Douglas A. Ducey, Governor Jami Snyder, Director

March 26, 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 February 29, 2020

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 February 29, 2020.

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.
Potential utilization impact from COVID-19 testing and treatment

Enrollment Update – February 2020 enrollment is 1,875,633 members, a 5,282 member decrease over the prior month. Enrollment for March 2020 increased to 1,878,960 members, a 3,327 member change.

Major March 2020 changes by eligibility category include: 1931 for Families and Children/SOBRA – decrease of 205, Supplemental Security Income – increase of 659; Prop 204

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 March 26, 2020
Page 2

Restoration - increase of 1,855, Adult Expansion – increase of 265 Medicare Cost Sharing – increase of 308; KidsCare – increase of 895; and Federal Emergency Services – decrease of 438.

Tobacco Funds Revenue Update - Tobacco tax collections through February 2020 are $4.9 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 February 29, 2020

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 February 29, 2020
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	$	65,606,400	$	58,625,163	$	6,981,237	$	88,542,300	$	-	
AHCCCS Prop 204 Administration	14,182,800	9,317,900	10,732,200	(1,414,300)	14,182,800		-	
Information Technology	9,878,000	-	-	-	9,878,000		-	
DES Eligibility	91,874,500		63,063,700		51,269,819		11,793,881		91,874,500		-		
DES Prop 204 Eligibility	44,358,700		30,423,400		25,021,099		5,402,301		44,358,700		-		
ADOA Data Center	19,325,800		12,883,600		8,703,291		4,180,309		19,325,800		-		
School District Suicide Prevention Coordinator	100,000		43,700		18,356		25,344		100,000		-		
TOTAL ADMINISTRATION	 	268,262,100 		 	181,338,700 		 	154,369,928 		 	26,968,772 		 	268,262,100 		 	-			

Traditional Medicaid Services	5,178,162,100	3,523,461,100	3,458,050,192	65,410,908	5,178,162,100	-	
Proposition 204 Services	4,168,410,500	2,709,101,900	2,694,349,349	14,752,551	4,168,410,500	-	
ACA Adult Expansion	527,018,800	349,275,300	288,101,467	61,173,833	527,018,800	-	
KidsCare Services	106,516,300	69,653,400	51,575,906	18,077,495	106,516,300	-	
ALTCS Services	1,796,913,800	1,175,306,300	1,196,540,236	(21,233,936)	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		278,794,620		278,794,620		-		345,281,700		-	
CMDP	180,729,500		119,584,900		124,241,150		(4,656,250)		180,729,500		-	
Behavioral Health Services - in Schools	9,990,000		4,995,000		6,910,000		(1,915,000)		9,990,000		-	
Targeted Investment Program	90,000,000		-		1,957,738		(1,957,738)		90,000,000		-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		51,764,800		51,203,444		561,356		77,646,900		-	
Supported Housing	5,324,800		3,549,600		3,626,328		(76,728)		5,324,800		-	
Crisis Services	16,391,300		10,927,200		10,837,533		89,667		16,391,300		-	
TOTAL PROGRAMMATIC	 	12,536,085,200 		 	8,304,641,320 		 	8,174,415,111 		 	130,226,209 		 	12,536,085,200 		 	-		

TOTAL EXPENDITURES

  $	12,804,347,300 

-

$	8,485,980,020

$	8,328,785,039

$	157,194,980

$   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	
$	42,495,900	
$	37,756,607	
4,739,293	
$	60,044,200	
$	
-	
Proposition 204 - Administrative Expenditures		21,538,900	14,528,500	11,694,642	2,833,858	21,538,900		-	

Programmatic Expenditures Traditional Medicaid Services		

1,170,113,300	

796,148,600	

827,826,735	

(31,678,135)	

1,170,113,300		

-	
Proposition 204 Services		95,088,500	60,527,000	63,392,333	(2,865,333)	95,088,500		-	
ACA Adult Expansion		5,393,400	3,258,600	3,595,600	(337,000)	5,393,400		-	
KidsCare Services		7,523,800	4,147,600	3,359,174	788,426	7,523,800		-	
ALTCS Services		234,042,300	152,711,500	156,028,200	(3,316,700)	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	35,957,900	37,337,525	(1,379,625)	54,297,600		-	
Behavior Health Services - in Schools		3,000,000	1,500,000	2,250,000	(750,000)	3,000,000		-	
Non Medicaid Seriously Mentally Ill Services		77,646,900	51,764,800	51,203,444	561,356	77,646,900		-	
Supported Housing		5,324,800	3,549,600	3,626,328	(76,728)	5,324,800		-	
Crisis Services		14,141,100	9,427,200	9,337,400	89,800	14,141,100		-	
Voluntary Political Subdivision Programs	 	3,750,000 	 	- 	 	- 	 	- 	 	3,750,000 	 	- 	
TOTAL GF EXPENDITURES	1,760,748,100	1,178,501,000	1,209,874,488	(31,373,488)	1,760,748,100	-	
	FEDERAL		
Administrative Expenditures	146,947,600	98,631,300	80,604,687	18,026,613	146,947,600	-	
Proposition 204 - Administrative Expenditures	33,035,300	22,533,800	24,058,657	(1,524,857)	33,035,300	-	
Programmatic Expenditures
Traditional Medicaid Services	
3,176,462,800	
2,158,583,200	
1,970,921,873	
187,661,327	
3,176,462,800	
-	
Proposition 204 Services	3,615,003,800	2,400,566,400	2,364,894,179	35,672,221	3,615,003,800	-	
ACA Adult Expansion	484,056,500	323,427,400	263,942,841	59,484,559	484,056,500	-	
KidsCare Services	86,764,900	57,967,900	42,069,606	15,898,294	86,764,900	-	
ALTCS Services and Nursing Facility Assessment	1,144,403,700	725,764,100	736,294,985	(10,530,885)	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	83,627,000	86,903,625	(3,276,625)	126,431,900	-	
Behavior Health Services - in Schools	6,990,000	3,495,000	4,660,000	(1,165,000)	6,990,000	-	
Targeted Investment Program	61,937,600	-	978,869	(978,869)	61,937,600	-	
Voluntary Political Subdivision Programs	 	240,664,300 	 	194,429,775 	 	194,429,775 	 	- 	 	240,664,300 	 	- 	
TOTAL FEDERAL EXPENDITURES	9,147,554,600	6,074,769,275	5,775,519,747	299,249,529	9,147,554,600	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF Programmatic Expenditures
Traditional Medicaid Services Acute Care	3,906,400

46,512,900	2,679,000

31,554,100	-

31,554,100	2,679,000

-	3,906,400

46,512,900	-

-	
ALTCS Services	 	268,554,800 	 	189,404,100 	 	193,737,823 	 	(4,333,723)	 	268,554,800 	 	- 	
TOTAL COUNTY EXPENDITURES	318,974,100	223,637,200	225,291,923	(1,654,723)	318,974,100	-	

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

Programmatic Expenditures							
Traditional Medicaid Services - Medically Needy	61,752,600	42,211,500	42,055,431	156,069	61,752,600	-	
Proposition 204 Services - Emergency Health Services	16,216,300	10,315,700	11,563,298	(1,247,598)	16,216,300	-	
Proposition 204 Services - Proposition 204 Protection	34,054,300	21,662,900	24,282,926	(2,620,026)	34,054,300	-	
Proposition 204 Services - ATLSF	 	102,000,000 	 	- 	 	- 	 	- 	 	102,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	214,023,200	74,190,100	77,901,654	(3,711,554)	214,023,200	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program	2,789,700	470,200	255,335	214,865	2,789,700	-	
Programmatic Expenditures							
Traditional Medicaid Services - IGA Fund	10,297,700	7,039,100	2,575,135	4,463,965	10,297,700	-	
Acute Care - Prescription Drug Rebate Program State Match	140,158,600	95,806,300	93,439,067	2,367,233	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	391,985,200	488,192,728	(96,207,528)	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	7,578,400	4,943,700	5,052,267	(108,567)	7,578,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	23,628,100	25,248,841	(1,620,741)	36,422,000	-	
Proposition 204 Services - Hospital Assessment	303,482,900	214,398,400	229,575,439	(15,177,039)	303,482,900	-	
Proposition 204 Services - IGA Fund	2,564,700	1,631,500	641,175	990,325	2,564,700	-	
ACA Adult Expansion - Hospital Assessment	37,389,000	22,589,300	20,518,051	2,071,249	37,389,000	-	
ACA Adult Expansion - IGA Fund	179,900	-	44,975	(44,975)	179,900	-	
Traditional Medicaid Services - TPL	194,700	133,100	1,403,003	(1,269,903)	194,700	-	
ALTCS Services - TPL	-	-	1,127,752	(1,127,752)	-	-	
ALTCS Services - Nursing Facility Assessment	105,912,600	78,854,800	79,050,369	(195,569)	105,912,600	-	
Targeted Investment Program	28,062,400	-	978,869	(978,869)	28,062,400	-	
KidsCare Services - IGA Fund	76,300	47,700	-	47,700	76,300	-	
KidsCare Services Premiums	12,151,300	7,490,200	6,147,126	1,343,074	12,151,300	-	
Freedom to Work Premiums	31,200	-	82,119	(82,119)	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	1,500,000	1,500,133	(133)	2,250,200	-	
Voluntary Political Subdivision Programs	 	100,867,400 	 	84,364,844 	 	84,364,844 	 	- 	 	100,867,400 	 	- 	
TOTAL OTHER EXPENDITURES	1,363,047,300	934,882,444	1,040,197,228	(105,314,783)	1,363,047,300	-	
	TOTAL		
Administrative Expenditures	268,262,100	181,338,700	154,369,928	26,968,772	268,262,100	-	
Acute Care	10,739,171,400	7,129,335,020	6,977,874,876	151,460,144	10,739,171,400	-	
Long Term Care	 	1,796,913,800 	 	1,175,306,300 	 	1,196,540,236 	 	(21,233,936)	 	1,796,913,800 	 	- 	
TOTAL EXPENDITURES	  $	12,804,347,300 	  $	8,485,980,020 	  $	8,328,785,040 	  $	157,194,980 	  $	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 February 29, 2020

BUDGET

BUDGET YTD

RECEIPTS YTD

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,251,144,200	$	845,886,900	$	870,299,842	
Proposition 204 Services & Administrative	116,627,400	75,055,500	75,728,150	
KidsCare Services	7,523,800.00	4,147,600.00	3,359,174	
ALTCS Services	234,042,300	152,711,500	156,028,200	
Behavioral Health Traditional Medicaid Services	 	151,410,400 	 	100,699,500 	 	101,504,696 	
TOTAL	1,760,748,100	1,178,501,000	1,206,920,063	

FEDERAL:
Acute & Administrative	7,789,954,100	5,207,410,275	5,086,021,108	
KidsCare Services	86,764,900	57,967,900	46,535,207	
ALTCS Services	1,144,403,700	725,764,100	827,545,234	
Behavioral Health Traditional Medicaid Services	 	126,431,900 	 	83,627,000 	 	91,600,801 	
TOTAL	9,147,554,600	6,074,769,275	6,051,702,349	

COUNTY:				
Acute & Administrative	50,419,300		34,233,100		32,160,836	
ALTCS Services	 	268,554,800 		 	189,404,100 		 	217,707,084 	
TOTAL	318,974,100		223,637,200		249,867,920	

TOBACCO FUNDS:						
Traditional Medicaid Services	61,752,600		42,211,500		42,055,431	
Proposition 204 Services	 	152,270,600 		 	31,978,600 		 	35,846,224 	
TOTAL	214,023,200		74,190,100		77,901,654	

OTHER:

Administrative	2,789,700	470,200	255,335	
Traditional Medicaid Services - IGA Fund	10,297,700	7,039,100	2,575,135	
Acute Care - Prescription Drug Rebate Program	712,796,900	487,791,500	581,631,795	
Long Term Care - Prescription Drug Rebate Program	44,000,400	28,571,800	30,301,108	
Hospital Assessment	343,616,500	238,619,200	241,825,199	
ALTCS - Nursing Facility Assessment	105,912,600	78,854,800	209,495	
Acute TPL - Note 1	194,700	133,100	1,403,003	
LTC TPL - Note 1	-	-	1,127,752	
KidsCare Services - IGA Fund	76,300	47,700	-	
KidsCare TPL - Note 1	-	-	(751.00)	
Member Premiums - CHIP	12,151,300	7,490,200	6,147,126	
Member Premiums - Freedom to Work	31,200	-	82,119	
Targeted Investment Program	28,062,400	-	13,710,018	
Behavioral Health Traditional Medicaid Services	2,250,200	1,500,000	1,056,968	
Voluntary Political Subdivision - State Match	 	100,867,400 	 	84,364,844 	 	172,895,374 	
TOTAL	1,363,047,300	934,882,444	1,053,219,676	

TOTAL REVENUE

$	12,804,347,300

$	8,485,980,020

$	8,639,611,662

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending February 29, 2020	
Note 1:	Third Party Liability Collections:	February 2020		February 2019		July 1, 2019		July 1, 2018	
	Gross Collections:					February 29, 2020		February 28, 2019	
	Acute	$	1,546,622		$	2,342,211		$	12,605,083		$	10,595,994	
	LTC	675,092		1,321,503		5,649,506		4,670,981	
	KidsCare	1,368		425		77,126		3,844	
	Total TPL Collections	  $	2,223,082 		$	3,664,139		$	18,331,715		$	15,270,819	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:	
Acute	$	136,467	$	251,763	$	1,403,003	$	1,082,088	
LTC		140,150	278,690	1,127,752	1,115,292	
KidsCare		(56)	(20)	(751)	(15)	
Total Expenditure Offsets	  $	276,561 		$	530,433		$	2,530,004		$	2,197,365		

Note 2: Authorized Positions
Actual Positions as of February 29, 2020

`

FY 20 Total

1,188.0
1,091.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending February 29, 2020

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2019	$ 5,258,991	
	Revenues	7,875,445	
	Transfers-In	 	384,399 	
	Total Revenues	 	8,259,843 	
	Expenditures	7,331,797	
	Transfers-out	 	2,424,350 	
	Total Expenditures	 	9,756,147 	
	Ending Balance February 29, 2020	  $ 3,762,688 	

Of the $3,762,688 ending balance, $2,716,302 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through March 2020.

Note 4:

Summary of Voluntary Political Subdivision Contribution Expenditures:

As of February 29, 2020 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		79,670,255		183,532,901		263,203,156	
Total Voluntary Political Subdivision Program Expenditures	$	345,281,700		$	84,364,844		$	194,429,775		$	278,794,620	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2020 APPROPRIATION STATUS REPORT
For the Period Ending February 29, 2020

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 February 29, 2020	
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	332,611,649	331,265,756	0	0	0	0	2,639,759,660	
CAPITATION - AIMHS	292,639	307,037	323,631	334,345	346,743	364,401	388,646	397,648	0	0	0	0	2,755,089	
CAPITATION - LTC	250,917,794	252,209,107	253,136,674	286,967,455	287,233,146	287,802,351	292,780,638	293,277,268	0	0	0	0	2,204,324,432	
MENTAL HEALTH - CHILD	865	2,317	-1,031	-270	1,084	-2,908	-1,672	-2,760	0	0	0	0	-4,376	
MENTAL HEALTH - ADULT	340,947	351,310	462,496	348,822	395,190	350,261	374,757	362,345	0	0	0	0	2,986,127	
MENTAL HEALTH - GENERAL	755	1,398	-2,562	3,511	1,243	1,875	748	-410	0	0	0	0	6,556	
MENTAL HEALTH - CMDP	11,210,666	11,149,954	11,526,705	12,227,439	12,150,542	12,426,514	12,466,410	12,610,716	0	0	0	0	95,768,945	
MENTAL HEALTH - DD	7,458,766	7,517,688	7,570,387	6,293	-134	11	-1,913	1,500	0	0	0	0	22,552,597	
MENTAL HEALTH - RBHA CRISIS	3,210,728	3,227,109	3,238,920	4,390,161	4,391,106	4,399,660	4,371,941	4,362,337	0	0	0	0	31,591,962	
FEE FOR SERVICE - ACUTE	48,820,855	49,681,027	42,280,433	52,930,957	68,773,323	49,769,243	58,409,680	57,039,404	0	0	0	0	427,704,922	
FFS - PRIOR QUARTER COVERAGE	953,544	609,982	539,248	471,399	289,234	322,445	594,307	260,867	0	0	0	0	4,041,026	
EMERGENCY SERVICES - FEDERAL	4,491,141	3,725,509	4,435,620	4,558,207	3,754,689	3,823,350	5,096,613	3,631,554	0	0	0	0	33,516,683	
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	1,273,615	1,217,608	0	0	0	0	7,719,391	
STATE ONLY TRBHA FFS	158,244	111,819	158,545	188,541	161,000	116,304	163,545	80,252	0	0	0	0	1,138,251	
INPATIENT INMATES FFS	244,004	235,027	245,518	346,036	345,038	387,696	241,155	230,561	0	0	0	0	2,275,035	
QMB - FEE FOR SERVICE	660,278	490,123	440,696	367,062	187,136	361,483	526,481	497,280	0	0	0	0	3,530,539	
FFS TRBHA FEE FOR SERVICE	12,287,430	11,525,809	8,927,578	12,220,179	11,423,941	11,050,947	10,338,005	10,775,105	0	0	0	0	88,548,995	
COCONINO COUNTY INMATES FFS	3,561	3,210	464	0	0	52	0	0	0	0	0	0	7,287	
MARICOPA CTY INMATES FFS	19,819	22,216	24,325	1,088	12,263	11,231	8,494	5,655	0	0	0	0	105,091	
PIMA COUNTY INMATES FFS	4,917	34,617	15,870	30,493	13,876	1,835	5,513	18,284	0	0	0	0	125,404	
PINAL COUNTY INMATES FFS	2,190	0	0	8,259	0	0	0	84	0	0	0	0	10,533	
MOHAVE COUNTY INMATES FFS	0	0	0	0	0	0	0	17,197	0	0	0	0	17,197	
FEE FOR SERVICE - LTC	14,641,720	12,577,411	12,175,076	14,560,491	13,493,550	13,627,408	14,255,720	13,281,847	0	0	0	0	108,613,224	
LFFS - PRIOR QUARTER COVERAGE	72,181	86,245	50,352	44,819	4,812	2,409	-14,997	3,923	0	0	0	0	249,744	
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	181	0	0	0	0	0	28,249	
COCONINO COUNTY INMATES LTC F	415	4,825	220	0	0	0	0	0	0	0	0	0	5,460	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,557,681	884,889	830,814	1,915,460	1,235,420	2,608,989	2,084,473	1,902,075	0	0	0	0	13,019,801	
REINSURANCE - ACC	13,954,921	15,652,135	16,821,600	19,456,077	19,517,983	12,784,925	11,917,250	12,416,047	0	0	0	0	122,520,940	
REINSURANCE - LTC	6,843,752	5,361,382	6,418,046	5,182,315	6,610,870	4,886,014	3,843,390	3,309,076	0	0	0	0	42,454,845	
SMIB - ACC	15,867,509	15,869,518	16,032,517	16,042,978	16,063,831	16,031,103	17,307,516	17,327,469	0	0	0	0	130,542,440	
HIB - ACC	775,609	843,035	893,679	881,950	862,191	876,720	915,055	933,305	0	0	0	0	6,981,544	
Q1	2,951,192	2,997,689	3,029,726	3,060,005	3,046,073	3,086,791	3,182,795	3,191,846	0	0	0	0	24,546,116	
SMIB - LTC	4,094,296	4,092,510	4,109,180	4,112,907	4,143,919	4,170,089	4,390,006	4,405,328	0	0	0	0	33,518,234	
HIB - LTC	381,353	383,342	394,397	388,191	386,272	382,641	403,157	406,559	0	0	0	0	3,125,910	
SUBTOTAL	728,338,191	726,618,665	718,813,286	776,751,337	787,871,089	764,545,328	777,933,160	773,225,726	0	0	0	0	6,054,096,782	

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	290,747,776	290,805,430	0	0	0	0	2,291,821,435	
CAPITATION - AIMHS	134,306	142,743	148,769	156,410	162,917	170,739	185,065	190,874	0	0	0	0	1,291,822	
MENTAL HEALTH - ADULT	414,838	404,766	357,960	339,574	346,048	314,392	316,392	326,710	0	0	0	0	2,820,678	
MENTAL HEALTH - GENERAL	-2,350	-4,545	-6,979	-1,026	-2,248	-1,867	1,442	0	0	0	0	0	-17,572	
MENTAL HEALTH - CMDP	0	393	762	818	1,922	2,291	2,454	3,298	0	0	0	0	11,938	
MENTAL HEALTH - RBHA CRISIS	3,634,857	3,668,731	3,689,681	4,433,299	4,430,127	4,407,033	4,399,743	4,402,054	0	0	0	0	33,065,525	
FEE FOR SERVICE - ACUTE	37,859,959	38,790,683	33,207,024	40,310,956	56,196,515	39,554,153	46,185,088	42,759,584	0	0	0	0	334,863,962	
FFS - PRIOR QUARTER COVERAGE	1,204,975	590,575	350,539	247,496	159,052	55,456	38,801	6,365	0	0	0	0	2,653,258	
EMERGENCY SERVICES - FEDERAL	3,246,745	2,798,913	3,488,929	3,312,152	2,963,400	2,750,306	3,028,325	2,774,129	0	0	0	0	24,362,899	
FFS MEDICAID IN PUBLIC SCHOOLS	723	218	330	768	520	983	1,243	2,304	0	0	0	0	7,090	
INPATIENT INMATES FFS	889,101	645,173	765,595	723,663	1,110,236	603,533	536,077	508,268	0	0	0	0	5,781,645	
STATE ONLY TRBHA FFS	399,387	372,201	456,058	565,497	378,481	440,746	361,290	430,194	0	0	0	0	3,403,853	
FFS TRBHA FEE FOR SERVICE	7,885,916	6,336,072	6,757,819	9,050,014	7,775,195	7,147,186	6,995,448	8,190,494	0	0	0	0	60,138,146	
MARICOPA CTY INMATES FFS	214,579	207,410	203,431	152,268	191,138	115,750	160,440	96,592	0	0	0	0	1,341,608	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	13,813	0	232	222	0	0	0	0	14,267	
PINAL COUNTY INMATES FFS	415	59	3,076	244	12,960	1,254	10,506	0	0	0	0	0	28,515	
PIMA COUNTY INMATES FFS	44,460	29,912	57,917	22,647	78,415	60,335	24,525	7,934	0	0	0	0	326,144	
MOHAVE COUNTY INMATES FFS	3,409	15,944	0	0	0	17,050	3,410	4,684	0	0	0	0	44,498	
COCONINO COUNTY INMATES FFS	302	3,171	0	165	80	4,062	0	392	0	0	0	0	8,172	
REINSURANCE - ACC	6,253,343	6,750,467	8,759,810	5,851,025	9,109,166	5,954,985	4,095,827	2,083,564	0	0	0	0	48,858,188	
SMIB - ACC	7,097,119	7,165,395	7,230,656	7,256,687	7,251,712	7,263,705	7,768,894	7,783,433	0	0	0	0	58,817,602	
HIB - ACC	6,248	4,850	4,894	4,894	4,413	4,173	4,996	5,933	0	0	0	0	40,401	
SUBTOTAL	347,582,951	348,190,644	344,620,338	364,432,537	380,644,543	358,962,627	364,867,975	360,382,458	0	0	0	0	2,869,684,073	

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	34,510,327	34,242,250	0	0	0	0	274,955,519	
CAPITATION - AIMHS	12,254	13,041	13,411	13,456	13,792	14,397	14,738	14,677	0	0	0	0	109,765	
MENTAL HEALTH - ADULT	12,078	12,834	13,307	10,299	9,656	28,879	19,601	13,393	0	0	0	0	120,047	
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	818	818	0	0	0	0	5,614	
MENTAL HEALTH - RBHA CRISIS	575,493	582,267	581,810	696,263	690,179	686,110	673,171	671,345	0	0	0	0	5,156,638	
FEE FOR SERVICE - ACUTE	2,872,751	3,384,201	2,596,379	3,610,161	4,963,978	2,932,703	3,602,293	3,352,011	0	0	0	0	27,314,477	
FFS - PRIOR QUARTER COVERAGE	200,446	340,753	89,570	110,297	27,989	10,047	4,338	2,863	0	0	0	0	786,302	
EMERGENCY SERVICES - FEDERAL	5,151,773	4,521,846	4,307,602	4,739,519	4,142,469	4,038,005	4,738,079	3,966,505	0	0	0	0	35,605,798	
FFS MEDICAID IN PUBLIC SCHOOLS	66	0	0	34	0	15	18	26	0	0	0	0	159	
STATE ONLY TRBHA FFS	39,350	9,279	10,091	52,331	11,941	33,648	25,528	29,595	0	0	0	0	211,763	
INPATIENT INMATES FFS	61,395	5,936	718	18,994	90,712	25,029	6,803	6,672	0	0	0	0	216,259	
FFS TRBHA FEE FOR SERVICE	279,336	136,082	159,112	163,246	150,059	186,733	211,249	183,405	0	0	0	0	1,469,222	
PIMA COUNTY INMATES FFS	11	11	0	0	0	0	0	0	0	0	0	0	21	
MARICOPA CTY INMATES FFS	8,779	2,632	4,840	20,343	660	5,792	217	3,726	0	0	0	0	46,990	
REINSURANCE - ACC	726,411	993,034	1,071,875	1,559,407	1,139,871	1,021,967	682,814	300,767	0	0	0	0	7,496,146	
SMIB - ACC	271	136	0	0	271	271	425	145	0	0	0	0	1,518	
	43,548,708	43,869,597	42,267,781	46,608,827	46,183,539	43,737,723	44,490,418	42,788,196	0	0	0	0	353,494,789	
	1,119,469,850	1,118,678,906	1,105,701,405	1,187,792,702	1,214,699,171	1,167,245,677	1,187,291,553	1,176,396,379	0	0	0	0	9,277,275,644	

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	16	0	0	0	0	78	
KidsCare - CAPITATION	6,102,844	6,193,197	6,245,205	6,672,896	6,665,471	6,631,335	6,634,574	6,644,746	0	0	0	0	51,790,269	
KidsCare - FEE FOR SERVICE	124,559	240,555	141,881	280,744	380,853	260,684	318,515	558,747	0	0	0	0	2,306,537	
KidsCare - MENTAL HEALTH	59,368	60,012	61,651	79,894	73,520	75,274	75,367	75,971	0	0	0	0	561,058	
KidsCare - REINSURANCE	200,701	116,470	178,310	68,995	201,596	571,913	269,944	84,653	0	0	0	0	1,692,581	

6,487,491	6,610,278	6,629,190	7,105,104	7,321,449	7,539,206	7,298,400	7,364,133	0	0	0	0	56,355,251	

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	1,194,589,953	1,183,760,512	0	0	0	0	9,333,630,895	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
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	123.63	123.63	0.00	0.00	0.00	0.00		370.89		
1006	TANF 21-44 MALE WITH	42,054.34	48,959.09	44,661.46	42,858.20	42,323.49	37,287.90	34,487.08	28,852.25	0.00	0.00	0.00	0.00		321,483.81		
1007	TANF 21-44 FEMALE WI	45,256.87	48,452.58	37,289.55	36,573.35	40,432.42	33,375.17	30,746.26	32,534.74	0.00	0.00	0.00	0.00		304,660.94		
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	63,375.97	55,745.10	0.00	0.00	0.00	0.00		471,906.73		
1009	TANF 65+ M & F WITH	16,091.48	14,740.77	12,841.93	10,830.21	11,819.98	12,341.56	12,394.17	13,948.07	0.00	0.00	0.00	0.00		105,008.17		
100F	TANF 21-44 MALE WITH	40.03	581.66	1,451.87	603.71	578.41	22.10	944.65	780.72	0.00	0.00	0.00	0.00		5,003.15		
100G	TANF 21-44 FEMALE WI	2,488.06	2,248.29	2,866.78	99.61	597.88	407.73	761.98	899.13	0.00	0.00	0.00	0.00		10,369.46		
100H	TANF 45-64 M & F WIT	4,175.05	3,092.89	2,374.57	461.51	341.84	33.15	3,960.19	2,465.05	0.00	0.00	0.00	0.00		16,904.25		
100J	TANF 65+ M & F WITH	212.66	202.84	436.85	0.00	359.39	345.28	0.00	549.49	0.00	0.00	0.00	0.00		2,106.51		
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	5,777,128.75	5,759,601.77	0.00	0.00	0.00	0.00		45,964,845.89		
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	3,905,348.49	3,841,954.13	0.00	0.00	0.00	0.00		29,543,062.72		
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	7,030,966.31	7,013,135.95	0.00	0.00	0.00	0.00		53,077,914.10		
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	2,151,971.54	2,143,213.86	0.00	0.00	0.00	0.00		16,269,888.43		
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	2,585,298.28	2,628,372.12	0.00	0.00	0.00	0.00		19,839,497.58		
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	9,825,232.98	9,751,081.96	0.00	0.00	0.00	0.00		77,318,417.26		
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	33,705,911.55	33,657,519.69	0.00	0.00	0.00	0.00		267,167,960.95		
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	8,149,023.26	8,125,722.30	0.00	0.00	0.00	0.00		63,804,651.63		
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	35,719.77	37,770.87	0.00	0.00	0.00	0.00		267,445.91		
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	324,004.60	299,888.62	0.00	0.00	0.00	0.00		2,456,828.01		
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	41,339.08	36,291.48	0.00	0.00	0.00	0.00		251,487.07		
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	31,945.63	73,139.38	0.00	0.00	0.00	0.00		229,731.83		
101D	TANF 14-20 MALE NON-	9,808.43	14,845.50	11,848.57	9,602.25	12,556.31	5,869.26	16,638.84	27,310.88	0.00	0.00	0.00	0.00		108,480.04		
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	19,325.18	57,159.61	0.00	0.00	0.00	0.00		180,872.32		
101F	TANF 21-44 MALE NON-	246,596.25	255,429.76	194,158.71	213,830.17	206,314.00	182,598.28	227,873.37	286,459.83	0.00	0.00	0.00	0.00		1,813,260.37		
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	494,335.15	565,980.85	0.00	0.00	0.00	0.00		4,121,517.50		
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	133,484.85	125,004.31	0.00	0.00	0.00	0.00		1,042,756.86		
101J	TANF 65+ N & F NON-M	198.84	566.38	1,210.63	1,307.79	510.50	0.00	797.19	264.45	0.00	0.00	0.00	0.00		4,855.78		
1024	TANF 14-20 MALE WITH	1,991.65	1,834.56	1,834.56	1,768.75	1,768.75	1,768.75	1,768.75	1,902.53	0.00	0.00	0.00	0.00		14,638.30		
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	16,620.77	15,604.03	0.00	0.00	0.00	0.00		161,226.54		
1027	TANF 21-44 FEMALE WI	33,845.08	29,934.75	39,393.39	30,840.59	29,261.43	35,954.66	36,614.66	42,470.89	0.00	0.00	0.00	0.00		278,315.45		
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	29,739.48	37,500.21	0.00	0.00	0.00	0.00		262,282.34		
1029	TANF 65+ M & F WITH	9,312.30	9,417.77	6,856.06	8,190.14	7,732.09	8,277.59	8,077.83	8,540.08	0.00	0.00	0.00	0.00		66,403.86		
102F	TANF 21-44 MALE WITH	0.00	77.29	129.25	15.42	3.98	220.10	35.89	0.00	0.00	0.00	0.00	0.00		481.93		
102G	TANF 21-44 FEMALE WI	0.00	67.86	0.00	200.16	65.14	38.54	125.15	3,007.42	0.00	0.00	0.00	0.00		3,504.27		
102H	TANF 44-64 M & F WIT	0.00	0.00	38.22	581.36	6,681.12	2,242.53	4,740.43	158.58	0.00	0.00	0.00	0.00		14,442.24		

ACC CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
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	35.89	0.00	0.00	0.00	0.00		372.11		
2100	SSI AGED WITH MEDIC A	712,678.64	703,164.71	703,123.48	667,339.40	650,196.87	657,181.14	677,617.50	687,752.61	0.00	0.00	0.00	0.00		5,459,054.35		
210Z	SSI AGED WITH MEDIC
A	52,660.57	41,774.04	32,514.74	42,682.27	33,049.12	44,752.44	36,886.84	62,350.20	0.00	0.00	0.00	0.00		346,670.22		
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	8,806,099.63	8,702,575.27	0.00	0.00	0.00	0.00		69,132,805.90		
211Z	SSI AGED NON-MEDIC
AR	216,958.62	161,562.33	135,278.37	170,335.07	191,280.57	135,826.02	187,738.71	184,626.00	0.00	0.00	0.00	0.00		1,383,605.69		
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	5,277,766.51	5,266,515.53	0.00	0.00	0.00	0.00		42,863,222.99		
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	8,995.15	8,275.40	0.00	0.00	0.00	0.00		55,079.14		
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	1,792,996.13	1,758,212.24	0.00	0.00	0.00	0.00		14,169,803.32		
220Z	SSI DISABLED WITH M E	96,386.79	59,787.78	85,084.80	74,882.47	52,442.41	72,487.17	53,596.33	145,112.84	0.00	0.00	0.00	0.00		639,780.59		
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	72,148,741.81	72,386,068.68	0.00	0.00	0.00	0.00		572,239,603.98		
221Z	SSI DISABLED NON-ME D	942,051.13	933,821.38	825,347.66	868,410.05	930,105.69	909,560.48	929,829.57	1,322,121.88	0.00	0.00	0.00	0.00		7,661,247.84		
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	15,294,334.16	15,295,438.20	0.00	0.00	0.00	0.00		121,209,966.45		
222Z	SSI DISABLED WITH Q M	31,562.80	38,109.67	39,444.48	60,437.56	39,111.68	41,092.31	25,336.17	30,874.55	0.00	0.00	0.00	0.00		305,969.22		
2300	SSI BLIND WITH MEDIC	7,894.62	8,025.40	7,600.96	7,717.09	7,721.76	7,800.88	7,766.94	7,643.31	0.00	0.00	0.00	0.00		62,170.96		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	18.06	223.92	0.00	0.00	0.00	0.00	0.00		241.98		
2310	SSI BLIND NON-MEDIC A	633,695.19	633,652.52	642,091.43	647,172.16	639,301.52	639,411.85	645,353.17	633,963.60	0.00	0.00	0.00	0.00		5,114,641.44		
231Z	SSI BLIND NON-MEDIC
A	5,251.90	10,051.71	22,411.45	23,240.84	2,465.53	18,241.02	3,956.38	3,048.83	0.00	0.00	0.00	0.00		88,667.66		
2320	SSI BLIND WITH QMB	47,291.74	47,835.53	47,975.47	45,708.70	48,382.38	50,070.52	50,528.24	50,142.19	0.00	0.00	0.00	0.00		387,934.77		
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	133.78	133.78	0.00	0.00	0.00	0.00		401.34		
4302	SOBRA CHILD 01-05 M	384.93	668.23	677.67	625.97	550.16	358.41	358.41	492.19	0.00	0.00	0.00	0.00		4,115.97		
4303	SOBRA CHILD 06-13 M	671.85	839.07	526.79	627.08	627.08	627.08	627.08	627.08	0.00	0.00	0.00	0.00		5,173.11		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	119.47	119.47	7.71	0.00	0.00	0.00	0.00	0.00		246.65		
4305	SOBRA CHILD 14-20 FE	598.98	472.87	136.70	127.40	127.40	127.40	127.40	127.40	0.00	0.00	0.00	0.00		1,845.55		
430B	SOBRA CHILD 01-05 M	0.00	283.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283.30		
430C	SOBRA CHILD 06-13 M	0.00	146.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146.96		
4311	SOBRA CHILD <1 M & F	20,305,933.37	20,224,322.07	20,036,959.06	20,542,211.59	20,289,176.01	20,315,889.75	20,171,313.14	20,038,556.66	0.00	0.00	0.00	0.00		161,924,361.65		
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	30,928,858.50	30,763,027.56	0.00	0.00	0.00	0.00		247,300,896.23		
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	40,345,795.42	40,198,250.57	0.00	0.00	0.00	0.00		320,964,154.85		
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	11,346,886.21	11,293,590.63	0.00	0.00	0.00	0.00		89,666,250.89		
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	11,285,327.03	11,272,645.93	0.00	0.00	0.00	0.00		89,378,344.84		
431A	SOBRA CHILD < 1 M &	255,349.52	216,051.62	182,881.71	205,334.74	189,022.10	152,376.43	194,649.26	197,631.46	0.00	0.00	0.00	0.00		1,593,296.84		
431B	SOBRA CHILD 01-05 M	734,288.72	672,792.26	556,972.69	630,508.19	606,921.80	588,207.67	652,378.10	807,689.49	0.00	0.00	0.00	0.00		5,249,758.92		
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	584,403.86	738,885.90	0.00	0.00	0.00	0.00		5,089,146.59		
431D	SOBRA CHILD 14-20 MA	203,649.34	208,008.27	168,887.99	169,048.28	179,621.04	184,605.07	158,106.23	216,384.67	0.00	0.00	0.00	0.00		1,488,310.89		
431E	SOBRA CHILD 14-20 FE	210,973.01	203,192.73	181,516.56	172,528.36	178,270.76	164,598.61	192,029.12	221,123.25	0.00	0.00	0.00	0.00		1,524,232.40		

