	-368.71	-1,388.95	1,344.21	1,730.28	109.06	1,536.14	0.00	0.00	0.00	0.00	0.00	0.00		2,962.03		
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	123.90	0.00	0.00	0.00	0.00	0.00	0.00		203.06		
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	304,336.28	0.00	0.00	0.00	0.00	0.00	0.00		1,691,783.94		
221Z	SSI DISABLED NON-ME D	232.93	-271.78	-3,810.00	1,516.45	862.55	-9,631.67	0.00	0.00	0.00	0.00	0.00	0.00		-11,101.52		
2220	SSI DISABLED WITH Q
M	762.00	762.00	762.00	817.98	817.98	998.50	0.00	0.00	0.00	0.00	0.00	0.00		4,920.46		
2310	SSI BLIND NON-MEDIC A	762.00	762.00	762.00	817.98	817.98	817.98	0.00	0.00	0.00	0.00	0.00	0.00		4,739.94		
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	11,443,538.65	0.00	0.00	0.00	0.00	0.00	0.00		65,763,897.72		
4311	SOBRA CHILD <1 M & F	13,625.43	15,714.43	26,374.80	64,140.68	41,219.20	59,058.28	0.00	0.00	0.00	0.00	0.00	0.00		220,132.82		
4312	SOBRA CHILD 01-05 M	-74,721.61	-78,041.28	-39,438.44	-22,022.88	-20,911.83	7,244.40	0.00	0.00	0.00	0.00	0.00	0.00		-227,891.64		
4313	SOBRA CHILD 06-13 M	-105,628.37	-106,985.86	-26,667.13	-38,539.84	-21,900.32	27,437.29	0.00	0.00	0.00	0.00	0.00	0.00		-272,284.23		
4314	SOBRA CHILD 14-20 MA	-43,134.77	-38,503.25	2,887.88	-13,089.30	-18,636.85	19,331.13	0.00	0.00	0.00	0.00	0.00	0.00		-91,145.16		
4315	SOBRA CHILD 14-20 FE	-40,754.75	-20,963.64	-19,790.76	-8,327.22	-6,843.88	12,845.59	0.00	0.00	0.00	0.00	0.00	0.00		-83,834.66		
431A	SOBRA CHILD < 1 M &	1,940.81	16,788.88	6,353.47	1,731.58	3,643.65	2,679.78	0.00	0.00	0.00	0.00	0.00	0.00		33,138.17		
431B	SOBRA CHILD 01-05 M	12,785.94	9,798.85	10,136.79	6,573.62	-2,311.77	37,843.20	0.00	0.00	0.00	0.00	0.00	0.00		74,826.63		
431C	SOBRA CHILD 6-13 M& F	25,205.14	21,852.27	12,251.98	22,429.04	1,841.51	9,714.00	0.00	0.00	0.00	0.00	0.00	0.00		93,293.94		
431D	SOBRA CHILD 14-20 MA	16,781.28	5,724.71	4,846.17	2,208.14	-63.14	4,029.48	0.00	0.00	0.00	0.00	0.00	0.00		33,526.64		
431E	SOBRA CHILD 14-20 FE	11,745.14	9,190.46	4,671.89	1,089.23	5,678.75	4,486.96	0.00	0.00	0.00	0.00	0.00	0.00		36,862.43		
5010	SOBRA PREGNANT WO MAN	13,738.15	13,995.75	20,755.25	22,862.96	19,191.32	18,173.48	0.00	0.00	0.00	0.00	0.00	0.00		108,716.91		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	817.98	-1,746.16	471.42	1,301.21	0.00	0.00	0.00	0.00	0.00	0.00		844.45		
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	12,415,234.63	0.00	0.00	0.00	0.00	0.00	0.00		70,608,168.12		

3710	AHC CARE EXPANDED FO	0.00	0.00	762.00	817.98	817.98	2,861.23	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	-163.37	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	211.09	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	-1,225.27	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,259.19	
434.13	
347.42	
-543.62	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending December 31, 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	606.89	0.00	0.00	0.00	0.00	0.00	0.00		688.69		
SUBTOTAL:	0.00	393.29	762.00	817.98	1,921.97	2,290.57	0.00	0.00	0.00	0.00	0.00	0.00		6,185.81		

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

 
3,215.94	
589.94	
172.06	
3,977.94	

4410	SOBRA 100-133% FOR F	12,926.90	12,373.25	10,432.55	10,404.37	11,422.21	10,604.23	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	171.82	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	158.32	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	345.41	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	11,279.78	0.00	0.00	0.00	0.00	0.00	0.00	

 
68,163.51	
9,985.64	
2,182.13	
3,273.94	
681.12	
127.00	
84,413.34	

-762.00

70,701,983.21

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	12,429,622.96	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 December 31, 2019

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

1012	TANF 01-05 M & F NON

1013	TANF 06-13 M & F NON

1014	TANF 14-20 MALE NON-

1015	TANF 14-20 FEMALE N
O
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 December 31, 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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	204.75	398.47	398.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,001.69		
1010	TANF NON-MEDICARE	88,390.05	113,571.24	121,494.47	2,457.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		325,912.76		
101Z	TANF ALTCS NON-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	-912.42	0.00	0.00	0.00	0.00	0.00	0.00		17,659,529.13		
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	923.04	0.00	0.00	0.00	0.00	0.00	0.00		2,920,801.06		
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	10.62	0.00	0.00	0.00	0.00	0.00	0.00		22,528,716.15		

8700	SSI DISABLED FREEDO M	4,554.83	3,929.55	4,328.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	785.91	979.63	1,765.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	2,380.90	2,585.65	2,984.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,721.64	7,494.83	9,077.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

22,553,010.31

7,458,765.69	7,517,688.26	7,570,386.98	6,293.18	-134.42	10.62	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending December 31, 2019

SUBTOTAL:

Cu0.0r0   ren0.0t0      an0.d00

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

0.00

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	37.95	37.95	26.37	0.00	0.00	0.00	0.00	0.00	0.00		102.27		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	2.74	0.00	0.00	0.00	0.00	0.00	0.00		2.74		
1006	TANF 21-44 MALE WITH	572.44	524.04	554.06	610.44	653.58	621.63	0.00	0.00	0.00	0.00	0.00	0.00		3,536.19		
1007	TANF 21-44 FEMALE WI	697.86	633.68	569.00	684.33	704.31	709.50	0.00	0.00	0.00	0.00	0.00	0.00		3,998.68		
1008	TANF 45-64 M & F WIT	1,292.20	1,256.05	1,295.38	1,740.93	1,802.07	1,823.28	0.00	0.00	0.00	0.00	0.00	0.00		9,209.91		
1009	TANF 65+ M & F WITH	784.65	740.61	658.68	876.87	918.39	962.73	0.00	0.00	0.00	0.00	0.00	0.00		4,941.93		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	1,298.21	1,375.91	1,357.25	0.00	0.00	0.00	0.00	0.00	0.00		4,031.37		
1011	TANF <1 M & F NON-ME	13,774.43	13,889.53	14,044.68	17,835.20	17,855.94	17,746.06	0.00	0.00	0.00	0.00	0.00	0.00		95,145.84		
1012	TANF 01-05 M & F NON	26,627.12	26,500.41	26,825.46	34,791.07	36,165.57	39,032.85	0.00	0.00	0.00	0.00	0.00	0.00		189,942.48		
1013	TANF 06-13 M & F NON	48,891.34	48,999.00	49,380.14	63,910.09	65,933.63	70,279.62	0.00	0.00	0.00	0.00	0.00	0.00		347,393.82		
1014	TANF 14-20 MALE NON-	29,752.48	29,183.72	29,422.86	36,763.51	37,072.83	39,533.02	0.00	0.00	0.00	0.00	0.00	0.00		201,728.42		
1015	TANF 14-20 FEMALE N O	50,257.49	49,708.32	49,693.38	60,864.17	60,283.24	61,746.72	0.00	0.00	0.00	0.00	0.00	0.00		332,553.32		
1016	TANF 21-44 MALE NON-	196,818.83	196,825.88	198,260.40	238,341.36	238,159.44	243,350.34	0.00	0.00	0.00	0.00	0.00	0.00		1,311,756.25		
1017	TANF 21-44 FEMALE N O	669,123.39	671,878.41	675,375.54	809,952.99	813,363.96	820,761.63	0.00	0.00	0.00	0.00	0.00	0.00		4,460,455.92		
1018	TANF 45-64 M & F NON	161,187.72	160,988.62	161,431.18	193,858.32	194,773.80	199,001.19	0.00	0.00	0.00	0.00	0.00	0.00		1,071,240.83		
1019	TANF 65+ M & F NON-M	674.30	651.26	689.40	813.75	820.95	920.79	0.00	0.00	0.00	0.00	0.00	0.00		4,570.45		
1020	TANF WITH QMB	0.00	0.00	0.00	40.74	40.74	20.37	0.00	0.00	0.00	0.00	0.00	0.00		101.85		
1024	TANF 14-20 MALE WITH	10.41	1.08	1.08	1.36	1.36	1.36	0.00	0.00	0.00	0.00	0.00	0.00		16.65		
1026	TANF 21-44 MALE WITH	387.68	364.94	366.97	429.87	417.06	424.65	0.00	0.00	0.00	0.00	0.00	0.00		2,391.17		
1027	TANF 21-44 FEMALE WI	653.45	638.63	661.09	729.06	730.26	746.64	0.00	0.00	0.00	0.00	0.00	0.00		4,159.13		
1028	TANF 45-64 M & F WIT	835.76	807.47	773.65	772.59	694.71	854.49	0.00	0.00	0.00	0.00	0.00	0.00		4,738.67		
1029	TANF 65+ M & F WITH	450.07	433.44	423.81	508.56	487.77	526.92	0.00	0.00	0.00	0.00	0.00	0.00		2,830.57		
2100	SSI AGED WITH MEDIC A	32,980.00	32,982.55	33,054.20	141,547.41	142,231.14	142,090.11	0.00	0.00	0.00	0.00	0.00	0.00		524,885.41		
2110	SSI AGED NON-MEDIC
AR	53,956.16	54,404.88	54,776.81	70,837.29	71,168.91	71,596.68	0.00	0.00	0.00	0.00	0.00	0.00		376,740.73		
2120	SSI AGED WITH QMB	256,470.33	258,178.50	259,225.39	392,946.39	393,935.16	395,182.59	0.00	0.00	0.00	0.00	0.00	0.00		1,955,938.36		
2200	SSI DISABLED WITH M E	25,887.66	25,631.83	25,902.25	69,776.70	69,843.69	69,360.39	0.00	0.00	0.00	0.00	0.00	0.00		286,402.52		
2210	SSI DISABLED NON-ME
D	277,976.12	277,927.49	278,125.13	480,981.11	482,036.96	483,811.33	0.00	0.00	0.00	0.00	0.00	0.00		2,280,858.14		
2220	SSI DISABLED WITH Q M	170,604.53	170,784.02	170,828.67	276,883.13	277,277.65	277,481.54	0.00	0.00	0.00	0.00	0.00	0.00		1,343,859.54		
2300	SSI BLIND WITH MEDIC	235.51	244.84	214.82	270.87	296.04	289.26	0.00	0.00	0.00	0.00	0.00	0.00		1,551.34		
2310	SSI BLIND NON-MEDIC A	3,591.59	3,599.17	3,649.81	4,587.91	4,550.70	4,565.88	0.00	0.00	0.00	0.00	0.00	0.00		24,545.06		
2320	SSI BLIND WITH QMB	1,900.92	1,912.30	1,925.39	2,370.60	2,435.31	2,388.99	0.00	0.00	0.00	0.00	0.00	0.00		12,933.51		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	1.36	0.00	0.00	0.00	0.00	0.00	0.00		1.36		
4302	SOBRA CHILD 01-05 M	3.24	3.24	5.40	6.80	6.80	4.08	0.00	0.00	0.00	0.00	0.00	0.00		29.56		
4303	SOBRA CHILD 06-13 M	9.76	9.76	10.85	13.70	13.70	13.70	0.00	0.00	0.00	0.00	0.00	0.00		71.47		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	1.36	1.36	0.00	0.00	0.00	0.00	0.00	0.00		2.72		
4305	SOBRA CHILD 14-20 FE	20.16	17.99	9.33	11.58	11.58	11.58	0.00	0.00	0.00	0.00	0.00	0.00		82.22		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4311	SOBRA CHILD <1 M & F	48,698.46	48,704.10	48,220.98	60,494.89	60,162.77	59,761.61	0.00	0.00	0.00	0.00	0.00	0.00		326,042.81		
4312	SOBRA CHILD 01-05 M	236,845.73	238,192.76	238,593.68	299,784.93	297,048.72	292,268.85	0.00	0.00	0.00	0.00	0.00	0.00		1,602,734.67		
4313	SOBRA CHILD 06-13 M	310,882.77	313,296.50	314,734.87	397,068.44	394,162.68	389,393.67	0.00	0.00	0.00	0.00	0.00	0.00		2,119,538.93		
4314	SOBRA CHILD 14-20 MA	155,400.15	157,444.43	158,328.17	193,512.39	192,498.84	190,731.36	0.00	0.00	0.00	0.00	0.00	0.00		1,047,915.34		
4315	SOBRA CHILD 14-20 FE	157,772.95	160,194.90	160,353.44	196,109.27	196,274.41	193,532.81	0.00	0.00	0.00	0.00	0.00	0.00		1,064,237.78		
4322	SOBRA CHILD 01-05 M	1.08	1.08	1.08	1.36	1.36	1.36	0.00	0.00	0.00	0.00	0.00	0.00		7.32		
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	5.48	0.00	0.00	0.00	0.00	0.00	0.00		60.03		
5007	SOBRA PREG 21-44 FE M	148.67	173.44	218.64	246.09	218.52	246.48	0.00	0.00	0.00	0.00	0.00	0.00		1,251.84		
5008	SOBRA PREG 45-64 FE
M	11.36	11.36	11.36	13.59	13.59	13.59	0.00	0.00	0.00	0.00	0.00	0.00		74.85		
5013	SOBRA PREG 09-13 FE M	3.32	8.72	6.56	4.30	8.40	16.51	0.00	0.00	0.00	0.00	0.00	0.00		47.81		
5015	SOBRA PREG 14-20 FE
M	18,252.71	19,137.94	19,530.79	23,029.58	22,663.01	22,611.09	0.00	0.00	0.00	0.00	0.00	0.00		125,225.12		
5017	SOBRA PREG 21-44 FE M	118,643.32	122,268.55	124,930.21	148,505.19	146,902.83	141,515.64	0.00	0.00	0.00	0.00	0.00	0.00		802,765.74		
5018	SOBRA PREG 45-64 FE
M	307.55	390.33	379.25	514.56	486.21	515.73	0.00	0.00	0.00	0.00	0.00	0.00		2,593.63		
5027	SOBRA PREG 21-44 FE M	205.51	237.30	212.81	245.67	246.87	278.04	0.00	0.00	0.00	0.00	0.00	0.00		1,426.20		
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	8.79	17.58	8.79	0.00	0.00	0.00	0.00	0.00	0.00		35.16		
SUBTOTAL:	3,073,603.35	3,089,794.99	3,103,689.65	4,224,649.54	4,226,823.89	4,238,150.01	0.00	0.00	0.00	0.00	0.00	0.00		21,956,711.43		

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	1,837.23	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	3,019.77	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	10,443.45	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	6,398.85	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	7.02	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	2,188.41	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	13,510.18	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	236,288.22	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	655,404.84	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	228,073.14	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	847.68	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	6,064.71	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	12,623.82	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	22,458.90	0.00	0.00	0.00	0.00	0.00	0.00	

7.58	
10,158.07	
17,498.16	
57,854.08	
34,733.23	
2.17	
55.85	
11,757.17	
76,217.16	
1,342,702.84	
3,674,484.71	
1,278,226.23	
4,402.60	
34,293.66	
70,982.52	
123,702.05	

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1129	TANF EXPANDED 65+
M&	12,988.91	13,110.24	13,310.80	16,421.55	16,549.35	16,636.83	0.00	0.00	0.00	0.00	0.00	0.00		89,017.68		
2400	SSI AGED EXPANDED WI	839.74	893.69	957.51	1,046.58	1,306.71	1,049.43	0.00	0.00	0.00	0.00	0.00	0.00		6,093.66		
2410	SSI AGED EXPANDED
NO	734.20	842.92	773.27	900.06	912.84	904.47	0.00	0.00	0.00	0.00	0.00	0.00		5,067.76		
2420	SSI AGED EXPANDED WI	200,778.15	202,142.27	203,515.08	246,928.83	247,840.44	249,594.81	0.00	0.00	0.00	0.00	0.00	0.00		1,350,799.58		
2520	SSI BLIND EXPANDED
W	7.58	7.58	7.58	8.79	17.58	17.58	0.00	0.00	0.00	0.00	0.00	0.00		66.69		
2600	SSI DISABLED EXPAND E	762.25	849.07	753.42	803.40	1,180.50	1,365.09	0.00	0.00	0.00	0.00	0.00	0.00		5,713.73		
2610	SSI DISABLED EXPAND
E	10,383.49	10,503.92	10,814.11	13,250.58	13,618.53	13,962.93	0.00	0.00	0.00	0.00	0.00	0.00		72,533.56		
2620	SSI DISABLED EXPAND E	99,455.39	99,763.22	99,882.81	119,843.46	119,853.90	119,801.04	0.00	0.00	0.00	0.00	0.00	0.00		658,599.82		
SUBTOTAL:	1,353,111.57	1,358,060.90	1,361,578.86	1,628,431.45	1,621,289.38	1,602,498.40	0.00	0.00	0.00	0.00	0.00	0.00		8,924,970.56		

