Douglas A. Ducey, Governor Jami Snyder, Director

October 28, 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 2021 Appropriation Status Report for the Period Ended September 30, 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 September 30, 2020.

Status Summary – Section 6008 of the Families First Coronavirus Response Act (FFCRA) (P.L. 116-127) provides a temporary 6.2 percentage point increase to the Federal Medical
Assistance Percentage (FMAP) extending through the last day of the calendar quarter in which the public health emergency terminates. One of the conditions of receipt of the enhanced federal match is maintenance of effort (MOE) requirement, prohibiting the agency from terminating the enrollment of any individual that was enrolled in the program as of the date of the beginning of the emergency period, as well as individuals enrolled during the emergency period.

In October, the Department of Health and Human Services extended the expiration date for the Public Health Emergency (PHE) to January 21, 2021. This extension will significantly impact the FY21 projections. AHCCCS is updating the FY22 Budget submittal and will include a FY21 rebase as part of that submission. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

Enrollment Update – September 2020 enrollment is 2,068,205 members, a 26,215 member increase over the prior month. Enrollment for October 2020 increased to 2,084,684 members, a 16,479 member change. The large increase is primarily attributed to the maintenance of eligibility requirements associated with the increased federal matching rates included in the FFCRA. Since March, AHCCCS enrollment has increased by 205,724 members or 10.9%.

Major October 2020 changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 4,662; Supplemental Security Income – increase of 629; Prop 204 Restoration - increase of 1,911; Adult Expansion – increase of 7,742; Medicare Cost Sharing
– decrease of 135; KidsCare – increase of 1,064; and Federal Emergency Services – increase of 568.

801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov

The Honorable Karen Fann
The Honorable Russell “Rusty” Bowers October 28, 2020
Page 2

Tobacco Funds Revenue Update - Tobacco tax collections through September 2020 are $950,000 more than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2021 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 2021
Through September 30, 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 2021…	2
Appropriated Expenditures by Funding Source…	3
Appropriated Revenue Received Detail Schedule…	5
FOOTNOTES	7
CASELOAD AND EXPENDITURES BY RATE CODE	10

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2021 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 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	$	90,630,700	$	23,351,691	$	23,351,691	$		-	$	90,630,700	$	-	
AHCCCS Prop 204 Administration	14,577,600	5,496,491	5,496,491			-	14,577,600		-	
DES Eligibility	91,874,500	9,083,995	9,083,995			-	91,874,500		-	
DES Prop 204 Eligibility	44,358,700	3,630,019	3,630,019			-	44,358,700		-	
ADOA Data Center	19,325,800	1,471,096	1,471,096			-	19,325,800		-	
School District Suicide Prevention Coordinator	100,000	28,498	28,498			-	100,000		-	
TOTAL ADMINISTRATION	 	260,867,300 		 	43,061,790 		 	43,061,790 		 	-			 	260,867,300 		 	-			

Traditional Medicaid Services	5,642,933,900	1,294,825,082	1,294,825,082		5,642,933,900	-	
Proposition 204 Services	4,670,376,000	1,152,073,136	1,152,073,136		4,670,376,000	-	
ACA Adult Expansion	587,108,200	184,412,773	184,412,773		587,108,200	-	
KidsCare Services	92,088,200	23,233,273	23,233,273		92,088,200	-	
ALTCS Services	1,966,345,300	457,142,364	457,142,364		1,966,345,300	-	
Disproportionate Share Payments	5,087,100	-	-	5,087,100	-	
Rural Hospitals	28,612,400	-	-	28,612,400	-	
Voluntary Political Subdivision Programs	384,758,800		142,120,512		142,120,512		-		384,758,800		-	
CMDP	197,732,200		50,611,527		50,611,527		-		197,732,200		-	
Behavioral Health Services - in Schools	10,003,300		2,500,825		2,500,825		-		10,003,300		-	
Targeted Investment Program	70,000,000		4,530		4,530		-		70,000,000		-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		18,253,153		18,253,153		-		77,646,900		-	
Supported Housing	5,324,800		1,331,200		1,331,200		-		5,324,800		-	
Crisis Services	16,391,300		4,079,241		4,079,241		-		16,391,300		-	
TOTAL PROGRAMMATIC	 	13,754,408,400 		 	3,330,587,617 		 	3,330,587,617 		 	-			 	13,754,408,400 		 	-		

-
-
-
-
-
-
-

TOTAL EXPENDITURES

  $	14,015,275,700 

  $	3,373,649,407 

  $	3,373,649,407 

  $	-	

  $ 14,015,275,700 

  $	-	

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		

Administrative Expenditures	
$	
60,887,600	
$	11,366,860	
$	11,366,860	
-	$	60,887,600	
$	
-	
Proposition 204 - Administrative Expenditures		21,552,000	2,586,237	2,586,237	-	21,552,000		-	
Programmatic Expenditures
Traditional Medicaid Services	
1,177,108,500	
248,634,300	
248,634,300		
-	1,177,108,500	
-	
Proposition 204 Services	206,211,500	78,450,765	78,450,765		-	206,211,500	-	
ACA Adult Expansion	22,361,600	6,990,948	6,990,948		-	22,361,600	-	
KidsCare Services	16,214,400	1,285,126	1,285,126		-	16,214,400	-	
ALTCS Services	265,435,600	65,145,848	65,145,848		-	265,435,600	-	
DSH and Rural Hospitals	8,846,200	-	-	-	8,846,200	-	
CMDP	59,250,900	12,078,169	12,078,169	-	59,250,900	-	
Behavior Health Services - in Schools	3,000,000	750,000	750,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	18,253,153	18,253,153	-	77,646,900	-	
Supported Housing	5,324,800	1,331,200	1,331,200	-	5,324,800	-	
Crisis Services	14,141,100	3,516,741	3,516,741	-	14,141,100	-	
Voluntary Political Subdivision Programs	 	6,000,000 	 	- 	 	- 	 	- 	 	6,000,000 	 	- 	
TOTAL GF EXPENDITURES	1,943,981,100	450,389,346	450,389,346	-	1,943,981,100	-	
	FEDERAL		
Administrative Expenditures	140,381,700	22,564,188	22,564,188		-	140,381,700	-	
Proposition 204 - Administrative Expenditures	33,286,000	6,540,274	6,540,274		-	33,286,000	-	
Programmatic Expenditures
Traditional Medicaid Services	
3,567,195,100	
753,878,030	
753,878,030		
-	3,567,195,100	
-	
Proposition 204 Services	3,939,570,800	1,005,654,194	1,005,654,194		-	3,939,570,800	-	
ACA Adult Expansion	520,086,200	167,264,590	167,264,590		-	520,086,200	-	
KidsCare Services	63,360,400	21,883,618	21,883,618		-	63,360,400	-	
ALTCS Services and Nursing Facility Assessment	1,255,443,608	311,293,338	311,293,338		-	1,255,443,608	-	
DSH and Rural Hospitals	24,853,300	-	-	-	24,853,300	-	
CMDP	138,481,300	38,533,358	38,533,358	-	138,481,300	-	
Behavior Health Services - in Schools	7,003,300	1,750,825	1,750,825	-	7,003,300	-	
Targeted Investment Program	48,313,300	4,530	4,530	-	48,313,300	-	
Voluntary Political Subdivision Programs	 	269,228,800 	 	103,843,932 	 	103,843,932 	 	- 	 	269,228,800 	 	- 	
TOTAL FEDERAL EXPENDITURES	10,007,203,808	2,433,210,878	2,433,210,878	-	10,007,203,808	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF	4,037,400	-	-	-	4,037,400	-	
Programmatic Expenditures
Traditional Medicaid Services Acute Care	
46,161,700	
11,454,750	
11,454,750	
-	
46,161,700	
-	
ALTCS Services	 	290,276,100 	 	39,042,945 	 	39,042,945 	 	- 	 	290,276,100 	 	- 	
TOTAL COUNTY EXPENDITURES	340,475,200	50,497,695	50,497,695
.	-	340,475,200	-	

ANNUAL APPROPRIATION	(A)      EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	
PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

TOBACCO FUNDS		

Programmatic Expenditures							
Traditional Medicaid Services - Medically Needy	65,627,200	16,406,800	16,406,800	-	65,627,200	-	
Proposition 204 Services - Emergency Health Services	16,216,300	4,054,075	4,054,075	-	16,216,300	-	
Proposition 204 Services - Proposition 204 Protection	34,797,900	8,699,475	8,699,475	-	34,797,900	-	
Proposition 204 Services - ATLSF	 	102,000,000 	 	- 	 	- 	 	- 	 	102,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	218,641,400	29,160,350	29,160,350	-	218,641,400	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program	722,600	4,231	4,231	-	722,600	-	
Programmatic Expenditures							
Traditional Medicaid Services - IGA Fund	73,818,600	-	-	-	73,818,600	-	
Acute Care - Prescription Drug Rebate Program State Match	140,158,600	35,039,650	35,039,650	-	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	229,055,320	229,055,320	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	8,729,300	1,894,600	1,894,600	-	8,729,300	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	8,653,313	8,653,313	-	36,422,000	-	
Proposition 204 Services - Hospital Assessment	364,184,700	55,214,627	55,214,627	-	364,184,700	-	
Proposition 204 Services - IGA Fund	7,394,800	-	-	-	7,394,800	-	
ACA Adult Expansion - Hospital Assessment	44,035,900	10,157,235	10,157,235	-	44,035,900	-	
ACA Adult Expansion - IGA Fund	624,500	-	-	-	624,500	-	
Traditional Medicaid Services - TPL	194,700	354,203	354,203	-	194,700	-	
ALTCS Services - TPL	-	497,825	497,825	-	-	-	
ALTCS Services - Nursing Facility Assessment	110,038,692	30,614,495	30,614,495	-	110,038,692	-	
Targeted Investment Program	21,686,700	-	-	-	21,686,700	-	
KidsCare Services - IGA Fund	362,100	-	-	-	362,100	-	
KidsCare Services Premiums	12,151,300	64,530	64,530	-	12,151,300	-	
Freedom to Work Premiums	31,200	2,030	2,030	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	562,500	562,500	-	2,250,200	-	
Voluntary Political Subdivision Programs	 	109,530,000 	 	38,276,580 	 	38,276,580 	 	- 	 	109,530,000 	 	- 	
TOTAL OTHER EXPENDITURES	1,504,974,192	410,391,139	410,391,139	-	1,504,974,192	-	
	TOTAL		
Administrative Expenditures	260,867,300	43,061,790	43,061,790	-	260,867,300	-	
Acute Care	11,788,063,100	2,873,445,254	2,873,445,254	-	11,788,063,100	-	
Long Term Care	 	1,966,345,300 	 	457,142,363 	 	457,142,363 	 	- 	 	1,966,345,300 	 	- 	
TOTAL EXPENDITURES	  $	14,015,275,700 	  $	3,373,649,407 	  $	3,373,649,407 	  $	- 	  $	14,015,275,700 	  $	- 	

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2021 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending September 30, 2020

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,278,203,900	$	267,742,107	$	260,751,160	
Proposition 204 Services & Administrative	227,763,500	81,037,002	81,037,002	
KidsCare Services	16,214,400.00	1,285,126.28	1,285,126	
ALTCS Services	265,435,600	65,145,848	65,145,848	
Behavioral Health Traditional Medicaid Services	 	156,363,700 	 	35,179,263 	 	35,179,263 	
TOTAL	1,943,981,100	450,389,346	443,398,398	

FEDERAL:
Acute & Administrative	8,549,918,500	2,061,500,564	2,063,112,304	
KidsCare Services	63,360,400	21,883,618	22,610,529	
ALTCS Services	1,255,443,608	311,293,338	334,629,861	
Behavioral Health Traditional Medicaid Services	 	138,481,300 	 	38,533,358 	 	39,754,397 	
TOTAL	10,007,203,808	2,433,210,878	2,460,107,091	

COUNTY:				
Acute & Administrative	50,199,100		11,454,750		12,192,977	
ALTCS Services	 	290,276,100 		 	39,042,945 		 	76,468,005 	
TOTAL	340,475,200		50,497,695		88,660,982	

TOBACCO FUNDS:						
Traditional Medicaid Services	65,627,200		16,406,800		16,406,800	
Proposition 204 Services	 	153,014,200 		 	12,753,550 		 	12,753,550 	
TOTAL	218,641,400		29,160,350		29,160,350	

OTHER:

Administrative	722,600	4,231	4,231	
Traditional Medicaid Services - IGA Fund	73,818,600	-	-	
Acute Care - Prescription Drug Rebate Program	712,796,900	264,094,970	264,094,970	
Long Term Care - Prescription Drug Rebate Program	45,151,300	10,547,913	10,547,913	
Hospital Assessment	416,239,900	65,371,862	97,994,706	
ALTCS - Nursing Facility Assessment	110,038,692	30,614,495	6,700,074	
Acute TPL - Note 1	194,700	354,203	354,203	
LTC TPL - Note 1	-	497,825	497,825	
KidsCare Services - IGA Fund	362,100	-	-	
KidsCare TPL - Note 1	-	-	(24.00)	
Member Premiums - CHIP	12,151,300	64,530	64,530	
Member Premiums - Freedom to Work	31,200	2,030	2,030	
Targeted Investment Program	21,686,700	-	2,265	
Behavioral Health Traditional Medicaid Services	2,250,200	562,500	352,362	
Voluntary Political Subdivision - State Match	 	109,530,000 	 	38,276,580 	 	76,553,160 	
TOTAL	1,504,974,192	410,391,139	457,168,243	

TOTAL REVENUE

$	14,015,275,700

$	3,373,649,407

$	3,478,495,065

BUDGET

BUDGET YTD

RECEIPTS YTD

Appropriation Status Report
Footnotes

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2021 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2020

Note 1: Third Party Liability Collections:
Gross Collections: Acute

$	1,305,868	$

1,340,630	$

3,575,449	$

3,797,903

LTC	1,244,040	205,085	2,665,597	2,082,208
KidsCare	120	3,872	1,539	12,877

Total TPL Collections

  $	2,550,028 

  $	1,549,587 

  $	6,242,585 

  $	5,892,988 

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	133,456	$	137,232	$	354,203	$	586,337	
LTC		235,097	42,900		497,825	402,478	
KidsCare		1	(162)		(24)	848	
Total Expenditure Offsets	  $	368,554 		  $	179,970 		  $	852,004 		  $	989,663 	

September 2020

September 2019

July 1, 2020	July 1, 2019
September 30, 2020	September 30, 2019

Note 2: Authorized Positions
Actual Positions as of September 30, 2020

`

FY 21 Total

1,226.0
1,109.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2021 APPROPRIATION STATUS REPORT
For the Period Ending September 30, 2020

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2020	$	946,359	
	Revenues	4,335,155	
	Transfers-In	 	1,014,170 	
	Total Revenues	 	5,349,325 	
	Expenditures	3,742,909	
	Transfers-out	 	1,104,000 	
	Total Expenditures	 	4,846,909 	
	Ending Balance September 30, 2020	  $ 1,448,775 	

Of the $1,448,775 ending balance, $1,334,879 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through October 2020.

Summary of Voluntary Political Subdivision Contribution Expenditures:

Note 4:

As of September 30, 2020 Expenditures
Appropriation	State Match	Federal	Total

DSH Voluntary	$	27,137,600		$	-		$	-		$	-	
GME Voluntary	357,621,200		38,276,580		103,843,932		142,120,512	
Total Voluntary Political Subdivision Program Expenditures	$	384,758,800		$	38,276,580		$	103,843,932		$	142,120,512	