ACC CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
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	168.64	168.64	0.00	0.00	0.00	0.00		1,416.53		
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		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	125.12	0.00	0.00	0.00	0.00	0.00		125.12		
4325	SOBRA CHILD 14-20 FE	194.52	400.68	400.68	370.94	370.94	243.05	243.05	243.05	0.00	0.00	0.00	0.00		2,466.91		
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	11,874.17	10,173.29	0.00	0.00	0.00	0.00		124,917.31		
5008	SOBRA PREG 45-64 FE
M	253.60	253.60	253.60	350.90	726.21	1,880.71	1,880.71	1,649.28	0.00	0.00	0.00	0.00		7,248.61		
500G	SOBRA PREG 21-44 FE M	3,420.46	2,107.63	794.66	0.00	293.32	273.77	1,500.12	2,348.92	0.00	0.00	0.00	0.00		10,738.88		
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	945.64	941.12	0.00	0.00	0.00	0.00		5,930.57		
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	537,674.30	522,768.48	0.00	0.00	0.00	0.00		4,353,501.77		
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	5,877,804.06	5,720,787.19	0.00	0.00	0.00	0.00		47,890,459.92		
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	26,166.61	24,845.62	0.00	0.00	0.00	0.00		192,359.38		
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	45,320.58	47,084.44	0.00	0.00	0.00	0.00		324,633.13		
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	376,885.23	440,216.26	0.00	0.00	0.00	0.00		2,959,955.68		
501H	SOBRA PREG 45-64 FE
M	54.35	1,725.17	6,412.35	1,312.28	4,770.91	1,216.81	1,747.28	638.69	0.00	0.00	0.00	0.00		17,877.84		
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	31,508.51	28,284.63	0.00	0.00	0.00	0.00		220,474.63		
5028	SOBRA PREG 45-64 FE
M	2,368.16	2,368.16	2,368.16	168.64	288.11	168.64	168.64	304.73	0.00	0.00	0.00	0.00		8,203.24		
502G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38.37	0.00	0.00	0.00	0.00		38.37		
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	303,423,642.78	303,769,370.48	0.00	0.00	0.00	0.00		2,406,938,448.61		

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	1,536,918.11	1,389,484.25	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	31,409.34	37,431.17	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	111,871.08	80,497.26	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	13,332,379.34 11,971,038.94	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	15,012,577.87	13,478,451.62	0.00	0.00	0.00	0.00	

 
13,109,660.19	
218,800.43	
843,997.61	
104,451,181.15	
118,623,639.38	

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	78,767.25	73,371.88	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	159,462.26	159,141.74	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	354,765.03	352,871.56	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	92,048.53	89,856.47	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	4,486.83	957.22	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	6,992.05	18,201.05	0.00	0.00	0.00	0.00	

 
145.06	
561,828.46	
1,394,807.48	
3,000,765.19	
737,777.04	
36,106.42	
77,128.64	

ACC CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110H	TANF EXPANDED 45-64	9,815.87	13,442.99	5,261.04	21,637.90	8,327.09	6,888.80	8,905.84	10,590.41	0.00	0.00	0.00	0.00		84,869.94		
110J	TANF EXPANDED 65+
M&	6,731.65	5,050.11	3,741.60	2,629.70	3,610.18	2,684.33	4,039.02	9,056.45	0.00	0.00	0.00	0.00		37,543.04		
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	568.71	593.83	0.00	0.00	0.00	0.00		7,860.09		
1114	TANF EXPANDED 14-20	38,415.06	38,413.55	38,265.78	41,902.37	41,498.84	41,767.22	40,179.45	39,804.12	0.00	0.00	0.00	0.00		320,246.39		
1115	TANF EXPANDED 14-20	275,091.63	277,526.66	267,373.68	289,322.19	281,371.71	274,968.78	267,437.63	265,219.61	0.00	0.00	0.00	0.00		2,198,311.89		
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	9,569,496.89	9,498,844.02	0.00	0.00	0.00	0.00		77,823,643.19		
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	27,051,113.88	26,977,638.58	0.00	0.00	0.00	0.00		217,095,710.47		
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	9,284,187.01	9,275,321.47	0.00	0.00	0.00	0.00		74,223,932.60		
1119	TANF EXPANDED 65+
M&	30,255.92	28,131.96	28,000.75	28,862.78	32,142.43	32,001.01	33,848.46	35,499.42	0.00	0.00	0.00	0.00		248,742.73		
111C	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	73.27	0.00	157.02	0.00	0.00	0.00	0.00		230.29		
111D	TANF EXPANDED 14-20	2,490.39	1,152.78	1,523.21	3,036.33	1,816.92	1,641.25	823.55	1,770.81	0.00	0.00	0.00	0.00		14,255.24		
111E	TANF EXPANDED 14-20	7,437.73	5,473.69	3,147.13	10,374.18	5,003.15	4,747.54	6,143.71	4,887.72	0.00	0.00	0.00	0.00		47,214.85		
111F	TANF EXPANDED 21-44	267,373.80	262,773.96	215,068.24	235,644.82	208,690.61	216,054.62	220,194.45	244,267.62	0.00	0.00	0.00	0.00		1,870,068.12		
111G	TANF EXPANDED 21-44	525,020.23	509,660.72	400,174.61	489,416.42	444,516.24	401,643.71	425,977.80	447,510.22	0.00	0.00	0.00	0.00		3,643,919.95		
111H	TANF EXPANDED 45-64	178,932.04	172,494.14	159,074.75	150,035.45	153,058.78	156,082.57	145,311.60	155,355.99	0.00	0.00	0.00	0.00		1,270,345.32		
111J	TANF EXPANDED 65+
M&	592.01	928.69	367.98	904.28	3,138.45	1,269.53	0.00	8,156.97	0.00	0.00	0.00	0.00		15,357.91		
1126	TANF EXPANDED 21-44	297,942.68	293,773.27	291,620.59	306,418.42	301,144.14	295,722.12	296,270.83	297,989.38	0.00	0.00	0.00	0.00		2,380,881.43		
1127	TANF EXPANDED 21-44	790,701.02	789,295.29	779,113.14	789,198.37	790,964.18	796,613.51	775,835.76	755,903.90	0.00	0.00	0.00	0.00		6,267,625.17		
1128	TANF EXPANDED 45-64	900,768.88	921,413.73	924,623.19	928,434.52	927,852.63	939,397.80	924,071.86	933,104.52	0.00	0.00	0.00	0.00		7,399,667.13		
1129	TANF EXPANDED 65+
M&	256,772.30	259,581.62	263,961.29	248,104.89	248,988.31	250,537.88	248,393.88	249,596.93	0.00	0.00	0.00	0.00		2,025,937.10		
112F	TANF EXPANDED 21-44	0.00	2,931.30	4,191.82	114.25	988.92	5,468.45	465.30	192.90	0.00	0.00	0.00	0.00		14,352.94		
112G	TANF EXPANDED 21-44	2,213.20	5,170.00	2,450.40	1,114.75	3,714.40	171.88	2,302.17	6,698.66	0.00	0.00	0.00	0.00		23,835.46		
112H	TANF EXPANDED 45-64	6,227.67	1,063.02	540.07	7,528.30	1,670.64	609.93	559.77	2,394.01	0.00	0.00	0.00	0.00		20,593.41		
112J	TANF EXPANDED 65+
M&	3,111.80	878.74	906.87	814.40	34.82	526.87	801.48	725.46	0.00	0.00	0.00	0.00		7,800.44		
2400	SSI AGED EXPANDED WI	40,745.64	49,658.35	38,234.62	42,281.47	37,211.36	35,322.07	43,741.63	58,657.20	0.00	0.00	0.00	0.00		345,852.34		
240Z	SSI AGED EXPANDED
WI	26,984.10	40,705.46	35,897.94	27,426.39	50,793.70	18,708.07	27,360.72	53,933.43	0.00	0.00	0.00	0.00		281,809.81		
2410	SSI AGED EXPANDED NO	116,302.77	124,836.95	115,780.95	113,521.05	114,817.69	113,632.17	110,777.55	104,414.03	0.00	0.00	0.00	0.00		914,083.16		
241Z	SSI AGED EXPANDED
NO	15,686.56	0.00	2,707.35	12,150.89	5,497.52	3,538.97	6,016.05	417.21	0.00	0.00	0.00	0.00		46,014.55		
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	5,303,470.90	5,275,757.16	0.00	0.00	0.00	0.00		42,746,027.87		
242Z	SSI AGED EXPANDED
WI	10,566.52	4,568.42	7,433.00	9,127.29	8,761.32	7,137.93	12,904.13	22,553.88	0.00	0.00	0.00	0.00		83,052.49		
2520	SSI BLIND EXPANDED W	191.11	191.11	191.11	168.64	288.11	288.11	288.11	288.11	0.00	0.00	0.00	0.00		1,894.41		
2600	SSI DISABLED EXPAND
E	95,669.32	118,092.54	108,033.75	124,095.05	114,799.54	133,457.04	152,130.91	150,083.31	0.00	0.00	0.00	0.00		996,361.46		
260Z	SSI DISABLED EXPAND E	60,164.41	59,191.60	53,022.25	48,257.79	46,863.89	51,512.21	59,351.12	94,109.93	0.00	0.00	0.00	0.00		472,473.20		
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	2,052,135.88	2,110,099.53	0.00	0.00	0.00	0.00		15,938,076.06		
261Z	SSI DISABLED EXPAND E	41,560.30	39,967.68	26,817.13	29,654.10	36,640.28	47,277.72	50,484.59	44,229.61	0.00	0.00	0.00	0.00		316,631.41		

ACC CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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	10,932,211.60	10,818,504.99	0.00	0.00	0.00	0.00		86,591,275.76		
262Z	SSI DISABLED EXPAND
E	24,786.63	13,062.99	25,997.02	38,102.49	8,699.07	14,396.81	26,636.13	40,475.12	0.00	0.00	0.00	0.00		192,156.26		
SUBTOTAL:	68,743,011.0	7 68,940,363.76	68,696,349.0	5 69,927,676.36	69,377,677.92	68,622,157.07	68,780,960.32	68,689,203.45	0.00	0.00	0.00	0.00		551,777,399.00		

3506	ADULT 40-100% MALE 2	5,764.11	5,307.37	5,088.93	7,318.11	4,692.15	4,968.15	2,761.74	9,657.12	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	3,542.85	6,550.15	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	47,071.08	52,248.10	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	4,366.43	17,877.81	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	4,295.29	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	7,801.29	4,526.69	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	3,807,754.80	3,822,655.31	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	4,113,475.81	4,125,539.63	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	12,741,143.55	12,576,247.76	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	10,880,013.40	10,781,203.90	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	24,721,076.83	24,404,239.94	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	1,780.25	18,605.22	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	53,586.12	93,171.48	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	89,073.87	74,870.37	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	295,394.16	316,620.93	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	269,833.48	281,991.33	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	529,444.00	517,053.12	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	4,177.23	24,719.35	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	662.30	662.30	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	2,574.76	6,201.00	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	723.88	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	661.10	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	22,182.22	37,669.55	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	17,964.79	20,844.54	0.00	0.00	0.00	0.00	

45,557.68	
48,826.82	
393,138.10	
75,964.60	
7,903.21	
12,449.21	
38,629.62	
29,830,869.39	
32,573,562.89	
101,481,894.70	
85,733,344.19	
196,956,177.49	
42,058.04	
512,083.75	
661,931.64	
2,377,454.04	
2,109,440.23	
3,856,926.61	
47,247.28	
5,143.87	
16,435.58	
5,863.53	
4,428.87	
3,790.97	
3,391.22	
5,021.19	
636.94	
291,260.56	
107,856.78	

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	935,621.05	968,271.53	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	6,170.47	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	941,791.52	968,271.53	0.00	0.00	0.00	0.00	

 
8,581,169.84	
12,280.45	
8,593,450.29	

ACC CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	82,822.22	73,725.58	0.00	0.00	0.00	0.00		576,228.61		
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	6,607.53	11,689.11	0.00	0.00	0.00	0.00		58,056.22		
370F	ADULT <40% EXP MALE	10,732.30	5,515.81	10,662.39	4,379.14	1,950.65	1,869.14	6,788.39	4,891.93	0.00	0.00	0.00	0.00		46,789.75		
370G	ADULT <40% EXP FEM AL	497.19	1,324.21	2,550.57	29,039.02	4,360.48	3,081.65	583.41	1,207.28	0.00	0.00	0.00	0.00		42,643.81		
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	25,300.10	7,890.94	0.00	0.00	0.00	0.00		91,276.83		
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	6,926,179.58	6,900,291.23	0.00	0.00	0.00	0.00		54,616,419.74		
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	6,242,427.91	6,255,813.77	0.00	0.00	0.00	0.00		49,375,627.98		
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	53,551,604.84	53,660,176.39	0.00	0.00	0.00	0.00		414,755,223.92		
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	31,445,116.28	31,489,472.88	0.00	0.00	0.00	0.00		245,308,448.49		
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	60,444,871.97	60,506,903.61	0.00	0.00	0.00	0.00		472,753,441.84		
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	6,747.74	42,725.97	0.00	0.00	0.00	0.00		86,092.02		
371D	ADULT <40% EXP MALE	173,398.88	166,910.98	142,642.92	149,675.54	149,602.20	123,554.04	158,471.95	199,919.41	0.00	0.00	0.00	0.00		1,264,175.92		
371E	ADULT <40% EXP FEM AL	170,863.21	142,486.87	112,122.69	121,004.92	130,024.61	116,777.74	139,355.90	175,827.08	0.00	0.00	0.00	0.00		1,108,463.02		
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	1,477,539.87	1,733,669.76	0.00	0.00	0.00	0.00		11,983,856.08		
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	889,865.27	953,074.91	0.00	0.00	0.00	0.00		6,736,438.26		
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	1,401,996.24	1,404,433.87	0.00	0.00	0.00	0.00		10,154,454.96		
371J	ADULT <40% EXP M&F 6	0.00	0.00	762.31	0.00	38.94	1,388.82	0.00	1,817.45	0.00	0.00	0.00	0.00		4,007.52		
3726	ADULT <40% EXP MALE	1,897.66	3,045.53	1,010.32	4,101.68	3,295.53	3,122.16	705.03	1,841.96	0.00	0.00	0.00	0.00		19,019.87		
3727	ADULT <40% EXP FEM AL	1,521.58	1,175.63	1,175.63	3,047.26	946.51	953.56	1,237.87	2,133.12	0.00	0.00	0.00	0.00		12,191.16		
3728	ADULT <40% EXP M&F
4	0.00	3,480.51	1,898.98	2,527.06	6,484.66	6,335.40	2,893.55	8,371.78	0.00	0.00	0.00	0.00		31,991.94		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	570.17	570.17	570.17	0.00	0.00	0.00	0.00	0.00		1,710.51		
372F	ADULT <40% EXP MALE	1,485.99	0.00	0.00	1,682.22	0.00	320.47	3,241.18	530.85	0.00	0.00	0.00	0.00		7,260.71		
372G	ADULT <40% EXP FEM AL	327.59	540.92	0.00	467.84	292.05	0.00	0.00	170.62	0.00	0.00	0.00	0.00		1,799.02		
372H	ADULT <40% EXP M&F
4	0.00	0.00	470.95	42.73	0.00	7,503.68	3,556.35	2,501.01	0.00	0.00	0.00	0.00		14,074.72		
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	220,434,164.31	220,637,916.38	0.00	0.00	0.00	0.00		1,726,299,498.30		

3906	NEWLY ELIGIBLE MALE	9,297.77	14,217.05	12,452.76	15,498.83	16,317.22	18,103.54	19,422.64	12,751.41	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	3,380.19	4,014.77	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	43,633.46	40,415.52	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	5,030.16	10,722.52	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	291.08	646.70	387.40	118.81	600.20	269.33	954.52	1,149.36	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	660.11	0.00	0.00	0.00	0.00	

118,061.22	
21,779.77	
287,090.80	
78,931.35	
4,417.40	
5,832.81	

9935	BIRTH SUPP PAYMENT A	151,291.91	252,079.35	221,179.92	136,085.21	217,101.77	168,953.67	216,959.12	142,771.50	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	373,900.76	367,267.17	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	590,859.88	510,038.67	0.00	0.00	0.00	0.00	

 
1,506,422.45	
3,644,664.64	
5,151,087.09	

ACC CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390H	NEWLY ELIGIBLE M&F 4	3,238.66	5,840.75	11,434.48	2,855.21	889.58	6,382.58	19,064.87	5,950.19	0.00	0.00	0.00	0.00		55,656.32		
390J	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	2,594.88	0.00	788.59	0.00	0.00	0.00	0.00	0.00		3,383.47		
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	1,429,568.27	1,432,379.67	0.00	0.00	0.00	0.00		11,093,457.42		
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	1,586,226.66	1,585,522.25	0.00	0.00	0.00	0.00		12,443,896.78		
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	7,389,157.59	7,315,983.72	0.00	0.00	0.00	0.00		59,668,528.72		
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	11,119,769.49	11,080,099.75	0.00	0.00	0.00	0.00		89,256,069.29		
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	11,601,024.22	11,531,327.54	0.00	0.00	0.00	0.00		91,931,244.66		
3919	NEWLY ELIGIBLE M&F 6	475.27	376.91	749.95	409.28	1,239.19	792.02	792.02	5,869.40	0.00	0.00	0.00	0.00		10,704.04		
391D	NEWLY ELIGIBLE MALE	35,162.36	25,533.98	27,119.68	23,581.76	22,180.15	26,647.21	24,378.07	34,293.28	0.00	0.00	0.00	0.00		218,896.49		
391E	NEWLY ELIGIBLE FEMA L	45,902.91	40,350.46	37,851.72	32,289.49	27,676.79	31,657.62	30,206.03	30,865.40	0.00	0.00	0.00	0.00		276,800.42		
391F	NEWLY ELIGIBLE MALE	276,730.87	235,207.91	218,621.78	242,758.31	213,094.79	214,885.93	243,831.98	246,176.73	0.00	0.00	0.00	0.00		1,891,308.30		
391G	NEWLY ELIGIBLE FEMA L	424,973.22	387,794.23	305,099.35	342,030.80	321,120.60	265,597.58	357,967.71	341,737.60	0.00	0.00	0.00	0.00		2,746,321.09		
391H	NEWLY ELIGIBLE M&F
4	330,872.11	269,795.17	240,089.92	291,740.21	283,965.91	236,422.95	313,726.47	282,903.94	0.00	0.00	0.00	0.00		2,249,516.68		
3926	NEWLY ELIGIBLE MALE	530.47	0.00	126.74	493.17	0.00	0.00	380.79	0.00	0.00	0.00	0.00	0.00		1,531.17		
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	3,913.58	884.43	0.00	0.00	0.00	0.00		8,713.49		
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	827.86	0.00	0.00	0.00	0.00	0.00		859.68		
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	34,194,045.17	33,963,707.59	0.00	0.00	0.00	0.00		272,389,601.33		

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	7,229,435.38	7,167,615.44	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	2,079,072.89	2,045,058.25	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	2,039,890.92	2,026,757.13	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	168,132.50	179,761.37	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	44,410.33	52,282.50	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	45,162.16	48,585.11	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	11,606,104.18	11,520,059.80	0.00	0.00	0.00	0.00	

138.81	
58,730,122.75	
16,874,988.38	
16,457,291.29	
40.49	
1,323,269.86	
375,076.50	
356,524.68	
94,117,452.76	

9944	BIRTH SUPP PAYMENT S	11,882.90	58,943.98	23,471.72	24,770.76	18,450.92	49,784.74	43,193.29	12,340.94	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	43,193.29	12,340.94	0.00	0.00	0.00	0.00	

242,839.25

242,839.25

9939	BIRTH SUPP PAYMENT N	287,755.48	369,407.99	310,122.63	396,494.47	285,000.67	322,312.46	316,281.67	278,542.09	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	316,281.67	278,542.09	0.00	0.00	0.00	0.00	

 

2,565,917.46

2,565,917.46

ACC CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4517	BC PATIENT FEMALE 2 1	10,376.74	10,793.95	10,912.09	10,415.24	9,325.23	9,093.68	8,867.51	8,661.61	0.00	0.00	0.00	0.00		78,446.05		
4518	BC PATIENT FEMALE 4
5	47,200.02	47,554.26	46,398.74	48,796.77	49,270.42	47,402.20	49,047.19	50,865.94	0.00	0.00	0.00	0.00		386,535.54		
4519	BC PATIENT FEMALE 6 5	0.00	245.28	0.00	0.00	0.00	805.63	805.63	0.00	0.00	0.00	0.00	0.00		1,856.54		
451G	BC PATIENT FEMALE 2
1	142.44	662.53	1,902.14	1,447.39	489.25	0.00	545.02	0.00	0.00	0.00	0.00	0.00		5,188.77		
451H	BC PATIENT FEMALE 4 5	6,761.14	474.81	281.62	3,948.99	1,159.45	5,906.73	6,817.45	2,579.03	0.00	0.00	0.00	0.00		27,929.22		
4617	CC PATIENT FEMALE 2
1	4,771.12	4,771.12	4,440.56	4,876.72	5,094.73	4,719.27	4,719.27	4,719.27	0.00	0.00	0.00	0.00		38,112.06		
4618	CC PATIENT FEMALE 4 5	2,661.05	2,661.05	2,759.18	3,797.60	3,797.60	4,173.06	4,173.06	4,321.39	0.00	0.00	0.00	0.00		28,343.99		
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	1,572.35	0.00	0.00	0.00	0.00		2,908.72		
SUBTOTAL:	71,912.51	67,163.00	67,332.1	6	76,773.50	69,136.68	72,100.57	74,975.13	72,719.59	0.00	0.00	0.00	0.00		572,113.14		

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	133.78	257.41	0.00	0.00	0.00	0.00	
860Z	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.32	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	127.40	127.40	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	1,603,693.02	1,602,086.05	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	65,437.84	56,459.00	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	460,095.44	464,044.76	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	71,900.50	26,730.24	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	248,063.46	260,353.62	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	1,704.56	2,531.58	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	2,451,156.00	2,412,813.38	0.00	0.00	0.00	0.00	

 
5,967.96	
223.32	
1,047.10	
12,749,912.94	
481,817.79	
3,800,333.36	
265,546.10	
1,902,057.97	
51,891.63	
19,258,798.17	

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

5,206,541,319.35

637,039,184.43	640,246,228.62	636,844,407.74	662,233,982.47	657,699,336.68	658,294,991.77	657,869,752.12	656,313,435.52	0.00	0.00	0.00	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending February 29, 2020	
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	1.00	1.00	0.00	0.00	0.00	0.00		3.00		
1006	TANF 21-44 MALE WITH	89.69	89.86	94.05	83.11	86.62	79.25	81.31	70.95	0.00	0.00	0.00	0.00		674.84		
1007	TANF 21-44 FEMALE WI	106.74	102.58	84.56	88.37	79.82	87.81	86.12	85.89	0.00	0.00	0.00	0.00		721.89		
1008	TANF 45-64 M & F WIT	178.61	170.54	178.92	199.62	207.26	207.76	201.75	190.89	0.00	0.00	0.00	0.00		1,535.35		
1009	TANF 65+ M & F WITH	99.53	90.51	78.92	84.48	91.34	95.56	93.54	105.57	0.00	0.00	0.00	0.00		739.45		
100F	TANF 21-44 MALE WITH	0.29	4.11	6.65	4.51	4.45	0.19	4.47	4.95	0.00	0.00	0.00	0.00		29.62		
100G	TANF 21-44 FEMALE WI	2.91	6.29	2.43	0.60	0.30	2.14	5.00	3.24	0.00	0.00	0.00	0.00		22.91		
100H	TANF 45-64 M & F WIT	14.60	3.52	2.06	3.33	2.73	0.29	4.20	8.06	0.00	0.00	0.00	0.00		38.79		
100J	TANF 65+ M & F WITH	1.43	1.47	2.63	0.00	2.45	2.41	0.00	3.41	0.00	0.00	0.00	0.00		13.80		
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	9,971.53	9,935.89	0.00	0.00	0.00	0.00		80,246.05		
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	20,674.35	20,303.04	0.00	0.00	0.00	0.00		158,745.23		
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	37,468.14	37,327.83	0.00	0.00	0.00	0.00		287,617.27		
1014	TANF 14-20 MALE NON-	9,849.08	9,736.84	9,761.39	10,065.68	10,310.22	10,952.57	10,717.02	10,729.54	0.00	0.00	0.00	0.00		82,122.34		
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	13,055.51	13,174.56	0.00	0.00	0.00	0.00		101,657.36		
1016	TANF 21-44 MALE NON-	24,304.85	24,468.54	24,434.66	24,611.48	24,513.33	25,120.03	24,808.79	24,637.09	0.00	0.00	0.00	0.00		196,898.77		
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	83,859.84	83,770.14	0.00	0.00	0.00	0.00		670,552.18		
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	20,236.73	20,200.54	0.00	0.00	0.00	0.00		159,603.85		
1019	TANF 65+ M & F NON-M	78.99	75.92	80.81	80.60	79.99	90.99	89.70	95.68	0.00	0.00	0.00	0.00		672.68		
101A	TANF < 1 M & F NON-M	622.00	588.68	516.55	592.34	544.82	327.21	550.50	511.79	0.00	0.00	0.00	0.00		4,253.89		
101B	TANF 01-05 M & F NON	200.41	160.77	137.33	188.42	120.93	185.25	221.15	177.09	0.00	0.00	0.00	0.00		1,391.35		
101C	TANF 06-13 M & F NON	91.26	107.35	109.58	170.91	48.56	138.19	169.50	354.62	0.00	0.00	0.00	0.00		1,189.97		
101D	TANF 14-20 MALE NON-	54.36	79.67	69.03	51.72	46.81	28.76	80.90	138.79	0.00	0.00	0.00	0.00		550.04		
101E	TANF 14-20 FEMALE N O	99.54	114.09	110.49	79.17	62.80	77.48	97.61	300.32	0.00	0.00	0.00	0.00		941.50		
101F	TANF 21-44 MALE NON-	653.45	692.46	519.54	565.94	544.91	477.85	592.79	733.86	0.00	0.00	0.00	0.00		4,780.80		
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	1,290.59	1,442.54	0.00	0.00	0.00	0.00		10,757.20		
101H	TANF 44-64 M & F NON	355.51	400.40	291.08	312.37	337.88	281.50	344.16	325.60	0.00	0.00	0.00	0.00		2,648.50		
101J	TANF 65+ N & F NON-M	0.64	1.67	3.15	3.37	1.46	0.00	2.29	0.77	0.00	0.00	0.00	0.00		13.35		
1024	TANF 14-20 MALE WITH	3.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00		18.00		
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	48.63	53.00	0.00	0.00	0.00	0.00		415.78		
1027	TANF 21-44 FEMALE WI	95.99	92.13	93.99	86.07	77.92	93.67	94.06	96.80	0.00	0.00	0.00	0.00		730.63		
1028	TANF 45-64 M & F WIT	108.90	105.00	101.16	90.88	84.45	96.12	87.95	102.23	0.00	0.00	0.00	0.00		776.69		
1029	TANF 65+ M & F WITH	47.70	48.38	47.00	49.54	46.83	50.00	49.00	52.68	0.00	0.00	0.00	0.00		391.13		
102F	TANF 21-44 MALE WITH	0.00	0.61	1.00	0.12	0.03	1.48	0.29	0.00	0.00	0.00	0.00	0.00		3.53		
102G	TANF 21-44 FEMALE WI	0.00	0.41	0.00	1.06	0.80	0.32	0.93	2.09	0.00	0.00	0.00	0.00		5.61		
102H	TANF 44-64 M & F WIT	0.00	0.00	0.20	3.31	3.52	0.87	2.03	0.13	0.00	0.00	0.00	0.00		10.06		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending February 29, 2020	
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	0.31	0.00	0.00	0.00	0.00		2.26		
2100	SSI AGED WITH MEDIC A	4,122.71	4,063.81	4,030.59	4,108.10	4,048.27	4,062.77	4,167.79	4,207.61	0.00	0.00	0.00	0.00		32,811.65		
210Z	SSI AGED WITH MEDIC
A	283.43	232.59	193.04	276.87	247.13	229.28	272.29	422.72	0.00	0.00	0.00	0.00		2,157.35		
2110	SSI AGED NON-MEDIC AR	6,783.06	6,849.40	6,866.93	6,935.45	6,998.23	7,016.51	7,082.13	7,002.31	0.00	0.00	0.00	0.00		55,534.02		
211Z	SSI AGED NON-MEDIC
AR	187.29	129.52	110.45	137.39	154.05	111.03	152.20	151.03	0.00	0.00	0.00	0.00		1,132.96		
2120	SSI AGED WITH QMB	31,783.16	31,989.36	32,152.27	32,229.28	32,346.82	32,412.95	32,548.58	32,555.07	0.00	0.00	0.00	0.00		258,017.49		
212Z	SSI AGED WITH QMB P P	32.92	44.99	61.94	25.29	34.13	58.11	35.04	50.36	0.00	0.00	0.00	0.00		342.78		
2200	SSI DISABLED WITH M
E	3,555.63	3,532.68	3,532.88	3,539.90	3,505.92	3,521.40	3,581.97	3,557.99	0.00	0.00	0.00	0.00		28,328.37		
220Z	SSI DISABLED WITH M E	164.92	159.53	143.29	159.73	135.95	170.42	172.45	336.88	0.00	0.00	0.00	0.00		1,443.17		
2210	SSI DISABLED NON-ME
D	51,491.33	51,464.64	51,465.03	51,603.90	51,642.87	51,806.36	52,018.27	52,187.45	0.00	0.00	0.00	0.00		413,679.85		
221Z	SSI DISABLED NON-ME D	759.58	802.25	717.53	700.50	733.57	703.10	738.95	996.40	0.00	0.00	0.00	0.00		6,151.88		
2220	SSI DISABLED WITH Q
M	26,441.87	26,456.91	26,414.26	26,455.17	26,448.91	26,447.26	26,460.48	26,446.93	0.00	0.00	0.00	0.00		211,571.79		
222Z	SSI DISABLED WITH Q M	37.02	44.89	66.85	48.70	31.86	58.93	35.40	58.91	0.00	0.00	0.00	0.00		382.56		
2300	SSI BLIND WITH MEDIC	28.00	28.99	26.00	28.00	28.50	29.22	29.00	28.00	0.00	0.00	0.00	0.00		225.71		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.16	2.00	0.00	0.00	0.00	0.00	0.00		2.16		
2310	SSI BLIND NON-MEDIC A	499.60	500.08	506.73	512.86	505.92	505.99	510.79	501.28	0.00	0.00	0.00	0.00		4,043.25		
231Z	SSI BLIND NON-MEDIC
A	4.50	8.28	24.78	19.76	2.06	15.60	3.29	2.54	0.00	0.00	0.00	0.00		80.81		
2320	SSI BLIND WITH QMB	225.80	229.88	231.00	229.92	235.89	233.00	235.99	233.12	0.00	0.00	0.00	0.00		1,854.60		
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	1.00	1.00	0.00	0.00	0.00	0.00		3.00		
4302	SOBRA CHILD 01-05 M	3.00	4.93	5.00	5.00	4.43	3.00	3.00	4.00	0.00	0.00	0.00	0.00		32.36		
4303	SOBRA CHILD 06-13 M	5.00	6.06	4.00	5.00	5.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00		40.06		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	1.00	1.00	0.06	0.00	0.00	0.00	0.00	0.00		2.06		
4305	SOBRA CHILD 14-20 FE	4.00	3.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		13.00		
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	34,768.88	34,530.88	0.00	0.00	0.00	0.00		282,057.67		
4312	SOBRA CHILD 01-05 M	166,797.05	167,404.10	167,216.79	167,017.16	165,079.46	162,596.55	162,006.26	161,143.21	0.00	0.00	0.00	0.00		1,319,260.58		
4313	SOBRA CHILD 06-13 M	215,941.09	217,553.86	217,670.05	217,534.97	215,638.95	213,001.62	212,730.02	211,966.61	0.00	0.00	0.00	0.00		1,722,037.17		
4314	SOBRA CHILD 14-20 MA	58,666.27	59,328.82	59,632.71	59,750.19	59,498.03	59,135.44	58,916.66	58,625.65	0.00	0.00	0.00	0.00		473,553.77		
4315	SOBRA CHILD 14-20 FE	58,655.28	59,190.73	59,306.71	59,371.69	59,098.17	58,468.91	58,430.42	58,291.67	0.00	0.00	0.00	0.00		470,813.58		
431A	SOBRA CHILD < 1 M &	446.25	383.74	320.66	352.09	321.94	256.30	335.20	337.47	0.00	0.00	0.00	0.00		2,753.65		
431B	SOBRA CHILD 01-05 M	4,091.48	3,709.51	3,111.72	3,350.73	3,149.52	3,001.99	3,339.68	4,121.14	0.00	0.00	0.00	0.00		27,875.77		
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	3,000.76	3,738.46	0.00	0.00	0.00	0.00		26,906.52		
431D	SOBRA CHILD 14-20 MA	1,094.86	1,112.84	911.48	886.86	878.77	882.91	777.68	1,098.27	0.00	0.00	0.00	0.00		7,643.67		
431E	SOBRA CHILD 14-20 FE	1,138.00	1,088.17	967.04	896.29	902.43	833.72	894.66	1,109.08	0.00	0.00	0.00	0.00		7,829.39		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending February 29, 2020	
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	1.00	1.00	0.00	0.00	0.00	0.00		8.00		
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		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.74	0.00	0.00	0.00	0.00	0.00		0.74		
4325	SOBRA CHILD 14-20 FE	1.41	3.00	3.00	3.00	3.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00		19.41		
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	30.53	27.87	0.00	0.00	0.00	0.00		238.43		
5008	SOBRA PREG 45-64 FE
M	2.00	2.00	2.00	3.00	2.30	3.00	3.00	1.00	0.00	0.00	0.00	0.00		18.30		
500G	SOBRA PREG 21-44 FE M	3.59	4.76	0.86	0.00	1.76	1.77	9.38	4.70	0.00	0.00	0.00	0.00		26.82		
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	5.00	5.00	0.00	0.00	0.00	0.00		32.67		
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	2,696.01	2,607.74	0.00	0.00	0.00	0.00		22,256.69		
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	15,113.33	14,726.95	0.00	0.00	0.00	0.00		124,734.32		
5018	SOBRA PREG 45-64 FE
M	38.47	49.97	52.57	61.04	57.72	57.95	55.14	51.37	0.00	0.00	0.00	0.00		424.23		
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	219.63	241.13	0.00	0.00	0.00	0.00		1,656.56		
501G	SOBRA PREG 21-44 FE M	1,105.01	1,101.06	926.53	904.10	855.54	849.97	1,005.21	1,131.56	0.00	0.00	0.00	0.00		7,878.98		
501H	SOBRA PREG 45-64 FE
M	0.16	4.86	13.38	3.91	3.26	1.03	4.79	1.61	0.00	0.00	0.00	0.00		33.00		
5027	SOBRA PREG 21-44 FE M	32.00	37.00	37.40	36.98	37.00	41.96	39.00	33.44	0.00	0.00	0.00	0.00		294.78		
5028	SOBRA PREG 45-64 FE
M	1.00	1.00	1.00	1.00	2.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00		10.00		
502G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.31	0.00	0.00	0.00	0.00		0.31		
SUBTOTAL:	909,956.0	5	913,841.68	911,256.6	1	914,835.20	911,002.15	911,180.34	907,436.04	907,493.61	0.00	0.00	0.00	0.00		7,287,001.68		

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	248.00	224.00	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	5.00	6.00	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	18.00	13.00	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	2,147.00	1,928.00	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	2,418.00	2,171.00	0.00	0.00	0.00	0.00	

 
2,164.00	
36.00	
139.00	
17,198.00	
19,537.00	

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	224.12	213.51	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	396.41	388.00	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	1,202.76	1,166.43	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	661.28	644.19	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	14.00	7.63	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	22.74	31.60	0.00	0.00	0.00	0.00	