3506	ADULT 40-100% MALE 2	39.65	24.49	41.40	58.32	40.74	52.32	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	37.95	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	450.21	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	77.49	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	54,553.98	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	58,904.52	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	174,022.02	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	147,407.37	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	340,915.26	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	63.90	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	17.58	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	157.41	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	67.11	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	652.77	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	84.69	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	100,291.56	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	90,172.05	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	684,993.87	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	386,480.67	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	765,019.50	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	58.32	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	13.59	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	8.79	0.00	0.00	0.00	0.00	0.00	0.00	

 
256.92	
127.31	
3,007.80	
738.70	
297,105.55	
322,560.89	
955,051.65	
803,836.14	
1,880,616.71	
325.00	
29.96	
52.70	
49.65	
7.58	
944.31	
396.43	
3,428.00	
498.10	
551,963.23	
500,526.62	
3,718,131.88	
2,109,745.79	
4,188,601.08	
423.89	
114.45	
77.60	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3728	ADULT <40% EXP M&F 4	0.00	3.78	20.69	29.16	42.75	20.37	0.00	0.00	0.00	0.00	0.00	0.00		116.75		
3729	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	11.58	11.58	0.00	0.00	0.00	0.00	0.00	0.00		23.16		
SUBTOTAL:	2,281,745.11	2,310,670.32	2,328,102.00	2,804,867.64	2,808,837.90	2,804,534.88	0.00	0.00	0.00	0.00	0.00	0.00		15,338,757.85		

4413	SOBRA 100-133% M&F
6	58,543.74	58,461.45	57,600.88	71,698.76	70,643.77	68,983.92	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	36,157.87	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	35,263.68	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	140,405.47	0.00	0.00	0.00	0.00	0.00	0.00	

385,932.52	
203,569.37	
198,449.93	
787,951.82	

4517	BC PATIENT FEMALE 2 1	143.38	164.09	156.51	211.74	220.53	220.53	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	1,163.31	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	47.55	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	110.64	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	1,542.03	0.00	0.00	0.00	0.00	0.00	0.00	

1,116.78	
6,284.98	
291.78	
494.85	
8,188.39	

8600	SSI BLIND FREEDOM/W O	7.58	7.58	7.58	8.79	8.79	8.79	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	11.58	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	13,845.21	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	3,105.03	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	2,591.49	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	19,562.10	0.00	0.00	0.00	0.00	0.00	0.00	

49.11	
62.73	
74,771.57	
16,728.50	
13,126.32	
104,738.23	

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	

61.68

3906	NEWLY ELIGIBLE MALE	90.34	82.78	88.61	131.82	118.23	146.61	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	39.96	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	633.57	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	137.40	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	30,673.53	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	34,452.78	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	153,056.91	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	230,381.76	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	236,541.72	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	16.38	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	
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	11.58	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	8.79	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	8.79	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	686,109.78	0.00	0.00	0.00	0.00	0.00	0.00	

 
658.39	
173.30	
3,494.38	
1,145.58	
164,464.76	
187,382.21	
859,903.51	
1,292,048.36	
1,302,566.71	
139.85	
18.12	
11.58	
93.89	
21.90	
3,812,122.54	

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

50,933,595.88

7,421,096.76	7,478,127.98	7,510,423.34	9,519,723.30	9,511,421.83	9,492,802.67	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE		TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1015

1016	TANF 14-20 FEMALE N O
TANF 21-44 MALE NON-	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

1018

TANF 45-64 M & F NON

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

1019

1020

1024

1026

1027

1028

1029

2100

2110

2120

2200

2210

2220

2300

2310

2320

4301

4302

4303

4304

4305

TANF 65+ M & F NON-M 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 <1 M & F SOBRA CHILD 01-05 M SOBRA CHILD 06-13 M SOBRA CHILD 14-20 MA 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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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 December 31, 2019

RATE CODE	DESCRIPTION

4311

SOBRA CHILD <1 M & F

4312

SOBRA CHILD 01-05 M

4313

SOBRA CHILD 06-13 M

4314

4315

SOBRA CHILD 14-20 MA

SOBRA CHILD 14-20 FE

4322

SOBRA CHILD 01-05 M

4323

SOBRA CHILD 06-13 M

4325

5007

5008

5013

5015

5017

5018

5027

SOBRA CHILD 14-20 FE

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

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

5028

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

M
SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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	

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

3514

ADULT 40-100% MALE 1

3515

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

Current and

0.00	0.00	0.00

0.00

0.00

0.00

prior m

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

onth

0.00

dat

0.00

a is

0.00

under re

0.00

0.00

visio

0.00

n.

0.00

3516

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
E
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00

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

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

3529

3704

ADULT 40-100% M&F 45
ADULT 40-100% M&F 65 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

3706

ADULT <40% EXP MALE

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3707

3708

3709

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

3714

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3715

3716

3717

ADULT <40% EXP FEM AL
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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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

3726

3727

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		
3729	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3906

NEWLY ELIGIBLE MALE

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3907

3908

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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

3915

3916

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F
6
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

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

3919

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3927

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE M&F
4
NEWLY ELIGIBLE M&F

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

n.

0.00

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

3929
6
SUBTOTAL:

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	

0.00

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

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

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.

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	7,179.92	4,842.01	4,556.71	7,527.68	5,436.84	7,075.16	0.00	0.00	0.00	0.00	0.00	0.00		36,618.32		
1007	TANF 21-44 FEMALE WI	5,660.13	8,315.12	3,656.17	5,435.78	2,517.23	3,959.23	0.00	0.00	0.00	0.00	0.00	0.00		29,543.66		
1008	TANF 45-64 M & F WIT	13,522.79	12,784.45	13,053.33	12,421.84	22,109.43	17,836.46	0.00	0.00	0.00	0.00	0.00	0.00		91,728.30		
1009	TANF 65+ M & F WITH	7,573.40	7,048.03	5,895.29	8,756.67	14,657.56	7,617.34	0.00	0.00	0.00	0.00	0.00	0.00		51,548.29		
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	1,001,623.05	0.00	0.00	0.00	0.00	0.00	0.00		7,119,253.26		
1012	TANF 01-05 M & F NON	321,855.78	307,163.81	292,577.80	407,348.20	543,346.28	385,437.42	0.00	0.00	0.00	0.00	0.00	0.00		2,257,729.29		
1013	TANF 06-13 M & F NON	530,515.76	501,663.79	446,044.70	600,476.34	775,465.98	541,503.30	0.00	0.00	0.00	0.00	0.00	0.00		3,395,669.87		
1014	TANF 14-20 MALE NON-	203,236.61	175,532.08	149,342.10	162,062.58	211,886.30	200,679.55	0.00	0.00	0.00	0.00	0.00	0.00		1,102,739.22		
1015	TANF 14-20 FEMALE N O	393,263.47	411,573.01	297,015.96	394,439.42	504,458.51	386,700.68	0.00	0.00	0.00	0.00	0.00	0.00		2,387,451.05		
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	2,121,076.17	0.00	0.00	0.00	0.00	0.00	0.00		12,856,030.11		
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	7,039,772.97	0.00	0.00	0.00	0.00	0.00	0.00		43,305,860.05		
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	2,724,948.18	0.00	0.00	0.00	0.00	0.00	0.00		17,661,622.22		
1019	TANF 65+ M & F NON-M	3,082.12	11,634.33	3,047.76	2,043.66	9,366.69	8,990.10	0.00	0.00	0.00	0.00	0.00	0.00		38,164.66		
1026	TANF 21-44 MALE WITH	5,452.82	2,600.75	875.03	1,475.75	455.00	910.00	0.00	0.00	0.00	0.00	0.00	0.00		11,769.35		
1027	TANF 21-44 FEMALE WI	8,052.27	3,119.24	1,357.57	1,942.85	3,864.76	1,351.45	0.00	0.00	0.00	0.00	0.00	0.00		19,688.14		
1028	TANF 45-64 M & F WIT	7,027.85	6,397.80	5,710.26	5,594.94	4,290.29	5,544.97	0.00	0.00	0.00	0.00	0.00	0.00		34,566.11		
1029	TANF 65+ M & F WITH	11,881.21	6,449.88	10,048.57	5,614.64	7,235.43	4,468.56	0.00	0.00	0.00	0.00	0.00	0.00		45,698.29		
2100	SSI AGED WITH MEDIC A	231,952.74	259,830.87	132,481.39	252,617.63	276,656.69	204,516.23	0.00	0.00	0.00	0.00	0.00	0.00		1,358,055.55		
2110	SSI AGED NON-MEDIC
AR	164,988.00	142,495.88	96,068.65	168,374.24	260,998.19	205,990.03	0.00	0.00	0.00	0.00	0.00	0.00		1,038,914.99		
2120	SSI AGED WITH QMB	696,504.68	647,287.68	605,933.24	718,218.99	1,059,551.70	625,448.61	0.00	0.00	0.00	0.00	0.00	0.00		4,352,944.90		
2200	SSI DISABLED WITH M E	509,724.57	597,467.37	548,111.03	834,347.54	1,004,039.17	543,632.01	0.00	0.00	0.00	0.00	0.00	0.00		4,037,321.69		
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	9,814,979.20	0.00	0.00	0.00	0.00	0.00	0.00		62,752,998.48		
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	1,584,966.66	0.00	0.00	0.00	0.00	0.00	0.00		10,236,570.05		
2300	SSI BLIND WITH MEDIC	2,786.12	2,517.54	1,645.59	4,405.82	6,481.73	6,297.08	0.00	0.00	0.00	0.00	0.00	0.00		24,133.88		
2310	SSI BLIND NON-MEDIC A	105,581.25	151,794.37	90,576.36	88,921.37	174,467.52	128,727.62	0.00	0.00	0.00	0.00	0.00	0.00		740,068.49		
2320	SSI BLIND WITH QMB	25,806.73	19,005.13	19,779.17	28,930.91	31,467.87	25,875.18	0.00	0.00	0.00	0.00	0.00	0.00		150,864.99		
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	2,899,521.14	0.00	0.00	0.00	0.00	0.00	0.00		15,997,354.25		
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	4,666,904.69	0.00	0.00	0.00	0.00	0.00	0.00		27,498,240.14		
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	6,670,009.41	0.00	0.00	0.00	0.00	0.00	0.00		42,125,642.30		
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	2,123,805.96	0.00	0.00	0.00	0.00	0.00	0.00		12,467,810.30		
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	2,259,622.51	0.00	0.00	0.00	0.00	0.00	0.00		14,989,827.33		
5007	SOBRA PREG 21-44 FE M	1,468.11	1,067.27	1,508.98	1,106.22	266.60	2,168.74	0.00	0.00	0.00	0.00	0.00	0.00		7,585.92		
5013	SOBRA PREG 09-13 FE
M	0.00	581.96	1,820.00	455.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00		3,311.96		
5015	SOBRA PREG 14-20 FE M	462,480.69	354,299.93	380,997.74	383,826.05	392,651.01	353,290.97	0.00	0.00	0.00	0.00	0.00	0.00		2,327,546.39		
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	2,231,000.14	0.00	0.00	0.00	0.00	0.00	0.00		15,192,962.89		
5018	SOBRA PREG 45-64 FE M	6,539.65	455.00	2,730.00	936.35	1,820.00	2,345.40	0.00	0.00	0.00	0.00	0.00	0.00		14,826.40		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	50.00	0.00	687.71	4,998.88	3,136.65	4,048.60	0.00	0.00	0.00	0.00	0.00	0.00		12,921.84		
SUBTOTAL:	47,800,049.38	48,593,680.36	41,274,480.48	51,848,514.54	67,445,758.40	48,813,099.77	0.00	0.00	0.00	0.00	0.00	0.00		305,775,582.93		

1106	TANF EXPANDED 21-44	5,110.76	1,764.45	2,329.25	6,481.93	7,114.30	3,731.06	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	8,933.09	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	28,750.88	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	34,483.65	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	455.00	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	2,832.34	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	26,237.77	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	903,043.05	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	2,638,385.50	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	1,726,419.61	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	4,229.24	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	14,651.30	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	38,366.52	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	114,745.70	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	82,673.64	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	8,076.90	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	15,360.37	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	612,107.58	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	7,271.85	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	214,392.30	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	474,456.46	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	6,959,603.81	0.00	0.00	0.00	0.00	0.00	0.00	

 
26,531.75	
62,115.54	
237,689.47	
247,163.85	
1,741.96	
85,142.27	
268,354.33	
5,396,887.43	
17,862,608.06	
11,545,532.25	
31,762.91	
135,748.00	
271,015.61	
859,363.58	
512,895.54	
73,289.08	
109,804.59	
4,065,935.94	
60,437.63	
1,899,340.54	
2,837,772.54	
46,591,132.87	

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

 
-153.38

-153.38

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3508	ADULT 40-100% M&F 45	1,036.20	138.56	673.58	2,267.30	2,653.98	1,503.90	0.00	0.00	0.00	0.00	0.00	0.00		8,273.52		
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	74,485.97	0.00	0.00	0.00	0.00	0.00	0.00		463,535.11		
3515	ADULT 40-100% FEMAL E	133,768.02	149,460.55	112,076.25	145,651.79	180,110.33	118,857.04	0.00	0.00	0.00	0.00	0.00	0.00		839,923.98		
3516	ADULT 40-100% MALE 2	929,328.88	812,103.33	787,166.18	844,775.60	1,276,235.33	1,000,833.04	0.00	0.00	0.00	0.00	0.00	0.00		5,650,442.36		
3517	ADULT 40-100% FEMAL E	719,939.62	657,905.17	549,744.70	603,380.57	1,078,217.05	640,116.71	0.00	0.00	0.00	0.00	0.00	0.00		4,249,303.82		
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	2,381,513.75	0.00	0.00	0.00	0.00	0.00	0.00		16,821,184.20		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	42.48	603.86	2,304.26	0.00	0.00	0.00	0.00	0.00	0.00		2,950.60		
3706	ADULT <40% EXP MALE	684.21	6,334.49	1,409.66	5,705.43	2,437.60	307.40	0.00	0.00	0.00	0.00	0.00	0.00		16,878.79		
3707	ADULT <40% EXP FEM AL	3,777.08	1,125.81	3,880.63	1,961.77	711.71	-142.66	0.00	0.00	0.00	0.00	0.00	0.00		11,314.34		
3708	ADULT <40% EXP M&F
4	4,674.03	12,630.88	7,588.13	11,215.80	19,967.97	7,062.75	0.00	0.00	0.00	0.00	0.00	0.00		63,139.56		
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	582,647.95	0.00	0.00	0.00	0.00	0.00	0.00		3,095,714.94		
3715	ADULT <40% EXP FEM AL	514,957.44	618,604.64	456,041.22	607,313.78	764,561.82	519,505.39	0.00	0.00	0.00	0.00	0.00	0.00		3,480,984.29		
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	9,570,405.43	0.00	0.00	0.00	0.00	0.00	0.00		57,888,262.20		
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	5,262,533.74	0.00	0.00	0.00	0.00	0.00	0.00		31,187,657.49		
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	12,431,794.90	0.00	0.00	0.00	0.00	0.00	0.00		75,519,355.71		
3719	ADULT <40% EXP M&F 6	0.00	26,564.29	866.02	5,037.08	4,738.22	819.48	0.00	0.00	0.00	0.00	0.00	0.00		38,025.09		
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	32,594,549.05	0.00	0.00	0.00	0.00	0.00	0.00		199,340,976.27		

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	485,867.67	0.00	0.00	0.00	0.00	0.00	0.00	

3,202,326.33

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	130.68	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	3,724.33	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	95.76	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	42,226.30	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	59,944.87	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	527,512.34	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	745,176.60	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	1,553,892.42	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	2,932,703.30	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,895.13	
6,932.13	
20,025.78	
6,218.28	
191,420.60	
360,280.14	
4,418,136.30	
5,113,425.98	
10,222,090.49	
4,749.22	
20,360,174.05	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 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	219,226.25	0.00	0.00	0.00	0.00	0.00	0.00		1,276,244.61		
4415	SOBRA 100-133% FEMA L	228,920.72	243,977.81	263,975.40	261,842.64	327,941.69	211,924.01	0.00	0.00	0.00	0.00	0.00	0.00		1,538,582.27		
SUBTOTAL:	904,642.2	2	1,005,919.81	946,429.7	7	986,298.01	1,257,300.47	917,017.93	0.00	0.00	0.00	0.00	0.00	0.00		6,017,608.21		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	910.00	455.00	1,365.00	1,365.00	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	-6,528.53	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	910.00	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	-4,253.53	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,095.00	
102,240.82	
4,095.00	
14,032.24	
124,463.06	

8700	SSI DISABLED FREEDO M	18,707.10	13,486.58	11,826.59	23,094.07	19,236.20	24,850.38	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	17,146.99	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	1,381.15	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	43,378.52	0.00	0.00	0.00	0.00	0.00	0.00	