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	351,214,763	351,875,360	353,701,009	0	0	0	0	0	0	0	0	0	1,056,791,132	
CAPITATION - AIMHS	428,410	430,948	434,545	0	0	0	0	0	0	0	0	0	1,293,903	
CAPITATION - LTC	290,925,965	290,572,481	290,613,426	0	0	0	0	0	0	0	0	0	872,111,872	
MENTAL HEALTH - CHILD	2,277	1,446	-719	0	0	0	0	0	0	0	0	0	3,005	
MENTAL HEALTH - ADULT	380,807	355,992	348,738	0	0	0	0	0	0	0	0	0	1,085,537	
MENTAL HEALTH - GENERAL	13,950	10,451	3,406	0	0	0	0	0	0	0	0	0	27,807	
MENTAL HEALTH - CMDP	12,276,585	12,457,764	12,481,448	0	0	0	0	0	0	0	0	0	37,215,798	
MENTAL HEALTH - DD	32,246	18,226	-2,175	0	0	0	0	0	0	0	0	0	48,297	
MENTAL HEALTH - RBHA CRISIS	4,751,155	4,768,486	4,764,679	0	0	0	0	0	0	0	0	0	14,284,321	
FEE FOR SERVICE - ACUTE	50,202,211	38,405,117	51,220,096	0	0	0	0	0	0	0	0	0	139,827,424	
FFS - PRIOR QUARTER COVERAGE	525,804	279,896	272,648	0	0	0	0	0	0	0	0	0	1,078,348	
EMERGENCY SERVICES - FEDERAL	3,758,804	3,482,081	4,181,075	0	0	0	0	0	0	0	0	0	11,421,960	
FFS MEDICAID IN PUBLIC SCHOOLS	512,731	226,028	162,718	0	0	0	0	0	0	0	0	0	901,477	
QMB - FEE FOR SERVICE	560,175	366,857	563,570	0	0	0	0	0	0	0	0	0	1,490,602	
INPATIENT INMATES FFS	328,698	230,026	445,921	0	0	0	0	0	0	0	0	0	1,004,646	
FFS TRBHA FEE FOR SERVICE	8,121,079	8,036,799	9,977,009	0	0	0	0	0	0	0	0	0	26,134,888	
STATE ONLY TRBHA FFS	128,659	157,307	364,070	0	0	0	0	0	0	0	0	0	650,036	
COCONINO COUNTY INMATES FFS	89	0	1,436	0	0	0	0	0	0	0	0	0	1,525	
PIMA COUNTY INMATES FFS	88	8,271	6,438	0	0	0	0	0	0	0	0	0	14,797	
MOHAVE COUNTY INMATES FFS	0	743	423	0	0	0	0	0	0	0	0	0	1,166	
YAVAPAI COUNTY INMATES FFS	11,214	0	342	0	0	0	0	0	0	0	0	0	11,557	
MARICOPA CTY INMATES FFS	17,312	13,478	6,406	0	0	0	0	0	0	0	0	0	37,197	
FEE FOR SERVICE - LTC	14,021,711	10,337,795	14,428,013	0	0	0	0	0	0	0	0	0	38,787,519	
LFFS - PRIOR QUARTER COVERAGE	-2,222	-5,829	269	0	0	0	0	0	0	0	0	0	-7,781	
LFFS MEDICAID IN PUBLIC SCHOOLS	607,580	255,441	189,102	0	0	0	0	0	0	0	0	0	1,052,124	
REINSURANCE - ACC	13,590,647	16,229,687	13,339,168	0	0	0	0	0	0	0	0	0	43,159,502	
REINSURANCE - LTC	3,391,581	8,020,729	5,953,416	0	0	0	0	0	0	0	0	0	17,365,726	
SMIB - ACC	17,512,926	17,842,202	17,823,376	0	0	0	0	0	0	0	0	0	53,178,505	
HIB - ACC	939,024	1,014,832	1,018,218	0	0	0	0	0	0	0	0	0	2,972,073	
Q1	3,107,017	3,143,330	3,119,658	0	0	0	0	0	0	0	0	0	9,370,005	
SMIB - LTC	4,303,885	4,303,643	4,201,672	0	0	0	0	0	0	0	0	0	12,809,200	
HIB - LTC	386,148	405,365	393,182	0	0	0	0	0	0	0	0	0	1,184,695	
SUBTOTAL	782,051,320	773,244,951	790,012,588	0	0	0	0	0	0	0	0	0	2,345,308,859	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL
TITLE XIX PROP 204
CAPITATION - ACC	310,760,657	313,240,082	318,874,940	0	0	0	0	0	0	0	0	0	942,875,679	
CAPITATION - AIMHS	201,435	202,551	206,196	0	0	0	0	0	0	0	0	0	610,182	
MENTAL HEALTH - ADULT	317,445	317,963	340,079	0	0	0	0	0	0	0	0	0	975,488	
MENTAL HEALTH - GENERAL	17,947	11,505	478	0	0	0	0	0	0	0	0	0	29,930	
MENTAL HEALTH - CMDP	2,525	2,654	2,654	0	0	0	0	0	0	0	0	0	7,832	
MENTAL HEALTH - RBHA CRISIS	4,685,074	4,720,709	4,781,338	0	0	0	0	0	0	0	0	0	14,187,122	
FEE FOR SERVICE - ACUTE	52,697,715	41,638,572	57,754,561	0	0	0	0	0	0	0	0	0	152,090,848	
FFS - PRIOR QUARTER COVERAGE	6,219	-925	-4,174	0	0	0	0	0	0	0	0	0	1,120	
EMERGENCY SERVICES - FEDERAL	3,940,111	3,229,763	4,570,583	0	0	0	0	0	0	0	0	0	11,740,457	
FFS MEDICAID IN PUBLIC SCHOOLS	680	191	79	0	0	0	0	0	0	0	0	0	949	
STATE ONLY TRBHA FFS	485,972	554,086	648,232	0	0	0	0	0	0	0	0	0	1,688,291	
FFS TRBHA FEE FOR SERVICE	8,167,640	7,429,009	9,697,887	0	0	0	0	0	0	0	0	0	25,294,536	
INPATIENT INMATES FFS	634,880	949,558	983,526	0	0	0	0	0	0	0	0	0	2,567,963	
COCONINO COUNTY INMATES FFS	6,644	0	9,430	0	0	0	0	0	0	0	0	0	16,074	
PINAL COUNTY INMATES FFS	1,098	2,454	207	0	0	0	0	0	0	0	0	0	3,760	
PIMA COUNTY INMATES FFS	12,600	43,980	17,411	0	0	0	0	0	0	0	0	0	73,992	
MARICOPA CTY INMATES FFS	90,234	55,621	48,405	0	0	0	0	0	0	0	0	0	194,260	
MOHAVE COUNTY INMATES FFS	9,593	3,912	17,882	0	0	0	0	0	0	0	0	0	31,386	
REINSURANCE - ACC	5,981,687	7,802,788	9,070,700	0	0	0	0	0	0	0	0	0	22,855,175	
SMIB - ACC	7,812,901	7,964,388	7,976,982	0	0	0	0	0	0	0	0	0	23,754,271	
HIB - ACC	5,038	5,496	5,038	0	0	0	0	0	0	0	0	0	15,572	
SUBTOTAL	395,838,095	388,174,358	415,002,433	0	0	0	0	0	0	0	0	0	1,199,014,885	

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

CAPITATION - ACC	43,478,262	46,584,798	48,465,454	0	0	0	0	0	0	0	0	0	138,528,514	
CAPITATION - AIMHS	20,082	21,970	22,899	0	0	0	0	0	0	0	0	0	64,951	
MENTAL HEALTH - ADULT	19,939	20,808	20,121	0	0	0	0	0	0	0	0	0	60,868	
MENTAL HEALTH - GENERAL	2,244	0	0	0	0	0	0	0	0	0	0	0	2,244	
MENTAL HEALTH - CMDP	818	818	818	0	0	0	0	0	0	0	0	0	2,454	
MENTAL HEALTH - RBHA CRISIS	868,177	925,746	952,242	0	0	0	0	0	0	0	0	0	2,746,164	
FEE FOR SERVICE - ACUTE	4,511,179	3,414,251	4,698,882	0	0	0	0	0	0	0	0	0	12,624,313	
FFS - PRIOR QUARTER COVERAGE	229	-303	-429	0	0	0	0	0	0	0	0	0	-503	
EMERGENCY SERVICES - FEDERAL	5,996,983	5,467,005	8,309,800	0	0	0	0	0	0	0	0	0	19,773,788	
FFS MEDICAID IN PUBLIC SCHOOLS	63	15	0	0	0	0	0	0	0	0	0	0	78	
STATE ONLY TRBHA FFS	37,689	53,626	54,347	0	0	0	0	0	0	0	0	0	145,663	
INPATIENT INMATES FFS	30,172	37,484	124,660	0	0	0	0	0	0	0	0	0	192,316	
FFS TRBHA FEE FOR SERVICE	183,576	206,506	258,500	0	0	0	0	0	0	0	0	0	648,582	
MARICOPA CTY INMATES FFS	6,097	364	27,113	0	0	0	0	0	0	0	0	0	33,573	
PIMA COUNTY INMATES FFS	0	5,778	5,789	0	0	0	0	0	0	0	0	0	11,566	
REINSURANCE - ACC	746,102	1,535,864	1,471,110	0	0	0	0	0	0	0	0	0	3,753,076	
SMIB - ACC	2,314	236	6,507	0	0	0	0	0	0	0	0	0	9,056	
	55,903,926	58,274,964	64,417,813	0	0	0	0	0	0	0	0	0	178,596,703	
	1,233,793,341	1,219,694,273	1,269,432,834	0	0	0	0	0	0	0	0	0	3,722,920,447	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
KidsCare - CAPITATION	7,336,023	7,539,106	7,723,214	0	0	0	0	0	0	0	0	0	22,598,343	
KidsCare - FEE FOR SERVICE	191,287	101,072	201,058	0	0	0	0	0	0	0	0	0	493,418	
KidsCare - MENTAL HEALTH	88,620	91,499	92,875	0	0	0	0	0	0	0	0	0	272,994	
KidsCare - REINSURANCE	232,715	302,606	167,450	0	0	0	0	0	0	0	0	0	702,771	
KidsCare - TRANSPLANT REIN	4,465	11,869	0	0	0	0	0	0	0	0	0	0	16,334	

7,853,110	8,046,152	8,184,597	0	0	0	0	0	0	0	0	0	24,083,859	

TOTAL TITLE XXI

1,241,646,451	1,227,740,425	1,277,617,431	0	0	0	0	0	0	0	0	0	3,747,004,306	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	127.65	127.65	127.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382.95		
1005	TANF 14-20 FEMALE WI	125.69	125.69	125.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		377.07		
1006	TANF 21-44 MALE WITH	34,208.35	30,410.95	37,883.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,502.64		
1007	TANF 21-44 FEMALE WI	64,050.55	74,207.68	73,586.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		211,844.38		
1008	TANF 45-64 M & F WIT	91,922.90	99,173.42	93,750.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284,846.87		
1009	TANF 65+ M & F WITH	18,619.51	17,597.69	17,920.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,138.08		
100F	TANF 21-44 MALE WITH	0.00	0.00	858.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		858.25		
100G	TANF 21-44 FEMALE WI	493.97	707.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,201.70		
100H	TANF 45-64 M & F WIT	3,381.21	922.03	977.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,280.60		
100J	TANF 65+ M & F WITH	36.22	106.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143.21		
1011	TANF <1 M & F NON-ME	5,800,131.50	5,837,957.54	5,940,435.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,578,524.34		
1012	TANF 01-05 M & F NON	4,305,066.80	4,486,437.41	4,619,810.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,411,314.22		
1013	TANF 06-13 M & F NON	7,643,444.07	7,874,959.92	7,972,435.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,490,839.25		
1014	TANF 14-20 MALE NON-	2,428,936.37	2,530,935.63	2,576,408.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,536,280.21		
1015	TANF 14-20 FEMALE N O	2,918,645.44	3,046,827.74	3,099,777.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,065,250.38		
1016	TANF 21-44 MALE NON-	11,717,475.03	11,784,940.59	11,852,048.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,354,464.29		
1017	TANF 21-44 FEMALE N O	39,060,744.01	39,509,188.92	39,757,271.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,327,204.08		
1018	TANF 45-64 M & F NON	9,758,890.39	9,880,559.18	9,896,900.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,536,349.85		
1019	TANF 65+ M & F NON-M	44,019.24	45,810.05	46,464.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,294.11		
101A	TANF < 1 M & F NON-M	242,715.00	230,273.70	229,936.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		702,924.92		
101B	TANF 01-05 M & F NON	9,697.81	18,957.60	16,218.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,873.78		
101C	TANF 06-13 M & F NON	9,633.07	14,592.66	14,361.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,587.54		
101D	TANF 14-20 MALE NON-	7,290.83	6,053.54	8,279.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,624.11		
101E	TANF 14-20 FEMALE N O	10,602.38	10,128.91	8,502.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,233.31		
101F	TANF 21-44 MALE NON-	174,219.43	160,889.34	171,949.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507,057.86		
101G	TANF 21-44 FEMALE N O	334,883.85	299,235.14	294,091.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		928,210.36		
101H	TANF 44-64 M & F NON	95,620.69	91,303.95	75,456.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,381.59		
101J	TANF 65+ N & F NON-M	591.24	157.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		748.71		
1023	TANF 06-13 M & F WIT	105.59	105.59	105.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316.77		
1024	TANF 14-20 MALE WITH	395.17	395.17	395.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,185.51		
1025	TANF 14-20 FEMALE WI	1,970.08	1,809.68	160.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,940.16		
1026	TANF 21-44 MALE WITH	27,495.43	31,970.87	29,841.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,307.60		
1027	TANF 21-44 FEMALE WI	51,398.03	51,936.61	48,965.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152,300.47		
1028	TANF 45-64 M & F WIT	47,878.93	52,321.27	56,029.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,229.87		
1029	TANF 65+ M & F WITH	9,549.56	10,101.57	10,252.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,903.29		
102F	TANF 21-44 MALE WITH	0.00	0.00	5.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.35		

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102G	TANF 21-44 FEMALE WI	4.45	0.00	85.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.28		
102H	TANF 44-64 M & F WIT	48.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.17		
2100	SSI AGED WITH MEDIC A	698,506.23	694,456.55	720,278.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,113,241.68		
210Z	SSI AGED WITH MEDIC
A	28,553.28	28,195.70	38,318.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,067.13		
2110	SSI AGED NON-MEDICA R	9,047,239.54	9,208,276.25	9,378,951.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,634,467.51		
211Z	SSI AGED NON-MEDICA
R	78,808.00	103,916.29	95,545.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		278,269.75		
2120	SSI AGED WITH QMB	5,666,161.42	5,728,081.35	5,803,203.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,197,446.64		
212Z	SSI AGED WITH QMB P P	2,614.05	3,303.39	2,838.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,755.59		
2200	SSI DISABLED WITH M
E	1,988,850.90	1,937,214.60	1,946,245.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,872,310.73		
220Z	SSI DISABLED WITH M E	55,243.94	52,261.49	40,385.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,890.89		
2210	SSI DISABLED NON-ME
D	74,206,259.51	74,247,747.94	74,375,463.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,829,470.67		
221Z	SSI DISABLED NON-ME D	911,078.19	674,713.13	566,425.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,152,216.71		
2220	SSI DISABLED WITH Q
M	16,027,790.55	16,001,034.33	16,063,323.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,092,148.14		
222Z	SSI DISABLED WITH Q M	15,718.28	19,520.65	12,647.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,886.64		
2300	SSI BLIND WITH MEDIC	8,075.33	8,235.73	8,367.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,678.26		
2310	SSI BLIND NON-MEDIC A	648,301.31	652,238.19	657,275.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,957,815.30		
231Z	SSI BLIND NON-MEDIC
A	1,042.60	1,030.24	13,566.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,638.91		
2320	SSI BLIND WITH QMB	46,856.10	46,839.73	48,573.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,269.42		
4301	SOBRA CHILD <1 M & F	138.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.01		
4302	SOBRA CHILD 01-05 M	471.28	1,476.32	970.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,917.94		
4303	SOBRA CHILD 06-13 M	702.38	829.23	923.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,455.55		
4304	SOBRA CHILD 14-20 MA	417.56	417.56	96.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		931.53		
4305	SOBRA CHILD 14-20 FE	107.06	127.65	93.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		328.32		
430B	SOBRA CHILD 01-05 M	159.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159.50		
430C	SOBRA CHILD 06-13 M	41.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.18		
430E	SOBRA CHILD 14-20 FE	20.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.59		
4311	SOBRA CHILD <1 M & F	19,993,471.88	19,746,208.31	19,441,321.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,181,001.87		
4312	SOBRA CHILD 01-05 M	32,694,361.76	32,840,690.29	33,105,834.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,640,886.07		
4313	SOBRA CHILD 06-13 M	42,216,382.06	42,241,870.63	42,486,916.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,945,169.67		
4314	SOBRA CHILD 14-20 MA	12,240,593.41	12,293,676.11	12,420,470.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,954,739.62		
4315	SOBRA CHILD 14-20 FE	12,176,873.29	12,221,437.80	12,371,672.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,769,983.45		
431A	SOBRA CHILD < 1 M &	190,018.19	129,565.61	150,896.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		470,480.78		
431B	SOBRA CHILD 01-05 M	357,231.33	341,141.31	291,594.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989,967.22		
431C	SOBRA CHILD 6-13 M&F	411,494.30	425,568.07	345,925.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,182,987.69		
431D	SOBRA CHILD 14-20 MA	122,376.81	112,205.00	113,616.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		348,198.25		
431E	SOBRA CHILD 14-20 FE	118,636.97	119,719.33	94,933.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		333,290.22		

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4322	SOBRA CHILD 01-05 M	160.40	160.40	160.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		481.20		
4323	SOBRA CHILD 06-13 M	260.49	406.10	92.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		758.76		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	106.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.78		
4325	SOBRA CHILD 14-20 FE	506.54	624.97	486.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,618.47		
5007	SOBRA PREG 21-44 FE M	6,893.89	7,623.51	6,516.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,033.79		
5008	SOBRA PREG 45-64 FE
M	772.43	-2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,802.33		
500G	SOBRA PREG 21-44 FE M	1,139.63	1,754.50	140.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,034.89		
5013	SOBRA PREG 09-13 FE
M	379.13	187.31	219.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		785.72		
5015	SOBRA PREG 14-20 FE M	514,099.93	500,676.68	497,532.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,512,309.07		
5017	SOBRA PREG 21-44 FE
M	6,245,141.22	6,059,840.82	6,088,763.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,393,745.62		
5018	SOBRA PREG 45-64 FE M	23,254.58	21,297.41	20,401.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,953.13		
501E	SOBRA PREG 14-20 FE
M	34,772.38	24,122.66	28,034.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,929.37		
501G	SOBRA PREG 21-44 FE M	332,215.06	294,512.36	280,017.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906,745.30		
501H	SOBRA PREG 45-64 FE
M	124.37	1,264.57	668.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,057.23		
5027	SOBRA PREG 21-44 FE M	16,055.18	10,460.69	13,278.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,794.07		
5028	SOBRA PREG 45-64 FE
M	160.40	1,653.54	1,653.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,467.48		
SUBTOTAL:	322,044,951.03	323,005,239.42	324,486,165.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		969,536,356.11		

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

49.50

49.50

9910	TANF & SOBRA CHILDR E	2,653,886.93	2,708,690.82	2,766,144.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	24,617.35	43,221.43	12,765.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	99,402.25	93,338.09	148,440.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	11,868,339.23	11,150,227.49	11,387,798.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,646,245.76	13,995,477.83	14,315,148.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,128,721.85	
80,603.86	
341,180.77	
34,406,365.47	
42,956,871.95	

1106	TANF EXPANDED 21-44	77,768.11	78,146.70	73,692.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	159,772.71	164,213.11	164,595.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	397,181.59	393,412.43	401,913.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	106,088.51	105,903.72	108,842.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	1,182.86	1,804.71	566.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	6,731.98	2,857.45	2,388.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	7,835.95	5,499.45	4,291.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	4,476.66	2,261.04	5,133.05	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	187.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	962.28	962.28	962.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	41,812.36	42,972.62	43,640.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
229,607.06	
488,581.12	
1,192,507.69	
320,834.98	
3,553.92	
11,978.05	
17,626.67	
11,870.75	
187.31	
2,886.84	
128,425.79	