 
1.00	
1,759.75	
3,258.80	
9,731.19	
5,133.68	
109.53	
187.18	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110H	TANF EXPANDED 45-64	41.01	52.51	25.08	46.96	40.49	31.50	42.96	42.67	0.00	0.00	0.00	0.00		323.18		
110J	TANF EXPANDED 65+
M&	37.89	35.69	27.08	19.59	26.51	13.72	29.15	69.68	0.00	0.00	0.00	0.00		259.31		
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	3.00	3.13	0.00	0.00	0.00	0.00		42.74		
1114	TANF EXPANDED 14-20	211.02	210.83	211.15	222.71	221.31	222.23	213.49	211.47	0.00	0.00	0.00	0.00		1,724.21		
1115	TANF EXPANDED 14-20	1,488.06	1,490.04	1,445.15	1,470.14	1,453.09	1,425.02	1,393.02	1,365.72	0.00	0.00	0.00	0.00		11,530.24		
1116	TANF EXPANDED 21-44	26,425.77	26,359.12	26,183.36	26,015.22	25,721.34	25,007.63	25,023.37	24,819.92	0.00	0.00	0.00	0.00		205,555.73		
1117	TANF EXPANDED 21-44	70,866.22	71,178.63	70,984.18	71,016.34	70,119.29	69,222.39	69,538.36	69,356.88	0.00	0.00	0.00	0.00		562,282.29		
1118	TANF EXPANDED 45-64	24,281.16	24,369.33	24,474.90	24,379.75	24,193.24	23,751.33	23,849.83	23,780.19	0.00	0.00	0.00	0.00		193,079.73		
1119	TANF EXPANDED 65+
M&	83.32	77.45	77.00	78.15	86.42	85.62	90.00	94.82	0.00	0.00	0.00	0.00		672.78		
111C	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.38	0.00	0.86	0.00	0.00	0.00	0.00		1.24		
111D	TANF EXPANDED 14-20	13.79	6.07	8.58	17.10	9.64	8.64	4.41	8.09	0.00	0.00	0.00	0.00		76.32		
111E	TANF EXPANDED 14-20	41.42	29.93	17.44	33.68	25.21	20.43	34.93	25.57	0.00	0.00	0.00	0.00		228.61		
111F	TANF EXPANDED 21-44	718.90	716.67	595.02	637.68	567.73	573.91	589.62	653.06	0.00	0.00	0.00	0.00		5,052.59		
111G	TANF EXPANDED 21-44	1,419.51	1,364.36	1,077.59	1,259.01	1,148.61	1,050.60	1,109.31	1,184.52	0.00	0.00	0.00	0.00		9,613.51		
111H	TANF EXPANDED 45-64	496.90	473.74	431.96	405.14	400.19	412.66	387.27	408.07	0.00	0.00	0.00	0.00		3,415.93		
111J	TANF EXPANDED 65+
M&	1.67	2.70	1.00	2.33	9.32	3.34	0.00	19.36	0.00	0.00	0.00	0.00		39.72		
1126	TANF EXPANDED 21-44	763.98	778.79	773.55	785.42	763.57	751.94	750.09	747.97	0.00	0.00	0.00	0.00		6,115.31		
1127	TANF EXPANDED 21-44	1,658.56	1,669.60	1,651.91	1,644.04	1,629.50	1,618.75	1,604.74	1,584.12	0.00	0.00	0.00	0.00		13,061.22		
1128	TANF EXPANDED 45-64	2,534.08	2,564.62	2,606.17	2,585.02	2,556.21	2,565.54	2,553.60	2,589.24	0.00	0.00	0.00	0.00		20,554.48		
1129	TANF EXPANDED 65+
M&	1,524.12	1,537.88	1,571.53	1,601.56	1,608.46	1,618.35	1,605.22	1,603.07	0.00	0.00	0.00	0.00		12,670.19		
112F	TANF EXPANDED 21-44	0.00	2.84	7.71	0.89	4.22	3.22	2.79	1.64	0.00	0.00	0.00	0.00		23.31		
112G	TANF EXPANDED 21-44	4.97	5.84	5.17	7.62	5.30	1.34	7.97	16.85	0.00	0.00	0.00	0.00		55.06		
112H	TANF EXPANDED 45-64	16.91	7.39	3.87	12.72	4.68	3.55	4.66	8.64	0.00	0.00	0.00	0.00		62.42		
112J	TANF EXPANDED 65+
M&	4.82	6.37	6.85	6.23	0.29	4.34	5.85	5.56	0.00	0.00	0.00	0.00		40.31		
2400	SSI AGED EXPANDED WI	227.17	239.12	215.13	247.18	221.29	218.75	262.39	295.28	0.00	0.00	0.00	0.00		1,926.31		
240Z	SSI AGED EXPANDED
WI	188.57	198.61	194.67	205.44	211.86	143.50	196.69	348.34	0.00	0.00	0.00	0.00		1,687.68		
2410	SSI AGED EXPANDED NO	95.13	101.60	93.82	91.90	93.05	93.89	91.77	86.64	0.00	0.00	0.00	0.00		747.80		
241Z	SSI AGED EXPANDED
NO	12.57	0.00	2.16	9.64	4.46	2.95	5.18	0.34	0.00	0.00	0.00	0.00		37.30		
2420	SSI AGED EXPANDED WI	26,237.74	26,428.76	26,615.69	26,756.08	26,883.94	27,117.23	27,021.82	26,985.18	0.00	0.00	0.00	0.00		214,046.44		
242Z	SSI AGED EXPANDED
WI	50.54	25.46	32.72	52.19	30.39	37.49	58.80	71.99	0.00	0.00	0.00	0.00		359.58		
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00		12.00		
2600	SSI DISABLED EXPAND
E	203.51	221.75	186.24	232.74	231.20	267.61	286.54	290.44	0.00	0.00	0.00	0.00		1,920.03		
260Z	SSI DISABLED EXPAND E	139.05	119.04	107.14	120.94	124.43	107.35	126.29	233.13	0.00	0.00	0.00	0.00		1,077.37		
2610	SSI DISABLED EXPAND
E	1,467.82	1,478.74	1,490.86	1,530.40	1,572.36	1,602.38	1,612.81	1,656.31	0.00	0.00	0.00	0.00		12,411.68		
261Z	SSI DISABLED EXPAND E	33.02	32.33	22.08	23.16	29.53	37.79	42.15	32.64	0.00	0.00	0.00	0.00		252.70		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2620	SSI DISABLED EXPAND E	16,996.27	17,035.00	17,062.79	17,051.98	17,095.19	17,074.84	17,033.63	16,910.98	0.00	0.00	0.00	0.00		136,260.68		
262Z	SSI DISABLED EXPAND
E	41.28	27.03	37.78	40.53	17.69	21.97	40.71	46.37	0.00	0.00	0.00	0.00		273.36		
SUBTOTAL:	180,908.2	8	181,437.38	180,791.1	7	181,142.54	179,625.15	177,613.14	178,145.73	178,012.10	0.00	0.00	0.00	0.00		1,437,675.49		

3506	ADULT 40-100% MALE 2	6.00	5.12	6.53	7.41	5.76	6.00	4.00	10.25	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	4.00	5.75	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	61.16	64.82	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	7.00	28.55	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	4.71	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	10.26	4.97	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	5,737.84	5,750.49	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	6,175.50	6,188.03	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	18,343.48	18,106.65	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	15,714.02	15,575.47	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	36,720.84	36,259.65	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	2.99	28.70	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	80.39	138.72	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	131.31	108.66	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	446.80	482.99	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	396.32	411.61	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	798.48	791.84	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	7.00	41.72	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	1.00	1.00	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	1.00	3.74	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	1.24	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	1.00	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	27.75	33.11	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	13.00	13.88	0.00	0.00	0.00	0.00	

51.07	
39.96	
517.08	
121.55	
7.70	
6.89	
42.76	
45,605.38	
49,657.24	
148,555.96	
126,021.36	
296,939.61	
68.10	
787.32	
1,011.53	
3,627.93	
3,210.46	
5,993.83	
79.79	
7.61	
8.06	
8.44	
6.00	
6.37	
3.00	
4.51	
1.00	
252.76	
90.32	

9911	SB PAYMENT FOR TAN F	203.00	204.00	201.00	158.00	161.00	182.00	151.00	156.00	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	1.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	203.00	204.00	201.0	0	158.00	162.00	182.00	152.00	156.00	0.00	0.00	0.00	0.00	

 
1,416.00	
2.00	
1,418.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3708	ADULT <40% EXP M&F 4	69.28	82.50	84.64	87.86	78.64	87.48	89.13	82.73	0.00	0.00	0.00	0.00		662.26		
3709	ADULT <40% EXP M&F
6	5.00	9.32	12.00	14.35	9.00	9.00	10.00	18.00	0.00	0.00	0.00	0.00		86.67		
370F	ADULT <40% EXP MALE	6.31	6.24	9.97	4.50	2.91	0.76	4.33	4.56	0.00	0.00	0.00	0.00		39.58		
370G	ADULT <40% EXP FEM AL	0.77	1.90	1.82	14.40	1.68	2.11	1.00	1.10	0.00	0.00	0.00	0.00		24.78		
370H	ADULT <40% EXP M&F
4	10.17	19.09	6.71	4.26	9.05	5.20	15.49	11.01	0.00	0.00	0.00	0.00		80.98		
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	10,238.44	10,230.15	0.00	0.00	0.00	0.00		82,013.87		
3715	ADULT <40% EXP FEM AL	9,173.98	9,315.29	9,393.59	9,445.92	9,365.97	9,237.13	9,296.48	9,301.01	0.00	0.00	0.00	0.00		74,529.37		
3716	ADULT <40% EXP MALE	69,372.63	70,752.32	70,889.00	72,351.04	72,311.97	72,514.16	73,079.87	73,191.06	0.00	0.00	0.00	0.00		574,462.05		
3717	ADULT <40% EXP FEM AL	40,598.88	41,281.54	41,336.24	41,987.49	41,972.63	41,922.26	42,126.17	42,182.76	0.00	0.00	0.00	0.00		333,407.97		
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	83,958.54	83,987.93	0.00	0.00	0.00	0.00		666,512.70		
3719	ADULT <40% EXP M&F 6	7.00	8.00	7.00	8.00	9.53	7.87	6.00	59.00	0.00	0.00	0.00	0.00		112.40		
371D	ADULT <40% EXP MALE	267.37	258.29	210.76	235.94	225.59	194.54	235.43	310.52	0.00	0.00	0.00	0.00		1,938.44		
371E	ADULT <40% EXP FEM AL	271.22	220.41	179.21	181.69	198.26	181.54	204.81	262.61	0.00	0.00	0.00	0.00		1,699.75		
371F	ADULT <40% EXP MALE	2,522.08	2,263.41	1,955.44	2,106.14	1,960.39	1,904.17	2,143.49	2,448.74	0.00	0.00	0.00	0.00		17,303.86		
371G	ADULT <40% EXP FEM AL	1,522.51	1,206.36	1,033.63	1,184.49	1,041.11	1,087.25	1,264.81	1,339.72	0.00	0.00	0.00	0.00		9,679.88		
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	2,046.92	2,087.04	0.00	0.00	0.00	0.00		15,127.94		
371J	ADULT <40% EXP M&F 6	0.00	0.00	1.00	0.00	0.06	2.12	0.00	3.00	0.00	0.00	0.00	0.00		6.18		
3726	ADULT <40% EXP MALE	3.18	5.00	1.60	4.35	2.99	3.35	1.06	3.06	0.00	0.00	0.00	0.00		24.59		
3727	ADULT <40% EXP FEM AL	2.48	2.00	2.00	3.64	1.50	1.45	2.00	1.89	0.00	0.00	0.00	0.00		16.96		
3728	ADULT <40% EXP M&F
4	0.00	3.00	3.20	3.93	5.76	4.77	4.24	5.80	0.00	0.00	0.00	0.00		30.70		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		3.00		
372F	ADULT <40% EXP MALE	2.46	0.00	0.00	2.64	0.00	0.48	4.93	0.93	0.00	0.00	0.00	0.00		11.44		
372G	ADULT <40% EXP FEM AL	0.51	1.00	0.00	0.31	0.50	0.00	0.00	0.10	0.00	0.00	0.00	0.00		2.42		
372H	ADULT <40% EXP M&F
4	0.00	0.00	0.73	0.06	0.00	3.21	4.72	3.11	0.00	0.00	0.00	0.00		11.83		
SUBTOTAL:	303,949.6	1	306,439.32	305,225.7	5	309,463.23	308,009.10	308,420.49	309,423.00	309,593.38	0.00	0.00	0.00	0.00		2,460,523.88		

3906	NEWLY ELIGIBLE MALE	13.21	15.49	16.06	16.36	17.53	21.41	21.06	18.57	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	8.00	9.44	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	92.04	84.64	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	12.03	25.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.77	1.48	0.93	0.29	1.46	0.58	1.93	2.41	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	1.54	0.00	0.00	0.00	0.00	

139.69	
44.06	
598.16	
172.02	
9.85	
10.89	

9935	BIRTH SUPP PAYMENT A	26.00	43.00	38.00	22.00	35.00	27.00	35.00	23.00	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	60.00	59.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	106.00	120.00	121.0	0	107.00	110.00	108.00	95.00	82.00	0.00	0.00	0.00	0.00	

 
249.00	
600.00	
849.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390H	NEWLY ELIGIBLE M&F 4	6.11	5.03	27.91	7.04	1.89	15.73	39.09	14.24	0.00	0.00	0.00	0.00		117.04		
390J	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	1.99	0.00	1.96	0.00	0.00	0.00	0.00	0.00		3.95		
3914	NEWLY ELIGIBLE MALE	3,064.23	3,121.58	3,122.24	3,256.63	3,248.67	3,293.79	3,229.74	3,246.31	0.00	0.00	0.00	0.00		25,583.19		
3915	NEWLY ELIGIBLE FEMA L	3,540.91	3,604.90	3,646.42	3,677.55	3,623.17	3,676.08	3,625.82	3,627.52	0.00	0.00	0.00	0.00		29,022.37		
3916	NEWLY ELIGIBLE MALE	16,984.12	17,133.92	16,970.49	17,013.38	16,625.63	16,487.97	16,205.26	16,002.45	0.00	0.00	0.00	0.00		133,423.22		
3917	NEWLY ELIGIBLE FEMA L	25,383.25	25,775.37	25,504.82	25,619.45	25,201.52	24,851.26	24,609.78	24,464.39	0.00	0.00	0.00	0.00		201,409.84		
3918	NEWLY ELIGIBLE M&F
4	25,738.62	25,803.75	25,652.50	25,817.83	25,578.91	25,629.81	25,261.35	25,126.90	0.00	0.00	0.00	0.00		204,609.67		
3919	NEWLY ELIGIBLE M&F 6	1.00	1.00	2.00	1.00	3.00	2.00	2.00	14.00	0.00	0.00	0.00	0.00		26.00		
391D	NEWLY ELIGIBLE MALE	83.05	62.33	67.48	56.10	48.41	58.21	56.68	80.24	0.00	0.00	0.00	0.00		512.50		
391E	NEWLY ELIGIBLE FEMA L	112.21	100.13	92.64	77.04	64.65	73.71	70.53	67.53	0.00	0.00	0.00	0.00		658.44		
391F	NEWLY ELIGIBLE MALE	668.38	562.71	524.11	550.66	477.90	465.01	548.29	533.38	0.00	0.00	0.00	0.00		4,330.44		
391G	NEWLY ELIGIBLE FEMA L	1,005.22	908.94	726.00	786.17	726.64	608.75	779.73	764.65	0.00	0.00	0.00	0.00		6,306.10		
391H	NEWLY ELIGIBLE M&F
4	791.17	652.01	570.18	625.85	639.85	537.10	719.00	635.18	0.00	0.00	0.00	0.00		5,170.34		
3926	NEWLY ELIGIBLE MALE	1.38	0.00	0.26	1.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00		3.64		
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	4.06	2.00	0.00	0.00	0.00	0.00		14.99		
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	1.93	0.00	0.00	0.00	0.00	0.00		1.99		
SUBTOTAL:	77,486.10	77,850.76	77,034.2	0	77,629.25	76,350.12	75,818.62	75,291.28	74,720.39	0.00	0.00	0.00	0.00		612,180.72		

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	38,583.33	38,246.12	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	11,036.13	10,850.18	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	10,763.48	10,658.39	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	858.45	922.72	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	225.91	268.33	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	231.58	246.25	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	61,698.88	61,191.99	0.00	0.00	0.00	0.00	

0.77	
318,962.32	
91,062.04	
88,671.34	
0.22	
7,041.35	
1,982.00	
1,878.21	
509,598.25	

9944	BIRTH SUPP PAYMENT S	2.00	10.00	4.00	4.00	3.00	8.00	7.00	2.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	10.00	4.00	4.00	3.00	8.00	7.00	2.00	0.00	0.00	0.00	0.00	

40.00

40.00

9939	BIRTH SUPP PAYMENT N	49.00	63.00	53.00	64.00	46.00	52.00	51.00	45.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	49.00	63.00	53.00	64.00	46.00	52.00	51.00	45.00	0.00	0.00	0.00	0.00	

 

423.00

423.00

ACC CAPITATION - MEMBER MONTHS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4517	BC PATIENT FEMALE 2 1	22.89	24.00	24.36	27.70	24.66	24.00	23.54	23.00	0.00	0.00	0.00	0.00		194.15		
4518	BC PATIENT FEMALE 4
5	127.00	128.33	124.33	127.19	127.75	126.15	131.12	135.51	0.00	0.00	0.00	0.00		1,027.38		
4519	BC PATIENT FEMALE 6 5	0.00	0.58	0.00	0.00	0.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00		4.58		
451G	BC PATIENT FEMALE 2
1	0.38	1.70	4.63	4.28	1.33	0.00	1.45	0.00	0.00	0.00	0.00	0.00		13.77		
451H	BC PATIENT FEMALE 4 5	19.22	1.28	0.66	10.71	3.25	17.82	13.69	6.42	0.00	0.00	0.00	0.00		73.05		
4617	CC PATIENT FEMALE 2
1	8.00	8.00	7.00	7.41	8.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00		59.41		
4618	CC PATIENT FEMALE 4 5	7.00	7.00	7.26	10.00	10.00	11.00	11.00	11.34	0.00	0.00	0.00	0.00		74.60		
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	3.65	0.00	0.00	0.00	0.00		7.38		
SUBTOTAL:	184.49	170.89	169.9	7	196.87	174.99	187.97	189.80	186.92	0.00	0.00	0.00	0.00		1,461.90		

8600	SSI BLIND FREEDOM/W O	2.00	2.00	1.00	1.00	1.00	1.00	1.00	2.06	0.00	0.00	0.00	0.00	
860Z	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.93	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	1.00	1.00	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	2,083.77	2,077.80	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	105.22	117.04	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	344.54	344.19	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	54.42	21.85	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	351.57	354.28	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	3.26	2.06	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	2,944.78	2,922.21	0.00	0.00	0.00	0.00	

11.06	
1.93	
8.00	
16,655.52	
756.28	
2,839.56	
207.01	
2,755.95	
49.57	
23,284.88	

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	1,537,852.51	1,536,576.60	0.00	0.00	0.00	0.00		12,354,008.70		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending February 29, 2020	
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	17.46	0.00	0.00	0.00	0.00		84.26		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	33.40	16.70	17.46	17.46	0.00	0.00	0.00	0.00		85.02		
1009	TANF 65+ M & F WITH	0.00	33.40	33.40	33.40	50.10	66.80	69.84	87.30	0.00	0.00	0.00	0.00		374.24		
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	1,938.06	2,007.90	0.00	0.00	0.00	0.00		15,151.66		
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	1,990.44	1,920.60	0.00	0.00	0.00	0.00		14,398.64		
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	2,252.34	2,409.48	0.00	0.00	0.00	0.00		14,564.92		
1014	TANF 14-20 MALE NON-	334.00	450.90	467.60	484.30	551.10	534.40	523.80	541.26	0.00	0.00	0.00	0.00		3,887.36		
1015	TANF 14-20 FEMALE N O	484.30	467.60	467.60	534.40	567.80	818.30	855.54	995.22	0.00	0.00	0.00	0.00		5,190.76		
1016	TANF 21-44 MALE NON-	1,419.50	1,553.10	1,937.20	2,271.20	2,404.80	2,471.60	2,741.22	2,845.98	0.00	0.00	0.00	0.00		17,644.60		
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	9,690.30	10,074.42	0.00	0.00	0.00	0.00		66,174.02		
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	3,369.78	3,526.92	0.00	0.00	0.00	0.00		25,316.80		
1019	TANF 65+ M & F NON-M	0.00	0.00	16.70	16.70	33.40	16.70	17.46	17.46	0.00	0.00	0.00	0.00		118.42		
1026	TANF 21-44 MALE WITH	0.00	16.70	16.70	33.40	16.70	16.70	17.46	0.00	0.00	0.00	0.00	0.00		117.66		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	16.70	16.70	16.70	17.46	17.46	0.00	0.00	0.00	0.00		85.02		
2100	SSI AGED WITH MEDIC A	83.50	133.60	133.60	133.60	167.00	150.30	157.14	139.68	0.00	0.00	0.00	0.00		1,098.42		
2110	SSI AGED NON-MEDIC
AR	116.90	116.90	200.40	267.20	233.80	150.30	157.14	157.14	0.00	0.00	0.00	0.00		1,399.78		
2120	SSI AGED WITH QMB	1,035.40	1,169.00	1,269.20	1,402.80	1,536.40	1,352.70	1,466.64	1,519.02	0.00	0.00	0.00	0.00		10,751.16		
2200	SSI DISABLED WITH M E	400.80	467.60	517.70	567.80	651.30	534.40	558.72	558.72	0.00	0.00	0.00	0.00		4,257.04		
2210	SSI DISABLED NON-ME
D	6,379.40	7,047.40	7,849.00	8,750.80	9,802.90	8,550.40	8,956.98	9,288.72	0.00	0.00	0.00	0.00		66,625.60		
2220	SSI DISABLED WITH Q M	2,271.20	2,338.00	2,538.40	2,738.80	3,189.70	2,905.80	3,177.72	3,282.48	0.00	0.00	0.00	0.00		22,442.10		
2310	SSI BLIND NON-MEDIC
A	66.80	66.80	83.50	100.20	100.20	66.80	69.84	87.30	0.00	0.00	0.00	0.00		641.44		
2320	SSI BLIND WITH QMB	16.70	16.70	16.70	16.70	16.70	16.70	17.46	17.46	0.00	0.00	0.00	0.00		135.12		
4311	SOBRA CHILD <1 M & F	4,876.40	4,809.60	5,160.30	5,394.10	5,410.80	5,193.70	5,290.38	5,325.30	0.00	0.00	0.00	0.00		41,460.58		
4312	SOBRA CHILD 01-05 M	14,762.80	16,416.10	18,169.60	19,505.60	21,376.00	20,641.20	22,278.96	22,767.84	0.00	0.00	0.00	0.00		155,918.10		
4313	SOBRA CHILD 06-13 M	14,094.80	16,132.20	17,985.90	19,438.80	21,643.20	20,574.40	22,086.90	23,012.28	0.00	0.00	0.00	0.00		154,968.48		
4314	SOBRA CHILD 14-20 MA	2,822.30	3,039.40	3,573.80	3,757.50	4,308.60	4,241.80	4,591.98	4,801.50	0.00	0.00	0.00	0.00		31,136.88		
4315	SOBRA CHILD 14-20 FE	2,922.50	3,306.60	4,024.70	4,408.80	4,909.80	4,625.90	5,098.32	5,395.14	0.00	0.00	0.00	0.00		34,691.76		
5015	SOBRA PREG 14-20 FE M	116.90	116.90	100.20	83.50	116.90	150.30	157.14	174.60	0.00	0.00	0.00	0.00		1,016.44		
5017	SOBRA PREG 21-44 FE
M	751.50	651.30	718.10	651.30	684.70	801.60	907.92	925.38	0.00	0.00	0.00	0.00		6,091.80		
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	98,474.40	101,931.48	0.00	0.00	0.00	0.00		695,878.18		

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	16.70	17.46	17.46	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	87.30	87.30	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	192.06	192.06	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	52.38	69.84	0.00	0.00	0.00	0.00	

 
51.62	
542.00	
1,369.42	
322.62	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending February 29, 2020	
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	87.30	122.22	0.00	0.00	0.00	0.00		760.62		
1116	TANF EXPANDED 21-44	885.10	1,135.60	1,369.40	1,603.20	1,820.30	1,720.10	1,833.30	1,868.22	0.00	0.00	0.00	0.00		12,235.22		
1117	TANF EXPANDED 21-44	3,306.60	3,774.20	4,024.70	4,759.50	5,243.80	5,060.10	5,430.06	5,691.96	0.00	0.00	0.00	0.00		37,290.92		
1118	TANF EXPANDED 45-64	1,987.30	2,271.20	2,404.80	2,638.60	2,972.60	2,939.20	3,177.72	3,160.26	0.00	0.00	0.00	0.00		21,551.68		
1119	TANF EXPANDED 65+
M&	16.70	16.70	16.70	16.70	16.70	16.70	17.46	17.46	0.00	0.00	0.00	0.00		135.12		
1126	TANF EXPANDED 21-44	50.10	50.10	66.80	83.50	100.20	100.20	104.76	104.76	0.00	0.00	0.00	0.00		660.42		
1127	TANF EXPANDED 21-44	66.80	66.80	83.50	66.80	66.80	50.10	52.38	52.38	0.00	0.00	0.00	0.00		505.56		
1128	TANF EXPANDED 45-64	350.70	334.00	317.30	367.40	434.20	400.80	436.50	436.50	0.00	0.00	0.00	0.00		3,077.40		
1129	TANF EXPANDED 65+
M&	250.50	233.80	233.80	250.50	283.90	283.90	296.82	279.36	0.00	0.00	0.00	0.00		2,112.58		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	69.84	0.00	0.00	0.00	0.00		69.84		
2420	SSI AGED EXPANDED
WI	1,452.90	1,753.50	1,920.50	1,987.30	2,204.40	2,237.80	2,426.94	2,392.02	0.00	0.00	0.00	0.00		16,375.36		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	16.70	16.70	16.70	17.46	17.46	0.00	0.00	0.00	0.00		85.02		
2610	SSI DISABLED EXPAND
E	133.60	150.30	200.40	183.70	250.50	283.90	314.28	331.74	0.00	0.00	0.00	0.00		1,848.42		
2620	SSI DISABLED EXPAND E	751.50	768.20	784.90	851.70	951.90	851.70	907.92	942.84	0.00	0.00	0.00	0.00		6,810.66		
SUBTOTAL:	9,519.00	10,838.30	11,756.8	0	13,209.70	14,812.90	14,362.00	15,452.10	15,853.68	0.00	0.00	0.00	0.00		105,804.48		

3908	NEWLY ELIGIBLE M&F 4	16.70	0.00	0.00	0.00	0.00	0.00	0.00	17.46	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	33.40	50.10	83.50	83.50	50.10	66.80	69.84	87.30	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	226.98	192.06	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	450.90	517.70	484.30	567.80	584.50	617.90	628.56	680.94	0.00	0.00	0.00	0.00	

34.16	
524.54	
1,354.24	
4,532.60	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	17.46	17.46	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	83.50	133.60	150.30	150.30	183.70	200.40	226.98	192.06	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	209.52	279.36	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	1,082.52	1,099.98	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	1,012.68	1,099.98	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	3,439.62	3,526.92	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	17.46	17.46	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	750.78	768.24	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	820.62	785.70	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	8,345.88	8,817.30	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	5,150.70	5,185.62	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	10,580.76	10,807.74	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	28,306.50	30,644.50	29,442.10	31,654.98	32,597.82	0.00	0.00	0.00	0.00	

 
34.92	
1,320.84	
1,607.78	
7,309.40	
6,989.06	
25,770.74	
16.70	
33.40	
101.72	
4,441.52	
5,079.92	
56,975.98	
35,018.92	
79,070.30	
16.70	
223,787.90	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	801.60	868.40	968.60	968.60	1,018.70	1,035.40	1,030.14	942.84	0.00	0.00	0.00	0.00		7,634.28		
3918	NEWLY ELIGIBLE M&F
4	1,586.50	1,837.00	1,953.90	2,020.70	2,020.70	1,903.80	1,780.92	1,920.60	0.00	0.00	0.00	0.00		15,024.12		
SUBTOTAL:	2,955.90	3,356.70	3,657.30	3,807.60	3,907.80	3,841.00	3,736.44	3,841.20	0.00	0.00	0.00	0.00		29,103.94		

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	2,147.58	2,112.66	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	576.18	611.10	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	384.12	384.12	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	3,107.88	3,107.88	0.00	0.00	0.00	0.00	

 
16,685.04	
4,059.68	
3,223.14	
23,967.86	

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	69.84	69.84	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	17.46	17.46	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	17.46	17.46	0.00	0.00	0.00	0.00	
SUBTOTAL:	83.50	116.90	100.2	0	50.10	66.80	83.50	104.76	104.76	0.00	0.00	0.00	0.00	

 
507.08	
118.42	
85.02	
710.52	

1,079,319.68

102,037.00	113,059.00	126,085.00	135,938.00	149,565.20	142,668.10	152,530.56	157,436.82	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending February 29, 2020	
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	1.00	0.00	0.00	0.00	0.00		5.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		5.00		
1009	TANF 65+ M & F WITH	0.00	2.00	2.00	2.00	3.00	4.00	4.00	5.00	0.00	0.00	0.00	0.00		22.00		
1011	TANF <1 M & F NON-ME	105.00	108.00	109.00	112.00	125.00	112.00	111.00	115.00	0.00	0.00	0.00	0.00		897.00		
1012	TANF 01-05 M & F NON	84.00	88.00	107.00	108.00	118.00	123.00	114.00	110.00	0.00	0.00	0.00	0.00		852.00		
1013	TANF 06-13 M & F NON	77.00	82.00	96.00	100.00	113.00	125.00	129.00	138.00	0.00	0.00	0.00	0.00		860.00		
1014	TANF 14-20 MALE NON-	20.00	27.00	28.00	29.00	33.00	32.00	30.00	31.00	0.00	0.00	0.00	0.00		230.00		
1015	TANF 14-20 FEMALE N O	29.00	28.00	28.00	32.00	34.00	49.00	49.00	57.00	0.00	0.00	0.00	0.00		306.00		
1016	TANF 21-44 MALE NON-	85.00	93.00	116.00	136.00	144.00	148.00	157.00	163.00	0.00	0.00	0.00	0.00		1,042.00		
1017	TANF 21-44 FEMALE N O	345.00	389.00	453.00	494.00	570.00	528.00	555.00	577.00	0.00	0.00	0.00	0.00		3,911.00		
1018	TANF 45-64 M & F NON	158.00	166.00	183.00	191.00	210.00	195.00	193.00	202.00	0.00	0.00	0.00	0.00		1,498.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	1.00	1.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		7.00		
1026	TANF 21-44 MALE WITH	0.00	1.00	1.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		7.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		5.00		
2100	SSI AGED WITH MEDIC A	5.00	8.00	8.00	8.00	10.00	9.00	9.00	8.00	0.00	0.00	0.00	0.00		65.00		
2110	SSI AGED NON-MEDIC
AR	7.00	7.00	12.00	16.00	14.00	9.00	9.00	9.00	0.00	0.00	0.00	0.00		83.00		
2120	SSI AGED WITH QMB	62.00	70.00	76.00	84.00	92.00	81.00	84.00	87.00	0.00	0.00	0.00	0.00		636.00		
2200	SSI DISABLED WITH M E	24.00	28.00	31.00	34.00	39.00	32.00	32.00	32.00	0.00	0.00	0.00	0.00		252.00		
2210	SSI DISABLED NON-ME
D	382.00	422.00	470.00	524.00	587.00	512.00	513.00	532.00	0.00	0.00	0.00	0.00		3,942.00		
2220	SSI DISABLED WITH Q M	136.00	140.00	152.00	164.00	191.00	174.00	182.00	188.00	0.00	0.00	0.00	0.00		1,327.00		
2310	SSI BLIND NON-MEDIC
A	4.00	4.00	5.00	6.00	6.00	4.00	4.00	5.00	0.00	0.00	0.00	0.00		38.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		8.00		
4311	SOBRA CHILD <1 M & F	292.00	288.00	309.00	323.00	324.00	311.00	303.00	305.00	0.00	0.00	0.00	0.00		2,455.00		
4312	SOBRA CHILD 01-05 M	884.00	983.00	1,088.00	1,168.00	1,280.00	1,236.00	1,276.00	1,304.00	0.00	0.00	0.00	0.00		9,219.00		
4313	SOBRA CHILD 06-13 M	844.00	966.00	1,077.00	1,164.00	1,296.00	1,232.00	1,265.00	1,318.00	0.00	0.00	0.00	0.00		9,162.00		
4314	SOBRA CHILD 14-20 MA	169.00	182.00	214.00	225.00	258.00	254.00	263.00	275.00	0.00	0.00	0.00	0.00		1,840.00		
4315	SOBRA CHILD 14-20 FE	175.00	198.00	241.00	264.00	294.00	277.00	292.00	309.00	0.00	0.00	0.00	0.00		2,050.00		
5015	SOBRA PREG 14-20 FE M	7.00	7.00	6.00	5.00	7.00	9.00	9.00	10.00	0.00	0.00	0.00	0.00		60.00		
5017	SOBRA PREG 21-44 FE
M	45.00	39.00	43.00	39.00	41.00	48.00	52.00	53.00	0.00	0.00	0.00	0.00		360.00		
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	5,640.00	5,838.00	0.00	0.00	0.00	0.00		41,147.00		

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	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	5.00	5.00	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	11.00	11.00	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	3.00	4.00	0.00	0.00	0.00	0.00	

 
3.00	
32.00	
81.00	
19.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending February 29, 2020	
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	5.00	7.00	0.00	0.00	0.00	0.00		45.00		
1116	TANF EXPANDED 21-44	53.00	68.00	82.00	96.00	109.00	103.00	105.00	107.00	0.00	0.00	0.00	0.00		723.00		
1117	TANF EXPANDED 21-44	198.00	226.00	241.00	285.00	314.00	303.00	311.00	326.00	0.00	0.00	0.00	0.00		2,204.00		
1118	TANF EXPANDED 45-64	119.00	136.00	144.00	158.00	178.00	176.00	182.00	181.00	0.00	0.00	0.00	0.00		1,274.00		
1119	TANF EXPANDED 65+
M&	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		8.00		
1126	TANF EXPANDED 21-44	3.00	3.00	4.00	5.00	6.00	6.00	6.00	6.00	0.00	0.00	0.00	0.00		39.00		
1127	TANF EXPANDED 21-44	4.00	4.00	5.00	4.00	4.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00		30.00		
1128	TANF EXPANDED 45-64	21.00	20.00	19.00	22.00	26.00	24.00	25.00	25.00	0.00	0.00	0.00	0.00		182.00		
1129	TANF EXPANDED 65+
M&	15.00	14.00	14.00	15.00	17.00	17.00	17.00	16.00	0.00	0.00	0.00	0.00		125.00		
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	0.00	0.00	0.00	0.00		4.00		
2420	SSI AGED EXPANDED
WI	87.00	105.00	115.00	119.00	132.00	134.00	139.00	137.00	0.00	0.00	0.00	0.00		968.00		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		5.00		
2610	SSI DISABLED EXPAND
E	8.00	9.00	12.00	11.00	15.00	17.00	18.00	19.00	0.00	0.00	0.00	0.00		109.00		
2620	SSI DISABLED EXPAND E	45.00	46.00	47.00	51.00	57.00	51.00	52.00	54.00	0.00	0.00	0.00	0.00		403.00		
SUBTOTAL:	570.00	649.00	704.0	0	791.00	887.00	860.00	885.00	908.00	0.00	0.00	0.00	0.00		6,254.00		

3908	NEWLY ELIGIBLE M&F 4	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	2.00	3.00	5.00	5.00	3.00	4.00	4.00	5.00	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	13.00	11.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	27.00	31.00	29.00	34.00	35.00	37.00	36.00	39.00	0.00	0.00	0.00	0.00	

2.00	
31.00	
80.00	
268.00	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	5.00	8.00	9.00	9.00	11.00	12.00	13.00	11.00	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	12.00	16.00	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	62.00	63.00	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	58.00	63.00	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	197.00	202.00	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	1.00	1.00	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	43.00	44.00	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	47.00	45.00	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	478.00	505.00	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	295.00	297.00	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	606.00	619.00	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	1,813.00	1,867.00	0.00	0.00	0.00	0.00	

 
2.00	
78.00	
95.00	
432.00	
413.00	
1,525.00	
1.00	
2.00	
6.00	
262.00	
300.00	
3,367.00	
2,070.00	
4,679.00	
1.00	
13,233.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	48.00	52.00	58.00	58.00	61.00	62.00	59.00	54.00	0.00	0.00	0.00	0.00		452.00		
3918	NEWLY ELIGIBLE M&F
4	95.00	110.00	117.00	121.00	121.00	114.00	102.00	110.00	0.00	0.00	0.00	0.00		890.00		
SUBTOTAL:	177.00	201.00	219.0	0	228.00	234.00	230.00	214.00	220.00	0.00	0.00	0.00	0.00		1,723.00		

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	4.00	4.00	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	1.00	1.00	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	1.00	1.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5.00	7.00	6.00	3.00	4.00	5.00	6.00	6.00	0.00	0.00	0.00	0.00	

30.00	
7.00	
5.00	
42.00	

4413	SOBRA 100-133% M&F
6	107.00	113.00	136.00	132.00	134.00	122.00	123.00	121.00	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	33.00	35.00	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	22.00	22.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	146.00	162.00	191.0	0	189.00	199.00	176.00	178.00	178.00	0.00	0.00	0.00	0.00	

 
988.00	
240.00	
191.00	
1,419.00	

TOTAL:	6,110.00	6,770.00	7,550.00	8,140.00	8,956.00	8,543.00	8,736.00	9,017.00	0.00	0.00	0.00	0.00		63,822.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending February 29, 2020	
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	23.76	23.76	0.00	0.00	0.00	0.00		161.07		
1008	TANF 45-64 M & F WIT	22.71	45.42	45.42	45.42	22.71	22.71	23.76	0.00	0.00	0.00	0.00	0.00		228.15		
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	95.04	118.80	0.00	0.00	0.00	0.00		1,326.63		
1012	TANF 01-05 M & F NON	431.49	545.04	499.62	522.33	567.75	545.04	641.52	617.76	0.00	0.00	0.00	0.00		4,370.55		
1013	TANF 06-13 M & F NON	408.78	431.49	408.78	522.33	635.88	681.30	641.52	570.24	0.00	0.00	0.00	0.00		4,300.32		
1014	TANF 14-20 MALE NON-	22.71	45.42	68.13	136.26	136.26	204.39	166.32	95.04	0.00	0.00	0.00	0.00		874.53		
1015	TANF 14-20 FEMALE N O	181.68	295.23	363.36	363.36	340.65	317.94	403.92	522.72	0.00	0.00	0.00	0.00		2,788.86		
1016	TANF 21-44 MALE NON-	567.75	681.30	681.30	681.30	885.69	862.98	831.60	807.84	0.00	0.00	0.00	0.00		5,999.76		
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	5,797.44	5,797.44	0.00	0.00	0.00	0.00		42,026.28		
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	2,138.40	2,352.24	0.00	0.00	0.00	0.00		14,869.11		
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		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.76	0.00	0.00	0.00	0.00		23.76		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	22.71	22.71	22.71	23.76	23.76	0.00	0.00	0.00	0.00		115.65		
2100	SSI AGED WITH MEDIC A	181.68	181.68	204.39	204.39	227.10	249.81	261.36	308.88	0.00	0.00	0.00	0.00		1,819.29		
2110	SSI AGED NON-MEDIC
AR	45.42	45.42	68.13	68.13	68.13	68.13	95.04	118.80	0.00	0.00	0.00	0.00		577.20		
2120	SSI AGED WITH QMB	1,975.77	2,112.03	2,157.45	2,429.97	2,475.39	2,543.52	2,684.88	2,589.84	0.00	0.00	0.00	0.00		18,968.85		
2200	SSI DISABLED WITH M E	681.30	704.01	749.43	749.43	794.85	817.56	855.36	855.36	0.00	0.00	0.00	0.00		6,207.30		
2210	SSI DISABLED NON-ME
D	4,110.51	4,428.45	4,610.13	4,950.78	4,996.20	5,018.91	5,346.00	5,441.04	0.00	0.00	0.00	0.00		38,902.02		
2220	SSI DISABLED WITH Q M	2,861.46	3,020.43	3,156.69	3,292.95	3,451.92	3,429.21	3,635.28	3,706.56	0.00	0.00	0.00	0.00		26,554.50		
2310	SSI BLIND NON-MEDIC
A	22.71	45.42	45.42	45.42	45.42	45.42	47.52	71.28	0.00	0.00	0.00	0.00		368.61		
2320	SSI BLIND WITH QMB	45.42	45.42	45.42	45.42	45.42	45.42	47.52	47.52	0.00	0.00	0.00	0.00		367.56		
4311	SOBRA CHILD <1 M & F	908.40	953.82	749.43	749.43	840.27	908.40	902.88	807.84	0.00	0.00	0.00	0.00		6,820.47		
4312	SOBRA CHILD 01-05 M	5,473.11	5,813.76	6,358.80	6,608.61	6,926.55	6,926.55	7,508.16	7,579.44	0.00	0.00	0.00	0.00		53,194.98		
4313	SOBRA CHILD 06-13 M	4,678.26	5,518.53	5,904.60	6,313.38	6,903.84	7,176.36	7,722.00	7,912.08	0.00	0.00	0.00	0.00		52,129.05		
4314	SOBRA CHILD 14-20 MA	976.53	1,226.34	1,294.47	1,317.18	1,408.02	1,566.99	1,782.00	1,686.96	0.00	0.00	0.00	0.00		11,258.49		
4315	SOBRA CHILD 14-20 FE	1,657.83	1,725.96	1,907.64	2,021.19	2,225.58	2,316.42	2,399.76	2,280.96	0.00	0.00	0.00	0.00		16,535.34		
5015	SOBRA PREG 14-20 FE M	113.55	113.55	90.84	90.84	204.39	272.52	261.36	213.84	0.00	0.00	0.00	0.00		1,360.89		
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	1,259.28	1,259.28	0.00	0.00	0.00	0.00		9,899.31		
SUBTOTAL:	32,611.56	35,768.25	37,607.7	6	39,651.66	41,990.79	43,149.00	45,595.44	45,833.04	0.00	0.00	0.00	0.00		322,207.50		