 
111,200.92	
204,069.99	
24,802.30	
340,073.21	

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

578,535,302.40

89,553,565.50	91,855,910.80	78,083,835.78	96,852,074.66	129,933,816.81	92,256,098.85	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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	41.58	81.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.23		
1008	TANF 45-64 M & F WIT	250.37	0.00	136.24	2,713.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,100.05		
1011	TANF <1 M & F NON-ME	1,720.56	515.08	4,324.42	811.70	940.96	846.45	0.00	0.00	0.00	0.00	0.00	0.00		9,159.17		
1012	TANF 01-05 M & F NON	0.00	455.00	196.06	221.06	0.00	9.71	0.00	0.00	0.00	0.00	0.00	0.00		881.83		
1013	TANF 06-13 M & F NON	27,471.80	1,636.87	2,281.82	1,603.52	360.10	508.31	0.00	0.00	0.00	0.00	0.00	0.00		33,862.42		
1014	TANF 14-20 MALE NON-	696.15	2,503.24	3,247.65	5,629.39	926.39	726.32	0.00	0.00	0.00	0.00	0.00	0.00		13,729.14		
1015	TANF 14-20 FEMALE N O	3,945.81	579.34	6,069.05	4,082.89	454.84	5,447.60	0.00	0.00	0.00	0.00	0.00	0.00		20,579.53		
1016	TANF 21-44 MALE NON-	42,364.00	16,517.72	2,089.15	5,485.58	2,831.04	-924.54	0.00	0.00	0.00	0.00	0.00	0.00		68,362.95		
1017	TANF 21-44 FEMALE N O	99,491.18	25,376.76	38,133.79	23,054.07	22,025.23	35,148.25	0.00	0.00	0.00	0.00	0.00	0.00		243,229.28		
1018	TANF 45-64 M & F NON	43,845.13	11,730.98	-5,418.24	1,206.07	341.55	91.06	0.00	0.00	0.00	0.00	0.00	0.00		51,796.55		
1028	TANF 45-64 M & F WIT	716.59	0.00	0.00	0.00	0.00	-716.59	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	12,444.34	8,579.22	5,435.32	3,380.49	1,675.34	375.71	0.00	0.00	0.00	0.00	0.00	0.00		31,890.42		
2110	SSI AGED NON-MEDIC
AR	37,219.25	24,330.99	5,813.58	11,051.99	16.38	1,299.37	0.00	0.00	0.00	0.00	0.00	0.00		79,731.56		
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	57.51	0.00	0.00	0.00	0.00	0.00	0.00		730.19		
2210	SSI DISABLED NON-ME
D	32,328.76	6,476.19	12,815.59	596.52	6,790.89	140.00	0.00	0.00	0.00	0.00	0.00	0.00		59,147.95		
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	21,622.51	0.00	0.00	0.00	0.00	0.00	0.00		275,256.35		
4312	SOBRA CHILD 01-05 M	171,883.85	118,793.66	52,409.54	33,938.23	31,230.50	53,187.22	0.00	0.00	0.00	0.00	0.00	0.00		461,443.00		
4313	SOBRA CHILD 06-13 M	39,579.36	92,454.57	127,080.50	57,433.95	24,484.31	14,618.28	0.00	0.00	0.00	0.00	0.00	0.00		355,650.97		
4314	SOBRA CHILD 14-20 MA	60,862.64	16,699.62	13,097.54	40,879.42	6,956.92	20,380.44	0.00	0.00	0.00	0.00	0.00	0.00		158,876.58		
4315	SOBRA CHILD 14-20 FE	39,098.46	12,346.02	27,377.62	56,688.03	14,027.94	29,164.13	0.00	0.00	0.00	0.00	0.00	0.00		178,702.20		
5007	SOBRA PREG 21-44 FE M	0.00	196.52	579.22	267.63	14.76	32.70	0.00	0.00	0.00	0.00	0.00	0.00		1,090.83		
5015	SOBRA PREG 14-20 FE
M	36,367.09	15,253.89	33,521.26	33,931.60	12,754.28	27,464.82	0.00	0.00	0.00	0.00	0.00	0.00		159,292.94		
5017	SOBRA PREG 21-44 FE M	145,231.52	116,182.97	137,749.55	145,267.58	107,510.58	100,552.14	0.00	0.00	0.00	0.00	0.00	0.00		752,494.34		
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	310,031.40	0.00	0.00	0.00	0.00	0.00	0.00		2,960,762.44		

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	8.17	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	736.90	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	2,849.59	0.00	0.00	0.00	0.00	0.00	0.00	

 
697.46	
1,368.75	
4,996.82	
1,445.54	
2,713.51	
114,186.95	
117,635.32	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	23,861.92	7,741.48	8,059.52	1,234.47	10,219.98	415.57	0.00	0.00	0.00	0.00	0.00	0.00		51,532.94		
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	1,551.93	0.00	0.00	0.00	0.00	0.00	0.00		31,984.60		
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	16.24	0.00	0.00	0.00	0.00	0.00	0.00		10,069.67		
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	1,551.26	0.00	0.00	0.00	0.00	0.00	0.00		3,078.62		
SUBTOTAL:	158,581.4	5	65,862.36	37,923.5	1	54,989.49	21,187.63	7,129.66	0.00	0.00	0.00	0.00	0.00	0.00		345,674.10		

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	33.26	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	5,012.05	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	1,676.89	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	9,747.48	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	121.87	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	1,306.30	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	9,212.93	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	5,902.22	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	15,313.32	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	48,326.32	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,407.26	
23,333.14	
8,212.43	
139,003.44	
73,348.26	
260,994.71	
48,625.14	
60,615.91	
692,625.26	
251,946.95	
702,306.04	
2,262,418.54	

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	-3,659.37	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	3,381.71	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	802.38	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	9,522.07	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	10,046.79	0.00	0.00	0.00	0.00	0.00	0.00	

 
106.30	
2,253.29	
10,132.04	
2,883.57	
141,113.60	
193,353.13	
429,258.95	
779,100.88	

4413	SOBRA 100-133% M&F
6	97,572.50	14,475.99	11,390.95	8,926.66	20,752.05	5,630.32	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	732.17	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	6,040.97	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	12,403.46	0.00	0.00	0.00	0.00	0.00	0.00	

 
158,748.47	
27,199.72	
31,442.86	
217,391.05	

8700

SSI DISABLED FREEDO M

144.13

203.30

1,545.39

0.00

108.16

10.21

0.00	0.00

0.00

0.00

0.00

0.00

2,011.19

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	0.00	5,206.52	0.00	480.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,686.90		
SUBTOTAL:	144.13	5,409.82	1,545.39	480.38	108.16	10.21	0.00	0.00	0.00	0.00	0.00	0.00		7,698.09		

TOTAL:	2,358,964.61	1,541,309.62	979,357.24	829,190.89	476,274.90	387,947.84	0.00	0.00	0.00	0.00	0.00	0.00		6,573,045.10		

FEDERAL EMERGENCY SERVICES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	2,216.23	3,492.52	29,766.20	3,922.02	22,945.09	6,056.49	0.00	0.00	0.00	0.00	0.00	0.00		68,398.55		
1012	TANF 01-05 M & F NON	77,421.94	71,881.43	120,924.31	163,993.83	20,887.81	19,942.96	0.00	0.00	0.00	0.00	0.00	0.00		475,052.28		
1013	TANF 06-13 M & F NON	67,181.43	79,607.43	75,624.93	49,537.63	89,698.91	30,361.57	0.00	0.00	0.00	0.00	0.00	0.00		392,011.90		
1014	TANF 14-20 MALE NON-	44,070.56	156,398.57	56,041.71	49,472.44	51,130.99	153,890.43	0.00	0.00	0.00	0.00	0.00	0.00		511,004.70		
1015	TANF 14-20 FEMALE N O	346,405.17	185,300.28	245,335.08	327,590.52	186,380.49	196,704.76	0.00	0.00	0.00	0.00	0.00	0.00		1,487,716.30		
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	1,875,028.47	0.00	0.00	0.00	0.00	0.00	0.00		11,619,604.28		
1018	TANF 45-64 M & F NON	9,102.32	9,101.37	7,812.93	9,840.98	269.53	27.61	0.00	0.00	0.00	0.00	0.00	0.00		36,154.74		
2100	SSI AGED WITH MEDIC A	22,518.78	19,427.61	17,554.57	10,826.93	28,454.50	9,579.31	0.00	0.00	0.00	0.00	0.00	0.00		108,361.70		
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	1,507,512.39	0.00	0.00	0.00	0.00	0.00	0.00		9,758,391.18		
2120	SSI AGED WITH QMB	144.29	32.85	8.60	56.23	0.00	1,364.00	0.00	0.00	0.00	0.00	0.00	0.00		1,605.97		
2200	SSI DISABLED WITH M E	9,179.10	14,416.02	3,482.91	8,649.81	9,853.82	208.56	0.00	0.00	0.00	0.00	0.00	0.00		45,790.22		
2210	SSI DISABLED NON-ME
D	52,112.74	40,196.05	75,208.50	38,646.07	54,475.66	22,673.10	0.00	0.00	0.00	0.00	0.00	0.00		283,312.12		
SUBTOTAL:	4,491,141.36	3,725,508.87	4,435,619.96	4,558,207.08	3,754,689.19	3,823,349.65	0.00	0.00	0.00	0.00	0.00	0.00		24,788,516.11		

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	3,472.65	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	8,947.35	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	50,898.19	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	838,465.05	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	635,168.56	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	2,501,053.02	0.00	0.00	0.00	0.00	0.00	0.00	

154.26	
31,235.85	
175,279.32	
219,610.36	
5,442,241.18	
3,055,495.98	
17,958,661.44	

1107	TANF EXPANDED 21-44	0.00	1,521.24	1,510.13	775.83	18.39	397.31	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	5,324.31	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	860.35	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	18,006.38	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	559,537.12	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	1,261,311.18	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	841,646.60	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	51,620.92	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	262.67	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	9,170.48	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	2,109.39	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	59.62	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	2,750,306.33	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,222.90	
50,224.86	
9,591.09	
131,866.64	
4,282,548.71	
8,813,175.06	
4,962,353.96	
214,705.70	
4,837.98	
2,711.39	
65,144.64	
19,002.78	
59.62	
18,560,445.33	

FEDERAL EMERGENCY SERVICES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		18,535.48		
SUBTOTAL:	5,151,773.36	4,521,846.40	4,307,601.76	4,739,518.88	4,142,468.65	4,038,004.82	0.00	0.00	0.00	0.00	0.00	0.00		26,901,213.87		

70,250,175.31

12,889,659.55	11,046,268.49	12,232,150.82	12,609,878.11	10,860,557.54	10,611,660.80	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

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

QMB - FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	660,202.07	490,087.07	440,384.81	367,061.97	187,136.46	361,482.60	0.00	0.00	0.00	0.00	0.00	0.00		2,506,354.98		
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	361,482.60	0.00	0.00	0.00	0.00	0.00	0.00		2,506,778.15		

0.00

0.00

0.00

367,061.97

TOTAL:

660,277.75

490,123.24

440,696.13

187,136.46

361,482.60

0.00

0.00

0.00

2,506,778.15

FFS TRBHA FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	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	20.34	0.00	0.00	0.00	0.00	0.00	0.00		572.24		
1011	TANF <1 M & F NON-ME	13,327.71	2,555.41	440.62	2,741.05	3,555.44	3,530.00	0.00	0.00	0.00	0.00	0.00	0.00		26,150.23		
1012	TANF 01-05 M & F NON	7,865.88	6,230.65	3,847.53	16,600.15	25,389.60	1,048.09	0.00	0.00	0.00	0.00	0.00	0.00		60,981.90		
1013	TANF 06-13 M & F NON	307,867.77	285,146.24	121,253.04	191,932.51	183,233.24	182,394.59	0.00	0.00	0.00	0.00	0.00	0.00		1,271,827.39		
1014	TANF 14-20 MALE NON-	72,162.55	27,686.96	22,237.41	54,500.62	24,988.66	49,775.23	0.00	0.00	0.00	0.00	0.00	0.00		251,351.43		
1015	TANF 14-20 FEMALE N O	109,108.33	104,274.36	91,303.97	148,372.80	116,514.66	87,832.87	0.00	0.00	0.00	0.00	0.00	0.00		657,406.99		
1016	TANF 21-44 MALE NON-	482,746.26	346,671.53	408,164.25	508,526.75	458,634.39	494,836.05	0.00	0.00	0.00	0.00	0.00	0.00		2,699,579.23		
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	1,589,283.20	0.00	0.00	0.00	0.00	0.00	0.00		8,858,135.59		
1018	TANF 45-64 M & F NON	285,431.75	240,088.50	276,977.66	260,726.04	299,518.50	313,464.50	0.00	0.00	0.00	0.00	0.00	0.00		1,676,206.95		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	45.61	0.00	0.00	0.00	0.00	0.00	0.00		45.61		
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	24,639.86	0.00	0.00	0.00	0.00	0.00	0.00		107,849.05		
2110	SSI AGED NON-MEDIC
AR	3,423.10	2,391.21	7,023.46	3,567.70	2,992.78	532.76	0.00	0.00	0.00	0.00	0.00	0.00		19,931.01		
2120	SSI AGED WITH QMB	66,532.03	48,594.38	50,139.30	42,216.05	47,939.77	48,743.58	0.00	0.00	0.00	0.00	0.00	0.00		304,165.11		
2200	SSI DISABLED WITH M E	63,339.72	50,009.45	55,104.31	57,799.84	52,251.85	51,335.59	0.00	0.00	0.00	0.00	0.00	0.00		329,840.76		
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	1,692,077.42	0.00	0.00	0.00	0.00	0.00	0.00		10,898,940.30		
2220	SSI DISABLED WITH Q M	388,879.11	342,330.15	328,681.88	351,532.78	352,022.04	270,632.69	0.00	0.00	0.00	0.00	0.00	0.00		2,034,078.65		
2310	SSI BLIND NON-MEDIC
A	36,358.35	59,301.51	24,367.36	15,444.33	13,764.82	10,488.46	0.00	0.00	0.00	0.00	0.00	0.00		159,724.83		
2320	SSI BLIND WITH QMB	5,271.02	1,918.97	1,852.18	1,952.66	2,400.59	2,726.04	0.00	0.00	0.00	0.00	0.00	0.00		16,121.46		
4311	SOBRA CHILD <1 M & F	6,460.61	6,068.40	6,860.01	8,565.44	20,779.70	4,898.18	0.00	0.00	0.00	0.00	0.00	0.00		53,632.34		
4312	SOBRA CHILD 01-05 M	239,174.74	187,542.33	207,568.43	288,173.03	246,312.30	198,239.80	0.00	0.00	0.00	0.00	0.00	0.00		1,367,010.63		
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	2,989,228.79	0.00	0.00	0.00	0.00	0.00	0.00		21,409,610.14		
4314	SOBRA CHILD 14-20 MA	974,878.74	1,029,423.72	690,182.62	862,224.33	899,977.44	1,147,796.56	0.00	0.00	0.00	0.00	0.00	0.00		5,604,483.41		
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	1,496,952.86	0.00	0.00	0.00	0.00	0.00	0.00		6,957,999.83		
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	5,556.16	0.00	0.00	0.00	0.00	0.00	0.00		87,711.03		
5017	SOBRA PREG 21-44 FE
M	146,024.25	157,851.29	176,250.02	173,453.52	199,370.69	163,511.39	0.00	0.00	0.00	0.00	0.00	0.00		1,016,461.16		
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	10,829,590.62	0.00	0.00	0.00	0.00	0.00	0.00		65,897,158.09		

221.74

1107	TANF EXPANDED 21-44	176.33	0.00	41.93	0.00	0.00	3.48	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	458.99	0.00	0.00	0.00	0.00	0.00	0.00	

11,819.25

FFS TRBHA FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+
M&	687.20	212.27	305.73	68.72	0.00	99.68	0.00	0.00	0.00	0.00	0.00	0.00		1,373.60		
1114	TANF EXPANDED 14-20	3,045.00	0.00	455.00	2,275.00	455.00	91.22	0.00	0.00	0.00	0.00	0.00	0.00		6,321.22		
1115	TANF EXPANDED 14-20	8,599.02	7,220.23	6,005.61	1,805.65	16,259.00	6,745.10	0.00	0.00	0.00	0.00	0.00	0.00		46,634.61		
1116	TANF EXPANDED 21-44	167,952.92	117,356.15	142,575.60	227,334.13	150,169.43	120,149.39	0.00	0.00	0.00	0.00	0.00	0.00		925,537.62		
1117	TANF EXPANDED 21-44	457,969.90	350,831.66	341,891.81	530,864.00	592,930.22	427,821.93	0.00	0.00	0.00	0.00	0.00	0.00		2,702,309.52		
1118	TANF EXPANDED 45-64	151,584.86	119,327.65	157,762.76	340,355.24	259,292.83	165,132.66	0.00	0.00	0.00	0.00	0.00	0.00		1,193,456.00		
1126	TANF EXPANDED 21-44	5,497.39	1,646.16	1,878.64	5,708.07	2,011.20	566.17	0.00	0.00	0.00	0.00	0.00	0.00		17,307.63		
1127	TANF EXPANDED 21-44	310.16	265.12	710.40	2,088.65	19,813.58	10,995.32	0.00	0.00	0.00	0.00	0.00	0.00		34,183.23		
1128	TANF EXPANDED 45-64	12,149.05	12,375.62	7,302.92	10,233.30	7,080.92	4,738.28	0.00	0.00	0.00	0.00	0.00	0.00		53,880.09		
1129	TANF EXPANDED 65+
M&	4,153.95	4,207.54	4,482.68	4,946.55	3,997.06	3,782.28	0.00	0.00	0.00	0.00	0.00	0.00		25,570.06		
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	24,539.07	0.00	0.00	0.00	0.00	0.00	0.00		207,166.48		
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	14,525.53	0.00	0.00	0.00	0.00	0.00	0.00		67,819.41		
2620	SSI DISABLED EXPAND
E	85,511.04	31,421.19	54,808.45	81,212.86	79,495.90	57,208.30	0.00	0.00	0.00	0.00	0.00	0.00		389,657.74		
SUBTOTAL:	963,690.3	5	700,065.73	768,322.7	2	1,246,725.01	1,171,803.66	836,857.40	0.00	0.00	0.00	0.00	0.00	0.00		5,687,464.87		