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	245,785.25	250,520.44	256,430.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		752,736.06		
1116	TANF EXPANDED 21-44	9,715,076.07	9,724,629.10	9,940,380.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,380,085.82		
1117	TANF EXPANDED 21-44	26,803,534.08	26,868,260.63	27,405,588.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,077,382.84		
1118	TANF EXPANDED 45-64	9,455,016.18	9,492,588.64	9,737,788.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,685,393.60		
1119	TANF EXPANDED 65+ M
&	35,524.37	34,975.43	37,615.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,115.02		
111D	TANF EXPANDED 14-20	781.60	2,173.88	446.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,401.56		
111E	TANF EXPANDED 14-20	1,592.49	2,017.46	1,880.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,490.33		
111F	TANF EXPANDED 21-44	204,286.43	216,747.68	178,596.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		599,631.03		
111G	TANF EXPANDED 21-44	314,523.46	325,930.93	289,036.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		929,490.46		
111H	TANF EXPANDED 45-64	134,829.59	136,379.99	135,303.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406,513.35		
111J	TANF EXPANDED 65+ M
&	775.08	800.34	488.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,063.78		
1126	TANF EXPANDED 21-44	289,842.11	294,104.27	293,697.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		877,643.52		
1127	TANF EXPANDED 21-44	803,571.42	783,127.12	776,510.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,363,208.71		
1128	TANF EXPANDED 45-64	908,788.13	921,716.91	944,743.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,775,248.23		
1129	TANF EXPANDED 65+ M
&	270,502.44	281,316.18	282,575.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		834,393.91		
112F	TANF EXPANDED 21-44	64.30	182.53	62.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		309.43		
112G	TANF EXPANDED 21-44	2,530.28	286.18	170.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,987.18		
112H	TANF EXPANDED 45-64	313.22	2,624.51	245.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,182.85		
112J	TANF EXPANDED 65+ M
&	427.57	76.34	590.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,094.35		
2400	SSI AGED EXPANDED WI	59,433.58	63,276.71	67,610.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190,321.16		
240Z	SSI AGED EXPANDED
WI	18,916.28	18,046.02	14,866.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,828.81		
2410	SSI AGED EXPANDED N O	155,456.35	151,213.66	151,779.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		458,449.84		
241Z	SSI AGED EXPANDED N
O	4,444.93	2,379.28	5,357.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,181.29		
2420	SSI AGED EXPANDED WI	5,535,744.02	5,575,749.40	5,645,158.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,756,651.50		
242Z	SSI AGED EXPANDED
WI	2,030.09	1,629.65	4,124.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,784.60		
2520	SSI BLIND EXPANDED W	286.09	286.09	286.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		858.27		
2600	SSI DISABLED EXPAND
E	194,699.39	166,838.62	163,278.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524,816.38		
260Z	SSI DISABLED EXPAND E	36,315.12	32,400.31	29,174.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,889.70		
2610	SSI DISABLED EXPAND
E	2,051,318.55	2,017,118.33	1,979,774.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,048,211.83		
261Z	SSI DISABLED EXPAND E	15,724.76	28,275.67	17,046.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,046.64		
2620	SSI DISABLED EXPAND
E	10,570,975.06	10,696,009.10	10,699,499.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,966,483.95		
262Z	SSI DISABLED EXPAND E	7,115.96	4,322.14	7,130.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,568.79		
SUBTOTAL:	68,644,037.26	68,894,037.05	69,873,450.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207,411,524.97		

4,207,873.61

9911	SB PAYMENT FOR TAN F	1,278,492.03	1,359,933.00	1,569,448.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	6,121.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,121.83

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1,284,613.86	1,359,933.00	1,569,448.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,213,995.44		

3506	ADULT 40-100% MALE 2	15,405.42	19,886.36	22,180.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	11,925.59	13,668.36	11,943.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	131,032.96	130,873.91	128,054.55	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	64,992.83	62,248.88	78,764.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	0.00	1,269.76	1,766.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	125.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	951.21	1,102.59	3,401.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	0.00	0.00	3,133.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	3,808,521.71	3,800,237.77	3,912,338.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	4,060,073.08	4,090,539.42	4,175,484.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	14,358,761.45	14,626,413.30	15,344,196.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	12,189,511.63	12,449,734.62	12,939,509.81	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	25,721,967.29	25,866,007.80	26,482,009.36	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	2,487.44	3,943.97	3,983.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	47,559.85	44,016.65	43,235.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	45,720.88	60,437.44	56,770.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	429,893.01	474,893.85	431,465.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	348,003.63	344,860.17	291,984.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	687,412.36	606,286.44	517,399.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	10,770.22	4,714.60	3,271.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	1,217.63	2,159.95	3,239.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	3,129.78	3,169.19	2,574.76	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	8,193.63	9,430.50	13,245.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	1,994.61	3,145.30	3,253.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352F	ADULT 40-100% MALE 2	0.00	3,654.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	1,149.10	0.00	23.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352J	ADULT 40-100% M&F 65	0.00	0.00	19.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	70,944.72	74,012.52	70,943.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	35,324.86	37,339.03	35,225.70	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	220,500.37	206,912.60	217,991.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	20,600.74	26,685.04	27,833.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370F	ADULT <40% EXP MALE	1,776.23	855.45	54.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370G	ADULT <40% EXP FEMA L	2,636.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370H	ADULT <40% EXP M&F
4	5,140.31	933.14	1,378.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
57,472.42	
37,537.55	
389,961.42	
206,006.06	
3,036.06	
125.61	
5,455.07	
3,133.62	
11,521,097.94	
12,326,097.41	
44,329,371.50	
37,578,756.06	
78,069,984.45	
10,414.77	
134,812.36	
162,928.69	
1,336,251.88	
984,848.34	
1,811,097.97	
18,755.93	
6,617.27	
8,873.73	
30,869.55	
8,393.88	
3,654.50	
1,172.96	
19.29	
215,900.40	
107,889.59	
645,404.25	
75,119.49	
2,686.66	
2,636.84	
7,451.65	

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	7,441,757.35	7,568,978.26	7,725,785.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,736,520.90		
3715	ADULT <40% EXP FEMA L	6,902,700.42	7,006,543.99	7,261,661.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,170,905.99		
3716	ADULT <40% EXP MALE	59,638,001.41	60,135,860.91	61,353,361.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,127,224.11		
3717	ADULT <40% EXP FEMA L	35,463,329.02	35,943,875.13	36,591,901.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,999,105.79		
3718	ADULT <40% EXP M&F
4	65,114,653.61	65,609,703.54	66,355,399.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		197,079,756.99		
3719	ADULT <40% EXP M&F 6	5,512.35	5,531.31	2,599.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,643.04		
371D	ADULT <40% EXP MALE	102,373.25	109,467.88	80,941.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292,782.53		
371E	ADULT <40% EXP FEMA L	113,577.21	96,289.88	83,381.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293,249.02		
371F	ADULT <40% EXP MALE	1,168,212.37	998,214.87	798,037.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,964,464.69		
371G	ADULT <40% EXP FEMA L	601,167.45	611,816.20	489,530.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,702,514.60		
371H	ADULT <40% EXP M&F
4	1,053,904.90	947,039.82	703,531.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,704,476.38		
371J	ADULT <40% EXP M&F 6	584.18	1,263.02	2,135.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,983.10		
3726	ADULT <40% EXP MALE	10,048.37	12,088.47	11,869.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,006.04		
3727	ADULT <40% EXP FEMA L	6,319.38	6,966.57	10,120.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,406.56		
3728	ADULT <40% EXP M&F
4	33,140.51	41,676.52	41,169.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,986.09		
3729	ADULT <40% EXP M&F 6	0.00	0.00	1,173.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,173.22		
372F	ADULT <40% EXP MALE	96.33	0.00	22.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118.49		
372H	ADULT <40% EXP M&F 4	230.94	668.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		899.47		
SUBTOTAL:	239,963,208.43	242,065,543.62	246,339,300.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		728,368,052.18		

3904	NEWLY ELIGIBLE MALE	854.57	425.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	0.00	3,003.56	5,263.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	34,016.27	43,187.85	48,530.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	23,819.16	27,767.16	30,064.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	340,120.37	429,700.06	499,442.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	192,067.80	222,525.48	275,579.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	938.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	622.45	0.00	2,317.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	239.56	712.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	326.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,899,896.05	2,049,996.66	2,145,102.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	2,054,295.81	2,241,233.43	2,302,459.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	10,088,476.23	10,938,561.26	11,379,189.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,279.81	
8,267.43	
125,734.38	
81,650.53	
1,269,262.65	
690,172.86	
938.17	
2,939.73	
951.74	
326.50	
6,094,995.22	
6,597,988.33	
32,406,226.91	

9935	BIRTH SUPP PAYMENT A	210,618.24	235,915.07	156,084.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	658,178.96	684,653.68	936,655.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	868,797.20	920,568.75	1,092,740.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
602,617.71	
2,279,488.37	
2,882,106.08	

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3917	NEWLY ELIGIBLE FEMA L	13,851,533.45	14,904,369.11	15,598,169.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,354,071.62		
3918	NEWLY ELIGIBLE M&F
4	13,941,720.12	14,662,403.58	15,065,023.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,669,147.66		
3919	NEWLY ELIGIBLE M&F 6	13,663.01	17,931.30	20,405.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,000.07		
391D	NEWLY ELIGIBLE MALE	13,184.76	8,885.91	11,360.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,430.82		
391E	NEWLY ELIGIBLE FEMA L	16,950.75	13,468.02	18,341.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,760.31		
391F	NEWLY ELIGIBLE MALE	135,369.09	130,953.43	131,414.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		397,736.85		
391G	NEWLY ELIGIBLE FEMA L	181,738.61	169,552.74	163,822.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		515,114.31		
391H	NEWLY ELIGIBLE M&F
4	182,177.20	163,889.96	174,697.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		520,764.17		
391J	NEWLY ELIGIBLE M&F 6	469.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		469.96		
3926	NEWLY ELIGIBLE MALE	0.00	429.33	429.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		858.66		
3927	NEWLY ELIGIBLE FEMA L	410.47	410.47	410.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,231.41		
3928	NEWLY ELIGIBLE M&F
4	8,251.79	6,959.14	4,453.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,664.47		
3929	NEWLY ELIGIBLE M&F 6	6,936.70	8,708.80	11,214.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,859.90		
SUBTOTAL:	42,987,752.35	46,045,074.67	47,888,017.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,920,844.47		

9939

BIRTH SUPP PAYMENT N

1,607,669.27

1,607,669.27

490,509.99	539,722.93	577,436.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
490,509.99	539,722.93	577,436.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4403	SOBRA 100-133% M&F
6	131.47	131.47	-4.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	118.43	118.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	379.56	192.25	192.25	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	7,434,503.06	7,629,869.37	7,667,937.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,202,017.49	2,273,355.46	2,289,526.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2,184,791.45	2,235,156.62	2,249,889.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	0.00	0.00	192.25	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	92,002.30	82,589.32	71,576.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	23,170.00	26,350.17	15,474.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	21,988.08	20,142.32	22,230.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	253.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,959,101.84	12,267,905.41	12,317,268.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

258.75	
236.86	
764.06	
22,732,309.71	
6,764,899.86	
6,669,837.37	
192.25	
246,167.97	
64,994.80	
64,360.81	
253.23	
36,544,275.67	

9944	BIRTH SUPP PAYMENT S	55,894.09	49,462.55	68,820.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	55,894.09	49,462.55	68,820.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

174,177.52

174,177.52

4517	BC PATIENT FEMALE 2 1	9,097.90	8,834.23	7,900.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	51,717.30	51,794.74	49,159.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	854.72	619.80	833.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	177.31	466.16	565.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25,832.86	
152,671.34	
2,308.36	
1,208.94	

ACC CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
451H	BC PATIENT FEMALE 4 5	1,456.34	73.35	56.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,586.47		
451J	BC PATIENT FEMALE 6
5	728.94	112.04	290.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,130.98		
4617	CC PATIENT FEMALE 2 1	4,041.35	3,675.43	3,675.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,392.21		
4618	CC PATIENT FEMALE 4
5	3,442.67	3,376.09	3,098.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,917.44		
SUBTOTAL:	71,516.53	68,951.84	65,580.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,048.60		

8600	SSI BLIND FREEDOM/W O	138.01	138.01	138.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W
O	131.47	131.47	131.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	1,638,182.67	1,625,606.76	1,623,341.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	59,052.04	56,907.81	37,846.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	437,294.87	437,573.54	433,207.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	5,359.78	23,115.59	7,775.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	296,664.18	323,529.49	343,435.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	214.12	21,303.89	2,133.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,437,037.14	2,488,306.56	2,448,009.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
414.03	
394.41	
4,887,130.88	
153,806.21	
1,308,075.49	
36,251.19	
963,628.98	
23,651.84	
7,373,353.03	

2,138,195,324.79

705,453,681.98	711,700,240.13	721,041,402.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1005	TANF 14-20 FEMALE WI	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		
1006	TANF 21-44 MALE WITH	92.99	97.90	104.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295.55		
1007	TANF 21-44 FEMALE WI	145.30	153.47	155.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454.22		
1008	TANF 45-64 M & F WIT	255.43	265.88	252.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		774.15		
1009	TANF 65+ M & F WITH	140.77	131.12	132.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		404.08		
100F	TANF 21-44 MALE WITH	0.00	0.00	0.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.33		
100G	TANF 21-44 FEMALE WI	4.07	3.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.33		
100H	TANF 45-64 M & F WIT	5.44	4.13	0.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.39		
100J	TANF 65+ M & F WITH	0.22	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.05		
1011	TANF <1 M & F NON-ME	9,967.97	10,033.35	10,215.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,216.73		
1012	TANF 01-05 M & F NON	22,748.91	23,698.77	24,378.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,825.91		
1013	TANF 06-13 M & F NON	40,609.15	41,832.31	42,322.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,763.54		
1014	TANF 14-20 MALE NON-	12,185.14	12,707.76	12,916.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,809.69		
1015	TANF 14-20 FEMALE N O	14,651.75	15,257.59	15,479.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,388.44		
1016	TANF 21-44 MALE NON-	29,701.60	29,950.91	30,106.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,759.48		
1017	TANF 21-44 FEMALE N O	97,525.08	98,767.87	99,402.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295,695.16		
1018	TANF 45-64 M & F NON	24,328.23	24,621.10	24,701.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,650.41		
1019	TANF 65+ M & F NON-M	106.20	110.31	111.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		328.50		
101A	TANF < 1 M & F NON-M	408.59	392.69	383.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,185.13		
101B	TANF 01-05 M & F NON	50.14	93.74	86.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230.78		
101C	TANF 06-13 M & F NON	39.75	62.71	66.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		168.75		
101D	TANF 14-20 MALE NON-	35.79	20.42	37.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		93.84		
101E	TANF 14-20 FEMALE N O	42.02	48.07	34.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124.66		
101F	TANF 21-44 MALE NON-	454.24	407.09	422.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,283.80		
101G	TANF 21-44 FEMALE N O	853.19	772.51	698.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,324.63		
101H	TANF 44-64 M & F NON	252.90	239.96	197.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		689.98		
101J	TANF 65+ N & F NON-M	1.41	0.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.82		
1023	TANF 06-13 M & F WIT	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		
1024	TANF 14-20 MALE WITH	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1025	TANF 14-20 FEMALE WI	3.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1026	TANF 21-44 MALE WITH	77.86	83.00	78.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239.12		
1027	TANF 21-44 FEMALE WI	125.63	134.24	120.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		380.23		
1028	TANF 45-64 M & F WIT	141.96	154.96	155.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		452.11		
1029	TANF 65+ M & F WITH	60.00	63.99	65.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188.99		
102F	TANF 21-44 MALE WITH	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.03		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102G	TANF 21-44 FEMALE WI	0.03	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.06		
102H	TANF 44-64 M & F WIT	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.03		
2100	SSI AGED WITH MEDIC A	4,402.33	4,355.48	4,357.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,115.35		
210Z	SSI AGED WITH MEDIC
A	169.67	173.31	137.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		480.39		
2110	SSI AGED NON-MEDICA R	7,270.07	7,396.14	7,535.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,201.92		
211Z	SSI AGED NON-MEDICA
R	62.71	82.74	77.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222.93		
2120	SSI AGED WITH QMB	34,634.33	34,813.15	35,177.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,624.53		
212Z	SSI AGED WITH QMB P P	16.83	21.69	12.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.18		
2200	SSI DISABLED WITH M
E	3,956.99	3,848.61	3,898.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,704.01		
220Z	SSI DISABLED WITH M E	113.49	98.84	94.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		306.84		
2210	SSI DISABLED NON-ME
D	53,599.11	53,645.97	53,764.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		161,009.39		
221Z	SSI DISABLED NON-ME D	681.38	520.46	454.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,656.73		
2220	SSI DISABLED WITH Q
M	27,326.19	27,348.70	27,447.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,122.71		
222Z	SSI DISABLED WITH Q M	34.06	46.23	10.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.82		
2300	SSI BLIND WITH MEDIC	31.00	32.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96.00		
2310	SSI BLIND NON-MEDIC A	508.77	511.94	515.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,536.32		
231Z	SSI BLIND NON-MEDIC
A	0.86	0.83	10.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.65		
2320	SSI BLIND WITH QMB	239.00	239.00	240.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		718.89		
4301	SOBRA CHILD <1 M & F	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		
4302	SOBRA CHILD 01-05 M	3.67	11.00	7.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.78		
4303	SOBRA CHILD 06-13 M	5.67	7.00	7.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.22		
4304	SOBRA CHILD 14-20 MA	3.00	3.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.73		
4305	SOBRA CHILD 14-20 FE	0.83	1.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.56		
430B	SOBRA CHILD 01-05 M	1.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.22		
430C	SOBRA CHILD 06-13 M	0.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.32		
430E	SOBRA CHILD 14-20 FE	0.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.16		
4311	SOBRA CHILD <1 M & F	34,405.24	33,970.39	33,465.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,840.94		
4312	SOBRA CHILD 01-05 M	170,887.21	171,552.77	172,827.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		515,267.63		
4313	SOBRA CHILD 06-13 M	221,804.59	221,802.86	222,997.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		666,604.85		
4314	SOBRA CHILD 14-20 MA	63,319.53	63,590.59	64,243.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,154.07		
4315	SOBRA CHILD 14-20 FE	62,977.93	63,153.10	63,923.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190,054.44		
431A	SOBRA CHILD < 1 M &	319.74	215.94	255.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		790.89		
431B	SOBRA CHILD 01-05 M	1,808.16	1,704.58	1,492.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,004.76		
431C	SOBRA CHILD 6-13 M&F	2,057.63	2,155.03	1,747.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,960.17		
431D	SOBRA CHILD 14-20 MA	601.41	556.54	569.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,727.37		
431E	SOBRA CHILD 14-20 FE	594.22	592.22	474.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,660.99		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4323	SOBRA CHILD 06-13 M	2.00	3.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.73		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.73		
4325	SOBRA CHILD 14-20 FE	4.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
5007	SOBRA PREG 21-44 FE M	30.43	26.35	31.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.00		
5008	SOBRA PREG 45-64 FE
M	0.30	-1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.70		
500G	SOBRA PREG 21-44 FE M	1.34	4.36	0.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.66		
5013	SOBRA PREG 09-13 FE
M	2.00	1.00	1.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.16		
5015	SOBRA PREG 14-20 FE M	2,610.55	2,511.48	2,498.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,620.99		
5017	SOBRA PREG 21-44 FE
M	16,020.96	15,581.20	15,626.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,228.47		
5018	SOBRA PREG 45-64 FE M	53.65	53.95	51.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.86		
501E	SOBRA PREG 14-20 FE
M	156.70	121.80	140.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		419.30		
501G	SOBRA PREG 21-44 FE M	871.36	768.53	729.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,369.53		
501H	SOBRA PREG 45-64 FE
M	0.32	3.02	1.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.07		
5027	SOBRA PREG 21-44 FE M	32.00	31.00	33.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96.32		
5028	SOBRA PREG 45-64 FE
M	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
SUBTOTAL:	966,646.72	971,682.15	977,538.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,915,867.80		