1108	TANF EXPANDED 45-64	45.42	45.42	45.42	45.42	45.42	68.13	47.52	47.52	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	71.28	71.28	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	403.92	427.68	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	3,659.04	3,801.60	0.00	0.00	0.00	0.00	

 
390.27	
90.84	
324.24	
2,466.72	
26,832.27	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	1,476.15	1,521.57	1,589.70	1,680.54	1,771.38	1,816.80	1,948.32	1,734.48	0.00	0.00	0.00	0.00		13,538.94		
1126	TANF EXPANDED 21-44	22.71	22.71	22.71	22.71	22.71	22.71	23.76	23.76	0.00	0.00	0.00	0.00		183.78		
1128	TANF EXPANDED 45-64	90.84	113.55	158.97	181.68	158.97	136.26	142.56	142.56	0.00	0.00	0.00	0.00		1,125.39		
1129	TANF EXPANDED 65+
M&	249.81	295.23	295.23	295.23	340.65	363.36	380.16	380.16	0.00	0.00	0.00	0.00		2,599.83		
2410	SSI AGED EXPANDED NO	22.71	22.71	22.71	45.42	45.42	45.42	47.52	47.52	0.00	0.00	0.00	0.00		299.43		
2420	SSI AGED EXPANDED
WI	1,703.25	1,884.93	1,930.35	2,021.19	2,112.03	2,112.03	2,280.96	2,257.20	0.00	0.00	0.00	0.00		16,301.94		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	22.71	22.71	23.76	23.76	0.00	0.00	0.00	0.00		92.94		
2610	SSI DISABLED EXPAND
E	68.13	45.42	22.71	90.84	45.42	45.42	47.52	71.28	0.00	0.00	0.00	0.00		436.74		
2620	SSI DISABLED EXPAND E	567.75	567.75	613.17	613.17	635.88	658.59	712.80	712.80	0.00	0.00	0.00	0.00		5,081.91		
SUBTOTAL:	7,448.88	7,903.08	8,243.73	8,561.67	8,970.45	9,106.71	9,789.12	9,741.60	0.00	0.00	0.00	0.00		69,765.24		

3908	NEWLY ELIGIBLE M&F 4	22.71	45.42	22.71	22.71	22.71	22.71	23.76	23.76	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	47.52	47.52	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	71.28	71.28	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	158.97	181.68	158.97	113.55	113.55	90.84	118.80	118.80	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	950.40	902.88	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	1,401.84	1,283.04	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	2,613.60	2,447.28	0.00	0.00	0.00	0.00	

206.49	
45.42	
412.98	
301.53	
1,055.16	
6,395.28	
9,702.27	
18,119.13	

4413	SOBRA 100-133% M&F
6	386.07	363.36	476.91	545.04	567.75	476.91	498.96	475.20	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	142.56	237.60	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	213.84	213.84	0.00	0.00	0.00	0.00	

3,790.20	
1,356.69	
1,472.34	

3514	ADULT 40-100% MALE 1	136.26	113.55	113.55	68.13	68.13	45.42	47.52	47.52	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	213.84	213.84	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	451.44	451.44	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	641.52	546.48	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	1,924.56	1,948.32	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	23.76	23.76	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	380.16	427.68	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	546.48	570.24	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	2,542.32	2,613.60	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	2,114.64	2,090.88	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	7,032.96	7,175.52	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.76	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	15,919.20	16,133.04	0.00	0.00	0.00	0.00	

 
640.08	
2,130.93	
3,332.85	
3,981.33	
14,296.77	
47.52	
90.84	
2,397.54	
3,387.72	
18,009.78	
14,811.09	
52,542.96	
23.76	
115,693.17	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	635.88	681.30	862.98	931.11	931.11	794.85	855.36	926.64	0.00	0.00	0.00	0.00		6,619.23		

4518	BC PATIENT FEMALE 4 5	22.71	22.71	22.71	22.71	22.71	22.71	23.76	23.76	0.00	0.00	0.00	0.00	
SUBTOTAL:	22.71	22.71	22.71	22.71	22.71	22.71	23.76	23.76	0.00	0.00	0.00	0.00	

 

183.78

183.78

8700	SSI DISABLED FREEDO M	45.42	45.42	45.42	45.42	45.42	45.42	47.52	71.28	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	47.52	23.76	0.00	0.00	0.00	0.00	
SUBTOTAL:	90.84	90.84	90.84	90.84	90.84	90.84	95.04	95.04	0.00	0.00	0.00	0.00	

 
391.32	
343.80	
735.12	

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

533,345.88

54,821.94	60,022.53	63,042.96	66,086.10	68,811.30	70,469.13	74,891.52	75,200.40	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending February 29, 2020	
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	1.00	1.00	0.00	0.00	0.00	0.00		7.00		
1008	TANF 45-64 M & F WIT	1.00	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		10.00		
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	4.00	5.00	0.00	0.00	0.00	0.00		58.00		
1012	TANF 01-05 M & F NON	19.00	24.00	22.00	23.00	25.00	24.00	27.00	26.00	0.00	0.00	0.00	0.00		190.00		
1013	TANF 06-13 M & F NON	18.00	19.00	18.00	23.00	28.00	30.00	27.00	24.00	0.00	0.00	0.00	0.00		187.00		
1014	TANF 14-20 MALE NON-	1.00	2.00	3.00	6.00	6.00	9.00	7.00	4.00	0.00	0.00	0.00	0.00		38.00		
1015	TANF 14-20 FEMALE N O	8.00	13.00	16.00	16.00	15.00	14.00	17.00	22.00	0.00	0.00	0.00	0.00		121.00		
1016	TANF 21-44 MALE NON-	25.00	30.00	30.00	30.00	39.00	38.00	35.00	34.00	0.00	0.00	0.00	0.00		261.00		
1017	TANF 21-44 FEMALE N O	195.00	211.00	216.00	227.00	244.00	247.00	244.00	244.00	0.00	0.00	0.00	0.00		1,828.00		
1018	TANF 45-64 M & F NON	68.00	71.00	77.00	75.00	78.00	88.00	90.00	99.00	0.00	0.00	0.00	0.00		646.00		
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		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	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	1.00	1.00	0.00	0.00	0.00	0.00		5.00		
2100	SSI AGED WITH MEDIC A	8.00	8.00	9.00	9.00	10.00	11.00	11.00	13.00	0.00	0.00	0.00	0.00		79.00		
2110	SSI AGED NON-MEDIC
AR	2.00	2.00	3.00	3.00	3.00	3.00	4.00	5.00	0.00	0.00	0.00	0.00		25.00		
2120	SSI AGED WITH QMB	87.00	93.00	95.00	107.00	109.00	112.00	113.00	109.00	0.00	0.00	0.00	0.00		825.00		
2200	SSI DISABLED WITH M E	30.00	31.00	33.00	33.00	35.00	36.00	36.00	36.00	0.00	0.00	0.00	0.00		270.00		
2210	SSI DISABLED NON-ME
D	181.00	195.00	203.00	218.00	220.00	221.00	225.00	229.00	0.00	0.00	0.00	0.00		1,692.00		
2220	SSI DISABLED WITH Q M	126.00	133.00	139.00	145.00	152.00	151.00	153.00	156.00	0.00	0.00	0.00	0.00		1,155.00		
2310	SSI BLIND NON-MEDIC
A	1.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00		16.00		
2320	SSI BLIND WITH QMB	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00		16.00		
4311	SOBRA CHILD <1 M & F	40.00	42.00	33.00	33.00	37.00	40.00	38.00	34.00	0.00	0.00	0.00	0.00		297.00		
4312	SOBRA CHILD 01-05 M	241.00	256.00	280.00	291.00	305.00	305.00	316.00	319.00	0.00	0.00	0.00	0.00		2,313.00		
4313	SOBRA CHILD 06-13 M	206.00	243.00	260.00	278.00	304.00	316.00	325.00	333.00	0.00	0.00	0.00	0.00		2,265.00		
4314	SOBRA CHILD 14-20 MA	43.00	54.00	57.00	58.00	62.00	69.00	75.00	71.00	0.00	0.00	0.00	0.00		489.00		
4315	SOBRA CHILD 14-20 FE	73.00	76.00	84.00	89.00	98.00	102.00	101.00	96.00	0.00	0.00	0.00	0.00		719.00		
5015	SOBRA PREG 14-20 FE M	5.00	5.00	4.00	4.00	9.00	12.00	11.00	9.00	0.00	0.00	0.00	0.00		59.00		
5017	SOBRA PREG 21-44 FE
M	45.00	50.00	58.00	61.00	54.00	57.00	53.00	53.00	0.00	0.00	0.00	0.00		431.00		
SUBTOTAL:	1,436.00	1,575.00	1,656.00	1,746.00	1,849.00	1,900.00	1,919.00	1,929.00	0.00	0.00	0.00	0.00		14,010.00		

1108	TANF EXPANDED 45-64	2.00	2.00	2.00	2.00	2.00	3.00	2.00	2.00	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	3.00	3.00	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	17.00	18.00	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	154.00	160.00	0.00	0.00	0.00	0.00	

 
17.00	
4.00	
14.00	
107.00	
1,167.00	

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	65.00	67.00	70.00	74.00	78.00	80.00	82.00	73.00	0.00	0.00	0.00	0.00		589.00		
1126	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		8.00		
1128	TANF EXPANDED 45-64	4.00	5.00	7.00	8.00	7.00	6.00	6.00	6.00	0.00	0.00	0.00	0.00		49.00		
1129	TANF EXPANDED 65+
M&	11.00	13.00	13.00	13.00	15.00	16.00	16.00	16.00	0.00	0.00	0.00	0.00		113.00		
2410	SSI AGED EXPANDED NO	1.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00		13.00		
2420	SSI AGED EXPANDED
WI	75.00	83.00	85.00	89.00	93.00	93.00	96.00	95.00	0.00	0.00	0.00	0.00		709.00		
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		4.00		
2610	SSI DISABLED EXPAND
E	3.00	2.00	1.00	4.00	2.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00		19.00		
2620	SSI DISABLED EXPAND E	25.00	25.00	27.00	27.00	28.00	29.00	30.00	30.00	0.00	0.00	0.00	0.00		221.00		
SUBTOTAL:	328.00	348.00	363.0	0	377.00	395.00	401.00	412.00	410.00	0.00	0.00	0.00	0.00		3,034.00		

3514	ADULT 40-100% MALE 1	6.00	5.00	5.00	3.00	3.00	2.00	2.00	2.00	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	9.00	9.00	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	19.00	19.00	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	27.00	23.00	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	81.00	82.00	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	1.00	1.00	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	16.00	18.00	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	23.00	24.00	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	107.00	110.00	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	89.00	88.00	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	296.00	302.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	531.00	592.00	620.0	0	644.00	637.00	659.00	670.00	679.00	0.00	0.00	0.00	0.00	

 
28.00	
93.00	
145.00	
173.00	
622.00	
2.00	
4.00	
104.00	
147.00	
783.00	
644.00	
2,286.00	
1.00	
5,032.00	

3908	NEWLY ELIGIBLE M&F 4	1.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00	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	2.00	2.00	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	3.00	3.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	7.00	8.00	7.00	5.00	5.00	4.00	5.00	5.00	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	40.00	38.00	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	59.00	54.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	86.00	92.00	94.00	97.00	103.00	103.00	110.00	103.00	0.00	0.00	0.00	0.00	

 
9.00	
2.00	
18.00	
13.00	
46.00	
278.00	
422.00	
788.00	

59.00

165.00

4413	SOBRA 100-133% M&F
6	17.00	16.00	21.00	24.00	25.00	21.00	21.00	20.00	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	6.00	10.00	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	9.00	9.00	0.00	0.00	0.00	0.00	

64.00

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	28.00	30.00	38.00	41.00	41.00	35.00	36.00	39.00	0.00	0.00	0.00	0.00		288.00		

8700	SSI DISABLED FREEDO M	2.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	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	2.00	1.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.00	4.00	4.00	4.00	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	

17.00	
15.00	
32.00	

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

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

 

8.00

8.00

TOTAL:	2,414.00	2,643.00	2,776.00	2,910.00	3,030.00	3,103.00	3,152.00	3,165.00	0.00	0.00	0.00	0.00		23,193.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending February 29, 2020	
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	52.10	26.05	0.00	0.00	0.00	0.00		401.85		
1009	TANF 65+ M & F WITH	49.80	49.80	74.70	74.70	74.70	49.80	52.10	78.15	0.00	0.00	0.00	0.00		503.75		
1011	TANF <1 M & F NON-ME	1,045.80	946.20	1,045.80	1,095.60	1,020.90	1,369.50	1,484.85	1,563.00	0.00	0.00	0.00	0.00		9,571.65		
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	3,178.10	2,891.55	0.00	0.00	0.00	0.00		20,237.75		
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	3,594.90	3,699.10	0.00	0.00	0.00	0.00		24,325.60		
1014	TANF 14-20 MALE NON-	423.30	597.60	771.90	821.70	921.30	1,195.20	1,120.15	1,198.30	0.00	0.00	0.00	0.00		7,049.45		
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	2,396.60	2,709.20	0.00	0.00	0.00	0.00		16,734.10		
1016	TANF 21-44 MALE NON-	6,474.00	6,548.70	6,648.30	6,623.40	6,498.90	7,171.20	7,424.25	7,632.65	0.00	0.00	0.00	0.00		55,021.40		
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	29,723.05	30,765.05	0.00	0.00	0.00	0.00		211,631.10		
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	9,508.25	9,768.75	0.00	0.00	0.00	0.00		66,562.10		
1019	TANF 65+ M & F NON-M	24.90	24.90	49.80	49.80	49.80	49.80	52.10	26.05	0.00	0.00	0.00	0.00		327.15		
1026	TANF 21-44 MALE WITH	24.90	24.90	24.90	0.00	0.00	0.00	0.00	26.05	0.00	0.00	0.00	0.00		100.75		
1028	TANF 45-64 M & F WIT	24.90	49.80	74.70	24.90	24.90	24.90	26.05	26.05	0.00	0.00	0.00	0.00		276.20		
1029	TANF 65+ M & F WITH	24.90	24.90	0.00	24.90	24.90	24.90	26.05	26.05	0.00	0.00	0.00	0.00		176.60		
2100	SSI AGED WITH MEDIC A	1,444.20	1,469.10	1,444.20	1,494.00	1,543.80	1,643.40	1,719.30	1,667.20	0.00	0.00	0.00	0.00		12,425.20		
2110	SSI AGED NON-MEDIC
AR	199.20	174.30	199.20	149.40	149.40	323.70	416.80	494.95	0.00	0.00	0.00	0.00		2,106.95		
2120	SSI AGED WITH QMB	5,229.00	5,453.10	5,453.10	5,577.60	5,577.60	5,876.40	6,382.25	6,486.45	0.00	0.00	0.00	0.00		46,035.50		
2200	SSI DISABLED WITH M E	3,336.60	3,560.70	3,635.40	3,685.20	3,710.10	4,158.30	4,480.60	4,454.55	0.00	0.00	0.00	0.00		31,021.45		
2210	SSI DISABLED NON-ME
D	18,077.40	18,351.30	18,525.60	18,774.60	18,874.20	21,588.30	23,080.30	23,471.05	0.00	0.00	0.00	0.00		160,742.75		
2220	SSI DISABLED WITH Q M	8,341.50	8,490.90	8,715.00	8,839.50	8,964.00	9,561.60	10,211.60	10,367.90	0.00	0.00	0.00	0.00		73,492.00		
2300	SSI BLIND WITH MEDIC	49.80	49.80	24.90	24.90	24.90	24.90	26.05	26.05	0.00	0.00	0.00	0.00		251.30		
2310	SSI BLIND NON-MEDIC A	273.90	298.80	298.80	323.70	348.60	398.40	442.85	442.85	0.00	0.00	0.00	0.00		2,827.90		
2320	SSI BLIND WITH QMB	99.60	99.60	124.50	124.50	124.50	124.50	130.25	130.25	0.00	0.00	0.00	0.00		957.70		
4311	SOBRA CHILD <1 M & F	3,884.40	3,610.50	3,411.30	3,311.70	3,062.70	3,859.50	4,194.05	4,428.50	0.00	0.00	0.00	0.00		29,762.65		
4312	SOBRA CHILD 01-05 M	31,847.10	32,046.30	32,768.40	32,793.30	32,768.40	35,681.70	38,345.60	39,153.15	0.00	0.00	0.00	0.00		275,403.95		
4313	SOBRA CHILD 06-13 M	42,330.00	44,421.60	45,865.80	46,363.80	46,388.70	51,244.20	54,210.05	55,095.75	0.00	0.00	0.00	0.00		385,919.90		
4314	SOBRA CHILD 14-20 MA	10,034.70	10,308.60	11,080.50	11,329.50	11,454.00	12,275.70	13,155.25	13,676.25	0.00	0.00	0.00	0.00		93,314.50		
4315	SOBRA CHILD 14-20 FE	11,727.90	12,300.60	12,450.00	12,798.60	12,549.60	13,495.80	14,614.05	15,082.95	0.00	0.00	0.00	0.00		105,019.50		
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	26.05	26.05	0.00	0.00	0.00	0.00		201.50		
5015	SOBRA PREG 14-20 FE M	473.10	522.90	572.70	597.60	398.40	448.20	416.80	234.45	0.00	0.00	0.00	0.00		3,664.15		
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	2,917.60	2,578.95	0.00	0.00	0.00	0.00		22,328.95		
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		
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	26.05	26.05	0.00	0.00	0.00	0.00		52.10		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	186,102.60	190,236.00	195,440.10	197,905.20	198,129.30	219,169.80	233,434.05	238,279.35	0.00	0.00	0.00	0.00		1,658,696.40		

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	755.45	833.60	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	1,015.95	1,042.00	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	1,667.20	1,667.20	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	1,458.80	1,458.80	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	4,923.45	5,262.10	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	3,360.45	3,386.50	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	3,516.75	3,647.00	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	25,268.50	26,388.65	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	12,504.00	12,868.70	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	26,258.40	27,118.05	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	26.05	0.00	0.00	0.00	0.00	

49.80	
4,577.05	
6,465.25	
11,626.10	
9,765.10	
34,687.15	
99.60	
23,056.45	
25,241.15	
172,546.65	
85,854.80	
177,751.95	
26.05	

1106	TANF EXPANDED 21-44	24.90	24.90	24.90	24.90	49.80	49.80	78.15	52.10	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	26.05	52.10	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	249.00	249.00	224.10	224.10	224.10	224.10	208.40	208.40	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	174.30	199.20	174.30	174.30	199.20	273.90	260.50	234.45	0.00	0.00	0.00	0.00	
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	
1115	TANF EXPANDED 14-20	249.00	224.10	174.30	174.30	124.50	149.40	182.35	208.40	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	3,237.00	3,212.10	3,361.50	3,436.20	3,486.00	3,809.70	4,220.10	4,324.30	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	9,935.10	10,134.30	10,308.60	10,731.90	11,030.70	11,528.70	12,477.95	12,764.50	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	5,004.90	4,955.10	4,880.40	5,004.90	5,204.10	5,577.60	6,017.55	6,720.90	0.00	0.00	0.00	0.00	
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	
1126	TANF EXPANDED 21-44	99.60	99.60	99.60	99.60	124.50	124.50	130.25	182.35	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	249.00	224.10	224.10	224.10	224.10	249.00	260.50	234.45	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	498.00	547.80	597.60	547.80	522.90	647.40	677.30	755.45	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	498.00	498.00	522.90	547.80	498.00	572.70	625.20	677.30	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	24.90	24.90	26.05	52.10	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	99.60	99.60	99.60	99.60	99.60	124.50	104.20	78.15	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	3,311.70	3,486.00	3,436.20	3,535.80	3,610.50	3,735.00	3,855.40	3,907.50	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	24.90	24.90	24.90	26.05	26.05	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	124.50	174.30	149.40	149.40	174.30	249.00	260.50	260.50	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	1,593.60	1,643.40	1,718.10	1,718.10	1,743.00	1,942.20	2,084.00	2,110.05	0.00	0.00	0.00	0.00	
SUBTOTAL:	25,373.10	25,796.40	26,020.5	26,742.60	27,390.00	29,332.20	31,520.50	32,849.05	0.00	0.00	0.00	0.00	

 
329.45	
78.15	
1,811.20	
1,690.15	
99.60	
1,486.35	
29,086.90	
88,911.75	
43,365.45	
49.80	
960.00	
1,889.35	
4,794.25	
4,439.90	
127.95	
804.85	
28,878.10	
126.80	
1,541.90	
14,552.45	
225,024.35	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	58,714.20	61,029.90	62,449.20	64,964.10	66,632.40	73,529.70	80,728.95	83,698.65	0.00	0.00	0.00	0.00		551,747.10		

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	26.05	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	26.05	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	224.10	249.00	249.00	273.90	249.00	273.90	260.50	286.55	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	298.80	348.60	323.70	249.00	273.90	398.40	390.75	338.65	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,269.90	1,369.50	1,394.40	1,294.80	1,245.00	1,294.80	1,354.60	1,354.60	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	2,589.60	2,639.40	2,465.10	2,365.50	2,415.30	2,465.10	2,422.65	2,448.70	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	2,913.30	2,963.10	3,187.20	3,261.90	3,361.50	3,784.80	3,933.55	3,933.55	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,345.50	7,594.50	7,619.40	7,445.10	7,544.70	8,217.00	8,388.10	8,388.10	0.00	0.00	0.00	0.00	

 
49.80	
26.05	
50.95	
2,065.95	
2,621.80	
10,577.60	
19,811.35	
27,338.90	
62,542.40	

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	4,141.95	4,350.35	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	1,224.35	1,380.65	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	1,484.85	1,510.90	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	6,851.15	7,241.90	0.00	0.00	0.00	0.00	

 
26,793.80	
9,103.90	
9,494.65	
45,392.35	

8710

SSI DISABLED FREEDO M

631.70

631.70

49.80	49.80	49.80	74.70	99.60	99.60	104.20	104.20	0.00	0.00	0.00	0.00	
49.80	49.80	49.80	74.70	99.60	99.60	104.20	104.20	0.00	0.00	0.00	0.00	

SUBTOTAL:

2,544,034.30

282,341.10	289,761.30	296,683.50	302,186.40	305,074.80	336,399.00	361,026.95	370,561.25	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending February 29, 2020	
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	2.00	1.00	0.00	0.00	0.00	0.00		16.00		
1009	TANF 65+ M & F WITH	2.00	2.00	3.00	3.00	3.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00		20.00		
1011	TANF <1 M & F NON-ME	42.00	38.00	42.00	44.00	41.00	55.00	57.00	60.00	0.00	0.00	0.00	0.00		379.00		
1012	TANF 01-05 M & F NON	88.00	80.00	85.00	95.00	100.00	121.00	122.00	111.00	0.00	0.00	0.00	0.00		802.00		
1013	TANF 06-13 M & F NON	94.00	102.00	109.00	114.00	123.00	142.00	138.00	142.00	0.00	0.00	0.00	0.00		964.00		
1014	TANF 14-20 MALE NON-	17.00	24.00	31.00	33.00	37.00	48.00	43.00	46.00	0.00	0.00	0.00	0.00		279.00		
1015	TANF 14-20 FEMALE N O	71.00	71.00	80.00	82.00	78.00	85.00	92.00	104.00	0.00	0.00	0.00	0.00		663.00		
1016	TANF 21-44 MALE NON-	260.00	263.00	267.00	266.00	261.00	288.00	285.00	293.00	0.00	0.00	0.00	0.00		2,183.00		
1017	TANF 21-44 FEMALE N O	960.00	966.00	996.00	1,003.00	1,017.00	1,128.00	1,141.00	1,181.00	0.00	0.00	0.00	0.00		8,392.00		
1018	TANF 45-64 M & F NON	302.00	299.00	304.00	312.00	320.00	362.00	365.00	375.00	0.00	0.00	0.00	0.00		2,639.00		
1019	TANF 65+ M & F NON-M	1.00	1.00	2.00	2.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00		13.00		
1026	TANF 21-44 MALE WITH	1.00	1.00	1.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00		4.00		
1028	TANF 45-64 M & F WIT	1.00	2.00	3.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		11.00		
1029	TANF 65+ M & F WITH	1.00	1.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		7.00		
2100	SSI AGED WITH MEDIC A	58.00	59.00	58.00	60.00	62.00	66.00	66.00	64.00	0.00	0.00	0.00	0.00		493.00		
2110	SSI AGED NON-MEDIC
AR	8.00	7.00	8.00	6.00	6.00	13.00	16.00	19.00	0.00	0.00	0.00	0.00		83.00		
2120	SSI AGED WITH QMB	210.00	219.00	219.00	224.00	224.00	236.00	245.00	249.00	0.00	0.00	0.00	0.00		1,826.00		
2200	SSI DISABLED WITH M E	134.00	143.00	146.00	148.00	149.00	167.00	172.00	171.00	0.00	0.00	0.00	0.00		1,230.00		
2210	SSI DISABLED NON-ME
D	726.00	737.00	744.00	754.00	758.00	867.00	886.00	901.00	0.00	0.00	0.00	0.00		6,373.00		
2220	SSI DISABLED WITH Q M	335.00	341.00	350.00	355.00	360.00	384.00	392.00	398.00	0.00	0.00	0.00	0.00		2,915.00		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		10.00		
2310	SSI BLIND NON-MEDIC A	11.00	12.00	12.00	13.00	14.00	16.00	17.00	17.00	0.00	0.00	0.00	0.00		112.00		
2320	SSI BLIND WITH QMB	4.00	4.00	5.00	5.00	5.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00		38.00		
4311	SOBRA CHILD <1 M & F	156.00	145.00	137.00	133.00	123.00	155.00	161.00	170.00	0.00	0.00	0.00	0.00		1,180.00		
4312	SOBRA CHILD 01-05 M	1,279.00	1,287.00	1,316.00	1,317.00	1,316.00	1,433.00	1,472.00	1,503.00	0.00	0.00	0.00	0.00		10,923.00		
4313	SOBRA CHILD 06-13 M	1,700.00	1,784.00	1,842.00	1,862.00	1,863.00	2,058.00	2,081.00	2,115.00	0.00	0.00	0.00	0.00		15,305.00		
4314	SOBRA CHILD 14-20 MA	403.00	414.00	445.00	455.00	460.00	493.00	505.00	525.00	0.00	0.00	0.00	0.00		3,700.00		
4315	SOBRA CHILD 14-20 FE	471.00	494.00	500.00	514.00	504.00	542.00	561.00	579.00	0.00	0.00	0.00	0.00		4,165.00		
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	1.00	1.00	0.00	0.00	0.00	0.00		8.00		
5015	SOBRA PREG 14-20 FE M	19.00	21.00	23.00	24.00	16.00	18.00	16.00	9.00	0.00	0.00	0.00	0.00		146.00		
5017	SOBRA PREG 21-44 FE
M	114.00	116.00	115.00	115.00	108.00	108.00	112.00	99.00	0.00	0.00	0.00	0.00		887.00		
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		
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00		2.00		

1106	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	2.00	2.00	3.00	2.00	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	1.00	2.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	10.00	10.00	9.00	9.00	9.00	9.00	8.00	8.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	7.00	8.00	7.00	7.00	8.00	11.00	10.00	9.00	0.00	0.00	0.00	0.00	
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	
1115	TANF EXPANDED 14-20	10.00	9.00	7.00	7.00	5.00	6.00	7.00	8.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	130.00	129.00	135.00	138.00	140.00	153.00	162.00	166.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	399.00	407.00	414.00	431.00	443.00	463.00	479.00	490.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	201.00	199.00	196.00	201.00	209.00	224.00	231.00	258.00	0.00	0.00	0.00	0.00	
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	
1126	TANF EXPANDED 21-44	4.00	4.00	4.00	4.00	5.00	5.00	5.00	7.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	10.00	9.00	9.00	9.00	9.00	10.00	10.00	9.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	20.00	22.00	24.00	22.00	21.00	26.00	26.00	29.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+
M&	20.00	20.00	21.00	22.00	20.00	23.00	24.00	26.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED
NO	4.00	4.00	4.00	4.00	4.00	5.00	4.00	3.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	133.00	140.00	138.00	142.00	145.00	150.00	148.00	150.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	5.00	7.00	6.00	6.00	7.00	10.00	10.00	10.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	64.00	66.00	69.00	69.00	70.00	78.00	80.00	81.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,019.00	1,036.00	1,045.00	1,074.00	1,100.00	1,178.00	1,210.00	1,261.00	0.00	0.00	0.00	0.00	

 
13.00	
3.00	
72.00	
67.00	
4.00	
59.00	
1,153.00	
3,526.00	
1,719.00	
2.00	
38.00	
75.00	
190.00	
176.00	
5.00	
32.00	
1,146.00	
5.00	
61.00	
577.00	
8,923.00	

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	29.00	32.00	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	39.00	40.00	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	64.00	64.00	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	56.00	56.00	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	189.00	202.00	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	129.00	130.00	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	135.00	140.00	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	970.00	1,013.00	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	480.00	494.00	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	1,008.00	1,041.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	

2.00	
181.00	
256.00	
461.00	
387.00	
1,375.00	
4.00	
914.00	
1,001.00	
6,838.00	
3,403.00	
7,044.00	
1.00	

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	
3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	1.00	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	1.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	9.00	10.00	10.00	11.00	10.00	11.00	10.00	11.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	12.00	14.00	13.00	10.00	11.00	16.00	15.00	13.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	51.00	55.00	56.00	52.00	50.00	52.00	52.00	52.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	104.00	106.00	99.00	95.00	97.00	99.00	93.00	94.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	117.00	119.00	128.00	131.00	135.00	152.00	151.00	151.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	295.00	305.00	306.0	0	299.00	303.00	330.00	322.00	322.00	0.00	0.00	0.00	0.00	

 
2.00	
1.00	
2.00	
82.00	
104.00	
420.00	
787.00	
1,084.00	
2,482.00	

4413	SOBRA 100-133% M&F
6	113.00	118.00	117.00	119.00	124.00	144.00	159.00	167.00	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	47.00	53.00	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	57.00	58.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	191.00	203.00	205.0	0	203.00	212.00	243.00	263.00	278.00	0.00	0.00	0.00	0.00	

1,061.00	
361.00	
376.00	
1,798.00	

8710

SSI DISABLED FREEDO M

25.00

25.00

2.00	2.00	2.00	3.00	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	
2.00	2.00	2.00	3.00	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

TOTAL:	11,339.00	11,637.00	11,915.00	12,136.00	12,252.00	13,510.00	13,859.00	14,225.00	0.00	0.00	0.00	0.00		100,873.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending February 29, 2020	
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	9,680.62	9,680.62	0.00	0.00	0.00	0.00		101,000.41		
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	3,228,013.75	3,189,174.50	0.00	0.00	0.00	0.00		20,171,409.03		
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	9,680.62	9,680.62	0.00	0.00	0.00	0.00		129,802.34		
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	38,812,038.91	38,972,964.83	0.00	0.00	0.00	0.00		300,517,466.84		
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	1,742,890.57	1,849,325.95	0.00	0.00	0.00	0.00		14,570,605.37		
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	3,926,542.31	4,279,169.27	0.00	0.00	0.00	0.00		31,297,716.10		
211Z	SSI AGED NON-MEDIC
AR	101,176.43	20,587.31	54,593.15	170,167.44	79,886.85	36,165.99	84,507.03	87,796.55	0.00	0.00	0.00	0.00		634,880.75		
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	31,248,368.62	31,815,993.00	0.00	0.00	0.00	0.00		232,533,615.34		
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	10,719.28	71,338.67	0.00	0.00	0.00	0.00		386,883.93		
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	17,118,228.38	16,727,655.99	0.00	0.00	0.00	0.00		132,676,686.74		
220Z	SSI DISABLED WITH M E	241,491.30	210,523.92	148,685.65	226,958.11	161,194.24	193,326.58	173,125.57	209,283.66	0.00	0.00	0.00	0.00		1,564,589.03		
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	160,534,941.64	160,648,694.35	0.00	0.00	0.00	0.00		1,203,709,826.48		
221Z	SSI DISABLED NON-ME D	220,330.68	212,099.65	164,951.73	216,450.20	303,719.32	282,573.62	219,255.43	252,622.44	0.00	0.00	0.00	0.00		1,872,003.07		
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	34,888,231.15	34,470,496.16	0.00	0.00	0.00	0.00		258,838,345.75		
222Z	SSI DISABLED WITH Q M	36,101.66	3,297.05	17,224.42	15,278.93	27,610.19	4,358.92	21,060.28	1,157.77	0.00	0.00	0.00	0.00		126,089.22		
2300	SSI BLIND WITH MEDIC	2,719.44	2,719.44	212.67	165.00	6,728.91	5,683.06	13,678.78	9,680.62	0.00	0.00	0.00	0.00		41,587.92		
2310	SSI BLIND NON-MEDIC A	108,525.41	110,540.42	91,578.43	100,852.27	134,721.86	137,827.34	146,032.76	44,009.74	0.00	0.00	0.00	0.00		874,088.23		
2320	SSI BLIND WITH QMB	20,374.22	15,937.16	9,369.05	12,502.85	14,831.19	21,169.01	21,700.50	-681.98	0.00	0.00	0.00	0.00		115,202.00		
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	292,208,696.20	292,648,042.76	0.00	0.00	0.00	0.00		2,200,161,798.55		

8700	SSI DISABLED FREEDO M	155,943.28	136,803.98	166,698.11	213,746.58	177,649.55	220,911.51	228,863.88	259,489.92	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	1,169.11	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	240,697.23	253,457.37	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	101,211.10	116,278.17	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	571,941.32	629,225.46	0.00	0.00	0.00	0.00	

 
1,560,106.81	
27,907.19	
1,859,387.01	
35,461.52	
679,282.97	
488.15	
4,162,633.65	

2,204,324,432.20

250,917,794.02	252,209,106.88	253,136,673.96	286,967,454.80	287,233,145.57	287,802,351.23	292,780,637.52	293,277,268.22	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending February 29, 2020	
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	2.00	2.00	0.00	0.00	0.00	0.00		22.00		
1010	TANF NON-MEDICARE	393.91	454.32	516.92	526.58	561.83	584.76	662.19	653.28	0.00	0.00	0.00	0.00		4,353.79		
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	2.00	2.00	0.00	0.00	0.00	0.00		29.00		
2100	SSI AGED WITH MEDIC A	11,901.36	11,949.18	11,925.57	12,001.32	11,967.23	11,999.05	11,671.87	11,753.31	0.00	0.00	0.00	0.00		95,168.89		
210Z	SSI AGED WITH MEDIC
A	562.03	623.08	527.53	634.91	558.72	534.58	507.79	534.66	0.00	0.00	0.00	0.00		4,483.30		
2110	SSI AGED NON-MEDIC AR	611.47	610.68	604.51	598.67	590.09	584.83	555.50	605.19	0.00	0.00	0.00	0.00		4,760.94		
211Z	SSI AGED NON-MEDIC
AR	16.60	3.70	9.02	26.02	10.86	5.20	11.29	12.14	0.00	0.00	0.00	0.00		94.83		
2120	SSI AGED WITH QMB	9,350.65	9,436.56	9,532.55	9,570.71	9,598.71	9,572.84	9,808.06	10,002.44	0.00	0.00	0.00	0.00		76,872.52		
212Z	SSI AGED WITH QMB P P	17.29	17.74	14.71	7.74	17.89	25.63	-0.66	19.80	0.00	0.00	0.00	0.00		120.14		
2200	SSI DISABLED WITH M
E	4,466.83	4,466.23	4,430.22	4,447.90	4,441.01	4,388.31	4,284.25	4,139.95	0.00	0.00	0.00	0.00		35,064.70		
220Z	SSI DISABLED WITH M E	78.72	70.28	48.18	70.48	48.05	56.18	49.99	60.38	0.00	0.00	0.00	0.00		482.26		
2210	SSI DISABLED NON-ME
D	30,896.55	31,019.03	31,105.49	31,176.95	31,215.80	31,304.36	31,351.49	31,385.47	0.00	0.00	0.00	0.00		249,455.14		
221Z	SSI DISABLED NON-ME D	35.96	35.18	26.20	33.83	43.97	39.50	29.87	32.82	0.00	0.00	0.00	0.00		277.33		
2220	SSI DISABLED WITH Q
M	7,937.60	7,999.85	8,044.45	8,080.55	8,115.37	8,157.44	8,282.52	8,099.10	0.00	0.00	0.00	0.00		64,716.88		
222Z	SSI DISABLED WITH Q M	11.96	1.08	5.01	4.72	8.98	1.21	5.94	0.29	0.00	0.00	0.00	0.00		39.19		
2300	SSI BLIND WITH MEDIC	2.00	2.00	1.00	1.00	2.50	2.25	3.99	2.00	0.00	0.00	0.00	0.00		16.74		
2310	SSI BLIND NON-MEDIC A	24.00	24.64	22.40	21.32	27.33	27.22	29.29	8.00	0.00	0.00	0.00	0.00		184.20		
2320	SSI BLIND WITH QMB	6.00	4.99	3.00	4.63	3.01	5.64	6.00	-0.23	0.00	0.00	0.00	0.00		33.04		
SUBTOTAL:	66,319.93	66,726.54	66,823.7	6	67,215.33	67,219.35	67,294.00	67,263.38	67,312.60	0.00	0.00	0.00	0.00		536,174.89		