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	1,143.14	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	6,237.44	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	75,728.85	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	43,085.28	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	60,538.62	0.00	0.00	0.00	0.00	0.00	0.00	

29.55	
18,810.61	
33,829.73	
431,166.01	
231,769.51	
358,963.15	

3514	ADULT 40-100% MALE 1	10,776.55	6,979.68	14,745.82	14,618.09	21,431.14	27,631.88	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	12,189.99	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	210,272.44	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	115,476.22	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	164,912.06	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	856.48	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	129,852.16	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	110,080.92	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	2,449,120.43	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	1,482,199.75	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	1,607,736.54	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	6,310,328.87	0.00	0.00	0.00	0.00	0.00	0.00	

 
96,183.16	
91,765.40	
1,104,367.82	
738,042.68	
1,072,249.33	
6,862.66	
921,332.66	
644,655.40	
16,045,876.70	
9,258,526.95	
9,284,875.86	
39,264,738.62	

FFS TRBHA FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	279,335.53	136,082.42	159,112.19	163,246.26	150,058.83	186,733.33	0.00	0.00	0.00	0.00	0.00	0.00		1,074,568.56		

4413	SOBRA 100-133% M&F
6	173,365.54	159,239.19	99,226.38	126,346.38	141,503.38	122,319.96	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	81,411.72	56,370.35	48,420.00	70,673.88	80,886.65	40,001.27	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	64,610.03	48,795.79	38,281.65	60,718.99	62,479.73	57,587.17	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	319,387.2	9	264,405.33	185,928.0	3	257,739.25	284,869.76	219,908.40	0.00	0.00	0.00	0.00	0.00	0.00	

 
822,000.83	
377,763.87	
332,473.36	
1,532,238.06	

4518

BC PATIENT FEMALE 4 5

1,820.00

1,820.00

455.00	455.00	455.00	0.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00	
455.00	455.00	455.00	0.00	0.00	455.00	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	538.35	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	455.00	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	993.35	0.00	0.00	0.00	0.00	0.00	0.00	

2,220.83	
2,275.00	
172.78	
4,668.61	

TOTAL:	20,452,681.91	17,997,963.86	15,844,509.37	21,433,439.88	19,349,194.82	18,384,866.97	0.00	0.00	0.00	0.00	0.00	0.00		113,462,656.81		

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	20,058.67	22,328.76	18,380.71	27,455.16	10,458.58	16,436.34	0.00	0.00	0.00	0.00	0.00	0.00		115,118.22		
1017	TANF 21-44 FEMALE N O	52,130.85	26,691.95	54,079.33	75,587.04	67,172.61	44,671.93	0.00	0.00	0.00	0.00	0.00	0.00		320,333.71		
1018	TANF 45-64 M & F NON	0.00	0.00	19,006.49	5,714.73	5,672.94	10,147.75	0.00	0.00	0.00	0.00	0.00	0.00		40,541.91		
2210	SSI DISABLED NON-ME D	84,690.30	48,792.04	60,634.16	78,420.21	77,695.93	40,843.77	0.00	0.00	0.00	0.00	0.00	0.00		391,076.41		
2220	SSI DISABLED WITH Q
M	1,364.00	1,364.00	1,399.00	1,364.00	0.00	4,204.40	0.00	0.00	0.00	0.00	0.00	0.00		9,695.40		
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	116,304.19	0.00	0.00	0.00	0.00	0.00	0.00		894,453.53		

1116	TANF EXPANDED 21-44	1,524.14	15,016.02	0.00	0.00	4,204.40	3,363.52	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	5,045.31	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	6,727.04	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	1,364.00	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	16,499.87	0.00	0.00	0.00	0.00	0.00	0.00	

 
24,108.08	
75,178.50	
24,385.52	
6,796.00	
130,468.10	

3516	ADULT 40-100% MALE 2	3,699.35	11,299.46	14,172.51	14,360.32	12,703.07	10,192.76	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	4,081.95	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	6,727.04	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	243,992.32	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	99,535.92	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	59,715.83	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	424,245.82	0.00	0.00	0.00	0.00	0.00	0.00	

 
66,427.47	
25,310.02	
34,774.09	
1,439,867.80	
515,606.50	
399,914.60	
2,481,900.48	

3916	NEWLY ELIGIBLE MALE	8,408.80	0.00	3,363.52	39,865.17	11,940.86	13,433.83	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	3,396.20	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	16,817.60	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	33,647.63	0.00	0.00	0.00	0.00	0.00	0.00	

 
77,012.18	
41,787.71	
37,839.60	
156,639.49	

0.00

0.00

0.00

806,369.12

TOTAL:

596,980.30

493,299.07

624,693.91

551,421.69

590,697.51

0.00

0.00

0.00

3,663,461.60

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	82,215.38	125,849.80	34,955.01	98,230.33	54,035.82	67,983.81	0.00	0.00	0.00	0.00	0.00	0.00		463,270.15		
2110	SSI AGED NON-MEDIC
AR	76,145.26	43,432.58	94,089.34	170,616.32	178,372.05	279,889.81	0.00	0.00	0.00	0.00	0.00	0.00		842,545.36		
2200	SSI DISABLED WITH M E	43,412.57	37,118.69	31,528.29	42,362.80	66,041.19	15,124.34	0.00	0.00	0.00	0.00	0.00	0.00		235,587.88		
2210	SSI DISABLED NON-ME
D	6,450.10	54.14	3,268.79	936.25	3,398.77	10,825.31	0.00	0.00	0.00	0.00	0.00	0.00		24,933.36		
2220	SSI DISABLED WITH Q M	0.00	5,818.84	74,831.29	1,429.31	5,191.34	368.79	0.00	0.00	0.00	0.00	0.00	0.00		87,639.57		
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	13,503.85	0.00	0.00	0.00	0.00	0.00	0.00		143,402.19		
SUBTOTAL:	244,004.3	7	235,026.81	245,517.6	3	346,036.42	345,038.47	387,695.91	0.00	0.00	0.00	0.00	0.00	0.00		1,803,319.61		

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	11,721.53	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	144.43	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	8,332.93	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	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	2,401.86	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	248,289.69	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	13,860.32	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	317,064.25	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	-12,527.02	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	589,287.99	0.00	0.00	0.00	0.00	0.00	0.00	

7,964.62	
16,834.86	
15,908.01	
127,810.10	
16,759.28	
2,401.86	
1,992,420.77	
56,182.21	
2,469,796.97	
-10,879.92	
4,695,198.76	

3916	NEWLY ELIGIBLE MALE	57,655.11	4,600.84	464.10	10,899.98	62,999.44	4,145.21	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	20,883.81	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	25,029.02	0.00	0.00	0.00	0.00	0.00	0.00	

140,764.68	
62,018.85	
202,783.53	

1108	TANF EXPANDED 45-64	1,594.54	0.00	13,423.28	0.00	0.00	5,175.04	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	2,550.15	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	556.86	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	5,962.90	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	14,244.95	0.00	0.00	0.00	0.00	0.00	0.00	

 
20,192.86	
8,207.64	
6,583.53	
7,117.36	
42,101.39	

TOTAL:	1,194,500.53	886,135.76	1,011,830.27	1,088,693.11	1,545,985.75	1,016,257.87	0.00	0.00	0.00	0.00	0.00	0.00		6,743,403.29		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1017	TANF 21-44 FEMALE N O	3,561.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,561.30		
4314	SOBRA CHILD 14-20 MA	0.00	3,210.12	464.47	0.00	0.00	51.58	0.00	0.00	0.00	0.00	0.00	0.00		3,726.17		
SUBTOTAL:	3,561.30	3,210.12	464.4	7	0.00	0.00	51.58	0.00	0.00	0.00	0.00	0.00	0.00		7,287.47		

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	4,062.02	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	4,062.02	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,221.03	
4,141.82	
417.33	
7,780.18	

3,863.35

6,381.37

464.47

79.80

4,113.60

0.00

0.00

0.00

0.00	0.00

0.00

165.06

15,067.65

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	3,026.28	69.19	0.00	224.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,320.29		
1015	TANF 14-20 FEMALE N O	0.00	0.00	12,412.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,412.80		
1016	TANF 21-44 MALE NON-	225.11	11,662.99	331.06	91.03	7,890.03	4,685.19	0.00	0.00	0.00	0.00	0.00	0.00		24,885.41		
1017	TANF 21-44 FEMALE N O	13,398.03	846.61	57.84	80.06	4,373.37	839.77	0.00	0.00	0.00	0.00	0.00	0.00		19,595.68		
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	5,706.43	0.00	0.00	0.00	0.00	0.00	0.00		26,153.33		
SUBTOTAL:	19,818.53	22,215.72	24,324.9	4	1,088.41	12,263.40	11,231.39	0.00	0.00	0.00	0.00	0.00	0.00		90,942.39		

3516	ADULT 40-100% MALE 2	-3,664.92	32.56	3,991.13	16,463.19	0.00	22,974.71	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	363.04	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	741.14	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	47,366.48	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	32,006.18	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	12,298.44	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	115,749.99	0.00	0.00	0.00	0.00	0.00	0.00	

39,796.67	
4,834.00	
18,192.08	
634,653.95	
91,274.72	
265,815.73	
1,054,567.15	

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	1,838.16	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	3,954.26	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	5,792.42	0.00	0.00	0.00	0.00	0.00	0.00	

421.95	
26,291.87	
11,396.99	
4,936.87	
43,047.68	

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	132,773.80	0.00	0.00	0.00	0.00	0.00	0.00		1,218,566.25		

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	17,050.22	0.00	0.00	0.00	0.00	0.00	0.00		17,050.22		
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	17,050.22	0.00	0.00	0.00	0.00	0.00	0.00		36,403.04		

36,403.04

3,409.21	15,943.61	0.00	0.00	0.00	17,050.22	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	2,096.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,096.29		
1017	TANF 21-44 FEMALE N O	0.00	843.13	0.00	5,000.02	2,914.31	380.94	0.00	0.00	0.00	0.00	0.00	0.00		9,138.40		
2100	SSI AGED WITH MEDIC
A	0.00	0.00	8,468.49	0.00	0.00	127.32	0.00	0.00	0.00	0.00	0.00	0.00		8,595.81		
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	1,326.47	0.00	0.00	0.00	0.00	0.00	0.00		59,992.39		
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	1,834.73	0.00	0.00	0.00	0.00	0.00	0.00		101,606.74		

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	42,662.83	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	698.33	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	16,973.42	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	60,334.58	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,283.13	
184,249.98	
55,658.20	
50,493.38	
293,684.69	

TOTAL:	49,387.38	64,539.25	73,786.31	53,139.17	92,291.17	62,169.31	0.00	0.00	0.00	0.00	0.00	0.00		395,312.59		

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

3716	ADULT <40% EXP MALE	160.48	0.00	967.16	0.00	12,869.15	1,085.84	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	168.62	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	1,254.46	0.00	0.00	0.00	0.00	0.00	0.00	

 
15,082.63	
2,109.20	
817.67	
18,009.50	

28,458.14

2,604.72	59.26	3,076.36	8,503.16	12,960.18	1,254.46	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending December 31, 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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,476.55	1,365.00	12,020.99	0.00	0.00	293.43	0.00	0.00	0.00	0.00	0.00	0.00		15,155.97		
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	3,294,408.85	0.00	0.00	0.00	0.00	0.00	0.00		19,098,445.31		
2110	SSI AGED NON-MEDIC
AR	270,248.25	199,558.99	170,599.97	185,012.21	184,709.21	180,585.85	0.00	0.00	0.00	0.00	0.00	0.00		1,190,714.48		
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	4,612,331.63	0.00	0.00	0.00	0.00	0.00	0.00		28,090,519.71		
2200	SSI DISABLED WITH M E	665,108.26	517,747.79	541,296.64	661,374.78	528,583.16	573,598.34	0.00	0.00	0.00	0.00	0.00	0.00		3,487,708.97		
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	3,821,966.60	0.00	0.00	0.00	0.00	0.00	0.00		22,592,180.62		
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	1,124,780.26	0.00	0.00	0.00	0.00	0.00	0.00		6,487,307.56		
2300	SSI BLIND WITH MEDIC	2,008.80	2,245.08	1,590.11	2,037.00	1,227.98	1,939.20	0.00	0.00	0.00	0.00	0.00	0.00		11,048.17		
2310	SSI BLIND NON-MEDIC A	10,075.80	9,689.37	10,601.79	12,667.17	20,147.11	13,694.71	0.00	0.00	0.00	0.00	0.00	0.00		76,875.95		
2320	SSI BLIND WITH QMB	4,970.93	1,483.22	264.76	2,694.37	352.47	381.46	0.00	0.00	0.00	0.00	0.00	0.00		10,147.21		
SUBTOTAL:	14,639,339.2	7 12,574,719.06	12,172,913.9	0 14,559,028.33	13,490,123.06	13,623,980.33	0.00	0.00	0.00	0.00	0.00	0.00		81,060,103.95		

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

 

15,552.60

15,552.60

81,075,656.55

14,641,720.07	12,577,411.41	12,175,076.15	14,560,491.13	13,493,550.26	13,627,407.53	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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	61,523.02	81,067.68	60,616.91	27,444.50	4,176.21	1,053.34	0.00	0.00	0.00	0.00	0.00	0.00		235,881.66		
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	695.16	0.00	0.00	0.00	0.00	0.00	0.00		18,352.55		
2210	SSI DISABLED NON-ME
D	5,636.33	1,595.00	-17,970.22	14,969.70	165.81	660.99	0.00	0.00	0.00	0.00	0.00	0.00		5,057.61		
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	2,409.49	0.00	0.00	0.00	0.00	0.00	0.00		260,817.86		

TOTAL:	72,181.04	86,244.99	50,351.64	44,818.59	4,812.11	2,409.49	0.00	0.00	0.00	0.00	0.00	0.00		260,817.86		

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	123.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.10		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	685.25	0.00	0.00	0.00	0.00	0.00	0.00		685.25		
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	685.25	0.00	0.00	0.00	0.00	0.00	0.00		28,068.14		

0.00

0.00

0.00

0.00

TOTAL:

27,259.79

0.00

0.00

123.10

685.25

0.00

0.00

0.00

28,068.14

COCONINO COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	415.40	4,824.76	219.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,459.94		
SUBTOTAL:	415.40	4,824.76	219.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,459.94		

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	418.80	0.00	3,722.67	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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	37,904.12	18,644.88	18,077.02	41,557.58	23,951.02	52,961.49	0.00	0.00	0.00	0.00	0.00	0.00		193,096.11		
1013	TANF 06-13 M & F NON	66,306.45	34,537.50	30,933.97	78,081.26	62,985.26	114,623.94	0.00	0.00	0.00	0.00	0.00	0.00		387,468.38		
1014	TANF 14-20 MALE NON-	8,676.21	4,254.94	4,356.71	9,494.57	4,136.60	12,535.31	0.00	0.00	0.00	0.00	0.00	0.00		43,454.34		
1015	TANF 14-20 FEMALE N O	4,890.64	2,240.60	3,653.73	5,679.18	2,819.23	6,380.79	0.00	0.00	0.00	0.00	0.00	0.00		25,664.17		
2200	SSI DISABLED WITH M
E	0.00	0.00	0.00	0.00	0.00	152.85	0.00	0.00	0.00	0.00	0.00	0.00		152.85		
2210	SSI DISABLED NON-ME D	274,297.27	169,632.61	140,315.24	309,801.13	179,463.84	398,104.48	0.00	0.00	0.00	0.00	0.00	0.00		1,471,614.57		
2220	SSI DISABLED WITH Q
M	391.92	153.36	40.00	11.48	11.48	113.00	0.00	0.00	0.00	0.00	0.00	0.00		721.24		
2310	SSI BLIND NON-MEDIC A	2,652.31	2,038.76	585.07	3,217.05	2,280.81	4,253.80	0.00	0.00	0.00	0.00	0.00	0.00		15,027.80		
4312	SOBRA CHILD 01-05 M	170,389.43	100,660.33	74,587.65	204,872.11	137,167.56	263,571.89	0.00	0.00	0.00	0.00	0.00	0.00		951,248.97		
4313	SOBRA CHILD 06-13 M	266,108.81	157,297.68	134,113.69	317,309.08	232,961.51	440,548.27	0.00	0.00	0.00	0.00	0.00	0.00		1,548,339.04		
4314	SOBRA CHILD 14-20 MA	22,058.21	12,674.72	8,832.55	22,642.46	12,326.15	32,211.87	0.00	0.00	0.00	0.00	0.00	0.00		110,745.96		
4315	SOBRA CHILD 14-20 FE	10,521.23	4,139.37	3,902.67	11,933.37	9,550.09	17,975.78	0.00	0.00	0.00	0.00	0.00	0.00		58,022.51		
SUBTOTAL:	864,196.6	0	506,274.75	419,398.3	0	1,004,599.27	667,653.55	1,343,433.47	0.00	0.00	0.00	0.00	0.00	0.00		4,805,555.94		

3514	ADULT 40-100% MALE 1	29.06	8.84	0.00	136.98	35.34	85.90	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	25.18	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	725.72	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	145.98	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	599.33	156.24	314.9	2	659.80	491.66	982.78	0.00	0.00	0.00	0.00	0.00	0.00	

296.12	
90.56	
1,965.91	
852.14	
3,204.73	

3914	NEWLY ELIGIBLE MALE	65.66	0.00	0.00	34.37	0.00	15.08	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	65.66	0.00	0.00	34.37	0.00	15.08	0.00	0.00	0.00	0.00	0.00	0.00	