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

3.00

3.00

9910	TANF & SOBRA CHILDR E	427.00	437.00	446.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	4.00	7.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	16.00	15.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	1,912.00	1,795.00	1,833.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,359.00	2,254.00	2,305.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,310.00	
13.00	
55.00	
5,540.00	
6,918.00	

1106	TANF EXPANDED 21-44	227.00	225.92	225.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	407.12	410.56	417.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,318.24	1,278.61	1,285.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	756.72	757.62	778.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	8.09	6.15	4.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	16.14	17.36	8.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	26.62	24.59	20.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	29.91	16.58	35.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	222.16	227.73	231.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
678.07	
1,235.49	
3,882.76	
2,292.86	
18.36	
41.82	
71.31	
81.49	
1.00	
15.00	
681.66	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	1,271.74	1,297.44	1,327.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,896.73		
1116	TANF EXPANDED 21-44	25,405.97	25,442.76	25,998.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,846.98		
1117	TANF EXPANDED 21-44	68,847.72	68,996.75	70,356.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,201.35		
1118	TANF EXPANDED 45-64	24,345.36	24,411.74	25,022.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,779.75		
1119	TANF EXPANDED 65+ M
&	93.93	92.74	99.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286.40		
111D	TANF EXPANDED 14-20	3.85	11.16	2.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.19		
111E	TANF EXPANDED 14-20	8.59	10.15	9.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.33		
111F	TANF EXPANDED 21-44	527.07	554.56	476.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,558.62		
111G	TANF EXPANDED 21-44	799.18	794.50	755.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,349.11		
111H	TANF EXPANDED 45-64	349.43	359.79	348.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,058.09		
111J	TANF EXPANDED 65+ M
&	2.06	2.00	1.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.32		
1126	TANF EXPANDED 21-44	722.06	727.52	731.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,180.78		
1127	TANF EXPANDED 21-44	1,603.40	1,607.75	1,616.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,828.05		
1128	TANF EXPANDED 45-64	2,621.04	2,658.82	2,699.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,978.95		
1129	TANF EXPANDED 65+ M
&	1,690.93	1,729.98	1,748.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,168.93		
112F	TANF EXPANDED 21-44	0.51	1.32	0.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.29		
112G	TANF EXPANDED 21-44	1.89	1.69	1.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.80		
112H	TANF EXPANDED 45-64	2.83	3.78	1.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.37		
112J	TANF EXPANDED 65+ M
&	3.16	0.58	4.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.96		
2400	SSI AGED EXPANDED WI	316.62	315.33	357.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989.72		
240Z	SSI AGED EXPANDED
WI	124.04	118.66	103.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		346.22		
2410	SSI AGED EXPANDED N O	126.45	121.59	121.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		369.98		
241Z	SSI AGED EXPANDED N
O	3.74	1.86	4.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.62		
2420	SSI AGED EXPANDED WI	27,810.16	28,078.05	28,360.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,249.03		
242Z	SSI AGED EXPANDED
WI	15.79	12.67	16.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.94		
2520	SSI BLIND EXPANDED W	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2600	SSI DISABLED EXPAND
E	399.04	387.48	389.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,175.71		
260Z	SSI DISABLED EXPAND E	70.71	74.48	62.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		207.27		
2610	SSI DISABLED EXPAND
E	1,609.01	1,581.73	1,552.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,742.87		
261Z	SSI DISABLED EXPAND E	12.50	23.37	14.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.27		
2620	SSI DISABLED EXPAND
E	16,636.88	16,747.92	16,787.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,172.31		
262Z	SSI DISABLED EXPAND E	16.92	14.28	10.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.94		
SUBTOTAL:	178,461.58	179,154.57	181,997.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		539,613.70		

678.00

9911	SB PAYMENT FOR TAN F	206.00	219.00	253.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	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

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	207.00	219.00	253.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		679.00		

3506	ADULT 40-100% MALE 2	17.00	21.63	24.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	13.00	15.77	14.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	169.14	177.34	173.08	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	92.00	88.98	113.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	0.00	1.34	1.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	0.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	1.09	1.63	1.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	0.00	0.00	4.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	5,719.26	5,710.05	5,881.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	6,098.24	6,150.02	6,279.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	20,669.37	21,071.10	22,126.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	17,672.77	18,031.21	18,727.33	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	38,227.24	38,397.04	39,300.71	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	4.00	6.00	6.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	71.07	64.16	65.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	69.74	86.39	88.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	625.93	710.51	617.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	513.83	499.01	434.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	1,025.68	894.26	767.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	16.00	7.00	5.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	2.00	1.58	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	1.99	2.00	1.00	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	10.00	12.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	3.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352F	ADULT 40-100% MALE 2	0.00	1.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	1.45	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352J	ADULT 40-100% M&F 65	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	65.26	66.99	67.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	27.25	28.00	26.75	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	261.27	253.17	272.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	31.00	40.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370F	ADULT <40% EXP MALE	0.95	0.99	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370G	ADULT <40% EXP FEMA L	1.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370H	ADULT <40% EXP M&F
4	3.91	1.41	2.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
62.75	
43.50	
519.56	
294.13	
2.96	
0.22	
4.45	
4.59	
17,310.87	
18,527.56	
63,867.30	
54,431.31	
115,924.99	
16.30	
200.32	
244.55	
1,954.40	
1,447.52	
2,687.85	
28.70	
5.58	
4.99	
37.00	
13.00	
1.41	
1.48	
0.03	
199.97	
82.00	
787.14	
111.00	
1.97	
1.73	
7.44	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	11,053.83	11,244.89	11,488.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,787.47		
3715	ADULT <40% EXP FEMA L	10,253.38	10,408.82	10,790.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,452.34		
3716	ADULT <40% EXP MALE	81,347.38	82,165.91	83,817.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		247,331.07		
3717	ADULT <40% EXP FEMA L	47,777.98	48,506.24	49,403.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,687.70		
3718	ADULT <40% EXP M&F
4	90,788.49	91,545.33	92,557.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,890.91		
3719	ADULT <40% EXP M&F 6	7.00	7.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
371D	ADULT <40% EXP MALE	144.10	161.65	121.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.45		
371E	ADULT <40% EXP FEMA L	165.29	140.83	123.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		429.21		
371F	ADULT <40% EXP MALE	1,606.51	1,390.67	1,091.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,089.05		
371G	ADULT <40% EXP FEMA L	864.79	874.26	692.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,431.32		
371H	ADULT <40% EXP M&F
4	1,532.85	1,349.05	1,020.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,902.51		
371J	ADULT <40% EXP M&F 6	1.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
3726	ADULT <40% EXP MALE	8.00	11.22	10.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.90		
3727	ADULT <40% EXP FEMA L	7.00	8.00	9.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.99		
3728	ADULT <40% EXP M&F
4	34.00	45.95	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122.95		
3729	ADULT <40% EXP M&F 6	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
372F	ADULT <40% EXP MALE	0.06	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.09		
372H	ADULT <40% EXP M&F 4	0.32	0.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.31		
SUBTOTAL:	337,007.15	340,209.02	346,246.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,023,462.84		

3904	NEWLY ELIGIBLE MALE	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	0.00	2.00	2.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	44.12	55.77	58.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	27.54	33.64	38.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	667.68	818.49	919.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	416.57	489.92	615.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	2.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	1.45	0.00	0.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.57	1.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,343.06	4,693.16	4,912.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	4,680.17	5,098.94	5,243.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	21,942.82	23,709.36	24,635.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
4.26	
157.89	
100.00	
2,405.39	
1,522.08	
2.19	
2.35	
2.14	
0.83	
13,948.81	
15,022.93	
70,288.00	

9935	BIRTH SUPP PAYMENT A	34.00	38.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	106.00	110.00	151.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	140.00	148.00	176.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
97.00	
367.00	
464.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3917	NEWLY ELIGIBLE FEMA L	30,421.79	32,719.36	34,193.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,335.00		
3918	NEWLY ELIGIBLE M&F
4	30,261.50	31,823.14	32,676.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,760.90		
3919	NEWLY ELIGIBLE M&F 6	32.00	42.00	47.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121.99		
391D	NEWLY ELIGIBLE MALE	30.13	20.32	25.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.75		
391E	NEWLY ELIGIBLE FEMA L	38.63	25.82	41.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105.89		
391F	NEWLY ELIGIBLE MALE	308.08	288.17	291.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		887.87		
391G	NEWLY ELIGIBLE FEMA L	384.30	361.56	371.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,117.47		
391H	NEWLY ELIGIBLE M&F
4	398.00	367.30	378.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,143.50		
391J	NEWLY ELIGIBLE M&F 6	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3926	NEWLY ELIGIBLE 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		2.00		
3927	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
3928	NEWLY ELIGIBLE M&F
4	19.00	16.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.00		
3929	NEWLY ELIGIBLE M&F 6	16.00	20.00	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.00		
SUBTOTAL:	94,039.60	100,589.52	104,492.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299,121.24		

9939

BIRTH SUPP PAYMENT N

259.00

259.00

79.00	87.00	93.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
79.00	87.00	93.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

4403	SOBRA 100-133% M&F
6	1.00	1.00	-0.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% 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	
4412	SOBRA 100-133% M&F
1	2.00	1.00	1.00	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	39,514.29	40,543.78	40,710.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	11,676.58	12,037.27	12,120.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	11,435.60	11,711.10	11,767.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441B	SOBRA 100-133% M&F
1	0.00	0.00	1.00	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	467.19	415.60	361.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	115.85	134.73	79.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	112.23	100.68	112.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	63,325.74	64,946.16	65,156.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.96	
2.00	
4.00	
120,768.77	
35,834.54	
34,913.95	
1.00	
1,244.56	
329.80	
325.42	
2.00	
193,428.00	

9944	BIRTH SUPP PAYMENT S	9.00	8.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9.00	8.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

28.00

28.00

4517	BC PATIENT FEMALE 2 1	24.57	23.72	21.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	137.52	137.80	130.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	2.15	1.70	2.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	0.41	1.25	1.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
69.82	
406.15	
5.98	
3.12	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
451H	BC PATIENT FEMALE 4 5	3.40	0.18	0.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.71		
451J	BC PATIENT FEMALE 6
5	1.82	0.28	0.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.96		
4617	CC PATIENT FEMALE 2 1	5.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
4618	CC PATIENT FEMALE 4
5	9.00	8.80	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.80		
SUBTOTAL:	183.87	177.73	168.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		530.54		

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W
O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	2,191.36	2,199.68	2,207.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	62.50	51.80	54.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	325.68	326.15	323.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	4.27	18.59	5.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	404.32	442.50	454.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	1.67	8.60	2.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,991.80	3,049.32	3,050.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
3.00	
6,598.07	
168.33	
975.72	
28.74	
1,301.58	
13.02	
9,091.46	

TOTAL:	1,645,451.46	1,662,525.47	1,681,489.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,989,466.58		

ACUTE CAPITATION - AMERICAN INDIAN A - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1018	TANF 45-64 M & F NON	15.18	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.54		
2110	SSI AGED NON-MEDICA R	0.00	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.36		
2120	SSI AGED WITH QMB	0.00	0.00	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.18		
2220	SSI DISABLED WITH Q M	0.00	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.36		
4312	SOBRA CHILD 01-05 M	15.18	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.54		
4313	SOBRA CHILD 06-13 M	0.00	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.36		
SUBTOTAL:	30.36	75.90	91.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		197.34		

1117	TANF EXPANDED 21-44	0.00	15.18	15.18	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	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	15.18	30.36	30.36	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	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15.18	75.90	75.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
30.36	
30.36	
75.90	
30.36	
166.98	

3516	ADULT 40-100% MALE 2	0.00	15.18	15.18	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	15.18	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	30.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	30.36	45.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
30.36	
15.18	
30.36	
75.90	

3917	NEWLY ELIGIBLE FEMA L	0.00	15.18	15.18	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	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	30.36	30.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
30.36	
30.36	
60.72	

500.94

45.54	212.52	242.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN A - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1018	TANF 45-64 M & F NON	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		
2110	SSI AGED NON-MEDICA R	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
2120	SSI AGED WITH QMB	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		
2220	SSI DISABLED WITH Q M	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
4312	SOBRA CHILD 01-05 M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4313	SOBRA CHILD 06-13 M	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
SUBTOTAL:	2.00	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		

3516	ADULT 40-100% MALE 2	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	1.00	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	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
1.00	
2.00	
5.00	

3917	NEWLY ELIGIBLE FEMA L	0.00	1.00	1.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
2.00	
4.00	

1117	TANF EXPANDED 21-44	0.00	1.00	1.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	1.00	2.00	2.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
2.00	
5.00	
2.00	
11.00	

TOTAL:	3.00	14.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	34.92	34.92	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.76		
1009	TANF 65+ M & F WITH	69.84	87.30	87.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244.44		
1011	TANF <1 M & F NON-ME	1,571.40	1,571.40	1,693.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,836.42		
1012	TANF 01-05 M & F NON	2,636.46	2,531.70	2,566.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,734.78		
1013	TANF 06-13 M & F NON	2,688.84	2,811.06	3,055.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,555.40		
1014	TANF 14-20 MALE NON-	506.34	628.56	698.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,833.30		
1015	TANF 14-20 FEMALE N O	1,257.12	1,292.04	1,169.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,718.98		
1016	TANF 21-44 MALE NON-	3,265.02	3,299.94	3,422.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,987.12		
1017	TANF 21-44 FEMALE N O	11,226.78	11,261.70	11,296.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,785.10		
1018	TANF 45-64 M & F NON	4,225.32	4,172.94	4,103.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,501.36		
1019	TANF 65+ M & F NON-M	34.92	34.92	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.76		
1028	TANF 45-64 M & F WIT	17.46	34.92	69.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122.22		
1029	TANF 65+ M & F WITH	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.38		
2100	SSI AGED WITH MEDIC A	122.22	122.22	139.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.12		
2110	SSI AGED NON-MEDICA
R	174.60	192.06	209.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		576.18		
2120	SSI AGED WITH QMB	1,693.62	1,676.16	1,658.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,028.48		
2200	SSI DISABLED WITH M E	576.18	593.64	646.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,815.84		
2210	SSI DISABLED NON-ME
D	10,004.58	9,847.44	9,725.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,577.24		
2220	SSI DISABLED WITH Q M	3,561.84	3,544.38	3,474.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,580.76		
2300	SSI BLIND WITH MEDIC	0.00	0.00	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.46		
2310	SSI BLIND NON-MEDIC A	87.30	87.30	69.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244.44		
2320	SSI BLIND WITH QMB	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.38		
4311	SOBRA CHILD <1 M & F	5,045.94	4,923.72	5,150.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,120.36		
4312	SOBRA CHILD 01-05 M	24,758.28	25,351.92	25,247.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75,357.36		
4313	SOBRA CHILD 06-13 M	23,710.68	23,815.44	23,955.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,481.24		
4314	SOBRA CHILD 14-20 MA	5,674.50	5,709.42	5,884.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,267.94		
4315	SOBRA CHILD 14-20 FE	5,953.86	6,023.70	6,023.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,001.26		
5015	SOBRA PREG 14-20 FE M	244.44	157.14	174.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		576.18		
5017	SOBRA PREG 21-44 FE
M	1,030.14	907.92	942.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,880.90		
SUBTOTAL:	110,207.52	110,748.78	111,586.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332,543.16		