8700	SSI DISABLED FREEDO M	42.00	36.25	45.99	51.93	42.87	52.85	54.60	61.99	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	0.38	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	36.00	38.05	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	23.00	27.00	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	113.98	127.04	0.00	0.00	0.00	0.00	

 
388.48	
8.30	
288.02	
4.99	
166.60	
0.16	
856.55	

TOTAL:	66,411.91	66,814.51	66,928.75	67,330.21	67,316.28	67,412.78	67,377.36	67,439.64	0.00	0.00	0.00	0.00		537,031.44		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending February 29, 2020	
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	-210.80	-288.28	0.00	0.00	0.00	0.00		-499.08		
1012	TANF 01-05 M & F NON	360.61	0.00	368.93	21.43	29.06	0.00	0.00	-363.05	0.00	0.00	0.00	0.00		416.98		
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	-708.72	0.00	0.00	0.00	0.00	0.00		-33.11		
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	-166.47	0.00	0.00	0.00	0.00		-2,417.38		
4312	SOBRA CHILD 01-05 M	-100.40	1,427.57	203.97	1,154.33	0.00	-1,788.51	0.00	-1,942.13	0.00	0.00	0.00	0.00		-1,045.17		
4313	SOBRA CHILD 06-13 M	292.16	-195.37	-41.12	0.00	182.68	-1,779.22	-737.03	0.00	0.00	0.00	0.00	0.00		-2,277.90		
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		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431C	SOBRA CHILD 6-13 M& F	67.66	0.00	0.00	0.00	0.00	0.00	-15.79	0.00	0.00	0.00	0.00	0.00		51.87		
SUBTOTAL:	864.84	1,910.97	-1,030.79	-270.07	1,084.05	-2,908.31	-1,672.34	-2,759.93	0.00	0.00	0.00	0.00		-4,781.58		

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

4415

SOBRA 100-133% FEMA L

405.96

405.96

SUBTOTAL:

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

-0.07

-0.07

-4,375.69

864.84	2,316.93	-1,030.86	-270.07	1,084.05	-2,908.31	-1,672.34	-2,759.93	0.00	0.00	0.00	0.00	

TOTAL:

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

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

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 < 1 M &

431A

0.00

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 February 29, 2020

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

SUBTOTAL:

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

0.00

0.00

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

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending February 29, 2020	
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	27,348.14	34,714.60	0.00	0.00	0.00	0.00		238,290.54		
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	625.59	0.00	0.00	0.00	0.00		732.00		
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	481.66	-27.82	0.00	0.00	0.00	0.00		64,291.02		
1018	TANF 45-64 M & F NON	0.00	0.00	20,190.63	1,223.66	0.00	2,076.42	0.00	2,921.31	0.00	0.00	0.00	0.00		26,412.02		
101D	TANF 14-20 MALE NON-	47.31	0.00	710.45	0.00	0.00	0.00	0.00	1,864.48	0.00	0.00	0.00	0.00		2,622.24		
101F	TANF 21-44 MALE NON-	3,972.40	0.00	0.00	83.06	0.00	1,578.08	0.00	83.06	0.00	0.00	0.00	0.00		5,716.60		
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	2,990.04	0.00	0.00	0.00	0.00	0.00		3,601.18		
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	1,308.05	0.00	0.00	0.00	0.00		3,666.42		
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	1,649.28	0.00	0.00	0.00	0.00		4,045.30		
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	5,561.04	7,054.18	0.00	0.00	0.00	0.00		58,247.58		
2200	SSI DISABLED WITH M E	6,705.80	6,218.03	9,375.73	5,561.04	5,561.04	10,710.56	13,078.72	10,710.56	0.00	0.00	0.00	0.00		67,921.48		
220Z	SSI DISABLED WITH M
E	1,230.03	0.00	1,706.25	2,617.33	2,574.76	2,368.16	4,621.53	266.35	0.00	0.00	0.00	0.00		15,384.41		
2210	SSI DISABLED NON-ME D	191,817.13	229,386.03	284,569.91	201,387.94	201,591.32	203,320.03	196,743.54	211,338.05	0.00	0.00	0.00	0.00		1,720,153.95		
221Z	SSI DISABLED NON-ME
D	4,176.42	1,262.61	0.00	1,777.83	5,372.05	2,956.83	6,893.72	88.78	0.00	0.00	0.00	0.00		22,528.24		
2220	SSI DISABLED WITH Q M	70,948.72	70,948.72	97,309.03	75,572.44	75,515.56	76,193.83	100,471.14	81,212.03	0.00	0.00	0.00	0.00		648,171.47		
222Z	SSI DISABLED WITH Q
M	880.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		880.65		
2310	SSI BLIND NON-MEDIC A	1,706.25	1,706.25	1,706.25	1,649.28	1,649.28	1,649.28	1,649.28	1,649.28	0.00	0.00	0.00	0.00		13,365.15		
4314	SOBRA CHILD 14-20 MA	1,680.63	0.00	113.75	159.61	0.00	0.00	212.81	0.00	0.00	0.00	0.00	0.00		2,166.80		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	157.88	913.62	171.66	242.67	1,926.64	88.78	0.00	0.00	0.00	0.00		3,501.25		
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	9,373.56	6,798.80	0.00	0.00	0.00	0.00		40,581.28		
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	371,351.82	362,345.36	0.00	0.00	0.00	0.00		2,970,224.98		

1100	TANF EXPANDED FPR FI	5,780.66	5,780.66	5,780.66	5,873.32	5,873.32	5,873.32	5,873.32	5,873.32	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	18,800.82	17,151.54	0.00	0.00	0.00	0.00	

 
46,708.58	
1,680.63	
625.63	
191,873.51	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending February 29, 2020	
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	355.14	0.00	0.00	0.00	0.00		12,881.85		
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	1,493.14	1,493.14	0.00	0.00	0.00	0.00		11,865.44		
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	6,642.66	6,642.66	0.00	0.00	0.00	0.00		70,723.70		
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	83.06	0.00	0.00	0.00	0.00		83.06		
260Z	SSI DISABLED EXPAND E	440.32	1,772.15	534.75	0.00	355.58	0.00	529.82	1,764.24	0.00	0.00	0.00	0.00		5,396.86		
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	24,875.82	27,450.58	0.00	0.00	0.00	0.00		230,740.44		
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	58,215.58	60,813.68	0.00	0.00	0.00	0.00		606,603.64		

3910	NEWLY ELIGIBLE FOR F	11,840.80	11,840.80	13,307.38	10,299.04	9,373.56	14,321.40	20,038.58	12,672.12	0.00	0.00	0.00	0.00	

103,693.68

3510	ADULT 40-100% FOR FI	49,075.49	46,707.33	45,143.84	49,294.58	57,018.86	52,383.30	52,383.30	52,227.16	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	-2,752.33	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	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	-1,383.27	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	175,697.10	179,921.14	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	-2,408.29	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	-2,944.51	11,781.33	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	25,607.36	-17.18	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	1,993.36	8,454.82	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	1,242.99	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	1,915.30	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	5,687.68	8,797.88	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	415.28	2,530.67	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	1,213.32	3,709.34	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	258,176.63	265,895.82	0.00	0.00	0.00	0.00	

 
404,233.86	
-2,656.22	
2,480.78	
-1,383.27	
7,091.43	
3,122.83	
266.01	
1,511,923.33	
1,554.27	
100,198.80	
80,957.03	
15,968.86	
1,669.35	
3,078.09	
45,924.35	
19,514.41	
20,130.81	
2,214,074.72	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	913.62	0.00	0.00	0.00	0.00	0.00		913.62		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	-532.03	0.00	0.00	0.00	0.00	0.00		-532.03		
3917	NEWLY ELIGIBLE FEMA L	236.82	0.00	0.00	0.00	0.00	1,011.48	-1,155.98	0.00	0.00	0.00	0.00	0.00		92.32		
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		4,119.62		
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	9,509.12	337.16	720.83	0.00	0.00	0.00	0.00		10,567.11		
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	19,601.35	13,392.95	0.00	0.00	0.00	0.00		120,046.51		

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

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	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	3,405.33	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	3,405.33	0.00	0.00	0.00	0.00	0.00	

 
7,938.08	
3,405.33	
2,574.76	
13,918.17	

1,818.14

5,926,852.27

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	

833,762.78	698,694.23	750,893.38	693,531.20	710,750.71	702,447.81	0.00	0.00	0.00	0.00	

1,818.14

TOTAL:

767,862.18

768,909.98

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 February 29, 2020

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 February 29, 2020

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

2600

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
SSI DISABLED EXPAND

Curren

0.00

0.00

t and

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

E
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

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	
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	
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	
0.00	

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

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

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	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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

Cu

0.00

r

0 ren

0.00

t

0 an

0.00

d

pr

0.00

i

o

0	r m

0.00

0.00 ont0

0.00

h

.00	da

0.00

t

0 a is

0.00

0.00 und0.00

0.00

er r

0e

0.00

.00 vis

0.00

i

o

0	n.0.00

0.00

0.0

0.0

0.

00

0

.0

0.0

0

.0

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 - GENERAL
For The Period Ending February 29, 2020	
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		
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		
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	980.16	0.00	0.00	0.00	0.00		4,068.85		
2110	SSI AGED NON-MEDIC
AR	0.00	0.00	-140.84	0.00	270.84	0.00	606.93	70.53	0.00	0.00	0.00	0.00		807.46		
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	141.06	0.00	0.00	0.00	0.00	0.00		2,848.48		
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	-1,460.62	0.00	0.00	0.00	0.00		-6,844.57		
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	747.99	-409.93	0.00	0.00	0.00	0.00		5,693.04		

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	

155.73

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	211.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	-182.58	-717.48	0.00	0.00	-239.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	1,192.81	0.00	0.00	51.35	-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	1,337.10	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	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	1,002.09	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-112.05	-1,019.66	0.00	0.00	164.84	-850.88	2,339.19	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	
1,901.34	
38.57	
1,002.09	
521.44	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		

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	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	-3.91	-227.52	-5.05	-4.54	-291.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	-3.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	-1,000.44	0.00	846.36	0.00	-594.04	0.00	-1,460.62	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	0.00	-22.67	0.00	0.00	-43.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	634.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	797.20	-195.66	0.00	79.72	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	-1,002.09	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	-806.04	-3,513.00	-2,336.03	0.00	-508.42	-6.85	741.35	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	-1,472.07	-946.56	-1,462.31	0.00	0.00	0.00	-630.22	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	-19.73	-13.68	-3,605.55	-1,021.40	-1,055.24	-6.77	452.62	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	211.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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	
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	
SUBTOTAL:	-2,393.56	-3,525.27	-6,979.02	-1,025.94	-2,412.92	-1,015.71	-896.87	0.00	0.00	0.00	0.00	0.00	

 
209.24	
0.00	
-532.24	
-3.41	
-2,208.74	
-66.39	
634.77	
681.26	
-1,002.09	
-6,428.99	
-4,511.16	
-5,269.75	
211.59	
-79.72	
441.46	
-43.00	
-282.12	
-18,249.29	

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

-12,464.15

-1,196.12	-3,952.91	-9,044.75	2,484.98	-2,543.71	7.98	2,190.31	-409.93	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 February 29, 2020

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

101E	TANF 14-20 FEMALE N
O
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

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	

221Z

2220

4312

4314

4315

5015

5017

SSI DISABLED NON-ME D
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	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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	

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending February 29, 2020	
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		

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

3514

3515

3516

3517

3518

351H

3709

3714

3715

3716

3717

3718

3719

371E

371F	ADULT 40-100% MALE 1

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

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

ADULT 40-100% M&F 45

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

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 FEM
AL
ADULT <40% EXP MALE	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
Cu0.00r
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
ren0.00t
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
an0.0d0
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
pr0i.00o
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
r m0.00 o
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
nt0h.00
0.00	0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00
da0.0t0 a is0.00
0.00	0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
und0.00e
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
r r0e.00
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
vis0i.0o0
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
n. 0.00
0.00	
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	
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 February 29, 2020	
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	446,156.43	453,507.28	0.00	0.00	0.00	0.00		4,127,273.09		
1011	TANF <1 M & F NON-ME	248.11	953.72	-5,125.27	13,521.89	13,832.51	15,769.15	11,885.33	9,531.50	0.00	0.00	0.00	0.00		60,616.94		
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	3,389.75	2,731.24	0.00	0.00	0.00	0.00		-50,036.46		
1013	TANF 06-13 M & F NON	-2,418.26	-7,544.45	3,346.51	2,532.68	-359.74	13,098.70	11,656.20	5,757.11	0.00	0.00	0.00	0.00		26,068.75		
1014	TANF 14-20 MALE NON-	-811.16	-1,806.09	1,478.38	4,248.21	3,277.70	2,891.87	7,366.93	6,689.71	0.00	0.00	0.00	0.00		23,335.55		
1015	TANF 14-20 FEMALE N O	-368.71	-1,388.95	1,344.21	1,730.28	109.06	1,536.14	1,829.98	535.91	0.00	0.00	0.00	0.00		5,327.92		
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	-952.17	-481.32	0.00	0.00	0.00	0.00		-1,230.43		
101B	TANF 01-05 M & F NON	-261.17	93.90	0.00	-3,216.83	-3,592.59	0.00	-3,671.64	10,326.32	0.00	0.00	0.00	0.00		-322.01		
101C	TANF 06-13 M & F NON	1,300.68	-970.35	-792.55	76.20	584.84	0.00	-2,421.11	8,880.71	0.00	0.00	0.00	0.00		6,658.42		
101D	TANF 14-20 MALE NON-	751.24	516.19	0.00	25.40	0.00	0.00	39.52	1,128.25	0.00	0.00	0.00	0.00		2,460.60		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	656.67	0.00	0.00	0.00	0.00	0.00		656.67		
2210	SSI DISABLED NON-ME
D	258,752.13	259,937.48	275,290.68	289,225.88	304,241.49	304,336.28	298,546.61	301,634.36	0.00	0.00	0.00	0.00		2,291,964.91		
221Z	SSI DISABLED NON-ME D	232.93	-271.78	-3,810.00	1,516.45	862.55	-9,631.67	630.94	402.28	0.00	0.00	0.00	0.00		-10,068.30		
2220	SSI DISABLED WITH Q
M	762.00	762.00	762.00	817.98	817.98	998.50	1,017.84	1,017.84	0.00	0.00	0.00	0.00		6,956.14		
2310	SSI BLIND NON-MEDIC A	762.00	762.00	762.00	817.98	817.98	817.98	817.98	817.98	0.00	0.00	0.00	0.00		6,375.90		
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	11,636,846.70	11,698,631.77	0.00	0.00	0.00	0.00		89,099,376.19		
4311	SOBRA CHILD <1 M & F	13,625.43	15,714.43	26,374.80	64,140.68	41,219.20	59,058.28	64,432.34	49,270.61	0.00	0.00	0.00	0.00		333,835.77		
4312	SOBRA CHILD 01-05 M	-74,721.61	-78,041.28	-39,438.44	-22,022.88	-20,911.83	7,244.40	-36,710.04	-41,526.32	0.00	0.00	0.00	0.00		-306,128.00		
4313	SOBRA CHILD 06-13 M	-105,628.37	-106,985.86	-26,667.13	-38,539.84	-21,900.32	27,437.29	-10,484.05	-12,268.73	0.00	0.00	0.00	0.00		-295,037.01		
4314	SOBRA CHILD 14-20 MA	-43,134.77	-38,503.25	2,887.88	-13,089.30	-18,636.85	19,331.13	-53,440.89	-3,144.48	0.00	0.00	0.00	0.00		-147,730.53		
4315	SOBRA CHILD 14-20 FE	-40,754.75	-20,963.64	-19,790.76	-8,327.22	-6,843.88	12,845.59	-8,684.91	-5,620.86	0.00	0.00	0.00	0.00		-98,140.43		
431A	SOBRA CHILD < 1 M &	1,940.81	16,788.88	6,353.47	1,731.58	3,643.65	2,679.78	11,422.99	7,436.07	0.00	0.00	0.00	0.00		51,997.23		
431B	SOBRA CHILD 01-05 M	12,785.94	9,798.85	10,136.79	6,573.62	-2,311.77	37,843.20	23,342.31	23,532.48	0.00	0.00	0.00	0.00		121,701.42		
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	13,896.58	39,962.65	0.00	0.00	0.00	0.00		147,153.17		
431D	SOBRA CHILD 14-20 MA	16,781.28	5,724.71	4,846.17	2,208.14	-63.14	4,029.48	9,926.38	13,416.52	0.00	0.00	0.00	0.00		56,869.54		
431E	SOBRA CHILD 14-20 FE	11,745.14	9,190.46	4,671.89	1,089.23	5,678.75	4,486.96	-241.30	6,037.92	0.00	0.00	0.00	0.00		42,659.05		
5010	SOBRA PREGNANT WO MAN	13,738.15	13,995.75	20,755.25	22,862.96	19,191.32	18,173.48	19,398.75	19,398.75	0.00	0.00	0.00	0.00		147,514.41		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	817.98	-1,746.16	471.42	1,301.21	0.00	-1,098.52	0.00	0.00	0.00	0.00		-254.07		
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	12,446,654.12	12,596,507.03	0.00	0.00	0.00	0.00		95,651,329.27		

3710	AHC CARE EXPANDED FO	0.00	0.00	762.00	817.98	817.98	2,861.23	2,453.94	2,453.94	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	733.36	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	111.01	0.00	0.00	0.00	0.00	

 
10,167.07	
1,167.49	
347.42	
-432.61	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending February 29, 2020	
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	2,453.94	3,298.31	0.00	0.00	0.00	0.00		11,938.06		

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

 
4,851.90	
589.94	
172.06	
5,613.90	

4410	SOBRA 100-133% FOR F	12,926.90	12,373.25	10,432.55	10,404.37	11,422.21	10,604.23	10,604.23	9,586.39	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	6,168.75	3,321.31	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	1,213.23	979.05	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	1,769.56	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	84.50	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	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	237.48	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	19,755.77	14,208.73	0.00	0.00	0.00	0.00	

 
88,354.13	
19,475.70	
4,374.41	
5,043.50	
765.62	
127.00	
237.48	
118,377.84	

S000

STATE-ONLY BHS

-762.00

-762.00

95,786,497.07

0.00	-762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	-762.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,210,666.00	11,151,108.99	11,528,229.23	12,229,074.55	12,153,281.48	12,429,622.96	12,469,681.81	12,614,832.05	0.00	0.00	0.00	0.00	

SUBTOTAL: TOTAL:

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 February 29, 2020

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 February 29, 2020	
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	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

S000

STATE-ONLY BHS

0.00

0.00

Cu0.00rr	en0.00	t an0.0d0	pr0i.00or	m0.00	ont0h.00	da0.0t0 a is0.00	und0.00er	r0e.00	vis0i.0o0	n. 0.00	
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:

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 February 29, 2020	
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	1,794.06	0.00	0.00	0.00	0.00		327,706.82		
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	-1,174.82	0.00	0.00	0.00	0.00		1,171,275.43		
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	-1,151.37	1,655.99	0.00	0.00	0.00	0.00		17,660,033.75		
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	-761.97	-774.88	0.00	0.00	0.00	0.00		2,919,264.21		
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	-1,913.34	1,500.35	0.00	0.00	0.00	0.00		22,528,303.16		

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

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

22,552,597.32

7,458,765.69	7,517,688.26	7,570,386.98	6,293.18	-134.42	10.62	-1,913.34	1,500.35	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending February 29, 2020

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 February 29, 2020	
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	17.58	17.58	0.00	0.00	0.00	0.00		137.43		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	2.74	2.74	2.74	0.00	0.00	0.00	0.00		8.22		
1006	TANF 21-44 MALE WITH	572.44	524.04	554.06	610.44	653.58	621.63	624.45	576.90	0.00	0.00	0.00	0.00		4,737.54		
1007	TANF 21-44 FEMALE WI	697.86	633.68	569.00	684.33	704.31	709.50	675.54	657.99	0.00	0.00	0.00	0.00		5,332.21		
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	1,757.73	1,676.19	0.00	0.00	0.00	0.00		12,643.83		
1009	TANF 65+ M & F WITH	784.65	740.61	658.68	876.87	918.39	962.73	1,016.22	1,095.72	0.00	0.00	0.00	0.00		7,053.87		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	1,298.21	1,375.91	1,357.25	1,475.44	1,520.07	0.00	0.00	0.00	0.00		7,026.88		
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	17,679.34	17,674.98	0.00	0.00	0.00	0.00		130,500.16		
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	37,416.14	36,826.17	0.00	0.00	0.00	0.00		264,184.79		
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	68,190.74	68,074.22	0.00	0.00	0.00	0.00		483,658.78		
1014	TANF 14-20 MALE NON-	29,752.48	29,183.72	29,422.86	36,763.51	37,072.83	39,533.02	38,989.76	39,415.19	0.00	0.00	0.00	0.00		280,133.37		
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	61,438.65	62,236.90	0.00	0.00	0.00	0.00		456,228.87		
1016	TANF 21-44 MALE NON-	196,818.83	196,825.88	198,260.40	238,341.36	238,159.44	243,350.34	239,944.65	238,359.09	0.00	0.00	0.00	0.00		1,790,059.99		
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	809,584.44	809,750.55	0.00	0.00	0.00	0.00		6,079,790.91		
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	197,617.32	198,233.13	0.00	0.00	0.00	0.00		1,467,091.28		
1019	TANF 65+ M & F NON-M	674.30	651.26	689.40	813.75	820.95	920.79	906.81	985.86	0.00	0.00	0.00	0.00		6,463.12		
1020	TANF WITH QMB	0.00	0.00	0.00	40.74	40.74	20.37	20.37	20.37	0.00	0.00	0.00	0.00		142.59		
1024	TANF 14-20 MALE WITH	10.41	1.08	1.08	1.36	1.36	1.36	1.36	10.15	0.00	0.00	0.00	0.00		28.16		
1026	TANF 21-44 MALE WITH	387.68	364.94	366.97	429.87	417.06	424.65	401.49	463.38	0.00	0.00	0.00	0.00		3,256.04		
1027	TANF 21-44 FEMALE WI	653.45	638.63	661.09	729.06	730.26	746.64	753.42	759.81	0.00	0.00	0.00	0.00		5,672.36		
1028	TANF 45-64 M & F WIT	835.76	807.47	773.65	772.59	694.71	854.49	760.23	884.85	0.00	0.00	0.00	0.00		6,383.75		
1029	TANF 65+ M & F WITH	450.07	433.44	423.81	508.56	487.77	526.92	516.12	559.23	0.00	0.00	0.00	0.00		3,905.92		
2100	SSI AGED WITH MEDIC A	32,980.00	32,982.55	33,054.20	141,547.41	142,231.14	142,090.11	140,892.66	141,052.32	0.00	0.00	0.00	0.00		806,830.39		
2110	SSI AGED NON-MEDIC
AR	53,956.16	54,404.88	54,776.81	70,837.29	71,168.91	71,596.68	71,768.49	71,666.76	0.00	0.00	0.00	0.00		520,175.98		
2120	SSI AGED WITH QMB	256,470.33	258,178.50	259,225.39	392,946.39	393,935.16	395,182.59	397,918.35	399,658.62	0.00	0.00	0.00	0.00		2,753,515.33		
2200	SSI DISABLED WITH M E	25,887.66	25,631.83	25,902.25	69,776.70	69,843.69	69,360.39	68,955.78	67,950.30	0.00	0.00	0.00	0.00		423,308.60		
2210	SSI DISABLED NON-ME
D	277,976.12	277,927.49	278,125.13	480,981.11	482,036.96	483,811.33	485,932.16	487,393.59	0.00	0.00	0.00	0.00		3,254,183.89		
2220	SSI DISABLED WITH Q M	170,604.53	170,784.02	170,828.67	276,883.13	277,277.65	277,481.54	278,444.62	277,364.76	0.00	0.00	0.00	0.00		1,899,668.92		
2300	SSI BLIND WITH MEDIC	235.51	244.84	214.82	270.87	296.04	289.26	302.85	282.48	0.00	0.00	0.00	0.00		2,136.67		
2310	SSI BLIND NON-MEDIC A	3,591.59	3,599.17	3,649.81	4,587.91	4,550.70	4,565.88	4,579.46	4,409.15	0.00	0.00	0.00	0.00		33,533.67		
2320	SSI BLIND WITH QMB	1,900.92	1,912.30	1,925.39	2,370.60	2,435.31	2,388.99	2,415.36	2,372.64	0.00	0.00	0.00	0.00		17,721.51		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	1.36	1.36	1.36	0.00	0.00	0.00	0.00		4.08		
4302	SOBRA CHILD 01-05 M	3.24	3.24	5.40	6.80	6.80	4.08	4.08	5.44	0.00	0.00	0.00	0.00		39.08		
4303	SOBRA CHILD 06-13 M	9.76	9.76	10.85	13.70	13.70	13.70	13.70	13.70	0.00	0.00	0.00	0.00		98.87		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	1.36	1.36	1.36	0.00	0.00	0.00	0.00	0.00		4.08		
4305	SOBRA CHILD 14-20 FE	20.16	17.99	9.33	11.58	11.58	11.58	11.58	11.58	0.00	0.00	0.00	0.00		105.38		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending February 29, 2020	
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	59,710.57	59,482.01	0.00	0.00	0.00	0.00		445,235.39		
4312	SOBRA CHILD 01-05 M	236,845.73	238,192.76	238,593.68	299,784.93	297,048.72	292,268.85	290,325.82	289,825.36	0.00	0.00	0.00	0.00		2,182,885.85		
4313	SOBRA CHILD 06-13 M	310,882.77	313,296.50	314,734.87	397,068.44	394,162.68	389,393.67	387,892.25	387,123.27	0.00	0.00	0.00	0.00		2,894,554.45		
4314	SOBRA CHILD 14-20 MA	155,400.15	157,444.43	158,328.17	193,512.39	192,498.84	190,731.36	189,892.04	187,415.99	0.00	0.00	0.00	0.00		1,425,223.37		
4315	SOBRA CHILD 14-20 FE	157,772.95	160,194.90	160,353.44	196,109.27	196,274.41	193,532.81	192,721.03	190,909.02	0.00	0.00	0.00	0.00		1,447,867.83		
4322	SOBRA CHILD 01-05 M	1.08	1.08	1.08	1.36	1.36	1.36	1.36	1.36	0.00	0.00	0.00	0.00		10.04		
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		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	1.36	0.00	0.00	0.00	0.00	0.00		1.36		
4325	SOBRA CHILD 14-20 FE	2.17	11.92	11.92	14.27	14.27	5.48	5.48	5.48	0.00	0.00	0.00	0.00		70.99		
5007	SOBRA PREG 21-44 FE M	148.67	173.44	218.64	246.09	218.52	246.48	198.15	235.68	0.00	0.00	0.00	0.00		1,685.67		
5008	SOBRA PREG 45-64 FE
M	11.36	11.36	11.36	13.59	13.59	13.59	13.59	0.00	0.00	0.00	0.00	0.00		88.44		
5013	SOBRA PREG 09-13 FE M	3.32	8.72	6.56	4.30	8.40	16.51	12.41	11.03	0.00	0.00	0.00	0.00		71.25		
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	21,648.74	21,309.65	0.00	0.00	0.00	0.00		168,183.51		
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	137,625.72	135,271.08	0.00	0.00	0.00	0.00		1,075,662.54		
5018	SOBRA PREG 45-64 FE
M	307.55	390.33	379.25	514.56	486.21	515.73	441.45	441.45	0.00	0.00	0.00	0.00		3,476.53		
5027	SOBRA PREG 21-44 FE M	205.51	237.30	212.81	245.67	246.87	278.04	276.84	219.72	0.00	0.00	0.00	0.00		1,922.76		
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	8.79	17.58	8.79	8.79	17.58	0.00	0.00	0.00	0.00		61.53		
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	4,211,807.95	4,204,252.45	0.00	0.00	0.00	0.00		30,372,771.83		

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	1,906.32	1,781.31	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	3,100.86	3,142.80	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	10,301.34	10,245.75	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	6,523.08	6,428.40	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	4.19	4.19	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	2,082.60	2,038.68	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	13,100.57	12,910.12	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	235,301.46	233,581.11	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	657,458.82	656,545.95	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	228,561.51	228,219.69	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	912.78	965.91	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	6,045.93	6,004.38	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	12,546.66	12,622.86	0.00	0.00	0.00	0.00	

7.58	
13,845.70	
23,741.82	
78,401.17	
47,684.71	
2.17	
64.23	
15,878.45	
102,227.85	
1,811,585.41	
4,988,489.48	
1,735,007.43	
6,281.29	
46,343.97	
96,152.04	

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 February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	18,557.98	18,675.72	19,068.13	22,623.30	22,318.02	22,458.90	22,337.49	22,445.46	0.00	0.00	0.00	0.00		168,485.00		
1129	TANF EXPANDED 65+
M&	12,988.91	13,110.24	13,310.80	16,421.55	16,549.35	16,636.83	16,559.34	16,460.28	0.00	0.00	0.00	0.00		122,037.30		
2400	SSI AGED EXPANDED WI	839.74	893.69	957.51	1,046.58	1,306.71	1,049.43	1,094.94	1,556.01	0.00	0.00	0.00	0.00		8,744.61		
2410	SSI AGED EXPANDED
NO	734.20	842.92	773.27	900.06	912.84	904.47	896.07	859.32	0.00	0.00	0.00	0.00		6,823.15		
2420	SSI AGED EXPANDED WI	200,778.15	202,142.27	203,515.08	246,928.83	247,840.44	249,594.81	249,472.80	248,471.70	0.00	0.00	0.00	0.00		1,848,744.08		
2520	SSI BLIND EXPANDED
W	7.58	7.58	7.58	8.79	17.58	17.58	17.58	17.58	0.00	0.00	0.00	0.00		101.85		
2600	SSI DISABLED EXPAND E	762.25	849.07	753.42	803.40	1,180.50	1,365.09	1,375.92	1,582.77	0.00	0.00	0.00	0.00		8,672.42		
2610	SSI DISABLED EXPAND
E	10,383.49	10,503.92	10,814.11	13,250.58	13,618.53	13,962.93	13,969.80	14,428.92	0.00	0.00	0.00	0.00		100,932.28		
2620	SSI DISABLED EXPAND E	99,455.39	99,763.22	99,882.81	119,843.46	119,853.90	119,801.04	119,302.05	118,826.94	0.00	0.00	0.00	0.00		896,728.81		
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	1,602,872.11	1,599,140.13	0.00	0.00	0.00	0.00		12,126,982.80		

3506	ADULT 40-100% MALE 2	39.65	24.49	41.40	58.32	40.74	52.32	40.74	61.11	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	29.16	29.16	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	518.13	617.94	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	63.12	278.43	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	54,326.61	54,476.40	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	58,019.37	58,407.60	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	170,121.33	168,163.38	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	144,637.32	143,631.18	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	336,207.87	333,160.95	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	77.49	284.43	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	8.79	8.79	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	188.55	209.73	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	64.32	55.53	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	653.55	590.46	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	92.28	178.56	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	100,110.90	100,409.34	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	90,615.39	90,742.68	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	687,947.79	692,997.18	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	387,174.00	388,857.66	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	765,906.66	769,092.42	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	37.95	585.27	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	29.16	0.00	0.00	0.00	0.00	

 
358.77	
185.63	
4,143.87	
1,080.25	
405,908.56	
438,987.86	
1,293,336.36	
1,092,104.64	
2,549,985.53	
686.92	
47.54	
52.70	
49.65	
7.58	
1,342.59	
516.28	
4,672.01	
768.94	
752,483.47	
681,884.69	
5,099,076.85	
2,885,777.45	
5,723,600.16	
1,047.11	
143.61	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3727	ADULT <40% EXP FEM AL	15.16	7.58	16.91	20.37	8.79	8.79	8.79	8.79	0.00	0.00	0.00	0.00		95.18		
3728	ADULT <40% EXP M&F
4	0.00	3.78	20.69	29.16	42.75	20.37	8.79	37.95	0.00	0.00	0.00	0.00		163.49		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	11.58	11.58	11.58	0.00	0.00	0.00	0.00	0.00		34.74		
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	2,796,870.48	2,802,914.10	0.00	0.00	0.00	0.00		20,938,542.43		

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	68,675.39	68,156.95	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	35,639.32	34,628.31	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	34,799.29	34,158.42	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	139,114.00	136,943.68	0.00	0.00	0.00	0.00	

522,764.86	
273,837.00	
267,407.64	
1,064,009.50	

4517	BC PATIENT FEMALE 2 1	143.38	164.09	156.51	211.74	220.53	220.53	202.95	202.95	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	1,195.26	1,229.22	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	47.55	47.55	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	110.64	110.64	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	1,556.40	1,590.36	0.00	0.00	0.00	0.00	

1,522.68	
8,709.46	
386.88	
716.13	
11,335.15	

8600	SSI BLIND FREEDOM/W O	7.58	7.58	7.58	8.79	8.79	8.79	8.79	8.79	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	11.58	11.58	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	13,824.06	13,855.71	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	3,073.05	3,143.76	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	2,545.56	2,530.77	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	19,463.04	19,550.61	0.00	0.00	0.00	0.00	

66.69	
85.89	
102,451.34	
22,945.31	
18,202.65	
143,751.88	

3906	NEWLY ELIGIBLE MALE	90.34	82.78	88.61	131.82	118.23	146.61	127.44	139.02	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	75.90	75.90	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	660.36	834.12	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	102.66	248.10	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	30,041.10	30,186.93	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	33,830.31	34,098.78	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	149,610.00	148,151.58	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	226,956.03	226,353.63	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	231,724.08	231,098.28	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	16.38	126.24	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	9.33	0.00	0.00	8.79	0.00	0.00	8.79	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	17.58	31.95	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	673,170.63	671,344.53	0.00	0.00	0.00	0.00	

 
924.85	
325.10	
4,988.86	
1,496.34	
224,692.79	
255,311.30	
1,157,665.09	
1,745,358.02	
1,765,389.07	
282.47	
26.91	
11.58	
143.42	
21.90	
5,156,637.70	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
6015	KIDS 14-19 FEMALE NO	18.76	21.00	12.32	0.00	9.60	0.00	0.00	16.38	0.00	0.00	0.00	0.00		78.06		
SUBTOTAL:	18.76	21.00	12.32	0.00	9.60	0.00	0.00	16.38	0.00	0.00	0.00	0.00		78.06		

69,814,202.73

7,421,096.76	7,478,127.98	7,510,423.34	9,519,723.30	9,511,421.83	9,492,802.67	9,444,854.61	9,435,752.24	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending February 29, 2020

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

4311

SOBRA CHILD <1 M & F

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

0.00

4313

SOBRA CHILD 06-13 M

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4314

4315

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

4322

SOBRA CHILD 01-05 M

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4323

SOBRA CHILD 06-13 M

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

4324

4325

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

5007

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5008

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5013

5015

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5017

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

5018

Current and

0.00

0.00

0.00

prior month

0.00

0.00

0.00

5027

0.00

0.00

0.00

0.00

0.00

0.00

data is under revisio

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

n.