115.11

115.11

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	101,062.70	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	7,739.94	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	3,247.94	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	112,050.58	0.00	0.00	0.00	0.00	0.00	0.00	

 
387,329.73	
27,162.78	
8,118.96	
422,611.47	

TOTAL:	950,558.83	549,098.89	454,090.88	1,090,485.75	731,108.79	1,456,481.91	0.00	0.00	0.00	0.00	0.00	0.00		5,231,825.05		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	12,928.83	7,704.40	11,737.08	25,845.92	20,899.57	40,115.95	0.00	0.00	0.00	0.00	0.00	0.00		119,231.75		
2200	SSI DISABLED WITH M E	2,586.31	606.85	362.12	1,724.42	617.57	2,108.95	0.00	0.00	0.00	0.00	0.00	0.00		8,006.22		
2210	SSI DISABLED NON-ME
D	1,533,543.66	873,651.18	817,014.12	1,881,520.37	1,209,002.69	2,555,973.77	0.00	0.00	0.00	0.00	0.00	0.00		8,870,705.79		
2220	SSI DISABLED WITH Q M	5,358.58	2,675.67	559.32	4,335.90	3,240.78	7,092.07	0.00	0.00	0.00	0.00	0.00	0.00		23,262.32		
2310	SSI BLIND NON-MEDIC
A	3,264.10	251.23	1,140.95	2,033.05	1,659.02	3,698.01	0.00	0.00	0.00	0.00	0.00	0.00		12,046.36		
SUBTOTAL:	1,557,681.48	884,889.33	830,813.5	9	1,915,459.66	1,235,419.63	2,608,988.75	0.00	0.00	0.00	0.00	0.00	0.00		9,033,252.44		

9,033,252.44

830,813.59	1,915,459.66	1,235,419.63	2,608,988.75	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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	-437.59	0.00	1,517.56	-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	1,008,261.86	0.00	0.00	0.00	0.00	0.00	0.00		7,172,820.45		
1012	TANF 01-05 M & F NON	4,347.40	32,160.78	45,922.59	341,221.48	166,194.00	19,816.82	0.00	0.00	0.00	0.00	0.00	0.00		609,663.07		
1013	TANF 06-13 M & F NON	324,791.53	193,449.53	186,177.60	201,887.65	181,031.05	214,049.64	0.00	0.00	0.00	0.00	0.00	0.00		1,301,387.00		
1014	TANF 14-20 MALE NON-	81,483.94	198,980.19	109,178.50	212,727.49	208,264.36	192,949.56	0.00	0.00	0.00	0.00	0.00	0.00		1,003,584.04		
1015	TANF 14-20 FEMALE N O	25,303.51	119,152.30	148,991.49	109,631.17	75,994.14	51,237.88	0.00	0.00	0.00	0.00	0.00	0.00		530,310.49		
1016	TANF 21-44 MALE NON-	180,616.91	142,894.03	150,910.06	204,896.09	338,346.36	138,018.06	0.00	0.00	0.00	0.00	0.00	0.00		1,155,681.51		
1017	TANF 21-44 FEMALE N O	454,160.18	326,646.13	492,410.41	224,211.20	360,502.35	322,705.83	0.00	0.00	0.00	0.00	0.00	0.00		2,180,636.10		
1018	TANF 45-64 M & F NON	37,034.63	198,804.51	125,576.39	301,998.14	186,652.48	184,650.55	0.00	0.00	0.00	0.00	0.00	0.00		1,034,716.70		
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	34,341.82	0.00	0.00	0.00	0.00	0.00	0.00		225,560.76		
2110	SSI AGED NON-MEDIC
AR	112,670.07	397,755.12	277,933.20	166,896.51	161,217.28	130,454.91	0.00	0.00	0.00	0.00	0.00	0.00		1,246,927.09		
2200	SSI DISABLED WITH M E	130,347.89	55,514.79	4,376.07	612,910.07	86,054.44	10,020.05	0.00	0.00	0.00	0.00	0.00	0.00		899,223.31		
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	5,438,581.12	0.00	0.00	0.00	0.00	0.00	0.00		44,140,419.53		
2310	SSI BLIND NON-MEDIC A	11,949.45	9,724.98	13,371.35	31,461.09	36,471.62	37,697.01	0.00	0.00	0.00	0.00	0.00	0.00		140,675.50		
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	2,730,769.85	0.00	0.00	0.00	0.00	0.00	0.00		16,120,071.86		
4312	SOBRA CHILD 01-05 M	811,967.95	925,721.48	609,324.26	498,970.44	629,281.34	420,519.22	0.00	0.00	0.00	0.00	0.00	0.00		3,895,784.69		
4313	SOBRA CHILD 06-13 M	1,033,377.89	800,538.20	912,119.74	360,302.27	1,862,487.92	565,692.18	0.00	0.00	0.00	0.00	0.00	0.00		5,534,518.20		
4314	SOBRA CHILD 14-20 MA	539,123.31	607,332.68	786,856.62	1,115,558.96	571,715.78	503,809.12	0.00	0.00	0.00	0.00	0.00	0.00		4,124,396.47		
4315	SOBRA CHILD 14-20 FE	253,541.95	1,134,418.78	573,956.65	384,409.34	1,168,479.44	302,779.26	0.00	0.00	0.00	0.00	0.00	0.00		3,817,585.42		
5015	SOBRA PREG 14-20 FE M	1,806.25	0.00	0.00	360.24	0.00	924.37	0.00	0.00	0.00	0.00	0.00	0.00		3,090.86		
5017	SOBRA PREG 21-44 FE
M	13,329.82	114,984.27	27,660.93	18,853.81	210,398.11	25,541.72	0.00	0.00	0.00	0.00	0.00	0.00		410,768.66		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	13,857.33	0.00	0.00	0.00	0.00	0.00	0.00		13,857.33		
SUBTOTAL:	13,360,776.0	9 15,197,920.09	16,585,151.6	5 19,162,523.07	18,920,135.48	12,346,678.16	0.00	0.00	0.00	0.00	0.00	0.00		95,573,184.54		

3100

TRANSPLANT OPTION 1

7,763.49

7,763.49

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	
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:

1106	TANF EXPANDED 21-44	0.00	4,184.74	-2,545.36	0.00	-2,127.97	127.89	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	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	38.19	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	124,878.78	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	123,924.73	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	194,681.49	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	

-360.70	
0.00	
38.19	
1,280,098.63	
1,126,493.95	
1,251,647.73	
3,522.55	

ACC REINSURANCE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	SSI AGED EXPANDED WI	15,468.37	40,843.87	6,947.74	-26,848.18	6,945.62	6,952.69	0.00	0.00	0.00	0.00	0.00	0.00		50,310.11		
2600	SSI DISABLED EXPAND
E	3,420.44	1,096.56	67,024.12	27,684.22	1,824.25	5,064.09	0.00	0.00	0.00	0.00	0.00	0.00		106,113.68		
2610	SSI DISABLED EXPAND E	143,236.05	152,119.17	134,456.56	51,542.13	26,484.40	110,166.59	0.00	0.00	0.00	0.00	0.00	0.00		618,004.90		
SUBTOTAL:	967,764.7	0	854,007.18	676,565.5	4	505,770.91	865,926.26	565,834.45	0.00	0.00	0.00	0.00	0.00	0.00		4,435,869.04		

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	2,532.55	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	4,514.02	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	327,684.64	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	61,184.68	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	448,776.47	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	3,786.18	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	2,760.65	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	43,661.36	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	1,752,677.17	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	440,585.63	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	2,301,867.02	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	-879.78	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	5,389,150.59	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,901.45	
10,336.97	
1,280,600.81	
42,905.54	
1,805,220.42	
368,366.79	
4,984,570.57	
19,414.37	
6,211.15	
130,351.32	
671,245.05	
271,763.14	
11,022,095.33	
2,913,990.39	
14,713,954.28	
0.00	
38,242,927.58	

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	3,250.78	0.00	3,823.01	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	199,454.14	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	297,285.25	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	50,812.97	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	470,591.71	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	1,021,967.08	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,073.79	
5,076.33	
1,053,811.06	
16,701.76	
1,942,110.21	
649,901.20	
2,837,890.24	
6,512,564.59	

4413	SOBRA 100-133% M&F
6	241,947.24	262,349.92	95,062.65	115,604.65	209,009.42	131,897.28	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	132,053.03	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	158,990.82	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	422,941.13	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,055,871.16	
1,138,601.75	
341,927.36	
2,536,400.27	

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

2,362.67

ACC REINSURANCE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4518	BC PATIENT FEMALE 4 5	0.00	0.00	3,356.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,356.87		
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		10,978.89		
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	15,305.95	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	15,305.95	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,794.11	
47,801.19	
53,595.30	

TOTAL:	20,934,675.20	23,395,635.93	26,653,285.54	26,866,509.44	29,767,019.77	19,761,877.36	0.00	0.00	0.00	0.00	0.00	0.00		147,379,003.24		

LONG TERM CARE REINSURANCE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	24,561.23	-15,106.07	63,031.16	0.00	49,711.67	52,066.20	0.00	0.00	0.00	0.00	0.00	0.00		174,264.19		
2100	SSI AGED WITH MEDIC A	111,580.83	328,992.29	236,109.46	222,547.27	152,904.21	232,826.65	0.00	0.00	0.00	0.00	0.00	0.00		1,284,960.71		
2110	SSI AGED NON-MEDIC
AR	69,649.07	75,558.87	47,319.07	3,027.28	106,909.09	68,677.18	0.00	0.00	0.00	0.00	0.00	0.00		371,140.56		
2200	SSI DISABLED WITH M E	314,831.72	463,347.96	539,913.45	476,106.77	314,740.63	327,985.38	0.00	0.00	0.00	0.00	0.00	0.00		2,436,925.91		
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	4,172,583.83	0.00	0.00	0.00	0.00	0.00	0.00		30,957,887.26		
2310	SSI BLIND NON-MEDIC A	1,504.99	5,274.08	0.00	330.20	2,049.72	31,359.75	0.00	0.00	0.00	0.00	0.00	0.00		40,518.74		
SUBTOTAL:	6,807,585.18	5,361,381.84	6,418,046.04	5,182,314.90	6,610,870.42	4,885,498.99	0.00	0.00	0.00	0.00	0.00	0.00		35,265,697.37		

8710	SSI DISABLED FREEDO M	36,167.00	0.00	0.00	0.00	0.00	514.81	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36,167.00	0.00	0.00	0.00	0.00	514.81	0.00	0.00	0.00	0.00	0.00	0.00	

 
36,681.81

36,681.81

35,302,379.18

6,843,752.18	5,361,381.84	6,418,046.04	5,182,314.90	6,610,870.42	4,886,013.80	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC SMIB
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	0.00	0.00	0.00	0.00	135.50	2,574.50	0.00	0.00	0.00	0.00	0.00	0.00		2,710.00		
1000	TANF WITH MEDICARE	49,447.00	52,667.50	49,591.50	45,730.30	54,123.80	48,449.80	0.00	0.00	0.00	0.00	0.00	0.00		300,009.90		
1010	TANF NON-MEDICARE	677.50	406.50	406.50	406.50	271.00	406.50	0.00	0.00	0.00	0.00	0.00	0.00		2,574.50		
1020	TANF WITH QMB	44,961.50	39,964.50	37,916.00	37,653.00	36,433.50	32,767.00	0.00	0.00	0.00	0.00	0.00	0.00		229,695.50		
2100	SSI AGED WITH MEDIC A	31,102.20	35,121.60	38,203.50	32,389.00	33,875.00	36,694.50	0.00	0.00	0.00	0.00	0.00	0.00		207,385.80		
2110	SSI AGED NON-MEDIC
AR	539,823.00	550,536.20	542,519.50	535,106.00	534,008.50	541,437.00	0.00	0.00	0.00	0.00	0.00	0.00		3,243,430.20		
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	4,492,576.40	0.00	0.00	0.00	0.00	0.00	0.00		26,702,291.80		
2200	SSI DISABLED WITH M E	79,390.30	75,152.80	78,504.30	81,050.60	69,228.50	77,643.80	0.00	0.00	0.00	0.00	0.00	0.00		460,970.30		
2210	SSI DISABLED NON-ME
D	457,985.50	459,066.50	459,745.50	464,882.50	459,887.00	461,441.70	0.00	0.00	0.00	0.00	0.00	0.00		2,763,008.70		
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	3,917,843.40	0.00	0.00	0.00	0.00	0.00	0.00		23,328,695.20		
2300	SSI BLIND WITH MEDIC	135.50	135.50	135.50	135.50	135.50	135.50	0.00	0.00	0.00	0.00	0.00	0.00		813.00		
2310	SSI BLIND NON-MEDIC A	4,607.00	4,200.50	4,336.00	3,794.00	5,555.50	4,742.50	0.00	0.00	0.00	0.00	0.00	0.00		27,235.50		
2320	SSI BLIND WITH QMB	38,872.00	35,636.50	36,178.50	37,669.00	36,314.00	37,940.00	0.00	0.00	0.00	0.00	0.00	0.00		222,610.00		
4320	SOBRA CHILD WITH Q MB	271.00	271.00	1,626.00	542.00	542.00	406.50	0.00	0.00	0.00	0.00	0.00	0.00		3,658.50		
5000	SOBRA PREGNANT WO
MAN	0.00	0.00	0.00	135.50	135.50	-135.50	0.00	0.00	0.00	0.00	0.00	0.00		135.50		
5020	SOBRA PREGNANT WO MAN	3,658.50	4,739.50	4,200.50	5,555.50	4,878.00	5,013.50	0.00	0.00	0.00	0.00	0.00	0.00		28,045.50		
8000	SMIB ONLY NOT ELIGIB	0.00	-271.00	0.00	0.00	-677.50	-271.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,219.50		
8020	QMB ONLY	803,619.00	813,138.30	802,950.10	816,375.00	804,392.50	801,930.30	0.00	0.00	0.00	0.00	0.00	0.00		4,842,405.20		
8040	SLMB	5,415,089.00	5,424,721.20	5,454,262.10	5,451,776.20	5,464,976.00	5,474,217.80	0.00	0.00	0.00	0.00	0.00	0.00		32,685,042.30		
8888	SMIB ONLY NOT ELIGIB	-40,718.50	-27,017.20	-34,454.20	-22,677.20	-33,932.60	-29,312.30	0.00	0.00	0.00	0.00	0.00	0.00		-188,112.00		
9999	SMIB ONLY NOT ELIGIB	159,459.10	25,881.20	152,852.80	169,311.10	187,950.00	78,395.50	0.00	0.00	0.00	0.00	0.00	0.00		773,849.70		
SUBTOTAL:	15,822,251.7	0 15,824,261.10	15,987,395.5	0 15,997,856.20	16,018,573.70	15,984,897.40	0.00	0.00	0.00	0.00	0.00	0.00		95,635,235.60		

3520	ADULT 40-100% FOR FI	0.00	271.00	542.00	271.00	271.00	135.50	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	135.50	0.00	0.00	0.00	0.00	0.00	0.00	

1,490.50	
135.50	
1,355.00	

1100	TANF EXPANDED FPR FI	200,075.30	203,897.00	200,246.00	208,634.00	193,151.00	200,501.50	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	1,219.50	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	922,651.80	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	11,111.00	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	1,084.00	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	3,761,298.30	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	271.00	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	17,904.00	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	2,347,393.10	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	7,263,434.20	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,206,504.80	
2,845.50	
5,532,190.70	
78,150.00	
1,626.00	
22,287,040.30	
948.50	
87,403.50	
14,065,583.50	
43,262,292.80	

ACC SMIB
For The Period Ending December 31, 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	271.00	0.00	0.00	0.00	0.00	0.00	0.00		2,981.00		

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	
8700	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	1,355.00	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	44,850.50	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	46,205.50	0.00	0.00	0.00	0.00	0.00	0.00	

135.50	
1,355.00	
270,729.00	
272,219.50	

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

 

948.50

948.50

TOTAL:	22,964,898.60	23,035,048.80	23,263,172.60	23,299,664.50	23,315,813.80	23,295,079.10	0.00	0.00	0.00	0.00	0.00	0.00		139,173,677.40		

ACC HIB
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	0.00	0.00	0.00	437.00	-437.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1020	TANF WITH QMB	1,311.00	1,311.00	1,311.00	1,311.00	874.00	874.00	0.00	0.00	0.00	0.00	0.00	0.00		6,992.00		
2100	SSI AGED WITH MEDIC A	917.70	2,665.70	1,704.30	3,059.00	2,271.00	4,370.00	0.00	0.00	0.00	0.00	0.00	0.00		14,987.70		
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	602,016.30	0.00	0.00	0.00	0.00	0.00	0.00		3,504,588.70		
2210	SSI DISABLED NON-ME D	4,807.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,807.00		
2220	SSI DISABLED WITH Q
M	246,186.50	258,399.50	275,849.30	273,008.10	267,249.70	267,643.70	0.00	0.00	0.00	0.00	0.00	0.00		1,588,336.80		
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	1,551.00	0.00	0.00	0.00	0.00	0.00	0.00		8,869.00		
8020	QMB ONLY	4,259.70	4,259.70	5,613.70	4,571.70	4,523.70	4,523.70	0.00	0.00	0.00	0.00	0.00	0.00		27,752.20		
9999	SMIB ONLY NOT ELIGIB	-7,682.70	-11,273.20	-3,735.30	-4,872.90	-6,183.70	-3,822.00	0.00	0.00	0.00	0.00	0.00	0.00		-37,569.80		
SUBTOTAL:	775,609.2	0	843,035.00	893,679.2	0	881,950.10	862,191.40	876,719.70	0.00	0.00	0.00	0.00	0.00	0.00		5,133,184.60		