1107	TANF EXPANDED 21-44	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	174.60	122.22	139.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	209.52	174.60	174.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	34.92	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	69.84	69.84	87.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
52.38	
436.50	
558.72	
69.84	
226.98	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	1,868.22	1,780.92	1,728.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,377.68		
1117	TANF EXPANDED 21-44	5,639.58	5,622.12	5,709.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,971.12		
1118	TANF EXPANDED 45-64	2,898.36	2,950.74	2,985.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,834.76		
1119	TANF EXPANDED 65+ M
&	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.92		
1126	TANF EXPANDED 21-44	139.68	122.22	122.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.12		
1127	TANF EXPANDED 21-44	69.84	52.38	52.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.60		
1128	TANF EXPANDED 45-64	419.04	488.88	488.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,396.80		
1129	TANF EXPANDED 65+ M
&	331.74	331.74	331.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		995.22		
2400	SSI AGED EXPANDED WI	52.38	34.92	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122.22		
2410	SSI AGED EXPANDED N
O	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.38		
2420	SSI AGED EXPANDED WI	2,409.48	2,426.94	2,409.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,245.90		
2600	SSI DISABLED EXPAND
E	34.92	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.84		
2610	SSI DISABLED EXPAND E	261.90	244.44	226.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		733.32		
2620	SSI DISABLED EXPAND
E	1,012.68	1,082.52	1,134.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,230.10		
SUBTOTAL:	15,679.08	15,591.78	15,696.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,967.40		

3908	NEWLY ELIGIBLE M&F 4	69.84	69.84	104.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	34.92	34.92	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	104.76	122.22	104.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	192.06	226.98	209.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,204.74	1,309.50	1,309.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

244.44	
104.76	
331.74	
628.56	
3,823.74	

3508	ADULT 40-100% M&F 45	34.92	34.92	34.92	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	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	244.44	244.44	226.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	314.28	296.82	296.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	1,169.82	1,169.82	1,274.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	1,047.60	995.22	995.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	3,457.08	3,422.16	3,422.16	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	17.46	17.46	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	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	785.70	785.70	873.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	750.78	803.16	820.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	9,306.18	9,183.96	9,568.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	5,447.52	5,447.52	5,534.82	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	11,261.70	11,244.24	11,506.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	33,872.40	33,680.34	34,588.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
104.76	
52.38	
715.86	
907.92	
3,614.22	
3,038.04	
10,301.40	
34.92	
52.38	
2,444.40	
2,374.56	
28,058.22	
16,429.86	
34,012.08	
102,141.00	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	1,606.32	1,798.38	1,798.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,203.08		
3918	NEWLY ELIGIBLE M&F
4	2,619.00	2,741.22	2,741.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,101.44		
SUBTOTAL:	5,831.64	6,303.06	6,303.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,437.76		

4413	SOBRA 100-133% M&F
6	2,444.40	2,252.34	2,304.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	698.40	680.94	680.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	506.34	558.72	593.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,649.14	3,492.00	3,579.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,001.46	
2,060.28	
1,658.70	
10,720.44	

8700	SSI DISABLED FREEDO M	87.30	87.30	87.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	122.22	122.22	122.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
261.90	
52.38	
52.38	
366.66	

511,176.42

169,362.00	169,938.18	171,876.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1009	TANF 65+ M & F WITH	4.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
1011	TANF <1 M & F NON-ME	90.00	90.00	97.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277.00		
1012	TANF 01-05 M & F NON	151.00	145.00	147.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		443.00		
1013	TANF 06-13 M & F NON	154.00	161.00	175.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		490.00		
1014	TANF 14-20 MALE NON-	29.00	36.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105.00		
1015	TANF 14-20 FEMALE N O	72.00	74.00	67.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213.00		
1016	TANF 21-44 MALE NON-	187.00	189.00	196.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572.00		
1017	TANF 21-44 FEMALE N O	643.00	645.00	647.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,935.00		
1018	TANF 45-64 M & F NON	242.00	239.00	235.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		716.00		
1019	TANF 65+ M & F NON-M	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1028	TANF 45-64 M & F WIT	1.00	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1029	TANF 65+ M & F WITH	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2100	SSI AGED WITH MEDIC A	7.00	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
2110	SSI AGED NON-MEDICA
R	10.00	11.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
2120	SSI AGED WITH QMB	97.00	96.00	95.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		288.00		
2200	SSI DISABLED WITH M E	33.00	34.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.00		
2210	SSI DISABLED NON-ME
D	573.00	564.00	557.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,694.00		
2220	SSI DISABLED WITH Q M	204.00	203.00	199.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		606.00		
2300	SSI BLIND WITH MEDIC	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		
2310	SSI BLIND NON-MEDIC A	5.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4311	SOBRA CHILD <1 M & F	289.00	282.00	295.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		866.00		
4312	SOBRA CHILD 01-05 M	1,418.00	1,452.00	1,446.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,316.00		
4313	SOBRA CHILD 06-13 M	1,358.00	1,364.00	1,372.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,094.00		
4314	SOBRA CHILD 14-20 MA	325.00	327.00	337.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989.00		
4315	SOBRA CHILD 14-20 FE	341.00	345.00	345.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,031.00		
5015	SOBRA PREG 14-20 FE M	14.00	9.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
5017	SOBRA PREG 21-44 FE
M	59.00	52.00	54.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165.00		
SUBTOTAL:	6,312.00	6,343.00	6,391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,046.00		

1107	TANF EXPANDED 21-44	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	10.00	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	12.00	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
25.00	
32.00	
4.00	
13.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	107.00	102.00	99.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308.00		
1117	TANF EXPANDED 21-44	323.00	322.00	327.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		972.00		
1118	TANF EXPANDED 45-64	166.00	169.00	171.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		506.00		
1119	TANF EXPANDED 65+ M
&	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1126	TANF EXPANDED 21-44	8.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
1127	TANF EXPANDED 21-44	4.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1128	TANF EXPANDED 45-64	24.00	28.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80.00		
1129	TANF EXPANDED 65+ M
&	19.00	19.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.00		
2400	SSI AGED EXPANDED WI	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2410	SSI AGED EXPANDED N
O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2420	SSI AGED EXPANDED WI	138.00	139.00	138.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415.00		
2600	SSI DISABLED EXPAND
E	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2610	SSI DISABLED EXPAND E	15.00	14.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.00		
2620	SSI DISABLED EXPAND
E	58.00	62.00	65.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185.00		
SUBTOTAL:	898.00	893.00	899.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,690.00		

3908	NEWLY ELIGIBLE M&F 4	4.00	4.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	6.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	11.00	13.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	69.00	75.00	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14.00	
6.00	
19.00	
36.00	
219.00	

3508	ADULT 40-100% M&F 45	2.00	2.00	2.00	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	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	14.00	14.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	18.00	17.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	67.00	67.00	73.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	60.00	57.00	57.00	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	198.00	196.00	196.00	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	1.00	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	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	45.00	45.00	50.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	43.00	46.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	533.00	526.00	548.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	312.00	312.00	317.00	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	645.00	644.00	659.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,940.00	1,929.00	1,981.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
3.00	
41.00	
52.00	
207.00	
174.00	
590.00	
2.00	
3.00	
140.00	
136.00	
1,607.00	
941.00	
1,948.00	
5,850.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3917	NEWLY ELIGIBLE FEMA L	92.00	103.00	103.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		298.00		
3918	NEWLY ELIGIBLE M&F
4	150.00	157.00	157.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		464.00		
SUBTOTAL:	334.00	361.00	361.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,056.00		

8700	SSI DISABLED FREEDO M	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15.00	
3.00	
3.00	
21.00	

4413	SOBRA 100-133% M&F
6	140.00	129.00	132.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	40.00	39.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	29.00	32.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	209.00	200.00	205.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
401.00	
118.00	
95.00	
614.00	

TOTAL:	9,700.00	9,733.00	9,844.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,277.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	23.76	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.52		
1011	TANF <1 M & F NON-ME	71.28	71.28	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.32		
1012	TANF 01-05 M & F NON	1,021.68	1,045.44	974.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,041.28		
1013	TANF 06-13 M & F NON	1,069.20	1,069.20	1,069.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,207.60		
1014	TANF 14-20 MALE NON-	142.56	166.32	118.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		427.68		
1015	TANF 14-20 FEMALE N O	475.20	594.00	594.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,663.20		
1016	TANF 21-44 MALE NON-	831.60	879.12	807.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,518.56		
1017	TANF 21-44 FEMALE N O	6,914.16	6,985.44	6,961.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,861.28		
1018	TANF 45-64 M & F NON	2,376.00	2,518.56	2,518.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,413.12		
1027	TANF 21-44 FEMALE WI	23.76	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.52		
1028	TANF 45-64 M & F WIT	23.76	23.76	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.28		
1029	TANF 65+ M & F WITH	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.76		
2100	SSI AGED WITH MEDIC A	332.64	308.88	285.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		926.64		
2110	SSI AGED NON-MEDICA
R	142.56	166.32	166.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		475.20		
2120	SSI AGED WITH QMB	2,922.48	2,970.00	2,993.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,886.24		
2200	SSI DISABLED WITH M E	950.40	902.88	902.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,756.16		
2210	SSI DISABLED NON-ME
D	5,654.88	5,678.64	5,678.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,012.16		
2220	SSI DISABLED WITH Q M	3,801.60	3,801.60	3,706.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,309.76		
2310	SSI BLIND NON-MEDIC
A	95.04	118.80	118.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332.64		
2320	SSI BLIND WITH QMB	95.04	95.04	95.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285.12		
4311	SOBRA CHILD <1 M & F	403.92	308.88	261.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		974.16		
4312	SOBRA CHILD 01-05 M	7,626.96	7,531.92	7,626.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,785.84		
4313	SOBRA CHILD 06-13 M	7,912.08	7,888.32	8,078.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,878.80		
4314	SOBRA CHILD 14-20 MA	1,972.08	1,995.84	2,090.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,058.80		
4315	SOBRA CHILD 14-20 FE	2,471.04	2,542.32	2,661.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,674.48		
5013	SOBRA PREG 09-13 FE M	0.00	23.76	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.52		
5015	SOBRA PREG 14-20 FE
M	213.84	142.56	95.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		451.44		
5017	SOBRA PREG 21-44 FE M	1,496.88	1,401.84	1,283.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,181.76		
SUBTOTAL:	49,064.40	49,278.24	49,183.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,525.84		

1108	TANF EXPANDED 45-64	71.28	47.52	47.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	47.52	47.52	47.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	71.28	118.80	95.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	498.96	451.44	546.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	3,754.08	3,730.32	3,920.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,924.56	1,805.76	1,829.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
166.32	
142.56	
285.12	
1,496.88	
11,404.80	
5,559.84	

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	23.76	23.76	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.28		
1127	TANF EXPANDED 21-44	0.00	0.00	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.76		
1128	TANF EXPANDED 45-64	118.80	118.80	118.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		356.40		
1129	TANF EXPANDED 65+ M
&	403.92	427.68	403.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,235.52		
2400	SSI AGED EXPANDED WI	23.76	23.76	47.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.04		
2410	SSI AGED EXPANDED N
O	47.52	47.52	47.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.56		
2420	SSI AGED EXPANDED WI	2,138.40	2,185.92	2,233.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,557.76		
2610	SSI DISABLED EXPAND
E	47.52	47.52	47.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.56		
2620	SSI DISABLED EXPAND E	855.36	855.36	902.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,613.60		
SUBTOTAL:	10,026.72	9,931.68	10,335.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,294.00		

3508	ADULT 40-100% M&F 45	0.00	47.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	95.04	95.04	95.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	118.80	166.32	190.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	570.24	570.24	641.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	617.76	546.48	594.00	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	1,877.04	1,877.04	1,924.56	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	23.76	23.76	23.76	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	71.28	71.28	71.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	451.44	498.96	451.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	546.48	498.96	451.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	2,946.24	2,993.76	3,017.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	2,423.52	2,423.52	2,471.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	7,294.32	7,294.32	7,436.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	17,035.92	17,107.20	17,392.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
47.52	
23.76	
285.12	
475.20	
1,782.00	
1,758.24	
5,678.64	
71.28	
213.84	
1,401.84	
1,496.88	
8,957.52	
7,318.08	
22,025.52	
51,535.44	

3908	NEWLY ELIGIBLE M&F 4	47.52	47.52	47.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	47.52	95.04	118.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	95.04	95.04	71.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	308.88	308.88	332.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	1,140.48	1,283.04	1,354.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,591.92	1,591.92	1,591.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	23.76	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,231.36	3,445.20	3,540.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
142.56	
261.36	
261.36	
950.40	
3,777.84	
4,775.76	
47.52	
10,216.80	

2,613.60

4413	SOBRA 100-133% M&F
6	760.32	902.88	950.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	261.36	237.60	261.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

760.32

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	332.64	285.12	308.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		926.64		
SUBTOTAL:	1,354.32	1,425.60	1,520.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,300.56		

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

 
71.28

71.28

8700	SSI DISABLED FREEDO M	71.28	47.52	47.52	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	23.76	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	23.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	71.28	71.28	71.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
166.32	
23.76	
23.76	
213.84	

244,157.76

80,807.76	81,282.96	82,067.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1011	TANF <1 M & F NON-ME	3.00	3.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1012	TANF 01-05 M & F NON	43.00	44.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128.00		
1013	TANF 06-13 M & F NON	45.00	45.00	45.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135.00		
1014	TANF 14-20 MALE NON-	6.00	7.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
1015	TANF 14-20 FEMALE N O	20.00	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.00		
1016	TANF 21-44 MALE NON-	35.00	37.00	34.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.00		
1017	TANF 21-44 FEMALE N O	291.00	294.00	293.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		878.00		
1018	TANF 45-64 M & F NON	100.00	106.00	106.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		312.00		
1027	TANF 21-44 FEMALE WI	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1028	TANF 45-64 M & F WIT	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		
1029	TANF 65+ M & F WITH	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		
2100	SSI AGED WITH MEDIC A	14.00	13.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.00		
2110	SSI AGED NON-MEDICA
R	6.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
2120	SSI AGED WITH QMB	123.00	125.00	126.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		374.00		
2200	SSI DISABLED WITH M E	40.00	38.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.00		
2210	SSI DISABLED NON-ME
D	238.00	239.00	239.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		716.00		
2220	SSI DISABLED WITH Q M	160.00	160.00	156.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		476.00		
2310	SSI BLIND NON-MEDIC
A	4.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
2320	SSI BLIND WITH QMB	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
4311	SOBRA CHILD <1 M & F	17.00	13.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
4312	SOBRA CHILD 01-05 M	321.00	317.00	321.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		959.00		
4313	SOBRA CHILD 06-13 M	333.00	332.00	340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,005.00		
4314	SOBRA CHILD 14-20 MA	83.00	84.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255.00		
4315	SOBRA CHILD 14-20 FE	104.00	107.00	112.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		323.00		
5013	SOBRA PREG 09-13 FE M	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5015	SOBRA PREG 14-20 FE
M	9.00	6.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
5017	SOBRA PREG 21-44 FE M	63.00	59.00	54.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176.00		
SUBTOTAL:	2,065.00	2,074.00	2,070.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,209.00		

1108	TANF EXPANDED 45-64	3.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	3.00	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	21.00	19.00	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	158.00	157.00	165.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	81.00	76.00	77.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7.00	
6.00	
12.00	
63.00	
480.00	
234.00	

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1127	TANF EXPANDED 21-44	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		
1128	TANF EXPANDED 45-64	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
1129	TANF EXPANDED 65+ M
&	17.00	18.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.00		
2400	SSI AGED EXPANDED WI	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2410	SSI AGED EXPANDED N
O	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2420	SSI AGED EXPANDED WI	90.00	92.00	94.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		276.00		
2610	SSI DISABLED EXPAND
E	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2620	SSI DISABLED EXPAND E	36.00	36.00	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.00		
SUBTOTAL:	422.00	418.00	435.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,275.00		

3508	ADULT 40-100% M&F 45	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	5.00	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	24.00	24.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	26.00	23.00	25.00	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	79.00	79.00	81.00	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	1.00	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	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	19.00	21.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	23.00	21.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	124.00	126.00	127.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	102.00	102.00	104.00	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	307.00	307.00	313.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	717.00	720.00	732.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2.00	
1.00	
12.00	
20.00	
75.00	
74.00	
239.00	
3.00	
9.00	
59.00	
63.00	
377.00	
308.00	
927.00	
2,169.00	

3908	NEWLY ELIGIBLE M&F 4	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	2.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	13.00	13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	48.00	54.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	67.00	67.00	67.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	136.00	145.00	149.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
11.00	
11.00	
40.00	
159.00	
201.00	
2.00	
430.00	

110.00

4413	SOBRA 100-133% M&F
6	32.00	38.00	40.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	11.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

32.00

ACUTE CAPITATION - AMERICAN INDIAN C - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	14.00	12.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.00		
SUBTOTAL:	57.00	60.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181.00		

8700	SSI DISABLED FREEDO M	3.00	2.00	2.00	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	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:	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.00	
1.00	
1.00	
9.00	