0.00

0.00

0.00

0.00

TOTAL

JUNE

MAY

APRIL

MARCH

FEBRUARY

JANUARY

DECEMBER

NOVEMBER

OCTOBER

AUGUST	SEPTEMBER

JULY

RATE CODE	DESCRIPTION

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending February 29, 2020

5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
																
3100	TRANSPLANT OPTION 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

1104	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
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 February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		

3509

ADULT 40-100% M&F 65

3514

ADULT 40-100% MALE 1

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

3515

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

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3516

3517

3518

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

3528

3529

ADULT 40-100% MALE 2

ADULT 40-100% M&F 45

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

3704

ADULT <40% EXP MALE

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3706

3707

3708

ADULT <40% EXP MALE

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

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

3709

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

3715

3716

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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
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

3718

3719

3726

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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	

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		

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	

3906

3907

3908

3909

3914

3915

3916

3917

3918

3919

3926

3927	NEWLY ELIGIBLE MALE

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

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

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

NEWLY ELIGIBLE FEMA L	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
Cu0.00r
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
ren0.00t
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
an0.0d0
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
pr0i.00o
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
r m0.00 o
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
nt0h.00
0.00	0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00
da0.0t0 a is0.00
0.00	0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
und0.00e
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
r r0e.00
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
vis0i.0o0
0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00
n. 0.00
0.00	
3928	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		
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 February 29, 2020	
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	17,760.82	6,375.96	0.00	0.00	0.00	0.00		60,755.10		
1007	TANF 21-44 FEMALE WI	5,660.13	8,315.12	3,656.17	5,435.78	2,517.23	3,959.23	7,058.31	1,052.26	0.00	0.00	0.00	0.00		37,654.23		
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	21,405.05	9,742.10	0.00	0.00	0.00	0.00		122,875.45		
1009	TANF 65+ M & F WITH	7,573.40	7,048.03	5,895.29	8,756.67	14,657.56	7,617.34	10,230.75	10,826.43	0.00	0.00	0.00	0.00		72,605.47		
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	1,615,448.25	1,427,161.08	0.00	0.00	0.00	0.00		10,161,862.59		
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	472,917.04	516,491.18	0.00	0.00	0.00	0.00		3,247,137.51		
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	656,374.99	624,231.08	0.00	0.00	0.00	0.00		4,676,275.94		
1014	TANF 14-20 MALE NON-	203,236.61	175,532.08	149,342.10	162,062.58	211,886.30	200,679.55	206,889.36	179,669.02	0.00	0.00	0.00	0.00		1,489,297.60		
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	461,146.32	438,465.28	0.00	0.00	0.00	0.00		3,287,062.65		
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	2,310,595.30	2,335,532.33	0.00	0.00	0.00	0.00		17,502,157.74		
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	7,788,280.56	7,605,552.88	0.00	0.00	0.00	0.00		58,699,693.49		
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	3,325,988.96	3,099,900.13	0.00	0.00	0.00	0.00		24,087,511.31		
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	6,128.13	6,388.27	0.00	0.00	0.00	0.00		50,681.06		
1026	TANF 21-44 MALE WITH	5,452.82	2,600.75	875.03	1,475.75	455.00	910.00	1,001.55	1,365.00	0.00	0.00	0.00	0.00		14,135.90		
1027	TANF 21-44 FEMALE WI	8,052.27	3,119.24	1,357.57	1,942.85	3,864.76	1,351.45	2,109.16	1,555.01	0.00	0.00	0.00	0.00		23,352.31		
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	8,334.34	2,659.18	0.00	0.00	0.00	0.00		45,559.63		
1029	TANF 65+ M & F WITH	11,881.21	6,449.88	10,048.57	5,614.64	7,235.43	4,468.56	5,552.58	6,152.20	0.00	0.00	0.00	0.00		57,403.07		
2100	SSI AGED WITH MEDIC A	231,952.74	259,830.87	132,481.39	252,617.63	276,656.69	204,516.23	234,251.53	232,635.10	0.00	0.00	0.00	0.00		1,824,942.18		
2110	SSI AGED NON-MEDIC
AR	164,988.00	142,495.88	96,068.65	168,374.24	260,998.19	205,990.03	184,281.88	186,528.49	0.00	0.00	0.00	0.00		1,409,725.36		
2120	SSI AGED WITH QMB	696,504.68	647,287.68	605,933.24	718,218.99	1,059,551.70	625,448.61	873,260.89	859,866.18	0.00	0.00	0.00	0.00		6,086,071.97		
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	685,069.38	579,291.36	0.00	0.00	0.00	0.00		5,301,682.43		
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	12,093,669.20	10,940,526.94	0.00	0.00	0.00	0.00		85,787,194.62		
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	2,013,773.20	1,864,049.43	0.00	0.00	0.00	0.00		14,114,392.68		
2300	SSI BLIND WITH MEDIC	2,786.12	2,517.54	1,645.59	4,405.82	6,481.73	6,297.08	4,508.06	5,758.30	0.00	0.00	0.00	0.00		34,400.24		
2310	SSI BLIND NON-MEDIC A	105,581.25	151,794.37	90,576.36	88,921.37	174,467.52	128,727.62	120,528.28	121,006.51	0.00	0.00	0.00	0.00		981,603.28		
2320	SSI BLIND WITH QMB	25,806.73	19,005.13	19,779.17	28,930.91	31,467.87	25,875.18	28,615.81	23,377.12	0.00	0.00	0.00	0.00		202,857.92		
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	3,466,429.44	3,322,061.36	0.00	0.00	0.00	0.00		22,785,845.05		
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	5,702,158.33	5,880,027.73	0.00	0.00	0.00	0.00		39,080,426.20		
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	7,151,316.71	8,235,568.68	0.00	0.00	0.00	0.00		57,512,527.69		
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	2,015,922.11	2,300,569.67	0.00	0.00	0.00	0.00		16,784,302.08		
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	2,873,824.67	2,586,095.27	0.00	0.00	0.00	0.00		20,449,747.27		
5007	SOBRA PREG 21-44 FE M	1,468.11	1,067.27	1,508.98	1,106.22	266.60	2,168.74	1,862.10	2,069.22	0.00	0.00	0.00	0.00		11,517.24		
5013	SOBRA PREG 09-13 FE
M	0.00	581.96	1,820.00	455.00	0.00	455.00	0.00	132.96	0.00	0.00	0.00	0.00		3,444.92		
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	232,802.95	305,171.50	0.00	0.00	0.00	0.00		2,865,520.84		
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	2,606,745.86	2,282,230.41	0.00	0.00	0.00	0.00		20,081,939.16		
5018	SOBRA PREG 45-64 FE M	6,539.65	455.00	2,730.00	936.35	1,820.00	2,345.40	541.85	3,229.00	0.00	0.00	0.00	0.00		18,597.25		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
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	4,527.98	3,545.68	0.00	0.00	0.00	0.00		20,995.50		
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	57,211,311.70	56,006,860.30	0.00	0.00	0.00	0.00		418,993,754.93		

1106	TANF EXPANDED 21-44	5,110.76	1,764.45	2,329.25	6,481.93	7,114.30	3,731.06	5,229.86	9,058.25	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	11,033.07	8,528.69	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	44,363.65	47,000.82	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	61,874.74	61,886.70	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	455.00	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	5,682.68	17,916.09	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	41,892.68	33,063.01	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	1,171,622.73	966,261.70	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	3,204,334.96	3,047,714.75	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	2,100,388.54	1,891,678.41	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	5,505.72	7,570.81	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	15,487.76	9,519.85	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	60,595.12	58,218.41	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	162,597.98	157,694.00	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	102,328.63	106,368.42	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	11,057.18	10,586.32	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	26,875.63	43,316.93	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	817,064.56	827,376.80	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	17,630.58	18,967.23	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	298,990.61	303,130.86	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	562,307.74	525,516.24	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	8,726,864.42	8,151,829.29	0.00	0.00	0.00	0.00	

 
40,819.86	
81,677.30	
329,053.94	
370,925.29	
2,196.96	
108,741.04	
343,310.02	
7,534,771.86	
24,114,657.77	
15,537,599.20	
44,839.44	
160,755.61	
389,829.14	
1,179,655.56	
721,592.59	
94,932.58	
179,997.15	
5,710,377.30	
97,035.44	
2,501,462.01	
3,925,596.52	
63,469,826.58	

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 February 29, 2020	
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	2,997.95	5,215.21	0.00	0.00	0.00	0.00		16,486.68		
3509	ADULT 40-100% M&F 65	107.15	0.00	43.40	193.58	272.73	0.00	0.00	234.13	0.00	0.00	0.00	0.00		850.99		
3514	ADULT 40-100% MALE 1	82,193.78	72,082.38	61,562.64	82,938.21	90,272.13	74,485.97	86,055.13	120,363.24	0.00	0.00	0.00	0.00		669,953.48		
3515	ADULT 40-100% FEMAL E	133,768.02	149,460.55	112,076.25	145,651.79	180,110.33	118,857.04	134,255.56	109,592.55	0.00	0.00	0.00	0.00		1,083,772.09		
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	1,216,554.39	898,745.19	0.00	0.00	0.00	0.00		7,765,741.94		
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	747,326.40	856,513.40	0.00	0.00	0.00	0.00		5,853,143.62		
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	2,766,446.17	2,569,151.61	0.00	0.00	0.00	0.00		22,156,781.98		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	42.48	603.86	2,304.26	2,010.68	4,035.60	0.00	0.00	0.00	0.00		8,996.88		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	267.19	0.00	0.00	0.00	0.00		267.19		
3706	ADULT <40% EXP MALE	684.21	6,334.49	1,409.66	5,705.43	2,437.60	307.40	1,127.74	3,068.01	0.00	0.00	0.00	0.00		21,074.54		
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	-1,416.10	6,273.46	0.00	0.00	0.00	0.00		67,996.92		
3709	ADULT <40% EXP M&F 6	-266.59	427.00	427.00	0.00	0.00	0.00	79.40	311.64	0.00	0.00	0.00	0.00		978.45		
3714	ADULT <40% EXP MALE	476,542.78	405,246.15	378,050.84	595,254.45	657,972.77	582,647.95	702,726.28	654,424.70	0.00	0.00	0.00	0.00		4,452,865.92		
3715	ADULT <40% EXP FEM AL	514,957.44	618,604.64	456,041.22	607,313.78	764,561.82	519,505.39	635,926.16	575,591.47	0.00	0.00	0.00	0.00		4,692,501.92		
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	11,381,376.59	10,303,514.90	0.00	0.00	0.00	0.00		79,573,153.69		
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	5,733,780.95	5,407,868.08	0.00	0.00	0.00	0.00		42,329,306.52		
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	14,045,005.62	13,087,687.80	0.00	0.00	0.00	0.00		102,652,049.13		
3719	ADULT <40% EXP M&F 6	0.00	26,564.29	866.02	5,037.08	4,738.22	819.48	3,970.31	4,501.03	0.00	0.00	0.00	0.00		46,496.43		
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	395.20	0.00	0.00	0.00	0.00		427.98		
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	37,458,223.23	34,607,754.41	0.00	0.00	0.00	0.00		271,406,953.91		

4412	SOBRA 100-133% M&F
1	455.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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	1,386.22	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	10,614.22	3,308.25	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	383.28	658.04	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	47,424.32	44,668.63	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	94,126.51	64,533.11	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	641,107.06	551,696.67	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	853,112.59	960,105.57	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	1,953,683.48	1,727,040.26	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	455.00	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	3,602,292.68	3,352,010.53	0.00	0.00	0.00	0.00	

 
16,895.13	
8,318.35	
33,948.25	
7,259.60	
283,513.55	
518,939.76	
5,610,940.03	
6,926,644.14	
13,902,814.23	
5,204.22	
27,314,477.26	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	599,498.93	544,211.19	0.00	0.00	0.00	0.00		4,346,036.45		
4414	SOBRA 100-133% MALE	190,200.70	184,917.01	233,700.68	185,130.04	263,069.93	219,226.25	333,793.59	213,039.87	0.00	0.00	0.00	0.00		1,823,078.07		
4415	SOBRA 100-133% FEMA L	228,920.72	243,977.81	263,975.40	261,842.64	327,941.69	211,924.01	212,942.39	230,797.89	0.00	0.00	0.00	0.00		1,982,322.55		
SUBTOTAL:	904,642.2	2	1,005,919.81	946,429.7	7	986,298.01	1,257,300.47	917,017.93	1,146,234.91	988,048.95	0.00	0.00	0.00	0.00		8,151,892.07		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	910.00	455.00	1,365.00	1,365.00	910.00	455.00	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	10,027.93	5,669.91	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	10,937.93	6,124.91	0.00	0.00	0.00	0.00	

 
5,460.00	
117,938.66	
4,095.00	
14,032.24	
141,525.90	

8700	SSI DISABLED FREEDO M	18,707.10	13,486.58	11,826.59	23,094.07	19,236.20	24,850.38	21,649.53	19,510.69	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	17,849.85	17,817.92	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	1,696.43	1,041.01	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	41,195.81	38,369.62	0.00	0.00	0.00	0.00	

 
152,361.14	
239,737.76	
27,539.74	
419,638.64	

-1,889.60

789,883,361.09

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	

78,083,835.78	96,852,074.66	129,933,816.81	92,256,098.85	108,197,060.68	103,150,998.01	0.00	0.00	0.00	0.00	

-1,889.60

TOTAL:

89,553,565.50

91,855,910.80

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending February 29, 2020	
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	2,027.19	1,279.05	0.00	0.00	0.00	0.00		12,465.41		
1012	TANF 01-05 M & F NON	0.00	455.00	196.06	221.06	0.00	9.71	0.00	341.53	0.00	0.00	0.00	0.00		1,223.36		
1013	TANF 06-13 M & F NON	27,471.80	1,636.87	2,281.82	1,603.52	360.10	508.31	615.41	0.00	0.00	0.00	0.00	0.00		34,477.83		
1014	TANF 14-20 MALE NON-	696.15	2,503.24	3,247.65	5,629.39	926.39	726.32	1,096.98	0.00	0.00	0.00	0.00	0.00		14,826.12		
1015	TANF 14-20 FEMALE N O	3,945.81	579.34	6,069.05	4,082.89	454.84	5,447.60	3,139.30	6,818.16	0.00	0.00	0.00	0.00		30,536.99		
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	14,732.10	7,388.74	0.00	0.00	0.00	0.00		265,350.12		
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	168.64	1,326.60	0.00	0.00	0.00	0.00		33,385.66		
2110	SSI AGED NON-MEDIC
AR	37,219.25	24,330.99	5,813.58	11,051.99	16.38	1,299.37	1,382.14	160.48	0.00	0.00	0.00	0.00		81,274.18		
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	180.00	24.86	0.00	0.00	0.00	0.00		935.05		
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	32,408.76	34,419.69	0.00	0.00	0.00	0.00		342,084.80		
4312	SOBRA CHILD 01-05 M	171,883.85	118,793.66	52,409.54	33,938.23	31,230.50	53,187.22	55,805.16	59,586.65	0.00	0.00	0.00	0.00		576,834.81		
4313	SOBRA CHILD 06-13 M	39,579.36	92,454.57	127,080.50	57,433.95	24,484.31	14,618.28	24,593.73	19,398.67	0.00	0.00	0.00	0.00		399,643.37		
4314	SOBRA CHILD 14-20 MA	60,862.64	16,699.62	13,097.54	40,879.42	6,956.92	20,380.44	53,946.16	-7,790.43	0.00	0.00	0.00	0.00		205,032.31		
4315	SOBRA CHILD 14-20 FE	39,098.46	12,346.02	27,377.62	56,688.03	14,027.94	29,164.13	246,527.72	11,138.36	0.00	0.00	0.00	0.00		436,368.28		
5007	SOBRA PREG 21-44 FE M	0.00	196.52	579.22	267.63	14.76	32.70	102.14	2,103.17	0.00	0.00	0.00	0.00		3,296.14		
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	17,291.52	13,863.01	0.00	0.00	0.00	0.00		190,447.47		
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	99,317.60	93,741.47	0.00	0.00	0.00	0.00		945,553.41		
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		
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	553,334.55	243,800.01	0.00	0.00	0.00	0.00		3,757,897.00		

1106	TANF EXPANDED 21-44	543.51	153.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	898.03	334.34	30.96	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	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	157.54	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	

 
697.46	
1,368.75	
4,996.82	
1,445.54	
157.54	
2,713.51	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	39,789.35	23,623.07	4,214.98	43,736.96	2,085.69	736.90	267.17	806.35	0.00	0.00	0.00	0.00		115,260.47		
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	991.30	0.00	0.00	0.00	0.00		118,626.62		
1118	TANF EXPANDED 45-64	23,861.92	7,741.48	8,059.52	1,234.47	10,219.98	415.57	175.82	455.00	0.00	0.00	0.00	0.00		52,163.76		
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	65.86	-699.45	0.00	0.00	0.00	0.00		31,351.01		
2420	SSI AGED EXPANDED
WI	791.45	260.86	0.00	0.00	455.00	0.00	87.62	0.00	0.00	0.00	0.00	0.00		1,594.93		
2600	SSI DISABLED EXPAND E	1,295.64	5,019.32	2,677.00	785.92	275.55	16.24	88.23	17.60	0.00	0.00	0.00	0.00		10,175.50		
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	33.48	0.00	0.00	0.00	0.00		3,112.10		
SUBTOTAL:	158,581.4	5	65,862.36	37,923.5	1	54,989.49	21,187.63	7,129.66	842.24	1,604.28	0.00	0.00	0.00	0.00		348,120.62		

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	82.85	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	-13,556.89	455.00	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	455.00	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	17,356.54	2,408.28	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	4,337.50	2,863.28	0.00	0.00	0.00	0.00	

106.30	
2,336.14	
10,132.04	
2,883.57	
128,011.71	
193,808.13	
449,023.77	
786,301.66	

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	26,649.46	1,870.76	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	7,256.92	5,303.17	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	7,066.33	9,871.39	0.00	0.00	0.00	0.00	

187,268.69	
39,759.81	
48,380.58	

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	100.77	534.42	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	6,926.74	908.06	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	249.30	151.85	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	455.00	218.09	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	5,593.14	2,313.64	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	9,748.20	41.90	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	14,885.13	592.31	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	37,958.28	4,760.27	0.00	0.00	0.00	0.00	

 
1,407.26	
23,333.14	
8,212.43	
139,003.44	
73,983.45	
268,829.51	
49,026.29	
61,289.00	
700,532.04	
261,737.05	
717,783.48	
2,305,137.09	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	105,114.91	29,380.71	20,499.90	12,829.37	37,162.70	12,403.46	40,972.71	17,045.32	0.00	0.00	0.00	0.00		275,409.08		

8700	SSI DISABLED FREEDO M	144.13	203.30	1,545.39	0.00	108.16	10.21	0.00	21.63	0.00	0.00	0.00	0.00	
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	
SUBTOTAL:	144.13	5,409.82	1,545.39	480.38	108.16	10.21	0.00	21.63	0.00	0.00	0.00	0.00	

 
2,032.82	
5,686.90	
7,719.72	

TOTAL:	2,358,964.61	1,541,309.62	979,357.24	829,190.89	476,274.90	387,947.84	637,445.28	270,094.79	0.00	0.00	0.00	0.00		7,480,585.17		

FEDERAL EMERGENCY SERVICES
For The Period Ending February 29, 2020	
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	25,894.84	105,716.92	0.00	0.00	0.00	0.00		200,010.31		
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	31,228.06	22,480.82	0.00	0.00	0.00	0.00		528,761.16		
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	329,557.35	56,995.34	0.00	0.00	0.00	0.00		778,564.59		
1014	TANF 14-20 MALE NON-	44,070.56	156,398.57	56,041.71	49,472.44	51,130.99	153,890.43	50,194.30	44,489.83	0.00	0.00	0.00	0.00		605,688.83		
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	276,237.83	178,794.20	0.00	0.00	0.00	0.00		1,942,748.33		
1016	TANF 21-44 MALE NON-	573.09	-107.55	0.00	553.78	92.85	0.00	2,340.34	6,747.03	0.00	0.00	0.00	0.00		10,199.54		
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	2,132,065.76	1,603,643.00	0.00	0.00	0.00	0.00		15,355,313.04		
1018	TANF 45-64 M & F NON	9,102.32	9,101.37	7,812.93	9,840.98	269.53	27.61	9,283.00	8.25	0.00	0.00	0.00	0.00		45,445.99		
2100	SSI AGED WITH MEDIC A	22,518.78	19,427.61	17,554.57	10,826.93	28,454.50	9,579.31	30,875.62	19,846.71	0.00	0.00	0.00	0.00		159,084.03		
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	2,159,133.21	1,554,848.15	0.00	0.00	0.00	0.00		13,472,372.54		
2120	SSI AGED WITH QMB	144.29	32.85	8.60	56.23	0.00	1,364.00	0.00	1,671.07	0.00	0.00	0.00	0.00		3,277.04		
2200	SSI DISABLED WITH M E	9,179.10	14,416.02	3,482.91	8,649.81	9,853.82	208.56	2,633.52	1,096.78	0.00	0.00	0.00	0.00		49,520.52		
2210	SSI DISABLED NON-ME
D	52,112.74	40,196.05	75,208.50	38,646.07	54,475.66	22,673.10	47,169.07	35,215.96	0.00	0.00	0.00	0.00		365,697.15		
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	5,096,612.90	3,631,554.06	0.00	0.00	0.00	0.00		33,516,683.07		

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	6,490.93	7,117.78	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	26,905.92	31,906.21	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	39,051.47	29,244.11	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	806,049.06	847,023.55	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	618,582.47	441,775.55	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	3,240,999.27	2,609,377.07	0.00	0.00	0.00	0.00	

154.26	
44,844.56	
234,091.45	
287,905.94	
7,095,313.79	
4,115,854.00	
23,809,037.78	

1107	TANF EXPANDED 21-44	0.00	1,521.24	1,510.13	775.83	18.39	397.31	92.02	26.81	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	745.24	856.43	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	81.18	1,165.56	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	9,636.52	15,329.04	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	646,771.51	623,682.87	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	1,370,286.28	1,190,440.46	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	930,189.31	930,126.95	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	37,793.34	9,504.54	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	109.73	94.13	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	182.83	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	30,521.64	181.76	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	1,986.07	2,484.46	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	112.16	52.82	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	3,028,325.00	2,774,128.66	0.00	0.00	0.00	0.00	

 
4,341.73	
51,826.53	
10,837.83	
156,832.20	
5,553,003.09	
11,373,901.80	
6,822,670.22	
262,003.58	
5,041.84	
2,894.22	
95,848.04	
23,473.31	
224.60	
24,362,898.99	

FEDERAL EMERGENCY SERVICES
For The Period Ending February 29, 2020	
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	60.25	0.00	0.00	0.00	0.00		18,595.73		
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	4,738,079.12	3,966,504.52	0.00	0.00	0.00	0.00		35,605,797.51		

93,485,379.57

12,889,659.55	11,046,268.49	12,232,150.82	12,609,878.11	10,860,557.54	10,611,660.80	12,863,017.02	10,372,187.24	0.00	0.00	0.00	0.00	

TOTAL:

FEDERAL ESP CHRONIC SERVICES
For The Period Ending February 29, 2020	
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 February 29, 2020	
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	525,823.34	497,261.76	0.00	0.00	0.00	0.00		3,529,440.08		
8040	SLMB	75.68	15.51	0.00	0.00	0.00	0.00	657.92	18.06	0.00	0.00	0.00	0.00		767.17		
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	526,481.26	497,279.82	0.00	0.00	0.00	0.00		3,530,539.23		

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

526,481.26

497,279.82

0.00

3,530,539.23

FFS TRBHA FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	1,361.20	5,890.72	0.00	0.00	0.00	0.00		33,402.15		
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	4,740.75	2,902.84	0.00	0.00	0.00	0.00		68,625.49		
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	231,262.81	187,864.31	0.00	0.00	0.00	0.00		1,690,954.51		
1014	TANF 14-20 MALE NON-	72,162.55	27,686.96	22,237.41	54,500.62	24,988.66	49,775.23	66,755.20	47,573.97	0.00	0.00	0.00	0.00		365,680.60		
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	84,163.34	113,771.16	0.00	0.00	0.00	0.00		855,341.49		
1016	TANF 21-44 MALE NON-	482,746.26	346,671.53	408,164.25	508,526.75	458,634.39	494,836.05	419,351.81	422,010.12	0.00	0.00	0.00	0.00		3,540,941.16		
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	1,417,079.69	1,649,324.70	0.00	0.00	0.00	0.00		11,924,539.98		
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	312,110.82	360,264.52	0.00	0.00	0.00	0.00		2,348,582.29		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	45.61	136.83	0.00	0.00	0.00	0.00	0.00		182.44		
1028	TANF 45-64 M & F WIT	184.73	173.16	1,730.03	2,588.94	828.52	0.00	403.49	403.49	0.00	0.00	0.00	0.00		6,312.36		
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	30,417.27	45,661.05	0.00	0.00	0.00	0.00		183,927.37		
2110	SSI AGED NON-MEDIC
AR	3,423.10	2,391.21	7,023.46	3,567.70	2,992.78	532.76	2,740.70	1,706.52	0.00	0.00	0.00	0.00		24,378.23		
2120	SSI AGED WITH QMB	66,532.03	48,594.38	50,139.30	42,216.05	47,939.77	48,743.58	50,517.56	40,261.33	0.00	0.00	0.00	0.00		394,944.00		
2200	SSI DISABLED WITH M E	63,339.72	50,009.45	55,104.31	57,799.84	52,251.85	51,335.59	60,997.30	55,797.22	0.00	0.00	0.00	0.00		446,635.28		
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	1,657,491.76	1,834,078.04	0.00	0.00	0.00	0.00		14,390,510.10		
2220	SSI DISABLED WITH Q M	388,879.11	342,330.15	328,681.88	351,532.78	352,022.04	270,632.69	291,249.10	288,732.46	0.00	0.00	0.00	0.00		2,614,060.21		
2310	SSI BLIND NON-MEDIC
A	36,358.35	59,301.51	24,367.36	15,444.33	13,764.82	10,488.46	22,311.71	17,970.75	0.00	0.00	0.00	0.00		200,007.29		
2320	SSI BLIND WITH QMB	5,271.02	1,918.97	1,852.18	1,952.66	2,400.59	2,726.04	3,498.94	2,785.84	0.00	0.00	0.00	0.00		22,406.24		
4311	SOBRA CHILD <1 M & F	6,460.61	6,068.40	6,860.01	8,565.44	20,779.70	4,898.18	6,437.17	5,519.76	0.00	0.00	0.00	0.00		65,589.27		
4312	SOBRA CHILD 01-05 M	239,174.74	187,542.33	207,568.43	288,173.03	246,312.30	198,239.80	187,376.07	215,587.35	0.00	0.00	0.00	0.00		1,769,974.05		
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	3,144,549.86	3,154,202.66	0.00	0.00	0.00	0.00		27,708,362.66		
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	896,716.88	930,620.40	0.00	0.00	0.00	0.00		7,431,820.69		
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	1,137,850.28	1,086,427.07	0.00	0.00	0.00	0.00		9,182,277.18		
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	1,820.00	0.00	0.00	0.00	0.00	0.00		22,750.00		
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	17,770.25	8,280.86	0.00	0.00	0.00	0.00		113,762.14		
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	140,091.76	146,130.27	0.00	0.00	0.00	0.00		1,302,683.19		
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	10,189,202.55	10,623,767.41	0.00	0.00	0.00	0.00		86,710,128.05		

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	81.00	0.00	0.00	0.00	0.00	0.00	

11,900.25

FFS TRBHA FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	1,577.48	0.00	0.00	0.00	0.00		2,951.08		
1114	TANF EXPANDED 14-20	3,045.00	0.00	455.00	2,275.00	455.00	91.22	45.61	0.00	0.00	0.00	0.00	0.00		6,366.83		
1115	TANF EXPANDED 14-20	8,599.02	7,220.23	6,005.61	1,805.65	16,259.00	6,745.10	13,829.64	14,140.13	0.00	0.00	0.00	0.00		74,604.38		
1116	TANF EXPANDED 21-44	167,952.92	117,356.15	142,575.60	227,334.13	150,169.43	120,149.39	115,665.67	140,044.19	0.00	0.00	0.00	0.00		1,181,247.48		
1117	TANF EXPANDED 21-44	457,969.90	350,831.66	341,891.81	530,864.00	592,930.22	427,821.93	299,089.32	477,749.73	0.00	0.00	0.00	0.00		3,479,148.57		
1118	TANF EXPANDED 45-64	151,584.86	119,327.65	157,762.76	340,355.24	259,292.83	165,132.66	126,710.30	255,028.72	0.00	0.00	0.00	0.00		1,575,195.02		
1126	TANF EXPANDED 21-44	5,497.39	1,646.16	1,878.64	5,708.07	2,011.20	566.17	8,952.53	5,580.33	0.00	0.00	0.00	0.00		31,840.49		
1127	TANF EXPANDED 21-44	310.16	265.12	710.40	2,088.65	19,813.58	10,995.32	10,112.23	36,500.86	0.00	0.00	0.00	0.00		80,796.32		
1128	TANF EXPANDED 45-64	12,149.05	12,375.62	7,302.92	10,233.30	7,080.92	4,738.28	7,278.22	7,792.77	0.00	0.00	0.00	0.00		68,951.08		
1129	TANF EXPANDED 65+
M&	4,153.95	4,207.54	4,482.68	4,946.55	3,997.06	3,782.28	3,940.64	2,709.08	0.00	0.00	0.00	0.00		32,219.78		
2400	SSI AGED EXPANDED WI	12.41	0.00	388.17	0.00	0.00	0.00	34.36	0.00	0.00	0.00	0.00	0.00		434.94		
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	24,941.45	33,280.79	0.00	0.00	0.00	0.00		265,388.72		
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	10,960.93	10,052.93	0.00	0.00	0.00	0.00		88,833.27		
2620	SSI DISABLED EXPAND
E	85,511.04	31,421.19	54,808.45	81,212.86	79,495.90	57,208.30	27,738.89	25,967.80	0.00	0.00	0.00	0.00		443,364.43		
SUBTOTAL:	963,690.3	5	700,065.73	768,322.7	2	1,246,725.01	1,171,803.66	836,857.40	649,380.79	1,010,424.81	0.00	0.00	0.00	0.00		7,347,270.47		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	29.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	7,754.44	3,904.60	1,619.22	361.44	4,027.77	1,143.14	1,726.05	2,120.42	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	11,819.44	6,215.03	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	70,376.52	73,510.96	0.00	0.00	0.00	0.00	

29.55	
22,657.08	
51,864.20	
575,053.49	

3514	ADULT 40-100% MALE 1	10,776.55	6,979.68	14,745.82	14,618.09	21,431.14	27,631.88	15,727.82	17,717.63	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	22,863.13	26,379.51	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	117,033.36	108,743.44	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	107,541.72	176,441.15	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	106,906.39	170,954.84	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	939.26	1,452.78	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	455.00	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	454.06	84.94	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	169,223.48	199,242.07	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	73,145.58	66,960.47	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	2,570,223.79	2,617,661.98	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	1,478,133.06	1,787,954.44	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	1,683,420.62	2,006,476.01	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	6,346,067.27	7,180,069.26	0.00	0.00	0.00	0.00	

 
129,628.61	
141,008.04	
1,330,144.62	
1,022,025.55	
1,350,110.56	
2,392.04	
455.00	
7,401.66	
1,289,798.21	
784,761.45	
21,233,762.47	
12,524,614.45	
12,974,772.49	
52,790,875.15	

FFS TRBHA FEE FOR SERVICE
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	62,391.07	31,309.32	28,567.30	28,589.71	37,826.83	43,085.28	62,911.30	55,904.03	0.00	0.00	0.00	0.00		350,584.84		
3918	NEWLY ELIGIBLE M&F
4	67,746.14	65,633.51	59,258.69	63,962.90	41,823.29	60,538.62	64,415.45	45,654.35	0.00	0.00	0.00	0.00		469,032.95		
SUBTOTAL:	279,335.5	3	136,082.42	159,112.1	9	163,246.26	150,058.83	186,733.33	211,248.76	183,404.79	0.00	0.00	0.00	0.00		1,469,222.11		

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

1,820.00

1,820.00

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	68,818.18	78,478.31	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	24,651.03	23,469.15	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	53,808.98	48,768.39	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	147,278.19	150,715.85	0.00	0.00	0.00	0.00	

 
969,297.32	
425,884.05	
435,050.73	
1,830,232.10	

8700	SSI DISABLED FREEDO M	444.71	126.96	282.09	322.07	506.65	538.35	1,069.57	166.56	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	455.00	455.00	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	1,524.57	621.56	0.00	0.00	0.00	0.00	

 
3,456.96	
3,185.00	
172.78	
6,814.74	

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	17,544,702.13	19,149,003.68	0.00	0.00	0.00	0.00		150,156,362.62		

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	21,814.00	12,387.83	0.00	0.00	0.00	0.00		149,320.05		
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	52,008.35	28,122.83	0.00	0.00	0.00	0.00		400,464.89		
1018	TANF 45-64 M & F NON	0.00	0.00	19,006.49	5,714.73	5,672.94	10,147.75	6,661.76	2,959.48	0.00	0.00	0.00	0.00		50,163.15		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	1,364.00	0.00	0.00	0.00	0.00	0.00		1,364.00		
2210	SSI DISABLED NON-ME
D	84,690.30	48,792.04	60,634.16	78,420.21	77,695.93	40,843.77	81,697.08	32,646.24	0.00	0.00	0.00	0.00		505,419.73		
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	4,136.00	0.00	0.00	0.00	0.00		13,831.40		
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	163,545.19	80,252.38	0.00	0.00	0.00	0.00		1,138,251.10		

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,364.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	1,524.14	15,016.02	0.00	0.00	4,204.40	3,363.52	0.00	2,498.16	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	9,711.06	14,221.52	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	4,204.40	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	1,364.00	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	2,728.00	4,136.00	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	18,007.46	22,219.68	0.00	0.00	0.00	0.00	

 
1,364.00	
26,606.24	
99,111.08	
28,589.92	
1,364.00	
13,660.00	
170,695.24	

3516	ADULT 40-100% MALE 2	3,699.35	11,299.46	14,172.51	14,360.32	12,703.07	10,192.76	14,609.40	9,100.78	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	3,330.88	5,943.35	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	7,641.45	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	172,877.53	233,341.02	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	83,912.83	93,031.93	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	60,910.94	66,557.62	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	343,283.03	407,974.70	0.00	0.00	0.00	0.00	

 
90,137.65	
34,584.25	
42,415.54	
1,846,086.35	
692,551.26	
527,383.16	
3,233,158.21	

3916	NEWLY ELIGIBLE MALE	8,408.80	0.00	3,363.52	39,865.17	11,940.86	13,433.83	12,645.88	24,501.10	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	5,281.95	5,094.30	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	7,600.60	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	25,528.43	29,595.40	0.00	0.00	0.00	0.00	

 
114,159.16	
52,163.96	
45,440.20	
211,763.32	

4,753,867.87

596,980.30	493,299.07	624,693.91	806,369.12	551,421.69	590,697.51	550,364.11	540,042.16	0.00	0.00	0.00	0.00	

TOTAL:

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	609.40	0.00	0.00	0.00	0.00	0.00		609.40		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,919.04	0.00	0.00	0.00	0.00		2,919.04		
2100	SSI AGED WITH MEDIC A	82,215.38	125,849.80	34,955.01	98,230.33	54,035.82	67,983.81	42,328.96	21,970.52	0.00	0.00	0.00	0.00		527,569.63		
2110	SSI AGED NON-MEDIC
AR	76,145.26	43,432.58	94,089.34	170,616.32	178,372.05	279,889.81	124,147.94	83,316.60	0.00	0.00	0.00	0.00		1,050,009.90		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	179.69	0.00	0.00	0.00	0.00		179.69		
2200	SSI DISABLED WITH M E	43,412.57	37,118.69	31,528.29	42,362.80	66,041.19	15,124.34	29,284.14	46,485.92	0.00	0.00	0.00	0.00		311,357.94		
2210	SSI DISABLED NON-ME
D	6,450.10	54.14	3,268.79	936.25	3,398.77	10,825.31	1,898.91	628.44	0.00	0.00	0.00	0.00		27,460.71		
2220	SSI DISABLED WITH Q M	0.00	5,818.84	74,831.29	1,429.31	5,191.34	368.79	17,791.61	41,402.30	0.00	0.00	0.00	0.00		146,833.48		
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	25,093.84	33,658.57	0.00	0.00	0.00	0.00		202,154.60		
SUBTOTAL:	244,004.3	7	235,026.81	245,517.6	3	346,036.42	345,038.47	387,695.91	241,154.80	230,561.08	0.00	0.00	0.00	0.00		2,275,035.49		

3516	ADULT 40-100% MALE 2	6,841.48	1,043.90	0.00	79.24	0.00	0.00	188.13	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	575.08	1,177.45	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	1,044.50	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	8,156.13	924.62	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	2,261.62	29,123.82	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	77.61	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	174,334.03	215,851.81	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	29,257.76	14,446.63	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	308,777.04	245,621.95	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	12,527.02	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	536,076.81	508,268.39	0.00	0.00	0.00	0.00	

8,152.75	
18,587.39	
16,952.51	
9,080.75	
159,195.54	
16,836.89	
2,401.86	
2,382,606.61	
99,886.60	
3,024,195.96	
1,647.10	
5,739,543.96	

3916	NEWLY ELIGIBLE MALE	57,655.11	4,600.84	464.10	10,899.98	62,999.44	4,145.21	4,772.25	6,190.32	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	2,030.82	482.09	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	6,803.07	6,672.41	0.00	0.00	0.00	0.00	

151,727.25	
64,531.76	
216,259.01	

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	784,034.68	745,501.88	0.00	0.00	0.00	0.00		8,272,939.85		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	391.72	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	391.72	0.00	0.00	0.00	0.00	

 
3,612.75	
4,141.82	
417.33	
8,171.90	

3,863.35

6,381.37

464.47

79.80

4,113.60

0.00

391.72

0.00

0.00	0.00

0.00

165.06

15,459.37

TOTAL:

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	4,359.49	0.00	0.00	0.00	0.00		29,244.90		
1017	TANF 21-44 FEMALE N O	13,398.03	846.61	57.84	80.06	4,373.37	839.77	79.73	0.00	0.00	0.00	0.00	0.00		19,675.41		
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	8,413.80	1,295.53	0.00	0.00	0.00	0.00		35,862.66		
SUBTOTAL:	19,818.53	22,215.72	24,324.9	4	1,088.41	12,263.40	11,231.39	8,493.53	5,655.02	0.00	0.00	0.00	0.00		105,090.94		

3516	ADULT 40-100% MALE 2	-3,664.92	32.56	3,991.13	16,463.19	0.00	22,974.71	24.75	964.70	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	159.31	9,213.38	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,185.76	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	127,539.85	34,513.84	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	20,137.90	10,419.53	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	12,577.88	32,385.84	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	160,439.69	93,683.05	0.00	0.00	0.00	0.00	

40,786.12	
4,834.00	
27,564.77	
6,185.76	
796,707.64	
121,832.15	
310,779.45	
1,308,689.89	

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	3,725.81	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	216.67	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	216.67	3,725.81	0.00	0.00	0.00	0.00	

421.95	
30,017.68	
11,396.99	
5,153.54	
46,990.16	

1116	TANF EXPANDED 21-44	19,096.08	276.04	0.00	218.09	578.78	0.00	0.00	2,909.21	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	2,909.21	0.00	0.00	0.00	0.00	

 
23,078.20	
9,840.04	
32,918.24	

TOTAL:	243,176.40	232,257.84	232,596.60	173,699.92	204,061.69	132,773.80	169,149.89	105,973.09	0.00	0.00	0.00	0.00		1,493,689.23		

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,414.10	0.00	0.00	0.00	0.00		16,414.10		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	783.35	0.00	0.00	0.00	0.00		783.35		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,197.45	0.00	0.00	0.00	0.00		17,197.45		

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	17,050.22	1,403.56	0.00	0.00	0.00	0.00	0.00	
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	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	2,006.92	4,684.10	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,409.21	15,943.61	0.00	0.00	0.00	17,050.22	3,410.48	4,684.10	0.00	0.00	0.00	0.00	

 
18,453.78	
19,352.82	
6,691.02	
44,497.62	

61,695.07

3,409.21	15,943.61	0.00	0.00	0.00	17,050.22	3,410.48	21,881.55	0.00	0.00	0.00	0.00	

TOTAL:

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	3,210.32	159.31	0.00	0.00	0.00	0.00		12,508.03		
2100	SSI AGED WITH MEDIC
A	0.00	0.00	8,468.49	0.00	0.00	127.32	321.81	0.00	0.00	0.00	0.00	0.00		8,917.62		
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		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,678.67	0.00	0.00	0.00	0.00		12,678.67		
2210	SSI DISABLED NON-ME
D	4,796.03	24,528.06	793.41	23,396.25	5,152.17	1,326.47	1,593.19	5,445.88	0.00	0.00	0.00	0.00		67,031.46		
5017	SOBRA PREG 21-44 FE M	120.60	9,182.78	547.22	0.00	5,809.98	0.00	387.80	0.00	0.00	0.00	0.00	0.00		16,048.38		
SUBTOTAL:	4,916.63	34,616.65	15,869.7	1	30,492.56	13,876.46	1,834.73	5,513.12	18,283.86	0.00	0.00	0.00	0.00		125,403.72		