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	4,173.00	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	4,173.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,511.00	
26,960.80	
29,471.80	

5,162,656.40

898,572.90	886,843.80	866,604.40	880,892.70	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

781,857.60

847,885.00

Q1
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	2,963,042.50	3,006,531.50	3,027,725.50	3,063,352.30	3,047,411.90	3,093,438.90	0.00	0.00	0.00	0.00	0.00	0.00		18,201,502.60		
9999	SMIB ONLY NOT ELIGIB	-11,850.50	-8,842.50	2,000.50	-3,347.50	-1,339.00	-6,647.50	0.00	0.00	0.00	0.00	0.00	0.00		-30,026.50		
SUBTOTAL:	2,951,192.00	2,997,689.00	3,029,726.00	3,060,004.80	3,046,072.90	3,086,791.40	0.00	0.00	0.00	0.00	0.00	0.00		18,171,476.10		

TOTAL:	2,951,192.00	2,997,689.00	3,029,726.00	3,060,004.80	3,046,072.90	3,086,791.40	0.00	0.00	0.00	0.00	0.00	0.00		18,171,476.10		

LTC SMIB
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	135.50	542.00	271.00	135.50	948.50	542.00	0.00	0.00	0.00	0.00	0.00	0.00		2,574.50		
1020	TANF WITH QMB	677.50	677.50	677.50	542.00	542.00	542.00	0.00	0.00	0.00	0.00	0.00	0.00		3,658.50		
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	1,143,748.90	0.00	0.00	0.00	0.00	0.00	0.00		6,863,036.10		
2110	SSI AGED NON-MEDIC
AR	224,638.00	229,025.80	228,886.30	217,342.00	218,832.50	210,057.00	0.00	0.00	0.00	0.00	0.00	0.00		1,328,781.60		
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	1,283,426.50	0.00	0.00	0.00	0.00	0.00	0.00		7,573,721.30		
2200	SSI DISABLED WITH M E	399,084.90	384,519.80	388,578.30	387,535.80	383,855.90	428,056.60	0.00	0.00	0.00	0.00	0.00	0.00		2,371,631.30		
2210	SSI DISABLED NON-ME
D	14,092.00	14,769.50	16,937.50	18,563.50	19,105.50	16,260.00	0.00	0.00	0.00	0.00	0.00	0.00		99,728.00		
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	1,083,933.00	0.00	0.00	0.00	0.00	0.00	0.00		6,462,289.60		
2300	SSI BLIND WITH MEDIC	271.00	135.50	271.00	0.00	0.00	135.50	0.00	0.00	0.00	0.00	0.00	0.00		813.00		
2310	SSI BLIND NON-MEDIC A	135.50	135.50	135.50	135.50	135.50	135.50	0.00	0.00	0.00	0.00	0.00	0.00		813.00		
2320	SSI BLIND WITH QMB	813.00	948.50	542.00	406.50	542.00	948.50	0.00	0.00	0.00	0.00	0.00	0.00		4,200.50		
SUBTOTAL:	4,092,940.50	4,090,748.20	4,107,418.10	4,110,739.20	4,141,615.90	4,167,785.50	0.00	0.00	0.00	0.00	0.00	0.00		24,711,247.40		

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

 
11,653.00

11,653.00

24,722,900.40

4,094,295.50	4,092,509.70	4,109,179.60	4,112,907.20	4,143,919.40	4,170,089.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC HIB
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	0.00	-874.00	0.00	437.00	-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	367,565.50	0.00	0.00	0.00	0.00	0.00	0.00		2,219,729.80		
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	14,594.40	0.00	0.00	0.00	0.00	0.00	0.00		93,143.40		
2320	SSI BLIND WITH QMB	480.70	480.70	480.70	480.70	480.70	480.70	0.00	0.00	0.00	0.00	0.00	0.00		2,884.20		
SUBTOTAL:	381,352.5	0	383,341.90	394,396.6	0	388,191.20	386,271.60	382,640.60	0.00	0.00	0.00	0.00	0.00	0.00		2,316,194.40		

TOTAL:	381,352.50	383,341.90	394,396.60	388,191.20	386,271.60	382,640.60	0.00	0.00	0.00	0.00	0.00	0.00		2,316,194.40		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1,459.38	2,376.85	536.00	1,132.63	695.14	3,263.76	0.00	0.00	0.00	0.00	0.00	0.00		9,463.76		
1007	TANF 21-44 FEMALE WI	1,844.01	2,435.65	604.00	81.00	925.75	910.00	0.00	0.00	0.00	0.00	0.00	0.00		6,800.41		
1008	TANF 45-64 M & F WIT	8,360.17	6,104.83	4,135.71	4,922.78	12,448.64	2,521.68	0.00	0.00	0.00	0.00	0.00	0.00		38,493.81		
1009	TANF 65+ M & F WITH	6,203.96	2,264.15	1,795.13	3,544.21	7,375.45	1,660.42	0.00	0.00	0.00	0.00	0.00	0.00		22,843.32		
1011	TANF <1 M & F NON-ME	1,069,634.86	501,655.84	518,233.37	524,144.83	659,731.94	644,526.31	0.00	0.00	0.00	0.00	0.00	0.00		3,917,927.15		
1012	TANF 01-05 M & F NON	371,200.65	232,647.74	216,168.38	291,939.12	433,104.41	312,110.32	0.00	0.00	0.00	0.00	0.00	0.00		1,857,170.62		
1013	TANF 06-13 M & F NON	550,058.56	373,315.59	287,418.12	412,270.41	595,520.44	387,594.00	0.00	0.00	0.00	0.00	0.00	0.00		2,606,177.12		
1014	TANF 14-20 MALE NON-	193,092.30	113,486.70	79,186.08	108,004.30	154,318.29	141,569.74	0.00	0.00	0.00	0.00	0.00	0.00		789,657.41		
1015	TANF 14-20 FEMALE N O	384,301.30	284,458.81	191,867.85	233,145.95	318,019.56	223,508.06	0.00	0.00	0.00	0.00	0.00	0.00		1,635,301.53		
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	1,247,105.67	0.00	0.00	0.00	0.00	0.00	0.00		8,086,222.22		
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	4,146,314.10	0.00	0.00	0.00	0.00	0.00	0.00		28,674,064.74		
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	1,604,917.09	0.00	0.00	0.00	0.00	0.00	0.00		12,612,897.60		
1019	TANF 65+ M & F NON-M	4,301.94	11,634.33	2,923.99	2,043.66	9,336.85	8,858.13	0.00	0.00	0.00	0.00	0.00	0.00		39,098.90		
1026	TANF 21-44 MALE WITH	379.83	0.00	15.75	617.00	455.00	910.00	0.00	0.00	0.00	0.00	0.00	0.00		2,377.58		
1027	TANF 21-44 FEMALE WI	8,469.49	1,464.04	1,280.01	997.93	2,824.75	1,285.85	0.00	0.00	0.00	0.00	0.00	0.00		16,322.07		
1028	TANF 45-64 M & F WIT	3,753.41	3,189.89	3,548.81	2,054.69	2,028.54	2,033.30	0.00	0.00	0.00	0.00	0.00	0.00		16,608.64		
1029	TANF 65+ M & F WITH	3,340.01	1,770.48	5,504.70	1,264.92	2,564.03	976.17	0.00	0.00	0.00	0.00	0.00	0.00		15,420.31		
2100	SSI AGED WITH MEDIC A	112,980.76	60,316.34	46,750.16	54,355.02	136,123.11	44,412.99	0.00	0.00	0.00	0.00	0.00	0.00		454,938.38		
2110	SSI AGED NON-MEDIC
AR	181,290.38	92,702.15	72,010.14	93,986.11	178,925.73	80,481.18	0.00	0.00	0.00	0.00	0.00	0.00		699,395.69		
2120	SSI AGED WITH QMB	409,253.22	316,117.24	254,509.28	267,835.19	704,155.60	280,527.26	0.00	0.00	0.00	0.00	0.00	0.00		2,232,397.79		
2200	SSI DISABLED WITH M E	264,684.94	158,980.48	165,849.59	168,145.07	453,783.23	145,031.61	0.00	0.00	0.00	0.00	0.00	0.00		1,356,474.92		
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	4,609,350.62	0.00	0.00	0.00	0.00	0.00	0.00		33,587,610.90		
2220	SSI DISABLED WITH Q M	768,151.66	555,419.51	446,900.87	460,923.55	1,142,267.70	472,774.34	0.00	0.00	0.00	0.00	0.00	0.00		3,846,437.63		
2300	SSI BLIND WITH MEDIC	2,403.28	1,253.88	1,539.79	2,094.11	5,774.34	2,801.26	0.00	0.00	0.00	0.00	0.00	0.00		15,866.66		
2310	SSI BLIND NON-MEDIC A	115,995.95	93,912.22	52,379.85	46,167.93	103,264.23	44,656.70	0.00	0.00	0.00	0.00	0.00	0.00		456,376.88		
2320	SSI BLIND WITH QMB	10,555.01	6,761.49	4,295.24	5,940.00	13,728.12	4,257.05	0.00	0.00	0.00	0.00	0.00	0.00		45,536.91		
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	1,654,600.21	0.00	0.00	0.00	0.00	0.00	0.00		10,582,344.76		
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	3,495,153.00	0.00	0.00	0.00	0.00	0.00	0.00		22,326,630.17		
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	4,738,347.13	0.00	0.00	0.00	0.00	0.00	0.00		32,692,156.77		
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	1,233,023.39	0.00	0.00	0.00	0.00	0.00	0.00		7,907,078.45		
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	1,505,201.00	0.00	0.00	0.00	0.00	0.00	0.00		10,811,565.53		
5007	SOBRA PREG 21-44 FE M	93.41	904.06	96.75	746.33	266.60	10.21	0.00	0.00	0.00	0.00	0.00	0.00		2,117.36		
5013	SOBRA PREG 09-13 FE
M	0.00	455.00	1,820.00	455.00	0.00	455.00	0.00	0.00	0.00	0.00	0.00	0.00		3,185.00		
5015	SOBRA PREG 14-20 FE M	517,147.34	253,118.58	308,182.52	262,843.92	322,610.19	251,194.02	0.00	0.00	0.00	0.00	0.00	0.00		1,915,096.57		
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	1,414,787.90	0.00	0.00	0.00	0.00	0.00	0.00		10,793,603.81		
5018	SOBRA PREG 45-64 FE M	3,229.98	455.00	2,730.00	910.00	1,820.00	2,275.00	0.00	0.00	0.00	0.00	0.00	0.00		11,419.98		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	32.85	414.10	467.10	531.02	0.00	0.00	0.00	0.00	0.00	0.00		1,445.07		
SUBTOTAL:	41,855,275.95	30,931,012.62	24,797,865.37	29,583,600.64	44,210,836.35	28,709,935.49	0.00	0.00	0.00	0.00	0.00	0.00		200,088,526.42		

1106	TANF EXPANDED 21-44	3,391.33	1,198.94	1,322.27	3,291.41	6,614.19	1,738.84	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	1,865.55	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	15,030.26	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	17,308.49	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	455.00	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	2,282.93	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	22,063.58	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	562,121.09	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	1,802,543.77	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	1,179,301.35	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	3,185.00	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	8,420.81	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	11,197.27	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	44,365.36	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	40,723.47	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	3,725.93	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	12,934.99	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	264,830.65	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	3,381.38	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	82,513.15	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	143,096.23	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	4,223,085.10	0.00	0.00	0.00	0.00	0.00	0.00	

 
17,556.98	
17,918.90	
128,204.20	
164,865.55	
1,615.00	
23,816.91	
196,685.39	
3,539,287.68	
13,125,308.25	
8,499,096.29	
31,215.02	
71,008.87	
100,094.76	
355,424.85	
277,940.12	
48,013.43	
109,394.02	
2,159,938.96	
21,401.34	
709,044.53	
1,080,126.33	
30,677,957.38	

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3508	ADULT 40-100% M&F 45	0.00	91.00	0.00	625.93	1,412.58	94.21	0.00	0.00	0.00	0.00	0.00	0.00		2,223.72		
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	44,370.90	0.00	0.00	0.00	0.00	0.00	0.00		316,600.06		
3515	ADULT 40-100% FEMAL E	126,223.47	102,765.83	67,081.04	110,495.47	144,308.61	66,387.88	0.00	0.00	0.00	0.00	0.00	0.00		617,262.30		
3516	ADULT 40-100% MALE 2	727,935.76	485,813.77	396,851.80	404,408.08	708,364.54	502,539.90	0.00	0.00	0.00	0.00	0.00	0.00		3,225,913.85		
3517	ADULT 40-100% FEMAL E	667,579.54	460,943.19	314,517.42	383,245.42	714,490.34	367,013.51	0.00	0.00	0.00	0.00	0.00	0.00		2,907,789.42		
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	1,456,413.39	0.00	0.00	0.00	0.00	0.00	0.00		11,156,053.17		
3519	ADULT 40-100% M&F 65	455.00	0.00	0.00	0.00	455.00	1,820.00	0.00	0.00	0.00	0.00	0.00	0.00		2,730.00		
3706	ADULT <40% EXP MALE	252.48	1,629.66	582.94	3,200.47	161.84	146.92	0.00	0.00	0.00	0.00	0.00	0.00		5,974.31		
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	4,262.38	0.00	0.00	0.00	0.00	0.00	0.00		43,885.18		
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	250,623.37	0.00	0.00	0.00	0.00	0.00	0.00		1,585,196.54		
3715	ADULT <40% EXP FEM AL	489,450.66	370,107.48	272,561.22	323,903.31	508,211.53	333,433.30	0.00	0.00	0.00	0.00	0.00	0.00		2,297,667.50		
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	3,984,597.57	0.00	0.00	0.00	0.00	0.00	0.00		27,981,565.86		
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	2,563,590.37	0.00	0.00	0.00	0.00	0.00	0.00		17,984,893.18		
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	6,183,072.61	0.00	0.00	0.00	0.00	0.00	0.00		43,646,693.47		
3719	ADULT <40% EXP M&F 6	455.00	21,292.98	455.00	3,665.69	3,458.81	463.21	0.00	0.00	0.00	0.00	0.00	0.00		29,790.69		
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	15,758,829.52	0.00	0.00	0.00	0.00	0.00	0.00		111,816,452.38		

4412	SOBRA 100-133% M&F
1	910.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	577,496.85	447,620.64	345,015.57	390,359.63	503,224.43	374,912.03	0.00	0.00	0.00	0.00	0.00	0.00	

2,638,629.15

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	2,164.82	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	95.76	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	34,587.93	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	31,740.28	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	263,841.64	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	543,297.03	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	934,945.55	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	1,810,673.01	0.00	0.00	0.00	0.00	0.00	0.00	

 
3,385.56	
93.41	
8,197.38	
1,581.01	
117,873.38	
236,123.59	
2,237,455.91	
3,795,945.19	
7,082,190.16	
918.96	
13,483,764.55	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 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	154,690.39	0.00	0.00	0.00	0.00	0.00	0.00		949,968.26		
4415	SOBRA 100-133% FEMA L	237,463.81	175,607.59	149,384.42	159,032.85	244,863.15	138,240.52	0.00	0.00	0.00	0.00	0.00	0.00		1,104,592.34		
SUBTOTAL:	1,013,023.62	761,388.60	649,434.4	5	684,581.72	917,828.42	667,842.94	0.00	0.00	0.00	0.00	0.00	0.00		4,694,099.75		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	910.00	455.00	1,365.00	1,365.00	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	2,275.00	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	910.00	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	4,550.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,095.00	
29,739.08	
4,095.00	
15,397.24	
53,326.32	

8700	SSI DISABLED FREEDO M	12,901.78	6,600.67	1,644.15	10,536.85	10,209.34	9,466.05	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	15,023.88	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	1,216.67	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	25,706.60	0.00	0.00	0.00	0.00	0.00	0.00	

 
51,358.84	
136,813.48	
5,671.57	
193,843.89	

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

360,996,420.69

74,111,672.71	56,982,751.98	44,847,279.40	51,791,599.27	82,062,494.67	51,200,622.66	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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	42,607.07	41,818.90	47,825.53	-37,884.57	-45,916.85	13,172.48	0.00	0.00	0.00	0.00	0.00	0.00		61,622.56		
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	13,172.48	0.00	0.00	0.00	0.00	0.00	0.00		61,622.56		