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

 
3.00

3.00

TOTAL:	3,401.00	3,421.00	3,454.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,276.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	52.10	26.05	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.25		
1009	TANF 65+ M & F WITH	78.15	78.15	78.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		234.45		
1011	TANF <1 M & F NON-ME	1,276.45	1,224.35	1,094.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,594.90		
1012	TANF 01-05 M & F NON	3,490.70	3,699.10	3,803.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,993.10		
1013	TANF 06-13 M & F NON	5,001.60	5,183.95	5,157.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,343.45		
1014	TANF 14-20 MALE NON-	1,302.50	1,354.60	1,458.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,115.90		
1015	TANF 14-20 FEMALE N O	2,448.70	2,474.75	2,631.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,554.50		
1016	TANF 21-44 MALE NON-	8,935.15	9,325.90	9,664.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,925.60		
1017	TANF 21-44 FEMALE N O	33,891.05	33,969.20	34,828.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,689.10		
1018	TANF 45-64 M & F NON	11,566.20	11,696.45	11,878.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,141.45		
1019	TANF 65+ M & F NON-M	26.05	52.10	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.25		
1029	TANF 65+ M & F WITH	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.15		
2100	SSI AGED WITH MEDIC A	1,745.35	1,771.40	1,771.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,288.15		
2110	SSI AGED NON-MEDICA
R	703.35	755.45	755.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,214.25		
2120	SSI AGED WITH QMB	7,033.50	7,189.80	7,294.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,517.30		
2200	SSI DISABLED WITH M E	4,662.95	4,689.00	4,871.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,223.30		
2210	SSI DISABLED NON-ME
D	24,200.45	24,330.70	24,408.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,940.00		
2220	SSI DISABLED WITH Q M	10,810.75	10,758.65	10,836.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,406.20		
2300	SSI BLIND WITH MEDIC	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.15		
2310	SSI BLIND NON-MEDIC A	442.85	416.80	416.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,276.45		
2320	SSI BLIND WITH QMB	182.35	182.35	182.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		547.05		
4311	SOBRA CHILD <1 M & F	3,829.35	3,464.65	2,969.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,263.70		
4312	SOBRA CHILD 01-05 M	41,237.15	41,185.05	41,393.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,815.65		
4313	SOBRA CHILD 06-13 M	58,820.90	59,211.65	59,862.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,895.45		
4314	SOBRA CHILD 14-20 MA	15,708.15	15,760.25	15,838.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,306.80		
4315	SOBRA CHILD 14-20 FE	16,385.45	16,619.90	16,984.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,989.95		
5013	SOBRA PREG 09-13 FE M	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.15		
5015	SOBRA PREG 14-20 FE
M	182.35	182.35	234.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		599.15		
5017	SOBRA PREG 21-44 FE M	2,344.50	2,474.75	2,631.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,450.30		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.05		
SUBTOTAL:	256,436.20	258,155.50	261,255.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		775,847.15		

1106	TANF EXPANDED 21-44	52.10	52.10	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	52.10	52.10	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	208.40	182.35	208.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	260.50	286.55	286.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
156.30	
156.30	
599.15	
833.60	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	260.50	260.50	260.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		781.50		
1116	TANF EXPANDED 21-44	4,454.55	4,454.55	4,194.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,103.15		
1117	TANF EXPANDED 21-44	13,415.75	13,363.65	13,363.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,143.05		
1118	TANF EXPANDED 45-64	7,085.60	7,215.85	7,320.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,621.50		
1119	TANF EXPANDED 65+ M
&	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.15		
1126	TANF EXPANDED 21-44	208.40	208.40	234.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		651.25		
1127	TANF EXPANDED 21-44	286.55	286.55	286.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		859.65		
1128	TANF EXPANDED 45-64	807.55	833.60	859.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,500.80		
1129	TANF EXPANDED 65+ M
&	755.45	755.45	755.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,266.35		
2400	SSI AGED EXPANDED WI	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.15		
2410	SSI AGED EXPANDED N
O	130.25	130.25	130.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390.75		
2420	SSI AGED EXPANDED WI	4,220.10	4,141.95	4,141.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,504.00		
2610	SSI DISABLED EXPAND
E	208.40	182.35	182.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		573.10		
2620	SSI DISABLED EXPAND E	1,901.65	1,953.75	1,953.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,809.15		
SUBTOTAL:	34,359.95	34,412.05	34,333.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,105.90		

3908	NEWLY ELIGIBLE M&F 4	104.20	104.20	130.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	338.65	364.70	364.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	442.85	573.10	625.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	2,162.15	2,396.60	2,657.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	3,308.35	3,751.20	3,985.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	4,636.90	4,975.55	5,236.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

338.65	
78.15	
1,068.05	
1,641.15	
7,215.85	
11,045.20	
14,848.50	

3509	ADULT 40-100% M&F 65	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	885.70	885.70	911.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,198.30	1,172.25	1,015.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	2,110.05	2,188.20	2,344.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	1,797.45	1,875.60	2,031.90	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	5,001.60	4,871.35	4,897.40	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	52.10	78.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	3,647.00	3,568.85	3,699.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	3,985.65	3,959.60	4,272.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	28,811.30	29,280.20	29,697.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	14,119.10	14,744.30	14,926.65	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	28,863.40	29,097.85	29,827.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	90,445.60	91,722.05	93,727.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
78.15	
2,683.15	
3,386.50	
6,642.75	
5,704.95	
14,770.35	
130.25	
10,914.95	
12,217.45	
87,788.50	
43,790.05	
87,788.50	
275,895.55	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	11,019.15	12,191.40	13,025.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,235.55		

4413	SOBRA 100-133% M&F
6	4,610.85	4,558.75	4,272.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	1,406.70	1,510.90	1,406.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,354.60	1,406.70	1,354.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,372.15	7,476.35	7,033.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,441.80	
4,324.30	
4,115.90	
21,882.00	

8700	SSI DISABLED FREEDO M	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	52.10	52.10	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	78.15	78.15	78.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
78.15	
156.30	
234.45	

1,213,200.60

399,711.20	404,035.50	409,453.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	2.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1009	TANF 65+ M & F WITH	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1011	TANF <1 M & F NON-ME	49.00	47.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138.00		
1012	TANF 01-05 M & F NON	134.00	142.00	146.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		422.00		
1013	TANF 06-13 M & F NON	192.00	199.00	198.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		589.00		
1014	TANF 14-20 MALE NON-	50.00	52.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.00		
1015	TANF 14-20 FEMALE N O	94.00	95.00	101.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		290.00		
1016	TANF 21-44 MALE NON-	343.00	358.00	371.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,072.00		
1017	TANF 21-44 FEMALE N O	1,301.00	1,304.00	1,337.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,942.00		
1018	TANF 45-64 M & F NON	444.00	449.00	456.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,349.00		
1019	TANF 65+ M & F NON-M	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1029	TANF 65+ M & F WITH	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2100	SSI AGED WITH MEDIC A	67.00	68.00	68.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203.00		
2110	SSI AGED NON-MEDICA
R	27.00	29.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.00		
2120	SSI AGED WITH QMB	270.00	276.00	280.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		826.00		
2200	SSI DISABLED WITH M E	179.00	180.00	187.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		546.00		
2210	SSI DISABLED NON-ME
D	929.00	934.00	937.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,800.00		
2220	SSI DISABLED WITH Q M	415.00	413.00	416.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,244.00		
2300	SSI BLIND WITH MEDIC	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		
2310	SSI BLIND NON-MEDIC A	17.00	16.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.00		
2320	SSI BLIND WITH QMB	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
4311	SOBRA CHILD <1 M & F	147.00	133.00	114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394.00		
4312	SOBRA CHILD 01-05 M	1,583.00	1,581.00	1,589.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,753.00		
4313	SOBRA CHILD 06-13 M	2,258.00	2,273.00	2,298.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,829.00		
4314	SOBRA CHILD 14-20 MA	603.00	605.00	608.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,816.00		
4315	SOBRA CHILD 14-20 FE	629.00	638.00	652.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,919.00		
5013	SOBRA PREG 09-13 FE M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
5015	SOBRA PREG 14-20 FE
M	7.00	7.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.00		
5017	SOBRA PREG 21-44 FE M	90.00	95.00	101.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286.00		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
SUBTOTAL:	9,844.00	9,910.00	10,029.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,783.00		

1106	TANF EXPANDED 21-44	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	8.00	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	10.00	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6.00	
6.00	
23.00	
32.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	10.00	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
1116	TANF EXPANDED 21-44	171.00	171.00	161.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		503.00		
1117	TANF EXPANDED 21-44	515.00	513.00	513.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,541.00		
1118	TANF EXPANDED 45-64	272.00	277.00	281.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		830.00		
1119	TANF EXPANDED 65+ M
&	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1126	TANF EXPANDED 21-44	8.00	8.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
1127	TANF EXPANDED 21-44	11.00	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
1128	TANF EXPANDED 45-64	31.00	32.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96.00		
1129	TANF EXPANDED 65+ M
&	29.00	29.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.00		
2400	SSI AGED EXPANDED WI	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		
2410	SSI AGED EXPANDED N
O	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
2420	SSI AGED EXPANDED WI	162.00	159.00	159.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		480.00		
2610	SSI DISABLED EXPAND
E	8.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
2620	SSI DISABLED EXPAND E	73.00	75.00	75.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223.00		
SUBTOTAL:	1,319.00	1,321.00	1,318.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,958.00		

3908	NEWLY ELIGIBLE M&F 4	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	13.00	14.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	17.00	22.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	83.00	92.00	102.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	127.00	144.00	153.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	178.00	191.00	201.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13.00	
3.00	
41.00	
63.00	
277.00	
424.00	
570.00	

3509	ADULT 40-100% M&F 65	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	34.00	34.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	46.00	45.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	81.00	84.00	90.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	69.00	72.00	78.00	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	192.00	187.00	188.00	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	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	140.00	137.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	153.00	152.00	164.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1,106.00	1,124.00	1,140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	542.00	566.00	573.00	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	1,108.00	1,117.00	1,145.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,472.00	3,521.00	3,598.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
3.00	
103.00	
130.00	
255.00	
219.00	
567.00	
5.00	
419.00	
469.00	
3,370.00	
1,681.00	
3,370.00	
10,591.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	423.00	468.00	500.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,391.00		

8700	SSI DISABLED FREEDO M	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
6.00	
9.00	

4413	SOBRA 100-133% M&F
6	177.00	175.00	164.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	54.00	58.00	54.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	52.00	54.00	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	283.00	287.00	270.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
516.00	
166.00	
158.00	
840.00	

TOTAL:	15,344.00	15,510.00	15,718.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,572.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	3,438.80	3,438.80	3,438.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,316.40		
1010	TANF NON-MEDICARE	3,291,897.58	3,285,053.48	3,288,548.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,865,499.78		
1020	TANF WITH QMB	9,680.62	4,840.31	4,840.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,361.24		
2100	SSI AGED WITH MEDIC A	36,886,150.06	36,257,168.41	36,003,911.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,147,229.95		
210Z	SSI AGED WITH MEDIC
A	1,298,077.28	1,402,442.60	1,257,963.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,958,483.28		
2110	SSI AGED NON-MEDICA R	3,936,251.45	3,919,215.33	3,905,281.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,760,748.32		
211Z	SSI AGED NON-MEDICA
R	58,332.16	48,168.31	33,594.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,094.65		
2120	SSI AGED WITH QMB	29,860,178.07	29,597,269.68	29,251,347.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,708,795.71		
212Z	SSI AGED WITH QMB P P	52,730.40	29,814.20	66,471.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,016.29		
2200	SSI DISABLED WITH M
E	17,059,477.72	17,032,420.82	16,952,713.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,044,612.12		
220Z	SSI DISABLED WITH M E	98,578.03	155,770.48	142,184.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		396,532.96		
2210	SSI DISABLED NON-ME
D	162,684,114.64	163,041,594.79	163,677,617.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		489,403,327.26		
221Z	SSI DISABLED NON-ME D	35,551.37	116,027.59	170,841.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322,420.15		
2220	SSI DISABLED WITH Q
M	34,878,015.83	34,889,678.58	35,047,772.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,815,467.05		
222Z	SSI DISABLED WITH Q M	6,530.37	27,041.24	249.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,821.54		
2300	SSI BLIND WITH MEDIC	13,493.19	13,493.19	18,333.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,319.88		
2310	SSI BLIND NON-MEDIC A	87,574.55	94,928.07	94,586.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277,089.46		
2320	SSI BLIND WITH QMB	13,529.94	13,596.77	14,463.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,590.34		
SUBTOTAL:	290,273,602.06	289,931,962.65	289,934,161.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		870,139,726.38		

8700	SSI DISABLED FREEDO M	259,279.78	247,188.10	270,149.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	264,671.23	265,551.59	264,399.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	5,473.25	0.00	21,775.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	122,938.58	127,778.89	122,938.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	652,362.84	640,518.58	679,264.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
776,617.74	
794,622.73	
27,249.16	
373,656.05	
1,972,145.68	

872,111,872.06

290,925,964.90	290,572,481.23	290,613,425.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	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		
1010	TANF NON-MEDICARE	674.29	672.89	673.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,020.31		
1020	TANF WITH QMB	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2100	SSI AGED WITH MEDIC A	11,098.06	10,918.90	10,833.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,850.89		
210Z	SSI AGED WITH MEDIC
A	373.44	404.87	364.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,142.33		
2110	SSI AGED NON-MEDICA R	554.21	552.90	548.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,655.12		
211Z	SSI AGED NON-MEDICA
R	8.27	6.41	4.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.57		
2120	SSI AGED WITH QMB	9,354.00	9,262.01	9,160.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,776.71		
212Z	SSI AGED WITH QMB P P	14.65	8.61	18.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.82		
2200	SSI DISABLED WITH M
E	4,238.21	4,227.15	4,206.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,672.29		
220Z	SSI DISABLED WITH M E	28.56	44.79	40.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.34		
2210	SSI DISABLED NON-ME
D	31,815.64	31,895.15	32,020.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,731.52		
221Z	SSI DISABLED NON-ME D	4.68	15.55	23.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.49		
2220	SSI DISABLED WITH Q
M	8,199.32	8,200.99	8,238.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,638.95		
222Z	SSI DISABLED WITH Q M	1.67	8.46	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.19		
2300	SSI BLIND WITH MEDIC	3.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
2310	SSI BLIND NON-MEDIC A	15.95	17.58	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.53		
2320	SSI BLIND WITH QMB	3.35	4.00	5.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.44		
SUBTOTAL:	66,390.30	66,245.26	66,162.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198,798.50		

8700	SSI DISABLED FREEDO M	62.00	59.00	61.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	39.16	39.41	38.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	0.83	0.00	3.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	28.00	29.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	129.99	127.41	131.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
182.99	
117.53	
3.86	
85.00	
389.38	

TOTAL:	66,520.29	66,372.67	66,294.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,187.88		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	0.00	338.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338.30		
2210	SSI DISABLED NON-ME D	1,006.49	202.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,209.47		
4311	SOBRA CHILD <1 M & F	482.75	-28.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		454.30		
4312	SOBRA CHILD 01-05 M	1,089.51	-183.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906.05		
4313	SOBRA CHILD 06-13 M	-301.38	0.00	-641.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-943.04		
4314	SOBRA CHILD 14-20 MA	0.00	676.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		676.60		
431B	SOBRA CHILD 01-05 M	0.00	-33.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-33.46		
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	-77.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-77.33		
SUBTOTAL:	2,277.37	972.51	-718.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,530.89		

4413	SOBRA 100-133% M&F
6	0.00	473.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	473.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
473.62

473.62

3,004.51

2,277.37	1,446.13	-718.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00

0.00

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

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	36,877.84	39,864.12	42,081.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,823.02		
1014	TANF 14-20 MALE NON-	0.00	166.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.11		
1015	TANF 14-20 FEMALE N O	0.00	249.17	219.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		469.08		
1017	TANF 21-44 FEMALE N
O	37,014.36	1,152.57	6,630.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,797.63		
2100	SSI AGED WITH MEDIC A	0.00	957.65	4,527.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,485.24		
2120	SSI AGED WITH QMB	1,493.14	4,206.47	1,649.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,348.89		
2200	SSI DISABLED WITH M E	12,359.84	10,710.56	13,285.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,355.72		
220Z	SSI DISABLED WITH M
E	0.00	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,574.76		
2210	SSI DISABLED NON-ME D	193,855.87	191,768.29	188,680.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		574,304.32		
221Z	SSI DISABLED NON-ME
D	2,237.23	2,574.76	398.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,210.16		
2220	SSI DISABLED WITH Q M	91,009.08	94,482.21	78,859.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		264,350.95		
2310	SSI BLIND NON-MEDIC
A	1,649.28	1,649.28	1,649.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,947.84		
4315	SOBRA CHILD 14-20 FE	0.00	1,411.97	96.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,508.30		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	85.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.83		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	1,649.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,649.28		
5010	SOBRA PREGNANT WO
MAN	4,224.04	4,224.04	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,022.84		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	1,201.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,201.55		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	5,149.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,149.52		
SUBTOTAL:	380,720.68	355,991.96	348,738.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,085,451.04		

3510	ADULT 40-100% FOR FI	39,398.90	45,272.22	42,697.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	3,232.94	4,069.78	-769.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	3,286.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	0.00	581.40	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	1,827.25	1,154.50	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	85.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

127,368.58	
6,533.06	
3,286.68	
581.40	
2,981.75	
85.83	

1100	TANF EXPANDED FPR FI	5,873.32	4,224.04	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR
FI	17,151.54	15,502.26	11,278.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	-2,203.50	0.00	1,117.25	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	319.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	1,493.14	4,791.70	4,791.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	1,276.86	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	6,642.66	6,642.66	6,642.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	-962.49	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	25,031.96	28,174.38	28,631.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	54,303.49	59,335.04	55,354.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,672.12	
43,932.02	
-1,086.25	
319.22	
11,076.54	
1,276.86	
19,927.98	
-962.49	
81,837.42	
168,993.42	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
370H	ADULT <40% EXP M&F 4	0.00	1,495.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,495.02		
3710	AHC CARE EXPANDED
FO	177,292.68	182,956.16	174,306.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		534,555.24		
3716	ADULT <40% EXP MALE	24,035.00	8,914.24	19,170.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,119.40		
3717	ADULT <40% EXP FEMA L	1,340.71	12,707.58	1,012.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,060.95		
3718	ADULT <40% EXP M&F
4	12,179.55	166.11	30,343.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,689.07		
371D	ADULT <40% EXP MALE	83.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.06		
371E	ADULT <40% EXP FEMA L	0.00	0.00	429.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		429.13		
371F	ADULT <40% EXP MALE	1,869.87	0.00	649.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,518.90		
371G	ADULT <40% EXP FEMA L	3,146.98	0.00	4,205.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,352.42		
371H	ADULT <40% EXP M&F
4	561.88	638.43	8,153.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,353.72		
SUBTOTAL:	263,141.57	258,628.19	284,724.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		806,494.21		