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	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	92.24	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	7,460.10	6,978.91	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	57.65	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	16,972.61	897.37	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	24,524.95	7,933.93	0.00	0.00	0.00	0.00	

 
3,283.13	
92.24	
198,688.99	
55,715.85	
68,363.36	
326,143.57	

TOTAL:	49,387.38	64,539.25	73,786.31	53,139.17	92,291.17	62,169.31	30,038.07	26,217.79	0.00	0.00	0.00	0.00		451,568.45		

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	84.34	0.00	0.00	0.00	0.00		84.34		
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	84.34	0.00	0.00	0.00	0.00		10,532.98		

3716	ADULT <40% EXP MALE	160.48	0.00	967.16	0.00	12,869.15	1,085.84	10,338.10	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	167.81	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	10,505.91	0.00	0.00	0.00	0.00	0.00	

 
25,420.73	
2,109.20	
985.48	
28,515.41	

39,048.39

2,604.72	59.26	3,076.36	8,503.16	12,960.18	1,254.46	10,505.91	84.34	0.00	0.00	0.00	0.00	

TOTAL:

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	232.27	221.60	0.00	0.00	0.00	0.00		14,266.53		
SUBTOTAL:	0.00	0.00	0.00	0.00	13,812.66	0.00	232.27	221.60	0.00	0.00	0.00	0.00		14,266.53		

TOTAL:	0.00	0.00	0.00	0.00	13,812.66	0.00	232.27	221.60	0.00	0.00	0.00	0.00		14,266.53		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending February 29, 2020	
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	455.00	0.00	0.00	0.00	0.00	0.00		15,610.97		
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	3,159,456.65	3,023,952.82	0.00	0.00	0.00	0.00		25,281,854.78		
2110	SSI AGED NON-MEDIC
AR	270,248.25	199,558.99	170,599.97	185,012.21	184,709.21	180,585.85	175,771.24	178,482.97	0.00	0.00	0.00	0.00		1,544,968.69		
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	5,014,417.60	4,831,650.15	0.00	0.00	0.00	0.00		37,936,587.46		
2200	SSI DISABLED WITH M E	665,108.26	517,747.79	541,296.64	661,374.78	528,583.16	573,598.34	616,530.41	445,228.93	0.00	0.00	0.00	0.00		4,549,468.31		
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	3,832,568.94	3,576,956.96	0.00	0.00	0.00	0.00		30,001,706.52		
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	1,434,387.96	1,214,344.03	0.00	0.00	0.00	0.00		9,136,039.55		
2300	SSI BLIND WITH MEDIC	2,008.80	2,245.08	1,590.11	2,037.00	1,227.98	1,939.20	1,777.60	830.40	0.00	0.00	0.00	0.00		13,656.17		
2310	SSI BLIND NON-MEDIC A	10,075.80	9,689.37	10,601.79	12,667.17	20,147.11	13,694.71	15,142.99	6,343.62	0.00	0.00	0.00	0.00		98,362.56		
2320	SSI BLIND WITH QMB	4,970.93	1,483.22	264.76	2,694.37	352.47	381.46	904.23	81.00	0.00	0.00	0.00	0.00		11,132.44		
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	14,251,412.62	13,277,870.88	0.00	0.00	0.00	0.00		108,589,387.45		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	455.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	2,380.80	2,692.35	2,162.25	1,462.80	3,427.20	3,427.20	4,307.66	3,521.28	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	4,307.66	3,976.28	0.00	0.00	0.00	0.00	

 
455.00	
23,381.54	
23,836.54	

108,613,223.99

14,641,720.07	12,577,411.41	12,175,076.15	14,560,491.13	13,493,550.26	13,627,407.53	14,255,720.28	13,281,847.16	0.00	0.00	0.00	0.00	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending February 29, 2020	
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	-672.27	1,934.05	0.00	0.00	0.00	0.00		237,143.44		
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	65.50	61.21	0.00	0.00	0.00	0.00		18,479.26		
2210	SSI DISABLED NON-ME
D	5,636.33	1,595.00	-17,970.22	14,969.70	165.81	660.99	-14,390.20	1,927.78	0.00	0.00	0.00	0.00		-7,404.81		
2220	SSI DISABLED WITH Q M	19.67	0.00	46.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.05		
SUBTOTAL:	72,181.04	86,244.99	50,351.6	4	44,818.59	4,812.11	2,409.49	-14,996.97	3,923.04	0.00	0.00	0.00	0.00		249,743.93		

TOTAL:	72,181.04	86,244.99	50,351.64	44,818.59	4,812.11	2,409.49	-14,996.97	3,923.04	0.00	0.00	0.00	0.00		249,743.93		

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	180.61	0.00	0.00	0.00	0.00	0.00		865.86		
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	180.61	0.00	0.00	0.00	0.00	0.00		28,248.75		

0.00

0.00

0.00

0.00

TOTAL:

27,259.79

0.00

0.00

123.10

685.25

180.61

0.00

0.00

28,248.75

COCONINO COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending February 29, 2020	
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 February 29, 2020	
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 February 29, 2020	
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	49,371.69	46,837.12	0.00	0.00	0.00	0.00		289,304.92		
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	99,909.38	93,750.37	0.00	0.00	0.00	0.00		581,128.13		
1014	TANF 14-20 MALE NON-	8,676.21	4,254.94	4,356.71	9,494.57	4,136.60	12,535.31	14,301.43	8,847.68	0.00	0.00	0.00	0.00		66,603.45		
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	6,338.60	5,683.80	0.00	0.00	0.00	0.00		37,686.57		
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	343,461.44	320,122.58	0.00	0.00	0.00	0.00		2,135,198.59		
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	4,927.22	5,067.43	0.00	0.00	0.00	0.00		25,022.45		
4312	SOBRA CHILD 01-05 M	170,389.43	100,660.33	74,587.65	204,872.11	137,167.56	263,571.89	242,159.30	230,646.22	0.00	0.00	0.00	0.00		1,424,054.49		
4313	SOBRA CHILD 06-13 M	266,108.81	157,297.68	134,113.69	317,309.08	232,961.51	440,548.27	378,537.56	367,167.93	0.00	0.00	0.00	0.00		2,294,044.53		
4314	SOBRA CHILD 14-20 MA	22,058.21	12,674.72	8,832.55	22,642.46	12,326.15	32,211.87	30,372.63	25,846.42	0.00	0.00	0.00	0.00		166,965.01		
4315	SOBRA CHILD 14-20 FE	10,521.23	4,139.37	3,902.67	11,933.37	9,550.09	17,975.78	17,010.92	14,407.96	0.00	0.00	0.00	0.00		89,441.39		
SUBTOTAL:	864,196.6	0	506,274.75	419,398.3	0	1,004,599.27	667,653.55	1,343,433.47	1,186,390.17	1,118,377.51	0.00	0.00	0.00	0.00		7,110,323.62		

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	15.58	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	14.07	28.22	0.00	0.00	0.00	0.00	
SUBTOTAL:	124.10	62.05	15.18	108.33	28.14	0.00	29.65	28.22	0.00	0.00	0.00	0.00	

 
124.10	
82.79	
188.78	
395.67	

3514	ADULT 40-100% MALE 1	29.06	8.84	0.00	136.98	35.34	85.90	182.19	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	477.25	662.61	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	554.23	1,613.38	0.00	0.00	0.00	0.00	
SUBTOTAL:	599.33	156.24	314.9	2	659.80	491.66	982.78	1,213.67	2,275.99	0.00	0.00	0.00	0.00	

 
478.31	
90.56	
3,105.77	
3,019.75	
6,694.39	

20.68

138.39

3914	NEWLY ELIGIBLE MALE	65.66	0.00	0.00	34.37	0.00	15.08	7.76	15.52	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	10.34	10.34	0.00	0.00	0.00	0.00	
SUBTOTAL:	65.66	0.00	0.00	34.37	0.00	15.08	18.10	25.86	0.00	0.00	0.00	0.00	

159.07

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	76,436.99	89,437.66	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	8,020.07	7,441.29	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	2,768.01	2,351.87	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	87,225.07	99,230.82	0.00	0.00	0.00	0.00	

553,204.38	
42,624.14	
13,238.84	
609,067.36	

TOTAL:	950,558.83	549,098.89	454,090.88	1,090,485.75	731,108.79	1,456,481.91	1,274,876.66	1,219,938.40	0.00	0.00	0.00	0.00		7,726,640.11		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending February 29, 2020	
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	47,252.54	43,803.37	0.00	0.00	0.00	0.00		210,287.66		
2200	SSI DISABLED WITH M E	2,586.31	606.85	362.12	1,724.42	617.57	2,108.95	650.86	816.73	0.00	0.00	0.00	0.00		9,473.81		
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	2,028,180.67	1,853,250.09	0.00	0.00	0.00	0.00		12,752,136.55		
2220	SSI DISABLED WITH Q M	5,358.58	2,675.67	559.32	4,335.90	3,240.78	7,092.07	6,624.81	3,182.90	0.00	0.00	0.00	0.00		33,070.03		
2310	SSI BLIND NON-MEDIC
A	3,264.10	251.23	1,140.95	2,033.05	1,659.02	3,698.01	1,764.41	1,021.81	0.00	0.00	0.00	0.00		14,832.58		
SUBTOTAL:	1,557,681.48	884,889.33	830,813.5	9	1,915,459.66	1,235,419.63	2,608,988.75	2,084,473.29	1,902,074.90	0.00	0.00	0.00	0.00		13,019,800.63		

13,019,800.63

830,813.59	1,915,459.66	1,235,419.63	2,608,988.75	2,084,473.29	1,902,074.90	0.00	0.00	0.00	0.00	

TOTAL:

1,557,681.48

884,889.33

ACC REINSURANCE
For The Period Ending February 29, 2020	
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	1,005.41	0.00	0.00	0.00	0.00		-151.01		
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	536,428.20	341,246.07	0.00	0.00	0.00	0.00		8,050,494.72		
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	57,473.85	22,369.04	0.00	0.00	0.00	0.00		689,505.96		
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	239,935.19	90,880.60	0.00	0.00	0.00	0.00		1,632,202.79		
1014	TANF 14-20 MALE NON-	81,483.94	198,980.19	109,178.50	212,727.49	208,264.36	192,949.56	201,746.77	45,494.36	0.00	0.00	0.00	0.00		1,250,825.17		
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	15,247.01	114,667.61	0.00	0.00	0.00	0.00		660,225.11		
1016	TANF 21-44 MALE NON-	180,616.91	142,894.03	150,910.06	204,896.09	338,346.36	138,018.06	124,961.36	170,027.11	0.00	0.00	0.00	0.00		1,450,669.98		
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	277,285.42	170,100.23	0.00	0.00	0.00	0.00		2,628,021.75		
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	151,506.39	149,725.82	0.00	0.00	0.00	0.00		1,335,948.91		
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	51.96	21,306.54	0.00	0.00	0.00	0.00		246,919.26		
2110	SSI AGED NON-MEDIC
AR	112,670.07	397,755.12	277,933.20	166,896.51	161,217.28	130,454.91	27,056.66	35,417.12	0.00	0.00	0.00	0.00		1,309,400.87		
2200	SSI DISABLED WITH M E	130,347.89	55,514.79	4,376.07	612,910.07	86,054.44	10,020.05	67,159.54	27,581.58	0.00	0.00	0.00	0.00		993,964.43		
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	5,355,902.65	5,531,841.84	0.00	0.00	0.00	0.00		55,028,164.02		
2310	SSI BLIND NON-MEDIC A	11,949.45	9,724.98	13,371.35	31,461.09	36,471.62	37,697.01	12,305.31	0.00	0.00	0.00	0.00	0.00		152,980.81		
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	1,437,231.76	2,758,785.50	0.00	0.00	0.00	0.00		20,316,089.12		
4312	SOBRA CHILD 01-05 M	811,967.95	925,721.48	609,324.26	498,970.44	629,281.34	420,519.22	2,656,227.20	831,421.55	0.00	0.00	0.00	0.00		7,383,433.44		
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	427,371.28	1,059,213.98	0.00	0.00	0.00	0.00		7,021,103.46		
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	328,367.15	411,879.02	0.00	0.00	0.00	0.00		4,864,642.64		
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	-179,168.80	126,806.56	0.00	0.00	0.00	0.00		3,765,223.18		
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	-21,899.17	5,127.43	0.00	0.00	0.00	0.00		393,996.92		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	13,857.33	-2,402.42	0.00	0.00	0.00	0.00	0.00		11,454.91		
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	11,712,787.31	11,914,897.37	0.00	0.00	0.00	0.00		119,200,869.22		

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	18.77	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	285.07	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	37,127.54	110,502.54	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	66,093.31	-10,281.87	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	98,360.48	36,006.99	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	

-341.93	
0.00	
323.26	
1,427,728.71	
1,182,305.39	
1,386,015.20	
3,522.55	

ACC REINSURANCE
For The Period Ending February 29, 2020	
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	6,887.56	6,904.07	0.00	0.00	0.00	0.00		64,101.74		
2600	SSI DISABLED EXPAND
E	3,420.44	1,096.56	67,024.12	27,684.22	1,824.25	5,064.09	-20,022.31	7,440.92	0.00	0.00	0.00	0.00		93,532.29		
2610	SSI DISABLED EXPAND E	143,236.05	152,119.17	134,456.56	51,542.13	26,484.40	110,166.59	-44,045.16	65,183.76	0.00	0.00	0.00	0.00		639,143.50		
SUBTOTAL:	967,764.7	0	854,007.18	676,565.5	4	505,770.91	865,926.26	565,834.45	144,705.26	215,756.41	0.00	0.00	0.00	0.00		4,796,330.71		

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	14,709.76	147,536.98	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	-13,665.59	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	439,146.14	111,956.27	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	7,263.47	39,001.53	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	327,677.59	355,877.86	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	-3,026.02	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	-2,767.51	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	-8,522.04	34,686.18	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	159,176.27	61,703.97	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	76,368.72	-45,832.99	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	1,042,303.97	220,373.04	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	208,062.83	292,127.71	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	1,704,159.43	650,376.75	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	235.13	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	3,951,122.15	1,867,807.30	0.00	0.00	0.00	0.00	

 
1,901.45	
10,336.97	
1,442,847.55	
29,239.95	
2,356,322.83	
414,631.79	
5,668,126.02	
16,388.35	
3,443.64	
156,515.46	
892,125.29	
302,298.87	
12,284,772.34	
3,414,180.93	
17,068,490.46	
235.13	
44,061,857.03	

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	3,250.78	0.00	3,823.01	537.76	-7,611.55	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	191,982.94	199,611.44	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	155,449.57	165,895.75	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	119,244.99	97,925.64	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	215,599.20	-155,054.38	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	682,814.46	300,766.90	0.00	0.00	0.00	0.00	

 
0.00	
5,076.33	
1,445,405.44	
16,701.76	
2,263,455.53	
867,071.83	
2,898,435.06	
7,496,145.95	

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	94,809.31	61,413.34	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	85,293.51	169,921.21	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	1,623.35	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	180,102.82	232,957.90	0.00	0.00	0.00	0.00	

 
1,212,093.81	
1,393,816.47	
343,550.71	
2,949,460.99	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

882.41

0.00

1,480.26

0.00

23,312.91	0.00

0.00

0.00

0.00

0.00

25,675.58

ACC REINSURANCE
For The Period Ending February 29, 2020	
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	23,312.91	0.00	0.00	0.00	0.00	0.00		40,011.34		

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	1,047.37	268,192.17	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	1,047.37	268,192.17	0.00	0.00	0.00	0.00	

 
5,794.11	
317,040.73	
322,834.84	

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	16,695,892.28	14,800,378.05	0.00	0.00	0.00	0.00		178,875,273.57		

LONG TERM CARE REINSURANCE
For The Period Ending February 29, 2020	
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	-877.23	162,071.11	0.00	0.00	0.00	0.00		335,458.07		
2100	SSI AGED WITH MEDIC A	111,580.83	328,992.29	236,109.46	222,547.27	152,904.21	232,826.65	287,554.26	110,798.56	0.00	0.00	0.00	0.00		1,683,313.53		
2110	SSI AGED NON-MEDIC
AR	69,649.07	75,558.87	47,319.07	3,027.28	106,909.09	68,677.18	-12,668.61	12,169.39	0.00	0.00	0.00	0.00		370,641.34		
2200	SSI DISABLED WITH M E	314,831.72	463,347.96	539,913.45	476,106.77	314,740.63	327,985.38	425,535.94	384,993.45	0.00	0.00	0.00	0.00		3,247,455.30		
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	3,145,869.03	2,639,043.07	0.00	0.00	0.00	0.00		36,742,799.36		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	-6.24	0.00	0.00	0.00	0.00	0.00		-6.24		
2310	SSI BLIND NON-MEDIC A	1,504.99	5,274.08	0.00	330.20	2,049.72	31,359.75	-2,016.69	0.00	0.00	0.00	0.00	0.00		38,502.05		
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	3,843,390.46	3,309,075.58	0.00	0.00	0.00	0.00		42,418,163.41		

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

42,454,845.22

6,843,752.18	5,361,381.84	6,418,046.04	5,182,314.90	6,610,870.42	4,886,013.80	3,843,390.46	3,309,075.58	0.00	0.00	0.00	0.00	

TOTAL:

ACC SMIB
For The Period Ending February 29, 2020	
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	54,196.60	49,291.80	0.00	0.00	0.00	0.00		403,498.30		
1010	TANF NON-MEDICARE	677.50	406.50	406.50	406.50	271.00	406.50	433.80	578.40	0.00	0.00	0.00	0.00		3,586.70		
1020	TANF WITH QMB	44,961.50	39,964.50	37,916.00	37,653.00	36,433.50	32,767.00	39,623.70	41,594.40	0.00	0.00	0.00	0.00		310,913.60		
2100	SSI AGED WITH MEDIC A	31,102.20	35,121.60	38,203.50	32,389.00	33,875.00	36,694.50	33,174.40	45,193.30	0.00	0.00	0.00	0.00		285,753.50		
2110	SSI AGED NON-MEDIC
AR	539,823.00	550,536.20	542,519.50	535,106.00	534,008.50	541,437.00	581,390.20	560,940.70	0.00	0.00	0.00	0.00		4,385,761.10		
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	4,810,448.90	4,840,088.10	0.00	0.00	0.00	0.00		36,352,828.80		
2200	SSI DISABLED WITH M E	79,390.30	75,152.80	78,504.30	81,050.60	69,228.50	77,643.80	83,531.20	93,414.80	0.00	0.00	0.00	0.00		637,916.30		
2210	SSI DISABLED NON-ME
D	457,985.50	459,066.50	459,745.50	464,882.50	459,887.00	461,441.70	491,944.40	489,483.40	0.00	0.00	0.00	0.00		3,744,436.50		
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	4,144,592.50	4,142,675.50	0.00	0.00	0.00	0.00		31,615,963.20		
2300	SSI BLIND WITH MEDIC	135.50	135.50	135.50	135.50	135.50	135.50	144.60	144.60	0.00	0.00	0.00	0.00		1,102.20		
2310	SSI BLIND NON-MEDIC A	4,607.00	4,200.50	4,336.00	3,794.00	5,555.50	4,742.50	4,627.20	4,627.20	0.00	0.00	0.00	0.00		36,489.90		
2320	SSI BLIND WITH QMB	38,872.00	35,636.50	36,178.50	37,669.00	36,314.00	37,940.00	39,882.30	39,909.60	0.00	0.00	0.00	0.00		302,401.90		
4320	SOBRA CHILD WITH Q MB	271.00	271.00	1,626.00	542.00	542.00	406.50	433.80	433.80	0.00	0.00	0.00	0.00		4,526.10		
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	4,898.20	5,024.60	0.00	0.00	0.00	0.00		37,968.30		
8000	SMIB ONLY NOT ELIGIB	0.00	-271.00	0.00	0.00	-677.50	-271.00	-271.00	-280.10	0.00	0.00	0.00	0.00		-1,770.60		
8020	QMB ONLY	803,619.00	813,138.30	802,950.10	816,375.00	804,392.50	801,930.30	874,533.20	872,728.10	0.00	0.00	0.00	0.00		6,589,666.50		
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	5,944,684.10	5,935,230.20	0.00	0.00	0.00	0.00		44,564,956.60		
8888	SMIB ONLY NOT ELIGIB	-40,718.50	-27,017.20	-34,454.20	-22,677.20	-33,932.60	-29,312.30	-16,515.60	-21,513.20	0.00	0.00	0.00	0.00		-226,140.80		
9999	SMIB ONLY NOT ELIGIB	159,459.10	25,881.20	152,852.80	169,311.10	187,950.00	78,395.50	165,660.10	177,067.90	0.00	0.00	0.00	0.00		1,116,577.70		
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	17,257,412.60	17,276,633.10	0.00	0.00	0.00	0.00		130,169,281.30		

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	144.60	135.50	0.00	0.00	0.00	0.00	

1,490.50	
135.50	
1,635.10	

1100	TANF EXPANDED FPR FI	200,075.30	203,897.00	200,246.00	208,634.00	193,151.00	200,501.50	214,111.50	207,707.70	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	433.80	289.20	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	985,079.40	979,404.90	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	12,091.80	14,387.20	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	578.40	578.40	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	4,030,873.10	4,041,098.00	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	289.20	289.20	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	26,513.50	25,548.80	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	2,498,779.10	2,513,994.50	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	7,768,749.80	7,783,297.90	0.00	0.00	0.00	0.00	

 
1,628,324.00	
3,568.50	
7,496,675.00	
104,629.00	
2,782.80	
30,359,011.40	
1,526.90	
139,465.80	
19,078,357.10	
58,814,340.50	

ACC SMIB
For The Period Ending February 29, 2020	
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	144.60	135.50	0.00	0.00	0.00	0.00		3,261.10		

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	50,103.40	50,835.50	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	50,103.40	50,835.50	0.00	0.00	0.00	0.00	

135.50	
1,355.00	
371,667.90	
373,158.40	

3920	NEWLY ELIGIBLE FOR F	271.00	135.50	0.00	0.00	271.00	271.00	424.70	144.60	0.00	0.00	0.00	0.00	
SUBTOTAL:	271.00	135.50	0.00	0.00	271.00	271.00	424.70	144.60	0.00	0.00	0.00	0.00	

 

1,517.80

1,517.80

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	25,076,835.10	25,111,046.60	0.00	0.00	0.00	0.00		189,361,559.10		

ACC HIB
For The Period Ending February 29, 2020	
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	916.00	916.00	0.00	0.00	0.00	0.00		8,824.00		
2100	SSI AGED WITH MEDIC A	917.70	2,665.70	1,704.30	3,059.00	2,271.00	4,370.00	697.00	-21.00	0.00	0.00	0.00	0.00		15,663.70		
2110	SSI AGED NON-MEDIC
AR	7,866.00	4,807.00	0.00	0.00	1,311.00	0.00	0.00	4,167.80	0.00	0.00	0.00	0.00		18,151.80		
2120	SSI AGED WITH QMB	516,393.00	581,314.30	611,385.20	603,322.20	590,157.70	602,016.30	635,949.60	640,523.20	0.00	0.00	0.00	0.00		4,781,061.50		
2210	SSI DISABLED NON-ME D	4,807.00	0.00	0.00	0.00	0.00	0.00	0.00	3,000.00	0.00	0.00	0.00	0.00		7,807.00		
2220	SSI DISABLED WITH Q
M	246,186.50	258,399.50	275,849.30	273,008.10	267,249.70	267,643.70	279,680.10	286,539.80	0.00	0.00	0.00	0.00		2,154,556.70		
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	1,626.00	1,626.00	0.00	0.00	0.00	0.00		12,121.00		
8020	QMB ONLY	4,259.70	4,259.70	5,613.70	4,571.70	4,523.70	4,523.70	3,706.00	6,554.00	0.00	0.00	0.00	0.00		38,012.20		
9999	SMIB ONLY NOT ELIGIB	-7,682.70	-11,273.20	-3,735.30	-4,872.90	-6,183.70	-3,822.00	-7,519.90	-10,001.30	0.00	0.00	0.00	0.00		-55,091.00		
SUBTOTAL:	775,609.2	0	843,035.00	893,679.2	0	881,950.10	862,191.40	876,719.70	915,054.80	933,304.50	0.00	0.00	0.00	0.00		6,981,543.90		

1120	TANF EXPANDED FOR FI	1,551.00	240.00	240.00	240.00	240.00	0.00	0.00	1,353.00	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	458.00	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	4,996.00	4,122.00	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	4,996.00	5,933.00	0.00	0.00	0.00	0.00	

 
3,864.00	
458.00	
36,078.80	
40,400.80	

7,021,944.70

781,857.60	847,885.00	898,572.90	886,843.80	866,604.40	880,892.70	920,050.80	939,237.50	0.00	0.00	0.00	0.00	

TOTAL:

Q1
For The Period Ending February 29, 2020	
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	2,847,895.70	2,919,917.10	0.00	0.00	0.00	0.00		23,969,315.40		
9999	SMIB ONLY NOT ELIGIB	-11,850.50	-8,842.50	2,000.50	-3,347.50	-1,339.00	-6,647.50	334,899.10	271,928.40	0.00	0.00	0.00	0.00		576,801.00		
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	3,182,794.80	3,191,845.50	0.00	0.00	0.00	0.00		24,546,116.40		

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	3,182,794.80	3,191,845.50	0.00	0.00	0.00	0.00		24,546,116.40		

LTC SMIB
For The Period Ending February 29, 2020	
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	433.80	289.20	0.00	0.00	0.00	0.00		3,297.50		
1020	TANF WITH QMB	677.50	677.50	677.50	542.00	542.00	542.00	289.20	289.20	0.00	0.00	0.00	0.00		4,236.90		
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	1,208,231.60	1,172,192.20	0.00	0.00	0.00	0.00		9,243,459.90		
2110	SSI AGED NON-MEDIC
AR	224,638.00	229,025.80	228,886.30	217,342.00	218,832.50	210,057.00	234,206.50	234,992.20	0.00	0.00	0.00	0.00		1,797,980.30		
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	1,373,189.40	1,400,038.20	0.00	0.00	0.00	0.00		10,346,948.90		
2200	SSI DISABLED WITH M E	399,084.90	384,519.80	388,578.30	387,535.80	383,855.90	428,056.60	383,914.90	387,602.10	0.00	0.00	0.00	0.00		3,143,148.30		
2210	SSI DISABLED NON-ME
D	14,092.00	14,769.50	16,937.50	18,563.50	19,105.50	16,260.00	17,641.20	21,391.70	0.00	0.00	0.00	0.00		138,760.90		
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	1,168,195.60	1,183,905.50	0.00	0.00	0.00	0.00		8,814,390.70		
2300	SSI BLIND WITH MEDIC	271.00	135.50	271.00	0.00	0.00	135.50	289.20	289.20	0.00	0.00	0.00	0.00		1,391.40		
2310	SSI BLIND NON-MEDIC A	135.50	135.50	135.50	135.50	135.50	135.50	144.60	289.20	0.00	0.00	0.00	0.00		1,246.80		
2320	SSI BLIND WITH QMB	813.00	948.50	542.00	406.50	542.00	948.50	723.00	867.60	0.00	0.00	0.00	0.00		5,791.10		
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	4,387,259.00	4,402,146.30	0.00	0.00	0.00	0.00		33,500,652.70		

8720	SSI DISABLED FREEDO M	1,355.00	1,761.50	1,761.50	2,168.00	2,303.50	2,303.50	2,747.40	3,181.20	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	2,747.40	3,181.20	0.00	0.00	0.00	0.00	

 
17,581.60

17,581.60

33,518,234.30

4,094,295.50	4,092,509.70	4,109,179.60	4,112,907.20	4,143,919.40	4,170,089.00	4,390,006.40	4,405,327.50	0.00	0.00	0.00	0.00	

TOTAL:

LTC HIB
For The Period Ending February 29, 2020	
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	916.00	0.00	0.00	0.00	0.00		2,227.00		
2120	SSI AGED WITH QMB	366,800.40	370,188.20	376,589.20	369,532.00	369,054.50	367,565.50	382,107.80	385,674.00	0.00	0.00	0.00	0.00		2,987,511.60		
2200	SSI DISABLED WITH M E	1,354.70	-1,354.70	437.00	0.00	-437.00	0.00	0.00	458.00	0.00	0.00	0.00	0.00		458.00		
2220	SSI DISABLED WITH Q
M	11,405.70	14,901.70	16,889.70	17,741.50	17,610.40	14,594.40	20,545.40	19,007.20	0.00	0.00	0.00	0.00		132,696.00		
2320	SSI BLIND WITH QMB	480.70	480.70	480.70	480.70	480.70	480.70	503.80	503.80	0.00	0.00	0.00	0.00		3,891.80		
SUBTOTAL:	381,352.5	0	383,341.90	394,396.6	0	388,191.20	386,271.60	382,640.60	403,157.00	406,559.00	0.00	0.00	0.00	0.00		3,125,910.40		

TOTAL:	381,352.50	383,341.90	394,396.60	388,191.20	386,271.60	382,640.60	403,157.00	406,559.00	0.00	0.00	0.00	0.00		3,125,910.40		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
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	2,275.27	952.34	0.00	0.00	0.00	0.00		12,691.37		
1007	TANF 21-44 FEMALE WI	1,844.01	2,435.65	604.00	81.00	925.75	910.00	922.55	469.76	0.00	0.00	0.00	0.00		8,192.72		
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	1,843.11	2,796.29	0.00	0.00	0.00	0.00		43,133.21		
1009	TANF 65+ M & F WITH	6,203.96	2,264.15	1,795.13	3,544.21	7,375.45	1,660.42	4,847.42	6,328.88	0.00	0.00	0.00	0.00		34,019.62		
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	766,688.94	634,148.39	0.00	0.00	0.00	0.00		5,318,764.48		
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	388,755.42	396,357.74	0.00	0.00	0.00	0.00		2,642,283.78		
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	449,147.10	487,248.13	0.00	0.00	0.00	0.00		3,542,572.35		
1014	TANF 14-20 MALE NON-	193,092.30	113,486.70	79,186.08	108,004.30	154,318.29	141,569.74	93,572.39	126,737.62	0.00	0.00	0.00	0.00		1,009,967.42		
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	262,582.73	267,599.98	0.00	0.00	0.00	0.00		2,165,484.24		
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	1,151,141.24	1,102,764.34	0.00	0.00	0.00	0.00		10,340,127.80		
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	4,489,895.73	4,616,522.97	0.00	0.00	0.00	0.00		37,780,483.44		
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	1,935,566.52	1,955,925.66	0.00	0.00	0.00	0.00		16,504,389.78		
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	6,128.13	6,388.27	0.00	0.00	0.00	0.00		51,615.30		
1026	TANF 21-44 MALE WITH	379.83	0.00	15.75	617.00	455.00	910.00	1,001.55	1,365.00	0.00	0.00	0.00	0.00		4,744.13		
1027	TANF 21-44 FEMALE WI	8,469.49	1,464.04	1,280.01	997.93	2,824.75	1,285.85	1,468.61	1,196.52	0.00	0.00	0.00	0.00		18,987.20		
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	3,724.84	2,161.07	0.00	0.00	0.00	0.00		22,494.55		
1029	TANF 65+ M & F WITH	3,340.01	1,770.48	5,504.70	1,264.92	2,564.03	976.17	2,297.26	748.14	0.00	0.00	0.00	0.00		18,465.71		
2100	SSI AGED WITH MEDIC A	112,980.76	60,316.34	46,750.16	54,355.02	136,123.11	44,412.99	86,075.90	81,593.15	0.00	0.00	0.00	0.00		622,607.43		
2110	SSI AGED NON-MEDIC
AR	181,290.38	92,702.15	72,010.14	93,986.11	178,925.73	80,481.18	97,150.32	105,735.12	0.00	0.00	0.00	0.00		902,281.13		
2120	SSI AGED WITH QMB	409,253.22	316,117.24	254,509.28	267,835.19	704,155.60	280,527.26	405,340.33	435,603.63	0.00	0.00	0.00	0.00		3,073,341.75		
2200	SSI DISABLED WITH M E	264,684.94	158,980.48	165,849.59	168,145.07	453,783.23	145,031.61	220,581.88	301,199.13	0.00	0.00	0.00	0.00		1,878,255.93		
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	5,258,930.48	5,049,158.10	0.00	0.00	0.00	0.00		43,895,699.48		
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	659,015.11	704,098.67	0.00	0.00	0.00	0.00		5,209,551.41		
2300	SSI BLIND WITH MEDIC	2,403.28	1,253.88	1,539.79	2,094.11	5,774.34	2,801.26	3,999.93	4,301.46	0.00	0.00	0.00	0.00		24,168.05		
2310	SSI BLIND NON-MEDIC A	115,995.95	93,912.22	52,379.85	46,167.93	103,264.23	44,656.70	58,168.84	60,807.39	0.00	0.00	0.00	0.00		575,353.11		
2320	SSI BLIND WITH QMB	10,555.01	6,761.49	4,295.24	5,940.00	13,728.12	4,257.05	7,424.26	6,910.42	0.00	0.00	0.00	0.00		59,871.59		
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	1,916,521.62	1,756,307.75	0.00	0.00	0.00	0.00		14,255,174.13		
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	4,273,011.01	4,495,404.02	0.00	0.00	0.00	0.00		31,095,045.20		
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	4,965,587.39	5,934,858.74	0.00	0.00	0.00	0.00		43,592,602.90		
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	1,224,621.79	1,354,193.12	0.00	0.00	0.00	0.00		10,485,893.36		
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	1,770,554.33	1,657,141.37	0.00	0.00	0.00	0.00		14,239,261.23		
5007	SOBRA PREG 21-44 FE M	93.41	904.06	96.75	746.33	266.60	10.21	1,255.25	1,108.17	0.00	0.00	0.00	0.00		4,480.78		
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	166,147.17	204,121.97	0.00	0.00	0.00	0.00		2,285,365.71		
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	1,521,385.68	1,430,969.55	0.00	0.00	0.00	0.00		13,745,959.04		
5018	SOBRA PREG 45-64 FE M	3,229.98	455.00	2,730.00	910.00	1,820.00	2,275.00	455.00	3,185.00	0.00	0.00	0.00	0.00		15,059.98		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
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	96.75	399.75	0.00	0.00	0.00	0.00		1,941.57		
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	32,198,181.85	33,196,807.61	0.00	0.00	0.00	0.00		265,483,515.88		

1106	TANF EXPANDED 21-44	3,391.33	1,198.94	1,322.27	3,291.41	6,614.19	1,738.84	3,199.83	6,425.44	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	3,399.95	1,805.97	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	17,762.32	28,100.96	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	24,417.97	22,650.47	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	455.00	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	5,514.69	17,916.09	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	31,681.04	22,290.20	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	661,561.96	607,268.88	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	2,124,668.99	2,075,057.58	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	1,262,850.81	1,323,673.56	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	3,185.00	5,915.00	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	8,362.44	5,502.74	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	12,107.84	11,787.74	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	65,608.42	73,162.35	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	52,473.83	58,845.87	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	5,260.20	9,113.51	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	23,583.94	34,933.39	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	368,782.84	403,908.58	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	6,173.74	9,076.93	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	109,068.54	133,319.55	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	185,275.70	200,124.65	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	4,974,940.05	5,051,334.46	0.00	0.00	0.00	0.00	

 
27,182.25	
23,124.82	
174,067.48	
211,933.99	
2,070.00	
47,247.69	
250,656.63	
4,808,118.52	
17,325,034.82	
11,085,620.66	
40,315.02	
84,874.05	
123,990.34	
494,195.62	
389,259.82	
62,387.14	
167,911.35	
2,932,630.38	
36,652.01	
951,432.62	
1,465,526.68	
40,704,231.89	

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 February 29, 2020	
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	2,216.07	2,509.03	0.00	0.00	0.00	0.00		6,948.82		
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	55,229.96	48,414.22	0.00	0.00	0.00	0.00		420,244.24		
3515	ADULT 40-100% FEMAL E	126,223.47	102,765.83	67,081.04	110,495.47	144,308.61	66,387.88	86,685.11	81,538.87	0.00	0.00	0.00	0.00		785,486.28		
3516	ADULT 40-100% MALE 2	727,935.76	485,813.77	396,851.80	404,408.08	708,364.54	502,539.90	694,874.53	493,266.47	0.00	0.00	0.00	0.00		4,414,054.85		
3517	ADULT 40-100% FEMAL E	667,579.54	460,943.19	314,517.42	383,245.42	714,490.34	367,013.51	407,073.96	443,597.13	0.00	0.00	0.00	0.00		3,758,460.51		
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	1,675,603.18	1,599,483.65	0.00	0.00	0.00	0.00		14,431,140.00		
3519	ADULT 40-100% M&F 65	455.00	0.00	0.00	0.00	455.00	1,820.00	1,365.00	3,185.00	0.00	0.00	0.00	0.00		7,280.00		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	267.19	0.00	0.00	0.00	0.00		267.19		
3706	ADULT <40% EXP MALE	252.48	1,629.66	582.94	3,200.47	161.84	146.92	0.00	310.00	0.00	0.00	0.00	0.00		6,284.31		
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	2,932.22	6,230.98	0.00	0.00	0.00	0.00		53,048.38		
3709	ADULT <40% EXP M&F 6	0.00	427.00	427.00	0.00	0.00	0.00	79.40	190.00	0.00	0.00	0.00	0.00		1,123.40		
3714	ADULT <40% EXP MALE	332,766.96	250,547.34	182,697.86	231,621.30	336,939.71	250,623.37	301,395.62	268,116.99	0.00	0.00	0.00	0.00		2,154,709.15		
3715	ADULT <40% EXP FEM AL	489,450.66	370,107.48	272,561.22	323,903.31	508,211.53	333,433.30	356,330.20	333,867.83	0.00	0.00	0.00	0.00		2,987,865.53		
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	4,526,494.08	3,902,597.27	0.00	0.00	0.00	0.00		36,410,657.21		
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	2,735,511.43	2,616,891.47	0.00	0.00	0.00	0.00		23,337,296.08		
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	6,910,922.73	6,698,638.44	0.00	0.00	0.00	0.00		57,256,254.64		
3719	ADULT <40% EXP M&F 6	455.00	21,292.98	455.00	3,665.69	3,458.81	463.21	3,640.00	3,074.24	0.00	0.00	0.00	0.00		36,504.93		
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	395.20	0.00	0.00	0.00	0.00		395.20		
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	17,760,353.49	16,502,573.98	0.00	0.00	0.00	0.00		146,079,379.85		