TOTAL:	42,607.07	41,818.90	47,825.53	-37,884.57	-45,916.85	13,172.48	0.00	0.00	0.00	0.00	0.00	0.00		61,622.56		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	7,031.94	2,402.11	8,987.48	2,175.10	3,768.73	18,285.87	0.00	0.00	0.00	0.00	0.00	0.00		42,651.23		
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	164.70	0.00	0.00	0.00	0.00	0.00	0.00		435.90		
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	164.30	0.00	0.00	0.00	0.00	0.00	0.00		11,183.05		
1016	TANF 21-44 MALE NON-	5,642.36	1,117.64	5,118.38	5,301.23	9,159.93	996.29	0.00	0.00	0.00	0.00	0.00	0.00		27,335.83		
1017	TANF 21-44 FEMALE N O	38,709.06	5,112.40	66,186.01	2,817.30	16,861.13	137,599.06	0.00	0.00	0.00	0.00	0.00	0.00		267,284.96		
1018	TANF 45-64 M & F NON	3,220.37	9,395.06	5,423.50	1,020.96	779.88	6,449.94	0.00	0.00	0.00	0.00	0.00	0.00		26,289.71		
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	1,516.73	0.00	0.00	0.00	0.00	0.00	0.00		12,712.02		
2110	SSI AGED NON-MEDIC
AR	4,535.42	5,494.64	3,476.23	8,172.49	13,764.93	35,420.11	0.00	0.00	0.00	0.00	0.00	0.00		70,863.82		
2120	SSI AGED WITH QMB	-5.22	718.26	13,438.47	-162.99	839.90	1,474.89	0.00	0.00	0.00	0.00	0.00	0.00		16,303.31		
2200	SSI DISABLED WITH M E	828.88	4,440.65	346.64	599.37	3,442.95	228.19	0.00	0.00	0.00	0.00	0.00	0.00		9,886.68		
2210	SSI DISABLED NON-ME
D	46,209.75	8,576.13	356,427.07	96,324.20	242,923.82	140,602.72	0.00	0.00	0.00	0.00	0.00	0.00		891,063.69		
2220	SSI DISABLED WITH Q M	6,575.10	48.79	92,736.81	2,768.44	1,258.44	1,779.86	0.00	0.00	0.00	0.00	0.00	0.00		105,167.44		
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	8,488.70	0.00	0.00	0.00	0.00	0.00	0.00		67,733.85		
4312	SOBRA CHILD 01-05 M	8,047.58	7,985.21	39,028.64	7,716.40	6,509.69	3,268.58	0.00	0.00	0.00	0.00	0.00	0.00		72,556.10		
4313	SOBRA CHILD 06-13 M	11,969.38	4,816.54	6,351.37	9,105.11	13,559.02	1,626.04	0.00	0.00	0.00	0.00	0.00	0.00		47,427.46		
4314	SOBRA CHILD 14-20 MA	1,518.14	858.50	2,084.57	11,953.91	3,589.16	9,482.08	0.00	0.00	0.00	0.00	0.00	0.00		29,486.36		
4315	SOBRA CHILD 14-20 FE	1,126.11	886.24	3,376.06	583.74	1,527.54	631.07	0.00	0.00	0.00	0.00	0.00	0.00		8,130.76		
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	16,140.20	0.00	0.00	0.00	0.00	0.00	0.00		137,772.57		
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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	168,743.56	85,709.15	648,677.13	207,976.37	361,234.49	384,319.33	0.00	0.00	0.00	0.00	0.00	0.00		1,856,660.03		

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	355.62	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	1,381.27	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	725.44	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	911.76	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	1,811.10	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	1,978.72	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	414.43	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	75.64	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	1,516.15	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	9,170.13	0.00	0.00	0.00	0.00	0.00	0.00	

 
64.55	
362.22	
2,030.30	
0.00	
0.00	
1,920.91	
725.44	
69,072.81	
39,672.43	
78,498.00	
0.00	
0.00	
108.16	
748.08	
0.00	
3,216.48	
1,131.11	
0.00	
6,182.04	
2,635.49	
24.82	
206,392.84	

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3514	ADULT 40-100% MALE 1	48.94	194.06	123.10	0.00	68.69	328.84	0.00	0.00	0.00	0.00	0.00	0.00		763.63		
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	368.66	966.39	0.00	0.00	0.00	0.00	0.00	0.00		1,335.05		
3516	ADULT 40-100% MALE 2	19,227.07	9,299.28	27,140.62	9,335.51	13,408.49	11,095.50	0.00	0.00	0.00	0.00	0.00	0.00		89,506.47		
3517	ADULT 40-100% FEMAL E	3,335.31	6,034.54	665.68	1,659.17	11,962.47	1,605.86	0.00	0.00	0.00	0.00	0.00	0.00		25,263.03		
3518	ADULT 40-100% M&F 45	119,068.49	118,784.75	153,724.03	19,853.51	58,444.75	45,947.10	0.00	0.00	0.00	0.00	0.00	0.00		515,822.63		
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	160.48	0.00	0.00	0.00	0.00	0.00	0.00		7,239.45		
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	1,033.35	0.00	0.00	0.00	0.00	0.00	0.00		16,097.60		
3715	ADULT <40% EXP FEM AL	462.06	1,931.76	1,739.85	2,414.05	5,075.84	3,727.17	0.00	0.00	0.00	0.00	0.00	0.00		15,350.73		
3716	ADULT <40% EXP MALE	365,435.81	51,493.65	58,404.37	83,378.22	76,487.24	65,554.80	0.00	0.00	0.00	0.00	0.00	0.00		700,754.09		
3717	ADULT <40% EXP FEM AL	28,305.36	19,951.64	62,170.84	56,367.73	23,722.61	22,256.41	0.00	0.00	0.00	0.00	0.00	0.00		212,774.59		
3718	ADULT <40% EXP M&F
4	250,841.33	74,155.25	56,080.07	78,701.19	84,778.80	50,024.29	0.00	0.00	0.00	0.00	0.00	0.00		594,580.93		
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	202,700.19	0.00	0.00	0.00	0.00	0.00	0.00		2,186,609.13		

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	51.42	0.00	0.00	0.00	0.00	0.00	0.00	

4,055.76

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	1,350.36	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	9,423.78	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	4,112.41	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	13,539.00	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	28,425.55	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
1,359.82	
0.00	
939.27	
488.57	
147,517.27	
209,806.44	
347,651.91	
47.55	
707,810.83	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending December 31, 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	54.19	0.00	0.00	0.00	0.00	0.00	0.00		860.87		
SUBTOTAL:	100.51	2,095.60	993.7	6	927.76	1,402.01	105.61	0.00	0.00	0.00	0.00	0.00	0.00		5,625.25		

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	485.23	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	485.23	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,615.05	
0.00	
976.16	
2,591.21	

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

5,004,017.64

1,206,055.14	560,583.24	1,194,018.97	547,376.79	870,777.46	625,206.04	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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	617,512.03	448,268.17	392,559.28	404,946.54	233,053.31	348,310.12	0.00	0.00	0.00	0.00	0.00	0.00		2,444,649.45		
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	348,310.12	0.00	0.00	0.00	0.00	0.00	0.00		2,445,051.96		

TOTAL:	617,587.71	448,283.68	392,870.60	404,946.54	233,053.31	348,310.12	0.00	0.00	0.00	0.00	0.00	0.00		2,445,051.96		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	1,365.00	1,365.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,730.00		
2100	SSI AGED WITH MEDIC A	249,129.13	166,906.44	235,451.24	161,043.71	353,900.27	160,086.73	0.00	0.00	0.00	0.00	0.00	0.00		1,326,517.52		
2110	SSI AGED NON-MEDIC
AR	62,182.20	66,431.52	41,317.62	34,066.46	47,965.58	28,430.09	0.00	0.00	0.00	0.00	0.00	0.00		280,393.47		
2120	SSI AGED WITH QMB	359,948.35	251,228.84	236,600.09	249,357.53	578,921.85	236,481.61	0.00	0.00	0.00	0.00	0.00	0.00		1,912,538.27		
2200	SSI DISABLED WITH M E	64,376.04	44,880.45	44,560.73	41,946.27	108,752.91	46,115.77	0.00	0.00	0.00	0.00	0.00	0.00		350,632.17		
2210	SSI DISABLED NON-ME
D	1,137,487.58	1,052,503.74	822,964.63	856,226.80	1,221,741.16	850,158.90	0.00	0.00	0.00	0.00	0.00	0.00		5,941,082.81		
2220	SSI DISABLED WITH Q M	153,160.28	111,134.47	98,763.76	108,290.17	217,713.95	122,683.65	0.00	0.00	0.00	0.00	0.00	0.00		811,746.28		
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	8,224.84	0.00	0.00	0.00	0.00	0.00	0.00		43,560.92		
2320	SSI BLIND WITH QMB	604.35	90.44	264.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		959.55		
SUBTOTAL:	2,036,731.71	1,700,154.18	1,485,151.09	1,456,500.10	2,540,386.70	1,452,181.59	0.00	0.00	0.00	0.00	0.00	0.00		10,671,105.37		

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

10,671,105.37

2,036,731.71	1,700,154.18	1,485,151.09	1,456,500.10	2,540,386.70	1,452,181.59	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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	12,020.99	0.00	0.00	293.43	0.00	0.00	0.00	0.00	0.00	0.00		12,314.42		
2100	SSI AGED WITH MEDIC A	6,413.95	27,718.44	11,302.88	25,620.67	13,751.44	15,203.43	0.00	0.00	0.00	0.00	0.00	0.00		100,010.81		
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	248.02	0.00	0.00	0.00	0.00	0.00	0.00		44,478.64		
2200	SSI DISABLED WITH M E	11,704.99	147.31	163.48	395.35	2,067.54	4,121.66	0.00	0.00	0.00	0.00	0.00	0.00		18,600.33		
2210	SSI DISABLED NON-ME
D	73,355.72	69,642.29	33,336.99	50,764.47	91,594.44	20,137.76	0.00	0.00	0.00	0.00	0.00	0.00		338,831.67		
2220	SSI DISABLED WITH Q M	2,493.77	1,494.83	26,114.02	5,892.44	2,553.73	4,518.86	0.00	0.00	0.00	0.00	0.00	0.00		43,067.65		
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	-1,086.54	0.00	0.00	0.00	0.00	0.00	0.00		-1,392.88		
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	43,436.62	0.00	0.00	0.00	0.00	0.00	0.00		586,995.79		

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	43,436.62	0.00	0.00	0.00	0.00	0.00	0.00		586,995.79		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	5,720.54	2,465.16	4,020.71	6,395.05	4,741.70	3,811.40	0.00	0.00	0.00	0.00	0.00	0.00		27,154.56		
1007	TANF 21-44 FEMALE WI	3,816.12	5,879.47	3,052.17	5,354.78	1,591.48	3,049.23	0.00	0.00	0.00	0.00	0.00	0.00		22,743.25		
1008	TANF 45-64 M & F WIT	5,162.62	6,679.62	8,917.62	7,499.06	9,660.79	15,314.78	0.00	0.00	0.00	0.00	0.00	0.00		53,234.49		
1009	TANF 65+ M & F WITH	1,369.44	4,783.88	4,100.16	5,212.46	7,282.11	5,956.92	0.00	0.00	0.00	0.00	0.00	0.00		28,704.97		
1011	TANF <1 M & F NON-ME	628,082.08	711,492.30	296,466.98	645,951.63	537,871.02	338,810.87	0.00	0.00	0.00	0.00	0.00	0.00		3,158,674.88		
1012	TANF 01-05 M & F NON	-50,122.75	71,884.03	76,313.07	115,241.02	110,241.87	73,327.10	0.00	0.00	0.00	0.00	0.00	0.00		396,884.34		
1013	TANF 06-13 M & F NON	-19,553.65	128,348.20	158,426.17	188,205.93	179,885.60	153,744.60	0.00	0.00	0.00	0.00	0.00	0.00		789,056.85		
1014	TANF 14-20 MALE NON-	10,100.26	62,045.38	70,011.32	54,058.28	57,568.01	59,109.81	0.00	0.00	0.00	0.00	0.00	0.00		312,893.06		
1015	TANF 14-20 FEMALE N O	6,465.57	126,772.99	103,778.36	159,527.56	181,393.67	163,028.32	0.00	0.00	0.00	0.00	0.00	0.00		740,966.47		
1016	TANF 21-44 MALE NON-	294,900.11	801,287.54	672,377.63	1,067,853.42	1,033,079.15	872,974.21	0.00	0.00	0.00	0.00	0.00	0.00		4,742,472.06		
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	2,755,859.81	0.00	0.00	0.00	0.00	0.00	0.00		14,364,510.35		
1018	TANF 45-64 M & F NON	-33,187.01	951,911.48	737,553.79	1,066,265.19	1,186,310.31	1,113,581.15	0.00	0.00	0.00	0.00	0.00	0.00		5,022,434.91		
1019	TANF 65+ M & F NON-M	-1,219.82	0.00	123.77	0.00	29.84	131.97	0.00	0.00	0.00	0.00	0.00	0.00		-934.24		
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	65.60	0.00	0.00	0.00	0.00	0.00	0.00		3,366.07		
1028	TANF 45-64 M & F WIT	3,274.44	3,207.91	2,161.45	3,540.25	2,261.75	3,511.67	0.00	0.00	0.00	0.00	0.00	0.00		17,957.47		
1029	TANF 65+ M & F WITH	8,541.20	4,679.40	4,543.87	4,349.72	4,671.40	3,492.39	0.00	0.00	0.00	0.00	0.00	0.00		30,277.98		
2100	SSI AGED WITH MEDIC A	118,534.81	198,886.57	83,623.90	193,229.67	137,543.69	158,586.51	0.00	0.00	0.00	0.00	0.00	0.00		890,405.15		
2110	SSI AGED NON-MEDIC
AR	-20,837.80	44,299.09	20,582.28	66,215.64	68,307.53	90,088.74	0.00	0.00	0.00	0.00	0.00	0.00		268,655.48		
2120	SSI AGED WITH QMB	287,256.68	330,452.18	337,985.49	450,546.79	354,556.20	343,446.46	0.00	0.00	0.00	0.00	0.00	0.00		2,104,243.80		
2200	SSI DISABLED WITH M E	244,210.75	434,046.24	381,914.80	665,603.10	546,812.99	398,372.21	0.00	0.00	0.00	0.00	0.00	0.00		2,670,960.09		
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	5,065,025.86	0.00	0.00	0.00	0.00	0.00	0.00		28,274,323.89		
2220	SSI DISABLED WITH Q M	1,024,738.22	919,873.87	907,980.42	1,337,441.44	984,518.57	1,110,412.46	0.00	0.00	0.00	0.00	0.00	0.00		6,284,964.98		
2300	SSI BLIND WITH MEDIC	382.84	1,263.66	105.80	2,311.71	707.39	3,495.82	0.00	0.00	0.00	0.00	0.00	0.00		8,267.22		
2310	SSI BLIND NON-MEDIC A	-10,414.70	57,882.15	38,196.51	42,753.44	71,203.29	84,070.92	0.00	0.00	0.00	0.00	0.00	0.00		283,691.61		
2320	SSI BLIND WITH QMB	15,251.72	12,243.64	15,483.93	22,990.91	17,739.75	21,618.13	0.00	0.00	0.00	0.00	0.00	0.00		105,328.08		
4311	SOBRA CHILD <1 M & F	276,758.94	806,294.97	811,636.78	1,159,492.46	1,056,660.26	1,236,432.23	0.00	0.00	0.00	0.00	0.00	0.00		5,347,275.64		
4312	SOBRA CHILD 01-05 M	-529,357.21	815,047.27	908,198.23	1,405,903.88	1,330,778.59	1,168,483.11	0.00	0.00	0.00	0.00	0.00	0.00		5,099,053.87		
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	1,930,036.24	0.00	0.00	0.00	0.00	0.00	0.00		9,386,058.07		
4314	SOBRA CHILD 14-20 MA	412,233.42	670,329.89	613,362.34	880,335.92	1,073,683.43	881,300.49	0.00	0.00	0.00	0.00	0.00	0.00		4,531,245.49		
4315	SOBRA CHILD 14-20 FE	176,458.66	660,455.78	637,320.79	919,012.91	1,023,092.46	753,790.44	0.00	0.00	0.00	0.00	0.00	0.00		4,170,131.04		
5007	SOBRA PREG 21-44 FE M	1,374.70	163.21	1,412.23	0.00	0.00	2,158.53	0.00	0.00	0.00	0.00	0.00	0.00		5,108.67		
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	102,096.95	0.00	0.00	0.00	0.00	0.00	0.00		404,297.50		
5017	SOBRA PREG 21-44 FE
M	32,799.46	847,611.96	664,440.78	1,070,291.90	846,370.37	800,072.04	0.00	0.00	0.00	0.00	0.00	0.00		4,261,586.51		
5018	SOBRA PREG 45-64 FE M	3,309.67	0.00	0.00	26.35	0.00	70.40	0.00	0.00	0.00	0.00	0.00	0.00		3,406.42		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	50.00	0.00	654.86	4,584.78	2,669.55	3,517.58	0.00	0.00	0.00	0.00	0.00	0.00		11,476.77		
SUBTOTAL:	5,776,029.87	17,576,958.59	15,827,937.98	22,056,937.53	22,873,687.56	19,718,844.95	0.00	0.00	0.00	0.00	0.00	0.00		103,830,396.48		

1106	TANF EXPANDED 21-44	1,673.27	565.51	1,006.98	3,172.13	500.11	1,992.22	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	6,711.92	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	12,339.35	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	17,175.16	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	549.41	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	3,448.75	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	340,010.20	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	834,030.63	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	545,139.54	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	1,044.24	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	6,230.49	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	27,169.25	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	70,380.34	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	41,950.17	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	3,936.54	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	2,349.74	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	347,276.93	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	2,374.32	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	131,879.15	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	331,360.23	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	2,727,348.58	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,910.22	
43,834.42	
107,454.97	
82,298.30	
126.96	
59,404.45	
70,943.50	
1,788,526.94	
4,697,627.38	
2,967,937.96	
547.89	
64,739.13	
170,812.69	
503,190.65	
234,955.42	
22,059.17	
-720.54	
1,905,996.98	
32,854.25	
1,187,660.52	
1,757,621.39	
15,706,782.65	