3910	NEWLY ELIGIBLE FOR F	16,740.02	18,233.16	20,807.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA
L	1,802.33	2,574.76	-686.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	1,396.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	19,939.16	20,807.92	20,121.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
55,781.10	
3,690.49	
1,396.81	
60,868.40	

4415

SOBRA 100-133% FEMA L

85.83

85.83

85.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
85.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

2,121,892.90

718,190.73	694,763.11	708,939.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending September 30, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1017	TANF 21-44 FEMALE N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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		
220Z	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		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO
MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

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	
351D	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
370H	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		
3710	AHC CARE EXPANDED
FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
371E	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

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:

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

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1015	TANF 14-20 FEMALE N O	0.00	0.00	-61.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-61.50		
1016	TANF 21-44 MALE NON-	648.42	1,662.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,310.58		
1017	TANF 21-44 FEMALE N O	2,472.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,472.80		
1018	TANF 45-64 M & F NON	0.00	491.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		491.43		
101E	TANF 14-20 FEMALE N O	0.00	0.00	-9.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-9.46		
2100	SSI AGED WITH MEDIC
A	2,843.08	3,808.62	392.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,044.33		
210Z	SSI AGED WITH MEDIC A	0.00	0.00	284.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284.79		
2110	SSI AGED NON-MEDICA
R	0.00	766.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		766.43		
2120	SSI AGED WITH QMB	1,440.73	0.00	1,344.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,785.53		
2200	SSI DISABLED WITH M E	2,260.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,260.80		
2210	SSI DISABLED NON-ME
D	3,736.31	3,460.72	1,131.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,328.89		
2220	SSI DISABLED WITH Q M	916.89	0.00	334.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,251.09		
4312	SOBRA CHILD 01-05 M	-634.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-634.77		
4314	SOBRA CHILD 14-20 MA	265.73	261.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		527.37		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
501E	SOBRA PREG 14-20 FE
M	0.00	0.00	-11.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-11.45		
SUBTOTAL:	13,949.99	10,451.00	3,405.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,806.86		

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	634.77	1,168.45	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	-517.32	1,481.13	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	398.60	195.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	0.00	1,693.00	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	8,364.36	1,438.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	2,870.03	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	2,310.38	3,764.52	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	-23.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA L	40.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,078.62	9,741.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
1,803.22	
963.81	
594.26	
1,693.00	
9,803.31	
2,870.03	
6,074.90	
-23.14	
40.94	
23,820.33	

1116	TANF EXPANDED 21-44	1,271.64	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	1,468.42	846.36	79.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	846.36	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	70.53	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	846.36	398.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	282.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,868.54	1,763.25	478.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,271.64	
2,394.50	
846.36	
70.53	
1,244.96	
282.12	
6,110.11	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3916	NEWLY ELIGIBLE MALE	846.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		846.36		
3918	NEWLY ELIGIBLE M&F 4	1,397.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,397.55		
SUBTOTAL:	2,243.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,243.91		

59,981.21

34,141.06	21,955.96	3,884.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
2100	SSI AGED WITH MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
210Z	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
501E	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA 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	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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

 
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		
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		
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		

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	453,274.51	475,300.18	494,051.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,422,625.99		
1011	TANF <1 M & F NON-ME	18,250.52	22,539.27	32,615.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,404.89		
1012	TANF 01-05 M & F NON	1,830.78	-799.39	7,686.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,717.57		
1013	TANF 06-13 M & F NON	2,624.03	9,884.36	17,196.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,704.48		
1014	TANF 14-20 MALE NON-	1,158.73	2,879.58	5,007.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,046.19		
1015	TANF 14-20 FEMALE N O	3,215.93	3,304.16	4,542.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,062.13		
101B	TANF 01-05 M & F NON	0.00	-1,017.84	441.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-576.78		
101C	TANF 06-13 M & F NON	9,263.82	0.00	33.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,297.75		
101D	TANF 14-20 MALE NON-	101.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101.78		
2210	SSI DISABLED NON-ME D	408,654.27	424,352.66	423,589.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,256,596.25		
221Z	SSI DISABLED NON-ME
D	-2,347.06	-560.34	-667.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,575.07		
2220	SSI DISABLED WITH Q M	1,835.82	817.98	654.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,308.18		
2310	SSI BLIND NON-MEDIC
A	817.98	817.98	1,417.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,053.79		
4310	SOBRA CHILD NON-ME DI	11,486,063.32	11,314,030.73	11,474,882.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,274,976.68		
4311	SOBRA CHILD <1 M & F	39,388.90	49,308.13	69,495.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,192.89		
4312	SOBRA CHILD 01-05 M	-77,519.72	24,412.60	-11,511.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-64,618.18		
4313	SOBRA CHILD 06-13 M	-99,853.49	28,110.86	-44,630.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-116,373.56		
4314	SOBRA CHILD 14-20 MA	-29,493.13	2,805.33	-32,320.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-59,008.08		
4315	SOBRA CHILD 14-20 FE	-18,582.82	5,555.02	-24,766.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-37,794.26		
431A	SOBRA CHILD < 1 M &	4,160.74	7,257.75	1,436.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,854.90		
431B	SOBRA CHILD 01-05 M	16,416.41	14,807.75	2,042.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,266.49		
431C	SOBRA CHILD 6-13 M&F	16,098.60	30,558.45	10,758.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,415.97		
431D	SOBRA CHILD 14-20 MA	1,389.83	2,961.87	3,442.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,794.54		
431E	SOBRA CHILD 14-20 FE	5,207.63	3,738.27	4,760.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,706.22		
5010	SOBRA PREGNANT WO MAN	5,714.89	6,932.59	9,586.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,233.87		
5015	SOBRA PREG 14-20 FE
M	0.00	-168.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-168.22		
SUBTOTAL:	12,247,672.27	12,427,829.73	12,449,744.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,125,246.41		

3710	AHC CARE EXPANDED FO	1,635.96	2,653.80	2,653.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	361.17	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	527.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,524.86	2,653.80	2,653.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,943.56	
361.17	
527.73	
7,832.46	

3910	NEWLY ELIGIBLE FOR F	817.98	817.98	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	817.98	817.98	817.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,453.94

2,453.94

65,290.85

4410	SOBRA 100-133% FOR F	22,851.99	22,237.27	20,201.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	1,710.46	6,970.68	8,115.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,796.54

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4414	SOBRA 100-133% MALE	2,248.94	330.73	163.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,743.27		
4415	SOBRA 100-133% FEMA L	2,101.36	395.80	3,223.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,720.49		
SUBTOTAL:	28,912.75	29,934.48	31,703.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,551.15		

37,226,083.96

12,279,927.86	12,461,235.99	12,484,920.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending September 30, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

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	
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

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	

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		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		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		

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	2,166.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,166.09		
2100	SSI AGED WITH MEDIC A	1,727.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,727.48		
2120	SSI AGED WITH QMB	2,197.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,197.06		
2200	SSI DISABLED WITH M E	901.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901.10		
2210	SSI DISABLED NON-ME
D	12,535.37	11,751.46	-1,110.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,176.57		
2220	SSI DISABLED WITH Q M	14,885.23	4,308.04	-1,064.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,128.57		
SUBTOTAL:	32,246.24	18,225.59	-2,174.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,296.87		

48,296.87

32,246.24	18,225.59	-2,174.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending September 30, 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	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		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	11.58	11.58	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.74		
1004	TANF 14-20 MALE WITH	2.74	2.74	2.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.22		
1005	TANF 14-20 FEMALE WI	8.79	8.79	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.37		
1006	TANF 21-44 MALE WITH	757.08	843.75	873.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,474.55		
1007	TANF 21-44 FEMALE WI	1,148.91	1,198.02	1,236.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,583.29		
1008	TANF 45-64 M & F WIT	2,224.32	2,273.07	2,170.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,668.22		
1009	TANF 65+ M & F WITH	1,453.62	1,368.54	1,396.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,219.05		
1010	TANF NON-MEDICARE	1,513.89	1,522.87	1,530.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,567.30		
1011	TANF <1 M & F NON-ME	17,524.33	17,720.42	17,977.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,222.72		
1012	TANF 01-05 M & F NON	41,559.69	43,158.68	44,335.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129,053.79		
1013	TANF 06-13 M & F NON	74,475.95	76,508.88	77,270.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228,255.06		
1014	TANF 14-20 MALE NON-	46,352.86	48,408.65	49,479.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,241.08		
1015	TANF 14-20 FEMALE N O	70,065.73	72,493.21	73,478.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		216,037.67		
1016	TANF 21-44 MALE NON-	286,728.72	289,833.36	290,380.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		866,942.91		
1017	TANF 21-44 FEMALE N O	943,158.63	956,021.67	959,043.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,858,223.45		
1018	TANF 45-64 M & F NON	237,180.33	239,933.91	240,275.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		717,389.85		
1019	TANF 65+ M & F NON-M	1,090.95	1,132.92	1,164.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,387.96		
1020	TANF WITH QMB	20.37	11.58	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.53		
1023	TANF 06-13 M & F WIT	2.74	2.74	2.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.22		
1024	TANF 14-20 MALE WITH	21.73	21.73	21.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65.19		
1025	TANF 14-20 FEMALE WI	17.58	8.79	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.16		
1026	TANF 21-44 MALE WITH	631.98	645.60	602.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,880.43		
1027	TANF 21-44 FEMALE WI	1,027.86	1,126.14	944.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,098.79		
1028	TANF 45-64 M & F WIT	1,226.46	1,331.52	1,340.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,898.26		
1029	TANF 65+ M & F WITH	616.38	634.38	648.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,899.51		
2100	SSI AGED WITH MEDIC A	139,858.53	136,666.14	134,835.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		411,360.27		
2110	SSI AGED NON-MEDICA
R	74,282.82	75,317.04	76,215.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225,814.98		
2120	SSI AGED WITH QMB	416,017.41	415,855.20	415,228.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,247,101.44		
2200	SSI DISABLED WITH M E	71,832.38	70,573.94	70,227.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		212,634.30		
2210	SSI DISABLED NON-ME
D	497,259.09	495,818.97	492,339.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,485,417.46		
2220	SSI DISABLED WITH Q M	283,547.52	281,536.17	278,255.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		843,338.89		
2300	SSI BLIND WITH MEDIC	317.64	317.64	342.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		978.09		
2310	SSI BLIND NON-MEDIC A	4,496.64	4,475.79	4,448.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,421.18		
2320	SSI BLIND WITH QMB	2,450.94	2,426.58	2,425.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,302.90		
4301	SOBRA CHILD <1 M & F	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.36		
4302	SOBRA CHILD 01-05 M	1.36	20.48	15.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.86		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4303	SOBRA CHILD 06-13 M	10.96	17.80	21.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.66		
4304	SOBRA CHILD 14-20 MA	12.89	12.89	2.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.52		
4305	SOBRA CHILD 14-20 FE	0.00	2.74	2.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.48		
4311	SOBRA CHILD <1 M & F	58,975.04	58,415.61	57,470.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,861.20		
4312	SOBRA CHILD 01-05 M	307,647.78	304,938.59	300,146.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		912,732.84		
4313	SOBRA CHILD 06-13 M	405,453.91	405,350.44	406,969.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,217,773.67		
4314	SOBRA CHILD 14-20 MA	207,687.12	208,433.72	210,759.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		626,880.80		
4315	SOBRA CHILD 14-20 FE	211,543.83	211,355.20	213,105.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		636,004.13		
4322	SOBRA CHILD 01-05 M	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.36		
4323	SOBRA CHILD 06-13 M	2.72	5.46	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.54		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	2.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.74		
4325	SOBRA CHILD 14-20 FE	25.85	27.32	27.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80.54		
5007	SOBRA PREG 21-44 FE M	258.87	206.55	285.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		750.66		
5013	SOBRA PREG 09-13 FE
M	4.19	4.30	7.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.62		
5015	SOBRA PREG 14-20 FE M	21,816.24	21,160.69	20,683.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,660.21		
5017	SOBRA PREG 21-44 FE
M	146,781.51	143,113.98	140,512.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		430,408.08		
5018	SOBRA PREG 45-64 FE M	448.26	457.05	453.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,359.15		
5027	SOBRA PREG 21-44 FE
M	256.44	261.24	269.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		786.93		
5028	SOBRA PREG 45-64 FE M	17.58	17.58	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.95		
SUBTOTAL:	4,579,833.46	4,593,012.65	4,589,283.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,762,129.13		

1106	TANF EXPANDED 21-44	1,918.77	1,893.18	1,907.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	3,377.31	3,341.73	3,319.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	11,446.20	11,053.53	11,050.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	7,541.79	7,709.91	7,839.36	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	1.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	8.29	8.29	8.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	2,137.89	2,183.40	2,235.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	12,100.24	12,228.97	12,617.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	238,739.25	239,613.36	244,305.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	652,361.52	652,619.94	661,786.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	233,628.21	233,769.60	238,621.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	980.31	989.88	1,018.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	5,821.38	5,855.67	5,901.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,719.92	
10,038.81	
33,550.02	
23,091.06	
1.36	
24.87	
6,556.70	
36,946.41	
722,658.12	
1,966,768.23	
706,019.58	
2,988.42	
17,578.62	

3100	TRANSPLANT OPTION 1	4.80	4.80	4.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.80	4.80	4.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14.40

14.40

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1127	TANF EXPANDED 21-44	12,463.98	12,483.15	12,462.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,409.46		
1128	TANF EXPANDED 45-64	23,018.61	23,227.65	23,438.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,684.78		
1129	TANF EXPANDED 65+ M
&	17,478.51	17,895.84	17,964.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,339.34		
2400	SSI AGED EXPANDED WI	2,198.04	2,297.10	2,639.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,134.63		
2410	SSI AGED EXPANDED N
O	1,276.38	1,223.25	1,174.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,673.71		
2420	SSI AGED EXPANDED WI	256,763.58	258,599.97	258,992.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		774,355.98		
2520	SSI BLIND EXPANDED
W	17.58	17.58	17.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.74		
2600	SSI DISABLED EXPAND E	2,905.74	2,863.05	2,777.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,545.98		
2610	SSI DISABLED EXPAND
E	13,819.14	13,633.71	13,254.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,707.06		
2620	SSI DISABLED EXPAND E	117,410.01	117,451.02	116,914.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		351,775.89		
SUBTOTAL:	1,617,412.73	1,620,959.78	1,640,249.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,878,621.69		

3506	ADULT 40-100% MALE 2	128.22	156.18	179.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	97.86	106.65	118.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	1,464.54	1,549.23	1,479.69	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	817.35	817.77	953.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	54,266.13	54,149.88	55,767.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	57,788.40	58,097.64	59,011.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	190,807.23	193,389.66	201,672.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	161,763.39	164,704.53	170,290.17	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	348,455.88	349,581.45	355,411.68	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	54.33	71.91	59.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	31.95	20.37	20.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	4.80	4.80	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	88.29	94.29	121.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	22.38	38.76	42.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	463.80	463.80	494.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	141.84	170.19	158.61	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	2,051.13	1,982.01	2,190.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	298.02	381.51	410.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	108,326.43	110,574.72	112,551.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	99,812.34	101,661.24	105,264.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	766,708.20	777,017.58	784,759.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	440,857.62	446,998.32	450,916.14	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	832,800.54	837,141.78	838,672.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	52.74	55.53	35.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
464.16	
322.74	
4,493.46	
2,588.34	
164,183.40	
174,897.48	
585,869.07	
496,758.09	
1,053,449.01	
185.37	
72.69	
9.60	
304.02	
103.89	
1,422.57	
470.64	
6,224.04	
1,090.20	
331,452.30	
306,738.15	
2,328,485.43	
1,338,772.08	
2,508,614.61	
143.43	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3726	ADULT <40% EXP MALE	49.53	83.49	83.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		216.51		
3727	ADULT <40% EXP FEMA L	42.75	51.54	63.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157.41		
3728	ADULT <40% EXP M&F
4	266.07	384.72	335.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		985.98		
3729	ADULT <40% EXP M&F 6	0.00	0.00	25.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.17		
SUBTOTAL:	3,067,661.76	3,099,749.55	3,141,088.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,308,499.84		

4403	SOBRA 100-133% M&F
6	2.74	2.74	4.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4404	SOBRA 100-133% MALE	1.47	1.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	4.10	2.74	2.74	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	70,892.26	72,680.86	72,786.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	39,394.30	40,593.60	40,749.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	38,473.55	39,585.94	39,796.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	2.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	148,768.42	152,867.35	153,341.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9.58	
2.94	
9.58	
216,359.70	
120,737.48	
117,855.54	
2.83	
454,977.65	

4517	BC PATIENT FEMALE 2 1	201.75	187.38	169.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	1,239.21	1,256.79	1,185.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	8.79	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	31.17	26.37	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	90.27	90.27	69.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

558.93	
3,681.69	
8.79	
66.33	
250.44	

3904	NEWLY ELIGIBLE MALE	17.58	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	0.00	11.58	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	308.43	407.49	404.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	217.29	258.84	306.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	6,100.62	7,267.92	7,950.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	3,880.74	4,506.75	5,665.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	41,282.46	44,557.26	46,498.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	44,199.27	48,133.23	49,325.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	205,392.54	220,855.68	227,190.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	285,434.55	305,256.90	315,653.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	280,711.11	293,736.39	298,421.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	288.48	369.18	439.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	8.79	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	11.58	11.58	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	171.78	152.22	97.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	160.17	202.92	258.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	868,176.60	925,745.52	952,242.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
26.37	
23.16	
1,120.20	
782.52	
21,319.29	
14,052.69	
132,338.28	
141,657.54	
653,438.52	
906,345.42	
872,869.02	
1,096.74	
17.58	
34.74	
421.08	
621.15	
2,746,164.30	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1,562.40	1,569.60	1,434.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,566.18		