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	

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	3,201.50	949.98	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	147.00	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	20,395.31	27,202.84	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	72,280.58	53,087.95	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	300,979.06	336,921.94	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	598,530.80	526,313.67	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	1,254,259.33	1,145,597.92	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	455.00	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	2,250,101.58	2,090,221.30	0.00	0.00	0.00	0.00	

 
3,385.56	
93.41	
12,348.86	
1,728.01	
165,471.53	
361,492.12	
2,875,356.91	
4,920,789.66	
9,482,047.41	
1,373.96	
17,824,087.43	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	432,649.74	421,396.01	0.00	0.00	0.00	0.00		3,492,674.90		
4414	SOBRA 100-133% MALE	197,152.96	138,160.37	155,034.46	135,189.24	169,740.84	154,690.39	133,818.60	134,915.13	0.00	0.00	0.00	0.00		1,218,701.99		
4415	SOBRA 100-133% FEMA L	237,463.81	175,607.59	149,384.42	159,032.85	244,863.15	138,240.52	134,509.64	142,463.49	0.00	0.00	0.00	0.00		1,381,565.47		
SUBTOTAL:	1,013,023.62	761,388.60	649,434.4	5	684,581.72	917,828.42	667,842.94	700,977.98	698,774.63	0.00	0.00	0.00	0.00		6,093,852.36		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	910.00	455.00	1,365.00	1,365.00	910.00	455.00	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	4,550.00	3,640.00	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	5,460.00	4,095.00	0.00	0.00	0.00	0.00	

 
5,460.00	
37,929.08	
4,095.00	
15,397.24	
62,881.32	

8700	SSI DISABLED FREEDO M	12,901.78	6,600.67	1,644.15	10,536.85	10,209.34	9,466.05	8,695.09	10,219.49	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	15,479.83	11,830.00	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	1,441.60	742.27	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	25,616.52	22,791.76	0.00	0.00	0.00	0.00	

 
70,273.42	
164,123.31	
7,855.44	
242,252.17	

0.00

476,478,650.90

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	

44,847,279.40	51,791,599.27	82,062,494.67	51,200,622.66	57,915,631.47	57,566,598.74	0.00	0.00	0.00	0.00	

0.00

TOTAL:

74,111,672.71

56,982,751.98

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
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	33,290.98	51,308.07	0.00	0.00	0.00	0.00		146,221.61		
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	33,290.98	51,308.07	0.00	0.00	0.00	0.00		146,221.61		

TOTAL:	42,607.07	41,818.90	47,825.53	-37,884.57	-45,916.85	13,172.48	33,290.98	51,308.07	0.00	0.00	0.00	0.00		146,221.61		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
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	7,906.19	4,494.96	0.00	0.00	0.00	0.00		55,052.38		
1012	TANF 01-05 M & F NON	777.88	2,632.04	96.35	168.06	0.00	0.00	0.00	282.27	0.00	0.00	0.00	0.00		3,956.60		
1013	TANF 06-13 M & F NON	10.85	0.00	200.41	0.00	59.94	164.70	1,095.58	0.00	0.00	0.00	0.00	0.00		1,531.48		
1014	TANF 14-20 MALE NON-	44.05	0.00	144.70	0.00	0.00	0.00	0.00	930.56	0.00	0.00	0.00	0.00		1,119.31		
1015	TANF 14-20 FEMALE N O	2,496.60	341.21	1,369.75	1,765.91	5,045.28	164.30	629.46	125.35	0.00	0.00	0.00	0.00		11,937.86		
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	15,021.86	0.00	0.00	0.00	0.00		42,357.69		
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	8,718.00	9,952.73	0.00	0.00	0.00	0.00		285,955.69		
1018	TANF 45-64 M & F NON	3,220.37	9,395.06	5,423.50	1,020.96	779.88	6,449.94	192.87	-41.50	0.00	0.00	0.00	0.00		26,441.08		
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	7,279.04	1,036.45	0.00	0.00	0.00	0.00		21,027.51		
2110	SSI AGED NON-MEDIC
AR	4,535.42	5,494.64	3,476.23	8,172.49	13,764.93	35,420.11	28,363.74	3,610.89	0.00	0.00	0.00	0.00		102,838.45		
2120	SSI AGED WITH QMB	-5.22	718.26	13,438.47	-162.99	839.90	1,474.89	181.89	10.55	0.00	0.00	0.00	0.00		16,495.75		
2200	SSI DISABLED WITH M E	828.88	4,440.65	346.64	599.37	3,442.95	228.19	1,805.04	272.48	0.00	0.00	0.00	0.00		11,964.20		
2210	SSI DISABLED NON-ME
D	46,209.75	8,576.13	356,427.07	96,324.20	242,923.82	140,602.72	216,882.12	432,123.65	0.00	0.00	0.00	0.00		1,540,069.46		
2220	SSI DISABLED WITH Q M	6,575.10	48.79	92,736.81	2,768.44	1,258.44	1,779.86	1,194.48	577.43	0.00	0.00	0.00	0.00		106,939.35		
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	186,696.16	132,656.55	0.00	0.00	0.00	0.00		387,086.56		
4312	SOBRA CHILD 01-05 M	8,047.58	7,985.21	39,028.64	7,716.40	6,509.69	3,268.58	15,373.97	9,754.94	0.00	0.00	0.00	0.00		97,685.01		
4313	SOBRA CHILD 06-13 M	11,969.38	4,816.54	6,351.37	9,105.11	13,559.02	1,626.04	9,183.42	10,590.49	0.00	0.00	0.00	0.00		67,201.37		
4314	SOBRA CHILD 14-20 MA	1,518.14	858.50	2,084.57	11,953.91	3,589.16	9,482.08	2,292.64	60,677.57	0.00	0.00	0.00	0.00		92,456.57		
4315	SOBRA CHILD 14-20 FE	1,126.11	886.24	3,376.06	583.74	1,527.54	631.07	2,909.33	3,865.81	0.00	0.00	0.00	0.00		14,905.90		
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	146.48	223.41	0.00	0.00	0.00	0.00		8,522.21		
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	37,761.75	16,709.78	0.00	0.00	0.00	0.00		192,244.10		
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 February 29, 2020	
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	528,612.16	702,876.23	0.00	0.00	0.00	0.00		3,088,148.42		

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	4.08	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	14.76	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	124.03	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	4,520.24	381.79	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	9,036.06	6,017.02	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	2,453.41	2,707.74	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	422.20	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	17.75	228.22	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	312.65	103.86	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	23.54	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	283.84	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	16,886.34	9,764.85	0.00	0.00	0.00	0.00	

 
64.55	
366.30	
2,045.06	
0.00	
0.00	
2,044.94	
725.44	
73,974.84	
54,725.51	
83,659.15	
0.00	
422.20	
354.13	
748.08	
0.00	
3,632.99	
1,131.11	
0.00	
6,205.58	
2,635.49	
308.66	
233,044.03	

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 February 29, 2020	
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	33.69	0.00	0.00	0.00	0.00		33.69		
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	289.21	4.09	0.00	0.00	0.00	0.00		1,628.35		
3516	ADULT 40-100% MALE 2	19,227.07	9,299.28	27,140.62	9,335.51	13,408.49	11,095.50	38,799.96	7,148.87	0.00	0.00	0.00	0.00		135,455.30		
3517	ADULT 40-100% FEMAL E	3,335.31	6,034.54	665.68	1,659.17	11,962.47	1,605.86	4,187.30	1,461.11	0.00	0.00	0.00	0.00		30,911.44		
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	90,311.78	11,029.31	0.00	0.00	0.00	0.00		617,163.72		
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		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	0.00	2,422.45	0.00	2,380.76	2,275.76	160.48	307.78	0.00	0.00	0.00	0.00	0.00		7,547.23		
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	8,485.25	4,695.17	0.00	0.00	0.00	0.00		29,278.02		
3715	ADULT <40% EXP FEM AL	462.06	1,931.76	1,739.85	2,414.05	5,075.84	3,727.17	1,107.67	0.00	0.00	0.00	0.00	0.00		16,458.40		
3716	ADULT <40% EXP MALE	365,435.81	51,493.65	58,404.37	83,378.22	76,487.24	65,554.80	113,758.64	153,051.50	0.00	0.00	0.00	0.00		967,564.23		
3717	ADULT <40% EXP FEM AL	28,305.36	19,951.64	62,170.84	56,367.73	23,722.61	22,256.41	26,298.05	8,087.77	0.00	0.00	0.00	0.00		247,160.41		
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	122,927.38	99,288.14	0.00	0.00	0.00	0.00		816,796.45		
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	406,473.02	284,799.65	0.00	0.00	0.00	0.00		2,877,881.80		

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	

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	48.84	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	1,000.18	1,938.74	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	8,984.95	6,226.56	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	2,579.96	205,338.11	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	38,533.14	33,365.35	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	51,098.23	246,917.60	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
1,359.82	
0.00	
988.11	
3,427.49	
162,728.78	
417,724.51	
419,550.40	
47.55	
1,005,826.66	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	0.00	2,095.60	986.25	377.58	544.91	51.42	1,306.17	1,032.54	0.00	0.00	0.00	0.00		6,394.47		
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	314.73	1,978.58	0.00	0.00	0.00	0.00		3,154.18		
SUBTOTAL:	100.51	2,095.60	993.7	6	927.76	1,402.01	105.61	1,620.90	3,011.12	0.00	0.00	0.00	0.00		10,257.27		

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	

-1,889.60

7,256,077.74

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	

1,194,018.97	547,376.79	870,777.46	625,206.04	1,004,690.65	1,247,369.45	0.00	0.00	0.00	0.00	

-1,889.60

TOTAL:

1,206,055.14

560,583.24

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending February 29, 2020	
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	492,532.36	445,953.69	0.00	0.00	0.00	0.00		3,383,135.50		
8040	SLMB	75.68	15.51	0.00	0.00	0.00	0.00	0.00	18.06	0.00	0.00	0.00	0.00		109.25		
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	448,283.68	392,870.6	0	404,946.54	233,053.31	348,310.12	492,532.36	445,971.75	0.00	0.00	0.00	0.00		3,383,556.07		

TOTAL:	617,587.71	448,283.68	392,870.60	404,946.54	233,053.31	348,310.12	492,532.36	445,971.75	0.00	0.00	0.00	0.00		3,383,556.07		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending February 29, 2020	
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	455.00	0.00	0.00	0.00	0.00	0.00		3,185.00		
2100	SSI AGED WITH MEDIC A	249,129.13	166,906.44	235,451.24	161,043.71	353,900.27	160,086.73	223,027.02	215,808.93	0.00	0.00	0.00	0.00		1,765,353.47		
2110	SSI AGED NON-MEDIC
AR	62,182.20	66,431.52	41,317.62	34,066.46	47,965.58	28,430.09	25,227.53	20,555.24	0.00	0.00	0.00	0.00		326,176.24		
2120	SSI AGED WITH QMB	359,948.35	251,228.84	236,600.09	249,357.53	578,921.85	236,481.61	340,578.78	331,686.03	0.00	0.00	0.00	0.00		2,584,803.08		
2200	SSI DISABLED WITH M E	64,376.04	44,880.45	44,560.73	41,946.27	108,752.91	46,115.77	57,259.21	32,671.21	0.00	0.00	0.00	0.00		440,562.59		
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	992,943.23	937,254.76	0.00	0.00	0.00	0.00		7,871,280.80		
2220	SSI DISABLED WITH Q M	153,160.28	111,134.47	98,763.76	108,290.17	217,713.95	122,683.65	140,908.07	149,606.99	0.00	0.00	0.00	0.00		1,102,261.34		
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	7,581.29	4,118.72	0.00	0.00	0.00	0.00		55,260.93		
2320	SSI BLIND WITH QMB	604.35	90.44	264.76	0.00	0.00	0.00	93.42	81.00	0.00	0.00	0.00	0.00		1,133.97		
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	1,788,073.55	1,691,782.88	0.00	0.00	0.00	0.00		14,150,961.80		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	455.00	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	455.00	0.00	0.00	0.00	0.00	

 
455.00	
0.00	
455.00	

14,151,416.80

2,036,731.71	1,700,154.18	1,485,151.09	1,456,500.10	2,540,386.70	1,452,181.59	1,788,073.55	1,692,237.88	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 February 29, 2020	
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	5,519.52	11,221.91	0.00	0.00	0.00	0.00		116,752.24		
2110	SSI AGED NON-MEDIC
AR	25,720.01	775.26	473.84	4,116.04	0.00	0.00	5,461.50	5,142.93	0.00	0.00	0.00	0.00		41,689.58		
2120	SSI AGED WITH QMB	11,865.96	23,336.47	4,003.90	4,412.31	611.98	248.02	6,095.60	818.80	0.00	0.00	0.00	0.00		51,393.04		
2200	SSI DISABLED WITH M E	11,704.99	147.31	163.48	395.35	2,067.54	4,121.66	4,062.28	1,110.28	0.00	0.00	0.00	0.00		23,772.89		
2210	SSI DISABLED NON-ME
D	73,355.72	69,642.29	33,336.99	50,764.47	91,594.44	20,137.76	50,188.63	35,551.75	0.00	0.00	0.00	0.00		424,572.05		
2220	SSI DISABLED WITH Q M	2,493.77	1,494.83	26,114.02	5,892.44	2,553.73	4,518.86	3,941.14	7,007.50	0.00	0.00	0.00	0.00		54,016.29		
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	75,268.67	60,853.17	0.00	0.00	0.00	0.00		723,117.63		

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	

 
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	75,268.67	60,853.17	0.00	0.00	0.00	0.00		723,117.63		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending February 29, 2020	
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	15,485.55	5,423.62	0.00	0.00	0.00	0.00		48,063.73		
1007	TANF 21-44 FEMALE WI	3,816.12	5,879.47	3,052.17	5,354.78	1,591.48	3,049.23	6,135.76	582.50	0.00	0.00	0.00	0.00		29,461.51		
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	19,561.94	6,945.81	0.00	0.00	0.00	0.00		79,742.24		
1009	TANF 65+ M & F WITH	1,369.44	4,783.88	4,100.16	5,212.46	7,282.11	5,956.92	5,383.33	4,497.55	0.00	0.00	0.00	0.00		38,585.85		
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	840,853.12	788,517.73	0.00	0.00	0.00	0.00		4,788,045.73		
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	84,161.62	119,851.17	0.00	0.00	0.00	0.00		600,897.13		
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	206,132.31	136,982.95	0.00	0.00	0.00	0.00		1,132,172.11		
1014	TANF 14-20 MALE NON-	10,100.26	62,045.38	70,011.32	54,058.28	57,568.01	59,109.81	113,316.97	52,000.84	0.00	0.00	0.00	0.00		478,210.87		
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	197,934.13	170,739.95	0.00	0.00	0.00	0.00		1,109,640.55		
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	1,159,454.06	1,217,746.13	0.00	0.00	0.00	0.00		7,119,672.25		
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	3,289,666.83	2,979,077.18	0.00	0.00	0.00	0.00		20,633,254.36		
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	1,390,229.57	1,144,015.97	0.00	0.00	0.00	0.00		7,556,680.45		
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	640.55	358.49	0.00	0.00	0.00	0.00		4,365.11		
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	4,609.50	498.11	0.00	0.00	0.00	0.00		23,065.08		
1029	TANF 65+ M & F WITH	8,541.20	4,679.40	4,543.87	4,349.72	4,671.40	3,492.39	3,255.32	5,404.06	0.00	0.00	0.00	0.00		38,937.36		
2100	SSI AGED WITH MEDIC A	118,534.81	198,886.57	83,623.90	193,229.67	137,543.69	158,586.51	140,896.59	150,005.50	0.00	0.00	0.00	0.00		1,181,307.24		
2110	SSI AGED NON-MEDIC
AR	-20,837.80	44,299.09	20,582.28	66,215.64	68,307.53	90,088.74	58,767.82	77,182.48	0.00	0.00	0.00	0.00		404,605.78		
2120	SSI AGED WITH QMB	287,256.68	330,452.18	337,985.49	450,546.79	354,556.20	343,446.46	467,738.67	424,252.00	0.00	0.00	0.00	0.00		2,996,234.47		
2200	SSI DISABLED WITH M E	244,210.75	434,046.24	381,914.80	665,603.10	546,812.99	398,372.21	462,682.46	277,819.75	0.00	0.00	0.00	0.00		3,411,462.30		
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	6,617,856.60	5,459,245.19	0.00	0.00	0.00	0.00		40,351,425.68		
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	1,353,563.61	1,159,373.33	0.00	0.00	0.00	0.00		8,797,901.92		
2300	SSI BLIND WITH MEDIC	382.84	1,263.66	105.80	2,311.71	707.39	3,495.82	508.13	1,456.84	0.00	0.00	0.00	0.00		10,232.19		
2310	SSI BLIND NON-MEDIC A	-10,414.70	57,882.15	38,196.51	42,753.44	71,203.29	84,070.92	62,359.44	60,199.12	0.00	0.00	0.00	0.00		406,250.17		
2320	SSI BLIND WITH QMB	15,251.72	12,243.64	15,483.93	22,990.91	17,739.75	21,618.13	21,191.55	16,466.70	0.00	0.00	0.00	0.00		142,986.33		
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	1,363,211.66	1,433,097.06	0.00	0.00	0.00	0.00		8,143,584.36		
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	1,413,773.35	1,374,868.77	0.00	0.00	0.00	0.00		7,887,695.99		
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	2,176,545.90	2,290,119.45	0.00	0.00	0.00	0.00		13,852,723.42		
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	789,007.68	885,698.98	0.00	0.00	0.00	0.00		6,205,952.15		
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	1,100,361.01	925,088.09	0.00	0.00	0.00	0.00		6,195,580.14		
5007	SOBRA PREG 21-44 FE M	1,374.70	163.21	1,412.23	0.00	0.00	2,158.53	606.85	961.05	0.00	0.00	0.00	0.00		6,676.57		
5013	SOBRA PREG 09-13 FE
M	0.00	126.96	0.00	0.00	0.00	0.00	0.00	132.96	0.00	0.00	0.00	0.00		259.92		
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	66,509.30	100,826.12	0.00	0.00	0.00	0.00		571,632.92		
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	1,047,598.43	834,551.08	0.00	0.00	0.00	0.00		6,143,736.02		
5018	SOBRA PREG 45-64 FE M	3,309.67	0.00	0.00	26.35	0.00	70.40	86.85	44.00	0.00	0.00	0.00	0.00		3,537.27		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending February 29, 2020	
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	4,431.23	3,145.93	0.00	0.00	0.00	0.00		19,053.93		
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	24,484,517.69	22,107,176.46	0.00	0.00	0.00	0.00		150,422,090.63		

1106	TANF EXPANDED 21-44	1,673.27	565.51	1,006.98	3,172.13	500.11	1,992.22	2,030.03	2,632.81	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	7,633.12	6,718.64	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	26,601.33	18,885.10	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	37,456.77	39,236.23	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	43.96	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	10,211.64	10,772.81	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	505,540.53	358,611.03	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	1,070,629.91	966,640.15	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	835,084.32	565,297.11	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	2,320.72	1,655.81	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	6,703.12	4,017.11	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	48,469.53	46,202.45	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	96,989.56	84,531.65	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	49,854.80	47,522.55	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	5,484.33	1,368.95	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	3,291.69	8,383.54	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	448,281.72	423,468.22	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	11,456.84	9,866.76	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	189,922.07	169,811.31	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	377,032.04	325,107.75	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	3,735,038.03	3,090,729.98	0.00	0.00	0.00	0.00	

 
13,573.06	
58,186.18	
152,941.40	
158,991.30	
126.96	
59,448.41	
91,927.95	
2,652,678.50	
6,734,897.44	
4,368,319.39	
4,524.42	
75,459.36	
265,484.67	
684,711.86	
332,332.77	
28,912.45	
10,954.69	
2,777,746.92	
54,177.85	
1,547,393.90	
2,459,761.18	
22,532,550.66	

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 February 29, 2020	
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	781.88	2,672.49	0.00	0.00	0.00	0.00		9,504.17		
3509	ADULT 40-100% M&F 65	26.15	0.00	0.00	0.00	0.00	0.00	0.00	234.13	0.00	0.00	0.00	0.00		260.28		
3514	ADULT 40-100% MALE 1	19,735.15	21,488.58	23,358.20	23,752.86	28,050.40	29,786.23	30,825.17	71,949.02	0.00	0.00	0.00	0.00		248,945.61		
3515	ADULT 40-100% FEMAL E	7,544.55	46,694.72	44,995.21	35,156.32	35,433.06	51,502.77	47,281.24	28,049.59	0.00	0.00	0.00	0.00		296,657.46		
3516	ADULT 40-100% MALE 2	182,166.05	316,990.28	363,173.76	431,032.01	554,462.30	487,197.64	482,879.90	398,329.85	0.00	0.00	0.00	0.00		3,216,231.79		
3517	ADULT 40-100% FEMAL E	49,024.77	190,927.44	234,561.60	218,475.98	351,764.24	271,497.34	336,065.14	411,455.16	0.00	0.00	0.00	0.00		2,063,771.67		
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	1,000,531.21	958,638.65	0.00	0.00	0.00	0.00		7,108,478.26		
3519	ADULT 40-100% M&F 65	-455.00	0.00	0.00	42.48	148.86	484.26	645.68	850.60	0.00	0.00	0.00	0.00		1,716.88		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	431.73	2,282.38	826.72	124.20	0.00	0.00	819.96	2,758.01	0.00	0.00	0.00	0.00		7,243.00		
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	-4,348.32	42.48	0.00	0.00	0.00	0.00		10,906.08		
3709	ADULT <40% EXP M&F 6	-266.59	0.00	0.00	0.00	0.00	0.00	0.00	121.64	0.00	0.00	0.00	0.00		-144.95		
3714	ADULT <40% EXP MALE	137,135.11	151,870.25	193,566.99	361,014.73	319,842.49	330,991.23	392,845.41	381,612.54	0.00	0.00	0.00	0.00		2,268,878.75		
3715	ADULT <40% EXP FEM AL	25,044.72	246,565.40	181,740.15	280,996.42	251,274.45	182,344.92	278,488.29	241,723.64	0.00	0.00	0.00	0.00		1,688,177.99		
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	6,741,123.87	6,247,866.13	0.00	0.00	0.00	0.00		42,194,932.25		
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	2,971,971.47	2,782,888.84	0.00	0.00	0.00	0.00		18,744,850.03		
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	7,011,155.51	6,289,761.22	0.00	0.00	0.00	0.00		44,578,998.04		
3719	ADULT <40% EXP M&F 6	-455.00	5,271.31	411.02	1,371.39	1,279.41	356.27	330.31	1,426.79	0.00	0.00	0.00	0.00		9,991.50		
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	19,291,396.72	17,820,380.78	0.00	0.00	0.00	0.00		122,449,692.26		

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	

-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	1,386.22	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	7,412.72	2,358.27	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	383.28	511.04	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	27,029.01	17,416.95	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	20,845.75	9,506.42	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	331,143.05	208,548.17	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	252,001.83	228,453.79	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	660,891.01	548,076.99	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	1,301,092.87	1,014,871.63	0.00	0.00	0.00	0.00	

 
13,509.57	
8,224.94	
20,239.57	
5,531.59	
117,053.91	
154,020.15	
2,572,854.34	
1,588,129.97	
4,001,216.42	
3,782.71	
8,484,563.17	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending February 29, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	165,543.02	121,782.64	0.00	0.00	0.00	0.00		846,967.08		
4414	SOBRA 100-133% MALE	-7,052.77	46,756.64	78,658.71	49,561.98	93,107.31	64,535.86	199,974.99	78,124.74	0.00	0.00	0.00	0.00		603,667.46		
4415	SOBRA 100-133% FEMA L	-8,543.09	68,370.22	114,590.98	102,638.43	82,443.22	73,629.30	78,118.02	86,355.82	0.00	0.00	0.00	0.00		597,602.90		
SUBTOTAL:	-108,481.91	242,435.61	296,001.5	6	300,788.53	338,070.04	249,069.38	443,636.03	286,263.20	0.00	0.00	0.00	0.00		2,047,782.44		

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	5,477.93	2,029.91	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	5,477.93	2,029.91	0.00	0.00	0.00	0.00	

 
0.00	
39,791.63	
0.00	
-1,365.00	
38,426.63	

8700	SSI DISABLED FREEDO M	5,748.24	6,806.69	10,182.44	11,563.70	9,026.86	14,899.10	12,954.44	9,291.20	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	2,370.02	5,987.92	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	254.83	298.74	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	15,579.29	15,577.86	0.00	0.00	0.00	0.00	

 
80,472.67	
75,614.45	
18,708.14	
174,795.26	

0.00

306,148,632.45

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	

32,042,537.41	44,513,098.60	47,000,544.68	40,430,270.15	49,276,738.56	44,337,029.82	0.00	0.00	0.00	0.00	

0.00

TOTAL:

14,235,837.65

34,312,575.58

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending February 29, 2020	
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	2,930,910.11	2,796,921.98	0.00	0.00	0.00	0.00		23,399,749.07		
2110	SSI AGED NON-MEDIC
AR	182,346.04	132,352.21	128,808.51	146,829.71	136,743.63	152,155.76	145,082.21	152,784.80	0.00	0.00	0.00	0.00		1,177,102.87		
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	4,667,743.22	4,499,145.32	0.00	0.00	0.00	0.00		35,300,391.34		
2200	SSI DISABLED WITH M E	589,027.23	472,720.03	496,572.43	619,033.16	417,762.71	523,360.91	555,208.92	411,447.44	0.00	0.00	0.00	0.00		4,085,132.83		
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	2,789,437.08	2,604,150.45	0.00	0.00	0.00	0.00		21,705,853.67		
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	1,289,538.75	1,057,729.54	0.00	0.00	0.00	0.00		7,979,761.92		
2300	SSI BLIND WITH MEDIC	2,008.80	1,636.80	1,350.99	1,956.00	1,212.00	1,939.20	1,777.60	830.40	0.00	0.00	0.00	0.00		12,711.79		
2310	SSI BLIND NON-MEDIC A	1,597.02	4,684.37	5,612.65	7,485.35	8,772.11	6,556.41	7,561.70	2,224.90	0.00	0.00	0.00	0.00		44,494.51		
2320	SSI BLIND WITH QMB	4,366.58	1,392.78	0.00	2,694.37	352.47	381.46	810.81	0.00	0.00	0.00	0.00	0.00		9,998.47		
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	12,388,070.40	11,525,234.83	0.00	0.00	0.00	0.00		93,715,308.02		

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	2,380.80	2,692.35	2,162.25	1,462.80	3,427.20	3,427.20	4,307.66	3,521.28	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	4,307.66	3,521.28	0.00	0.00	0.00	0.00	

 
0.00	
23,381.54	
23,381.54	

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	12,392,378.06	11,528,756.11	0.00	0.00	0.00	0.00		93,738,689.56		

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending February 29, 2020	
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	657.92	0.00	0.00	0.00	0.00	0.00		657.92		
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	657.92	0.00	0.00	0.00	0.00	0.00		678.58		

0.00

0.00

0.00

0.00

TOTAL:

0.00

20.66

0.00

0.00

0.00

657.92

0.00

0.00

678.58

KidsCare - CAPITATION AMOUNTS
For The Period Ending February 29, 2020	
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	157,075.18	158,954.55	0.00	0.00	0.00	0.00		1,312,363.45		
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	1,677,918.13	1,670,579.86	0.00	0.00	0.00	0.00		13,030,793.27		
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	3,118,924.60	3,133,603.48	0.00	0.00	0.00	0.00		24,453,181.40		
6014	KIDS 14-19 MALE NON-	741,190.91	756,932.03	769,166.95	820,270.24	813,103.99	807,226.15	820,457.94	826,659.32	0.00	0.00	0.00	0.00		6,355,007.53		
6015	KIDS 14-19 FEMALE NO	751,128.68	770,184.18	781,392.45	842,956.11	848,685.24	843,573.73	847,857.13	836,498.11	0.00	0.00	0.00	0.00		6,522,275.63		
9960	KIDSCARE KICK PAYM EN	6,000.27	5,997.30	5,984.82	12,216.41	37,269.86	18,386.88	12,340.94	18,450.92	0.00	0.00	0.00	0.00		116,647.40		
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	6,634,573.92	6,644,746.24	0.00	0.00	0.00	0.00		51,790,268.68		

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	6,634,573.92	6,644,746.24	0.00	0.00	0.00	0.00		51,790,268.68		

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending February 29, 2020	
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	267.15	269.73	0.00	0.00	0.00	0.00		2,246.23		
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	8,908.40	8,866.02	0.00	0.00	0.00	0.00		70,448.51		
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	16,582.49	16,667.11	0.00	0.00	0.00	0.00		132,355.04		
6014	KIDS 14-19 MALE NON-	4,132.98	4,218.92	4,287.26	4,374.96	4,331.19	4,291.05	4,349.32	4,365.36	0.00	0.00	0.00	0.00		34,351.04		
6015	KIDS 14-19 FEMALE NO	4,170.12	4,274.87	4,336.42	4,469.58	4,498.43	4,452.40	4,472.62	4,422.49	0.00	0.00	0.00	0.00		35,096.93		
9960	KIDSCARE KICK PAYM EN	1.00	1.00	1.00	2.00	6.00	3.00	2.00	3.00	0.00	0.00	0.00	0.00		19.00		
SUBTOTAL:	33,365.44	33,851.39	34,124.6	3	34,816.00	34,644.29	34,539.31	34,581.98	34,593.71	0.00	0.00	0.00	0.00		274,516.75		

274,516.75

33,365.44	33,851.39	34,124.63	34,816.00	34,644.29	34,539.31	34,581.98	34,593.71	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending February 29, 2020	
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	473.34	466.63	0.00	0.00	0.00	0.00		3,518.92		
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	15,612.19	15,440.58	0.00	0.00	0.00	0.00		120,655.64		
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	31,057.68	31,378.96	0.00	0.00	0.00	0.00		233,221.77		
6014	KIDS 14-19 MALE NON-	10,487.13	10,708.53	10,950.58	13,577.00	13,259.48	13,226.07	13,156.25	12,957.75	0.00	0.00	0.00	0.00		98,322.79		
6015	KIDS 14-19 FEMALE NO	10,410.58	10,572.35	10,948.34	13,929.03	13,953.39	14,730.00	15,067.95	15,726.86	0.00	0.00	0.00	0.00		105,338.50		
SUBTOTAL:	59,368.17	60,012.17	61,650.9	5	79,894.31	73,519.91	75,273.92	75,367.41	75,970.78	0.00	0.00	0.00	0.00		561,057.62		

TOTAL:	59,368.17	60,012.17	61,650.95	79,894.31	73,519.91	75,273.92	75,367.41	75,970.78	0.00	0.00	0.00	0.00		561,057.62		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending February 29, 2020	
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	278.00	274.00	0.00	0.00	0.00	0.00		2,299.00		
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	9,159.00	9,062.00	0.00	0.00	0.00	0.00		72,364.75		
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	17,095.06	17,215.06	0.00	0.00	0.00	0.00		136,600.60		
6014	KIDS 14-19 MALE NON-	4,347.00	4,404.00	4,514.00	4,609.00	4,531.00	4,520.00	4,545.00	4,556.00	0.00	0.00	0.00	0.00		36,026.00		
6015	KIDS 14-19 FEMALE NO	4,353.00	4,428.00	4,520.00	4,664.00	4,647.00	4,637.03	4,655.03	4,602.69	0.00	0.00	0.00	0.00		36,506.75		
SUBTOTAL:	34,573.12	34,908.12	35,375.1	5	36,004.75	35,688.03	35,806.09	35,732.09	35,709.75	0.00	0.00	0.00	0.00		283,797.10		

283,797.10

35,375.15	36,004.75	35,688.03	35,806.09	35,732.09	35,709.75	0.00	0.00	0.00	0.00	

TOTAL:

34,573.12

34,908.12

KidsCare - FEE FOR SERVICE
For The Period Ending February 29, 2020	
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	3,220.23	-4,522.72	0.00	0.00	0.00	0.00		8,749.39		
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	63,624.66	65,451.32	0.00	0.00	0.00	0.00		350,320.43		
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	120,323.69	406,951.71	0.00	0.00	0.00	0.00		1,176,378.38		
6014	KIDS 14-19 MALE NON-	39,303.11	50,503.51	36,039.38	88,935.48	51,814.60	28,375.98	54,355.63	34,378.29	0.00	0.00	0.00	0.00		383,705.98		
6015	KIDS 14-19 FEMALE NO	25,467.01	21,720.72	26,081.79	47,116.95	79,986.31	53,531.07	76,990.81	56,488.24	0.00	0.00	0.00	0.00		387,382.90		
SUBTOTAL:	124,559.0	1	240,554.77	141,880.6	0	280,744.28	380,852.85	260,683.71	318,515.02	558,746.84	0.00	0.00	0.00	0.00		2,306,537.08		

TOTAL:	124,559.01	240,554.77	141,880.60	280,744.28	380,852.85	260,683.71	318,515.02	558,746.84	0.00	0.00	0.00	0.00		2,306,537.08		

KidsCare - REINSURANCE
For The Period Ending February 29, 2020	
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	21,780.11	0.00	0.00	0.00	0.00	0.00		36,656.16		
6012	KIDS 1-5 M & F NON-M	0.00	0.00	57,524.29	0.00	0.00	0.00	118,524.66	0.00	0.00	0.00	0.00	0.00		176,048.95		
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	70,136.06	84,487.84	0.00	0.00	0.00	0.00		842,878.35		
6014	KIDS 14-19 MALE NON-	113,827.14	40,260.35	35,353.19	35,159.29	96,771.95	91,843.93	59,502.78	82,990.08	0.00	0.00	0.00	0.00		555,708.71		
6015	KIDS 14-19 FEMALE NO	1,145.72	0.00	0.00	0.00	18,050.71	144,917.66	0.00	-82,825.18	0.00	0.00	0.00	0.00		81,288.91		
SUBTOTAL:	200,701.0	1	116,470.46	178,309.6	4	68,994.99	201,595.81	571,912.82	269,943.61	84,652.74	0.00	0.00	0.00	0.00		1,692,581.08		

1,692,581.08

178,309.64	68,994.99	201,595.81	571,912.82	269,943.61	84,652.74	0.00	0.00	0.00	0.00	

TOTAL:

200,701.01

116,470.46

9

00

22.00

4,293.29

29.00

2,139.80

91.00

3,487.64

15,212.59

212,998.49

2.57

39,723.98

6.00

115.35

4.99

201.52

70.98

119.77

278,518.97

278,518.97

TOTAL

JUNE

MAY

APRIL

MARCH

FEBRUARY

JANUARY

OCTOBER	NOVEMBER	DECEMBER

AUGUST SEPTEMBER

JULY

DESCRIPTION

RATE CODE

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending February 29, 2020

1000	TANF WITH MEDICARE	2.00	3.00	2.00	4.00	4.00	3.00	2.00	2.00	0.00	0.00	0.00	0.00	
1010	TANF NON-MEDICARE	389.91	450.32	511.92	518.88	553.83	576.96	650.19	641.28	0.00	0.00	0.00	0.00	
1020	TANF WITH QMB	5.00	5.00	5.00	4.00	4.00	2.00	2.00	2.00	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	279.97	282.89	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	11.00	11.00	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	447.66	455.38	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	1,875.35	1,854.34	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	26,797.54	26,854.38	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	5,044.12	5,083.67	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	2.00	2.00	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	22.00	6.00	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	26.58	31.99	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDOM	3.99	5.00	9.00	9.00	9.00	11.00	11.00	12.99	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDOM	10.99	12.00	14.00	14.96	15.00	15.82	18.00	19.00	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	35,189.41	35,258.92	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	35,189.41	35,258.92	0.00	0.	0.00	0.00	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending February 29, 2020

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	433,784.91	430,354.72	0.00	0.00	0.00	0.00	3,669,943.36	
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	122,039,237.16	122,189,207.79	0.00	0.00	0.00	0.00	928,659,791.98	
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	122,473,022.07	122,619,562.51	0.00	0.00	0.00	0.00	932,329,735.34	
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	170,307,615.45	170,657,705.71	0.00	0.00	0.00	0.00	1,271,994,696.86	
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	170,307,615.45	170,657,705.71	0.00	0.00	0.00	0.00	1,271,994,696.86	
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	292,780,637.52	293,277,268.22	0.00	0.00	0.00	0.00	2,204,324,432.20	

EPD/DD FEE-FOR-SERVICE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	14,641,720.07	12,577,411.41	12,175,076.15	14,560,491.13	13,493,550.26	13,627,407.53	14,255,720.28	13,281,847.16	0.00	0.00	0.00	0.00	108,613,223.99	
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	14,255,720.28	13,281,847.16	0.00	0.00	0.00	0.00	108,613,223.99	

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	1,403,952.94	1,784,804.44	0.00	0.00	0.00	0.00	21,619,320.26	
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	2,439,437.52	1,524,271.14	0.00	0.00	0.00	0.00	20,835,524.96	
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	2,439,437.52	1,524,271.14	0.00	0.00	0.00	0.00	20,835,524.96	
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	3,843,390.46	3,309,075.58	0.00	0.00	0.00	0.00	42,454,845.22	

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	4,793,163.40	4,811,886.50	0.00	0.00	0.00	0.00	36,644,244.70	

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	223,543.95	257,967.14	0.00	0.00	0.00	0.00	3,904,871.26	
Subtotal	203,452.53	932,589.80	216,051.55	1,264,254.81	518,538.84	288,472.64	223,543.95	257,967.14	0.00	0.00	0.00	0.00	3,904,871.26	

206,373.18	932,589.80	216,051.55	1,264,254.81	518,538.84	288,472.64	223,543.95	257,967.14	0.00	0.00	0.00	0.00	3,907,791.91	

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 February 29, 2020

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