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3508	ADULT 40-100% M&F 45	1,036.20	47.56	673.58	1,641.37	1,241.40	1,409.69	0.00	0.00	0.00	0.00	0.00	0.00		6,049.80		
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	29,786.23	0.00	0.00	0.00	0.00	0.00	0.00		146,171.42		
3515	ADULT 40-100% FEMAL E	7,544.55	46,694.72	44,995.21	35,156.32	35,433.06	51,502.77	0.00	0.00	0.00	0.00	0.00	0.00		221,326.63		
3516	ADULT 40-100% MALE 2	182,166.05	316,990.28	363,173.76	431,032.01	554,462.30	487,197.64	0.00	0.00	0.00	0.00	0.00	0.00		2,335,022.04		
3517	ADULT 40-100% FEMAL E	49,024.77	190,927.44	234,561.60	218,475.98	351,764.24	271,497.34	0.00	0.00	0.00	0.00	0.00	0.00		1,316,251.37		
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	879,153.26	0.00	0.00	0.00	0.00	0.00	0.00		5,149,308.40		
3519	ADULT 40-100% M&F 65	-455.00	0.00	0.00	42.48	148.86	484.26	0.00	0.00	0.00	0.00	0.00	0.00		220.60		
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	-142.66	0.00	0.00	0.00	0.00	0.00	0.00		319.56		
3708	ADULT <40% EXP M&F
4	-450.34	1,622.11	2,005.33	2,429.21	6,805.24	2,800.37	0.00	0.00	0.00	0.00	0.00	0.00		15,211.92		
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	330,991.23	0.00	0.00	0.00	0.00	0.00	0.00		1,494,420.80		
3715	ADULT <40% EXP FEM AL	25,044.72	246,565.40	181,740.15	280,996.42	251,274.45	182,344.92	0.00	0.00	0.00	0.00	0.00	0.00		1,167,966.06		
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	5,520,253.06	0.00	0.00	0.00	0.00	0.00	0.00		29,205,942.25		
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	2,676,686.96	0.00	0.00	0.00	0.00	0.00	0.00		12,989,989.72		
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	6,198,698.00	0.00	0.00	0.00	0.00	0.00	0.00		31,278,081.31		
3719	ADULT <40% EXP M&F 6	-455.00	5,271.31	411.02	1,371.39	1,279.41	356.27	0.00	0.00	0.00	0.00	0.00	0.00		8,234.40		
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	16,633,019.34	0.00	0.00	0.00	0.00	0.00	0.00		85,337,914.76		

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	110,904.22	0.00	0.00	0.00	0.00	0.00	0.00	

559,641.42

-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	130.68	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	209.15	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	7,638.37	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	28,204.59	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	254,246.92	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	197,767.16	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	605,407.87	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	1,093,604.74	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,509.57	
6,838.72	
10,468.58	
4,637.27	
72,607.95	
123,667.98	
2,033,163.12	
1,107,674.35	
2,792,248.42	
3,782.71	
6,168,598.67	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending December 31, 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	64,535.86	0.00	0.00	0.00	0.00	0.00	0.00		325,567.73		
4415	SOBRA 100-133% FEMA L	-8,543.09	68,370.22	114,590.98	102,638.43	82,443.22	73,629.30	0.00	0.00	0.00	0.00	0.00	0.00		433,129.06		
SUBTOTAL:	-108,481.91	242,435.61	296,001.5	6	300,788.53	338,070.04	249,069.38	0.00	0.00	0.00	0.00	0.00	0.00		1,317,883.21		

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	-8,803.53	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	-8,803.53	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
32,283.79	
0.00	
-1,365.00	
30,918.79	

8700	SSI DISABLED FREEDO M	5,748.24	6,806.69	10,182.44	11,563.70	9,026.86	14,899.10	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	2,123.11	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	164.48	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	17,186.69	0.00	0.00	0.00	0.00	0.00	0.00	

 
58,227.03	
67,256.51	
18,154.57	
143,638.11	

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

212,534,864.07

14,235,837.65	34,312,575.58	32,042,537.41	44,513,098.60	47,000,544.68	40,430,270.15	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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	111.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111.55		
2100	SSI AGED WITH MEDIC A	3,141,298.02	2,783,579.05	2,655,926.93	3,278,008.15	2,693,986.14	3,119,118.69	0.00	0.00	0.00	0.00	0.00	0.00		17,671,916.98		
2110	SSI AGED NON-MEDIC
AR	182,346.04	132,352.21	128,808.51	146,829.71	136,743.63	152,155.76	0.00	0.00	0.00	0.00	0.00	0.00		879,235.86		
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	4,375,602.00	0.00	0.00	0.00	0.00	0.00	0.00		26,133,502.80		
2200	SSI DISABLED WITH M E	589,027.23	472,720.03	496,572.43	619,033.16	417,762.71	523,360.91	0.00	0.00	0.00	0.00	0.00	0.00		3,118,476.47		
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	2,951,669.94	0.00	0.00	0.00	0.00	0.00	0.00		16,312,266.14		
2220	SSI DISABLED WITH Q M	928,876.44	954,747.01	838,487.63	1,066,518.31	846,286.49	997,577.75	0.00	0.00	0.00	0.00	0.00	0.00		5,632,493.63		
2300	SSI BLIND WITH MEDIC	2,008.80	1,636.80	1,350.99	1,956.00	1,212.00	1,939.20	0.00	0.00	0.00	0.00	0.00	0.00		10,103.79		
2310	SSI BLIND NON-MEDIC A	1,597.02	4,684.37	5,612.65	7,485.35	8,772.11	6,556.41	0.00	0.00	0.00	0.00	0.00	0.00		34,707.91		
2320	SSI BLIND WITH QMB	4,366.58	1,392.78	0.00	2,694.37	352.47	381.46	0.00	0.00	0.00	0.00	0.00	0.00		9,187.66		
SUBTOTAL:	12,471,053.1	6 10,751,450.28	10,600,346.7	1 13,011,633.29	10,839,157.23	12,128,362.12	0.00	0.00	0.00	0.00	0.00	0.00		69,802,002.79		

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

 

15,552.60

15,552.60

TOTAL:	12,473,433.96	10,754,142.63	10,602,508.96	13,013,096.09	10,842,584.43	12,131,789.32	0.00	0.00	0.00	0.00	0.00	0.00		69,817,555.39		

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8050	QI1	0.00	20.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.66		
SUBTOTAL:	0.00	20.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.66		

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 December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	163,955.19	166,288.57	166,584.01	170,052.62	168,594.96	160,858.37	0.00	0.00	0.00	0.00	0.00	0.00		996,333.72		
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	1,667,076.49	0.00	0.00	0.00	0.00	0.00	0.00		9,682,295.28		
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	3,134,213.61	0.00	0.00	0.00	0.00	0.00	0.00		18,200,653.32		
6014	KIDS 14-19 MALE NON-	741,190.91	756,932.03	769,166.95	820,270.24	813,103.99	807,226.15	0.00	0.00	0.00	0.00	0.00	0.00		4,707,890.27		
6015	KIDS 14-19 FEMALE NO	751,128.68	770,184.18	781,392.45	842,956.11	848,685.24	843,573.73	0.00	0.00	0.00	0.00	0.00	0.00		4,837,920.39		
9960	KIDSCARE KICK PAYM EN	6,000.27	5,997.30	5,984.82	12,216.41	37,269.86	18,386.88	0.00	0.00	0.00	0.00	0.00	0.00		85,855.54		
SUBTOTAL:	6,102,844.36	6,193,196.75	6,245,205.03	6,672,896.03	6,665,471.12	6,631,335.23	0.00	0.00	0.00	0.00	0.00	0.00		38,510,948.52		

TOTAL:	6,102,844.36	6,193,196.75	6,245,205.03	6,672,896.03	6,665,471.12	6,631,335.23	0.00	0.00	0.00	0.00	0.00	0.00		38,510,948.52		

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	283.84	288.66	289.09	288.38	286.57	272.81	0.00	0.00	0.00	0.00	0.00	0.00		1,709.35		
6012	KIDS 1-5 M & F NON-M	8,605.77	8,720.94	8,773.24	8,915.48	8,796.71	8,861.95	0.00	0.00	0.00	0.00	0.00	0.00		52,674.09		
6013	KIDS 6-13 M & F NON-	16,171.73	16,347.00	16,437.62	16,765.60	16,725.39	16,658.10	0.00	0.00	0.00	0.00	0.00	0.00		99,105.44		
6014	KIDS 14-19 MALE NON-	4,132.98	4,218.92	4,287.26	4,374.96	4,331.19	4,291.05	0.00	0.00	0.00	0.00	0.00	0.00		25,636.36		
6015	KIDS 14-19 FEMALE NO	4,170.12	4,274.87	4,336.42	4,469.58	4,498.43	4,452.40	0.00	0.00	0.00	0.00	0.00	0.00		26,201.82		
9960	KIDSCARE KICK PAYM EN	1.00	1.00	1.00	2.00	6.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
SUBTOTAL:	33,365.44	33,851.39	34,124.6	3	34,816.00	34,644.29	34,539.31	0.00	0.00	0.00	0.00	0.00	0.00		205,341.06		

205,341.06

33,365.44	33,851.39	34,124.63	34,816.00	34,644.29	34,539.31	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	372.22	377.84	377.73	488.19	488.44	474.53	0.00	0.00	0.00	0.00	0.00	0.00		2,578.95		
6012	KIDS 1-5 M & F NON-M	14,030.25	13,776.71	13,002.24	17,818.51	15,470.44	15,504.72	0.00	0.00	0.00	0.00	0.00	0.00		89,602.87		
6013	KIDS 6-13 M & F NON-	24,067.99	24,576.74	26,372.06	34,081.58	30,348.16	31,338.60	0.00	0.00	0.00	0.00	0.00	0.00		170,785.13		
6014	KIDS 14-19 MALE NON-	10,487.13	10,708.53	10,950.58	13,577.00	13,259.48	13,226.07	0.00	0.00	0.00	0.00	0.00	0.00		72,208.79		
6015	KIDS 14-19 FEMALE NO	10,410.58	10,572.35	10,948.34	13,929.03	13,953.39	14,730.00	0.00	0.00	0.00	0.00	0.00	0.00		74,543.69		
SUBTOTAL:	59,368.17	60,012.17	61,650.9	5	79,894.31	73,519.91	75,273.92	0.00	0.00	0.00	0.00	0.00	0.00		409,719.43		

TOTAL:	59,368.17	60,012.17	61,650.95	79,894.31	73,519.91	75,273.92	0.00	0.00	0.00	0.00	0.00	0.00		409,719.43		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	289.00	292.00	291.00	300.00	293.00	282.00	0.00	0.00	0.00	0.00	0.00	0.00		1,747.00		
6012	KIDS 1-5 M & F NON-M	8,836.06	8,937.06	9,053.03	9,159.60	9,046.00	9,112.00	0.00	0.00	0.00	0.00	0.00	0.00		54,143.75		
6013	KIDS 6-13 M & F NON-	16,748.06	16,847.06	16,997.12	17,272.15	17,171.03	17,255.06	0.00	0.00	0.00	0.00	0.00	0.00		102,290.48		
6014	KIDS 14-19 MALE NON-	4,347.00	4,404.00	4,514.00	4,609.00	4,531.00	4,520.00	0.00	0.00	0.00	0.00	0.00	0.00		26,925.00		
6015	KIDS 14-19 FEMALE NO	4,353.00	4,428.00	4,520.00	4,664.00	4,647.00	4,637.03	0.00	0.00	0.00	0.00	0.00	0.00		27,249.03		
SUBTOTAL:	34,573.12	34,908.12	35,375.1	5	36,004.75	35,688.03	35,806.09	0.00	0.00	0.00	0.00	0.00	0.00		212,355.26		

212,355.26

35,375.15	36,004.75	35,688.03	35,806.09	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

34,573.12

34,908.12

KidsCare - FEE FOR SERVICE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	284.12	1,147.85	637.02	1,114.92	5,561.84	1,306.13	0.00	0.00	0.00	0.00	0.00	0.00		10,051.88		
6012	KIDS 1-5 M & F NON-M	14,179.76	23,135.73	17,015.05	46,530.65	75,177.40	45,205.86	0.00	0.00	0.00	0.00	0.00	0.00		221,244.45		
6013	KIDS 6-13 M & F NON-	45,325.01	144,046.96	62,107.36	97,046.28	168,312.70	132,264.67	0.00	0.00	0.00	0.00	0.00	0.00		649,102.98		
6014	KIDS 14-19 MALE NON-	39,303.11	50,503.51	36,039.38	88,935.48	51,814.60	28,375.98	0.00	0.00	0.00	0.00	0.00	0.00		294,972.06		
6015	KIDS 14-19 FEMALE NO	25,467.01	21,720.72	26,081.79	47,116.95	79,986.31	53,531.07	0.00	0.00	0.00	0.00	0.00	0.00		253,903.85		
SUBTOTAL:	124,559.0	1	240,554.77	141,880.6	0	280,744.28	380,852.85	260,683.71	0.00	0.00	0.00	0.00	0.00	0.00		1,429,275.22		

TOTAL:	124,559.01	240,554.77	141,880.60	280,744.28	380,852.85	260,683.71	0.00	0.00	0.00	0.00	0.00	0.00		1,429,275.22		

KidsCare - REINSURANCE
For The Period Ending December 31, 2019	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	0.00	10,129.35	0.00	0.00	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	335,151.23	0.00	0.00	0.00	0.00	0.00	0.00		688,254.45		
6014	KIDS 14-19 MALE NON-	113,827.14	40,260.35	35,353.19	35,159.29	96,771.95	91,843.93	0.00	0.00	0.00	0.00	0.00	0.00		413,215.85		
6015	KIDS 14-19 FEMALE NO	1,145.72	0.00	0.00	0.00	18,050.71	144,917.66	0.00	0.00	0.00	0.00	0.00	0.00		164,114.09		
SUBTOTAL:	200,701.0	1	116,470.46	178,309.6	4	68,994.99	201,595.81	571,912.82	0.00	0.00	0.00	0.00	0.00	0.00		1,337,984.73		

1,337,984.73

178,309.64	68,994.99	201,595.81	571,912.82	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

200,701.01

116,470.46

9

00

18.00

3,001.82

25.00

1,576.94

69.00

2,584.60

11,482.90

159,346.57

2.57

29,596.19

2.00

87.35

4.99

142.95

46.99

82.77

208,070.64

208,070.64

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 December 31, 2019

1000	TANF WITH MEDICARE	2.00	3.00	2.00	4.00	4.00	3.00	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	576.96	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	2.00	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	266.14	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	12.00	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	432.12	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	1,891.81	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	26,731.98	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	4,999.80	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	1.00	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	18.22	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	1.00	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	27.99	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	11.00	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	15.82	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	34,990.84	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	34,990.84	0.00	0.00	0.00	0.	0.00	0.00	

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

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	422,468.96	427,754.94	636,779.32	441,164.01	439,709.65	437,926.85	0.00	0.00	0.00	0.00	0.00	0.00	2,805,803.73	
EPD	106,533,521.90	107,126,210.66	107,209,520.71	121,442,144.75	121,053,408.84	121,066,540.17	0.00	0.00	0.00	0.00	0.00	0.00	684,431,347.03	
TOTAL AHCCCS LTC	106,955,990.86	107,553,965.60	107,846,300.03	121,883,308.76	121,493,118.49	121,504,467.02	0.00	0.00	0.00	0.00	0.00	0.00	687,237,150.76	
DES/DD	143,961,803.16	144,655,141.28	145,290,373.93	165,084,146.04	165,740,027.08	166,297,884.21	0.00	0.00	0.00	0.00	0.00	0.00	931,029,375.70	
TOTAL DES LTC	143,961,803.16	144,655,141.28	145,290,373.93	165,084,146.04	165,740,027.08	166,297,884.21	0.00	0.00	0.00	0.00	0.00	0.00	931,029,375.70	
TOTAL LTC - CAP	250,917,794.02	252,209,106.88	253,136,673.96	286,967,454.80	287,233,145.57	287,802,351.23	0.00	0.00	0.00	0.00	0.00	0.00	1,618,266,526.46	

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	13,627,407.53	0.00	0.00	0.00	0.00	0.00	0.00	81,075,656.55	
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	13,627,407.53	0.00	0.00	0.00	0.00	0.00	0.00	81,075,656.55	

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	2,779,865.98	0.00	0.00	0.00	0.00	0.00	0.00	18,430,562.88	
DES/DD	4,204,532.65	1,620,152.95	3,500,067.02	2,770,247.33	2,670,668.53	2,106,147.82	0.00	0.00	0.00	0.00	0.00	0.00	16,871,816.30	
TOTAL DES LTC	4,204,532.65	1,620,152.95	3,500,067.02	2,770,247.33	2,670,668.53	2,106,147.82	0.00	0.00	0.00	0.00	0.00	0.00	16,871,816.30	
TOTAL LTC - REIN	6,843,752.18	5,361,381.84	6,418,046.04	5,182,314.90	6,610,870.42	4,886,013.80	0.00	0.00	0.00	0.00	0.00	0.00	35,302,379.18	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	4,475,748.00	4,475,851.60	4,503,576.20	4,501,098.40	4,530,191.00	4,552,729.60	0.00	0.00	0.00	0.00	0.00	0.00	27,039,194.80	

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

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	288,472.64	0.00	0.00	0.00	0.00	0.00	0.00	3,423,360.17	
Subtotal	203,452.53	932,589.80	216,051.55	1,264,254.81	518,538.84	288,472.64	0.00	0.00	0.00	0.00	0.00	0.00	3,423,360.17	

206,373.18	932,589.80	216,051.55	1,264,254.81	518,538.84	288,472.64	0.00	0.00	0.00	0.00	0.00	0.00	3,426,280.82	

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 December 31, 2019

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

00010715
00010735
00010795

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

1,289.88

0.00

1,522.60

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

2,812.48

-7,052.52

0.00

-7,362.34

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-14,414.86

-60,720.16

10,522.46

615.08

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-49,582.62

Subtotal

-66,482.80

10,522.46

-5,224.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-61,185.00

-66,482.80

10,522.46

-5,224.66

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

-61,185.00

GRAND TOTAL