8600	SSI BLIND FREEDOM/W O	8.79	8.79	8.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W
O	11.58	11.58	11.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	15,056.52	15,040.95	14,679.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	3,013.47	2,912.82	2,885.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	2,895.96	3,057.36	3,030.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,986.32	21,031.50	20,615.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
26.37	
34.74	
44,776.83	
8,811.51	
8,983.89	
62,633.34	

31,217,606.53

10,304,406.49	10,414,940.75	10,498,259.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending September 30, 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		
1005	TANF 14-20 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		
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	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
1023	TANF 06-13 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		
1024	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1025	TANF 14-20 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		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5027	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	

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

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

 
0.00

0.00

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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 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		
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		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	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	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA 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	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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 FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

4403	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	
4404	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	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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	
4519	BC PATIENT FEMALE 6 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	

0.00	
0.00	
0.00	
0.00	
0.00	

3904	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	
3905	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	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	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	
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	
0.00	
0.00	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending September 30, 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		

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	

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

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	7,405.58	2,128.10	4,844.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,378.12		
1007	TANF 21-44 FEMALE WI	2,399.61	2,476.68	1,470.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,346.74		
1008	TANF 45-64 M & F WIT	16,050.19	2,693.87	9,242.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,986.28		
1009	TANF 65+ M & F WITH	3,934.85	3,443.16	8,365.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,743.72		
1011	TANF <1 M & F NON-ME	1,143,390.86	675,922.36	1,386,768.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,206,081.46		
1012	TANF 01-05 M & F NON	302,488.54	183,924.52	319,614.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		806,027.39		
1013	TANF 06-13 M & F NON	442,447.04	357,697.74	470,463.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,270,608.12		
1014	TANF 14-20 MALE NON-	179,326.07	115,950.93	147,569.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		442,846.55		
1015	TANF 14-20 FEMALE N O	403,238.79	280,105.48	400,421.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,083,765.85		
1016	TANF 21-44 MALE NON-	2,144,392.81	1,992,851.99	2,588,930.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,726,175.07		
1017	TANF 21-44 FEMALE N O	8,152,997.95	6,589,523.27	7,909,860.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,652,382.14		
1018	TANF 45-64 M & F NON	3,859,402.03	2,843,221.69	3,858,062.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,560,686.66		
1019	TANF 65+ M & F NON-M	17,787.96	12,713.74	17,492.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,994.32		
1026	TANF 21-44 MALE WITH	958.00	0.00	8,171.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,129.26		
1027	TANF 21-44 FEMALE WI	3.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.40		
1028	TANF 45-64 M & F WIT	16,080.90	3,050.13	15,165.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,296.37		
1029	TANF 65+ M & F WITH	3,044.78	2,956.97	2,415.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,417.01		
2100	SSI AGED WITH MEDIC A	194,486.50	175,951.46	235,250.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		605,688.37		
2110	SSI AGED NON-MEDICA
R	391,217.59	195,742.50	293,734.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		880,694.23		
2120	SSI AGED WITH QMB	766,999.79	502,596.08	788,594.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,058,190.10		
2200	SSI DISABLED WITH M E	607,153.39	552,267.62	628,213.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,787,634.49		
2210	SSI DISABLED NON-ME
D	12,335,676.27	9,169,869.59	11,995,340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,500,885.86		
2220	SSI DISABLED WITH Q M	1,793,601.32	1,226,778.38	1,898,431.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,918,810.86		
2300	SSI BLIND WITH MEDIC	1,608.24	673.68	2,512.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,794.75		
2310	SSI BLIND NON-MEDIC A	152,422.10	93,321.49	149,231.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394,974.67		
2320	SSI BLIND WITH QMB	25,634.25	24,559.95	37,139.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87,334.19		
4311	SOBRA CHILD <1 M & F	3,286,484.12	2,149,405.66	2,096,933.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,532,823.15		
4312	SOBRA CHILD 01-05 M	2,764,300.30	2,373,818.71	2,958,098.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,096,217.80		
4313	SOBRA CHILD 06-13 M	4,369,679.47	3,524,628.76	4,931,798.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,826,106.43		
4314	SOBRA CHILD 14-20 MA	1,698,812.85	1,177,270.58	2,438,408.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,314,491.54		
4315	SOBRA CHILD 14-20 FE	1,981,745.20	1,686,206.40	2,062,842.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,730,793.70		
5007	SOBRA PREG 21-44 FE M	0.00	-869.63	1,227.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		358.30		
5013	SOBRA PREG 09-13 FE
M	479.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,437.00		
5015	SOBRA PREG 14-20 FE M	280,143.25	255,035.69	321,386.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		856,565.85		
5017	SOBRA PREG 21-44 FE
M	2,120,937.76	1,696,357.50	2,481,926.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,299,221.89		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	131.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131.02		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	85.40	0.00	5.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.56		
SUBTOTAL:	49,466,816.16	37,873,233.05	50,470,064.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,810,113.22		

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

0.00

1106	TANF EXPANDED 21-44	10,719.07	2,754.62	10,524.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	12,744.48	5,787.56	7,452.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	49,184.51	37,567.63	57,495.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	38,767.41	35,261.90	71,251.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	479.00	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	19,707.00	9,009.57	2,634.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	40,100.87	45,046.73	70,200.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	1,342,640.50	868,768.35	1,166,372.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	3,394,282.21	2,701,352.12	3,657,911.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	2,537,025.98	1,797,460.96	2,218,353.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	17,517.32	15,998.57	7,155.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	13,901.46	16,461.71	14,904.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	65,453.82	39,775.55	141,091.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	132,467.26	83,131.59	137,301.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	87,910.22	56,540.60	100,676.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	20,666.39	20,877.98	22,604.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	35,531.79	27,537.55	21,296.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	728,155.76	456,967.26	757,729.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	11,068.56	11,417.78	17,322.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	325,985.77	103,184.75	130,458.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	453,609.45	306,446.97	571,061.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,337,918.83	6,641,349.75	9,183,800.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
23,998.20	
25,984.95	
144,248.06	
145,280.79	
479.00	
31,351.35	
155,348.28	
3,377,781.69	
9,753,545.36	
6,552,840.20	
40,671.54	
45,267.57	
246,321.22	
352,900.12	
245,126.85	
64,148.45	
84,366.19	
1,942,852.99	
39,808.84	
559,629.26	
1,331,117.93	
25,163,068.84	

3508	ADULT 40-100% M&F 45	12,572.79	16,545.52	7,419.92	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	1,081.04	1,067.08	2,528.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	66,723.94	84,453.67	67,988.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	124,622.95	144,039.95	128,224.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	1,280,577.50	1,060,819.12	1,527,306.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	942,928.75	737,836.39	1,241,710.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	3,600,449.04	2,689,959.88	3,570,086.53	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	1,122.48	807.96	2,756.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	5.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
36,538.23	
4,676.63	
219,166.58	
396,887.50	
3,868,703.38	
2,922,475.39	
9,860,495.45	
4,687.39	
5.16	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3528	ADULT 40-100% M&F 45	2,862.31	13,617.53	3,327.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,807.05		
3706	ADULT <40% EXP MALE	862.07	537.53	4,219.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,619.03		
3707	ADULT <40% EXP FEMA L	5,201.56	3,370.01	606.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,178.33		
3708	ADULT <40% EXP M&F
4	7,945.68	7,604.64	52,277.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,828.21		
3709	ADULT <40% EXP M&F 6	697.97	500.67	84.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,283.62		
3714	ADULT <40% EXP MALE	549,983.14	425,687.45	439,852.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,415,523.16		
3715	ADULT <40% EXP FEMA L	476,422.20	362,759.11	530,706.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,369,887.98		
3716	ADULT <40% EXP MALE	13,663,876.43	10,989,796.96	15,694,862.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,348,535.46		
3717	ADULT <40% EXP FEMA L	6,400,827.19	5,817,880.47	7,144,686.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,363,393.90		
3718	ADULT <40% EXP M&F
4	16,215,570.02	12,524,194.77	18,122,144.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,861,909.73		
3719	ADULT <40% EXP M&F 6	3,519.78	106,471.32	2,050.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,041.53		
3726	ADULT <40% EXP MALE	455.00	479.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,892.00		
3727	ADULT <40% EXP FEMA L	936.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		936.72		
3728	ADULT <40% EXP M&F
4	552.34	8,792.98	26,960.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,306.29		
SUBTOTAL:	43,359,796.06	34,997,222.01	48,570,760.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,927,778.72		

3908	NEWLY ELIGIBLE M&F 4	13,732.61	19,160.95	23,373.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	7,583.37	2,846.17	8,882.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	54,617.76	57,176.78	62,252.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	58,564.32	46,277.33	135,450.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	995,607.08	676,745.41	807,264.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	1,186,770.89	868,904.91	1,059,189.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	2,193,038.61	1,740,974.41	2,596,485.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	479.00	1,090.56	4,214.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	546.44	1,074.65	1,291.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	239.25	0.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,511,179.33	3,414,251.17	4,698,882.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
56,267.01	
19,311.92	
174,046.54	
240,292.19	
2,479,616.82	
3,114,865.15	
6,530,498.18	
5,784.02	
2,912.46	
718.25	
12,624,312.54	

4413	SOBRA 100-133% M&F
6	350,048.99	246,594.45	388,953.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	141,121.62	102,127.86	115,367.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	142,896.34	135,750.04	159,966.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	634,066.95	484,472.35	664,288.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
985,596.74	
358,617.42	
438,613.29	
1,782,827.45	

4517	BC PATIENT FEMALE 2 1	479.00	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	10,039.34	2,607.82	19,699.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,518.34	2,607.82	19,699.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
479.00	
32,346.27	
32,825.27	

8700

SSI DISABLED FREEDO M

26,937.59

15,130.22

30,464.05

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

72,531.86

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	31,044.49	14,723.13	13,850.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,618.44		
8720	SSI DISABLED FREEDO
M	26,216.72	21,512.86	21,777.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,507.55		
SUBTOTAL:	84,198.80	51,366.21	66,092.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,657.85		

0.00

113,673,538.97

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

304,542,583.89

S000	STATE-ONLY BHS	6,610.59	-6,562.50	-48.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,610.59	-6,562.50	-48.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

TOTAL:

107,411,105.06

83,457,939.86

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	1,711.66	125.58	1,544.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,381.86		
1012	TANF 01-05 M & F NON	647.22	136.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		783.81		
1013	TANF 06-13 M & F NON	1,255.10	0.00	9,406.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,661.39		
1014	TANF 14-20 MALE NON-	553.23	273.18	3,498.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,325.19		
1015	TANF 14-20 FEMALE N O	2,538.69	2,147.84	4,602.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,288.77		
1017	TANF 21-44 FEMALE N
O	31,834.14	12,820.33	6,592.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,246.58		
2100	SSI AGED WITH MEDIC A	0.00	0.00	-62.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-62.02		
2200	SSI DISABLED WITH M
E	-27.62	0.00	1,200.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,172.42		
2210	SSI DISABLED NON-ME D	0.00	0.00	48.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.84		
4311	SOBRA CHILD <1 M & F	60,059.97	30,560.13	36,385.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,005.14		
4312	SOBRA CHILD 01-05 M	96,645.58	29,504.41	14,980.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,130.13		
4313	SOBRA CHILD 06-13 M	28,540.89	41,368.11	21,037.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,946.74		
4314	SOBRA CHILD 14-20 MA	15,316.91	13,767.28	31,611.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,695.77		
4315	SOBRA CHILD 14-20 FE	35,626.01	10,194.98	22,640.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,461.88		
5007	SOBRA PREG 21-44 FE M	27.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.91		
5015	SOBRA PREG 14-20 FE
M	20,756.69	11,700.05	20,494.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,951.22		
5017	SOBRA PREG 21-44 FE M	118,243.42	110,937.05	85,990.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315,170.57		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	874.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		874.93		
SUBTOTAL:	413,729.80	263,535.53	260,845.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		938,111.13		

3516	ADULT 40-100% MALE 2	0.00	0.00	-670.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	-660.75	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	-639.78	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	-344.99	-373.46	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	10,613.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	-46.12	0.00	-3,311.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	-2,602.28	-551.73	-192.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,319.15	-925.19	-4,174.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-670.80	
-660.75	
-639.78	
-718.45	
10,613.07	
-3,357.29	
-3,346.06	
1,219.94	

3917	NEWLY ELIGIBLE FEMA L	-7.47	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	236.25	-302.72	-429.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	228.78	-302.72	-429.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-7.47	
-495.49	
-502.96	

1108	TANF EXPANDED 45-64	33.48	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	-112.02	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	-21.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-100.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
33.48	
-112.02	
-21.60	
-100.14	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4413	SOBRA 100-133% M&F
6	3,690.96	1,766.09	4,790.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,247.12		
4414	SOBRA 100-133% MALE	103,321.39	13,115.92	6,531.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,968.65		
4415	SOBRA 100-133% FEMA L	5,061.43	1,478.57	480.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,020.90		
SUBTOTAL:	112,073.78	16,360.58	11,802.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,236.67		

TOTAL:	532,251.37	278,668.20	268,045.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,078,964.64		

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	325.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		325.44		
1012	TANF 01-05 M & F NON	29,766.61	5,058.03	27,650.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,474.88		
1013	TANF 06-13 M & F NON	48,909.26	269,034.29	84,803.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		402,746.75		
1014	TANF 14-20 MALE NON-	142,120.31	36,400.94	76,985.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,506.52		
1015	TANF 14-20 FEMALE N O	193,775.73	243,632.31	169,948.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		607,356.24		
1016	TANF 21-44 MALE NON-	398.83	20.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		419.11		
1017	TANF 21-44 FEMALE N O	1,503,087.87	1,418,081.95	1,807,767.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,728,937.64		
1018	TANF 45-64 M & F NON	14,122.04	726.72	4,499.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,348.50		
2100	SSI AGED WITH MEDIC A	27,107.23	11,301.18	14,673.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,081.49		
2110	SSI AGED NON-MEDICA
R	1,748,492.75	1,469,447.90	1,954,407.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,172,348.63		
2200	SSI DISABLED WITH M E	7,695.04	2,242.16	2,186.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,123.24		
2210	SSI DISABLED NON-ME
D	43,003.05	25,262.16	37,324.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105,589.48		
2220	SSI DISABLED WITH Q M	0.00	872.61	829.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,702.06		
SUBTOTAL:	3,758,804.16	3,482,080.53	4,181,075.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,421,959.98		

3906	NEWLY ELIGIBLE MALE	27.16	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	8,546.19	2,165.29	6,833.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	48,771.41	26,843.13	38,162.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	30,491.91	32,512.18	81,659.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,461,404.61	1,248,551.93	1,628,465.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	582,367.45	380,259.32	676,716.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

27.16	
17,545.00	
113,777.07	
144,663.10	
4,338,421.68	
1,639,343.26	

1107	TANF EXPANDED 21-44	4,466.01	104.64	3,762.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	959.42	257.18	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
&	45.44	0.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	1,467.16	57.65	2,619.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	16,920.86	8,954.44	9,776.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	860,479.90	660,307.93	1,291,967.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,774,441.54	1,385,439.56	1,701,591.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,239,813.06	1,145,727.11	1,532,374.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	17,553.31	27,593.94	23,073.73	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	78.04	71.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	292.93	0.00	2,765.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	21,114.87	136.59	-67.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,553.46	624.96	2,507.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	3.37	481.07	116.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,940,111.33	3,229,763.11	4,570,582.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
8,332.94	
1,216.60	
69.44	
4,143.96	
35,651.55	
2,812,755.68	
4,861,473.03	
3,917,914.80	
68,220.98	
149.32	
3,058.84	
21,183.90	
5,685.62	
600.51	
11,740,457.17	

FEDERAL EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3918	NEWLY ELIGIBLE M&F 4	3,858,610.94	3,761,991.85	5,859,045.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,479,648.55		
3919	NEWLY ELIGIBLE M&F
6	6,763.68	14,681.00	18,917.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,362.36		
SUBTOTAL:	5,996,983.35	5,467,004.70	8,309,800.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,773,788.18		

42,936,205.33

13,695,898.84	12,178,848.34	17,061,458.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	559,092.27	366,469.82	563,076.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,488,639.01		
8040	SLMB	859.02	384.95	416.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,660.43		
8050	QI1	223.92	1.85	76.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302.09		
SUBTOTAL:	560,175.21	366,856.62	563,569.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,490,601.53		

TOTAL:	560,175.21	366,856.62	563,569.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,490,601.53		

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	45.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.61		
1011	TANF <1 M & F NON-ME	2,229.05	682.70	1,916.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,827.75		
1012	TANF 01-05 M & F NON	6,130.49	6,317.48	6,021.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,469.39		
1013	TANF 06-13 M & F NON	185,370.72	142,831.84	95,609.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		423,812.35		
1014	TANF 14-20 MALE NON-	61,620.57	53,913.40	60,192.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,726.09		
1015	TANF 14-20 FEMALE N O	117,992.97	113,226.00	123,239.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		354,458.57		
1016	TANF 21-44 MALE NON-	620,695.88	661,887.71	508,772.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,791,356.31		
1017	TANF 21-44 FEMALE N O	1,377,131.11	1,347,188.67	2,150,745.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,875,065.55		
1018	TANF 45-64 M & F NON	215,528.64	200,049.81	187,946.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		603,524.54		
1026	TANF 21-44 MALE WITH	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		479.00		
2100	SSI AGED WITH MEDIC A	7,356.70	7,970.44	32,587.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,914.97		
2110	SSI AGED NON-MEDICA
R	3,465.84	2,684.56	4,610.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,760.80		
2120	SSI AGED WITH QMB	32,438.17	3,015.69	22,662.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,115.98		
2200	SSI DISABLED WITH M E	30,039.85	40,301.42	111,308.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,650.00		
2210	SSI DISABLED NON-ME
D	1,255,916.44	1,615,532.63	1,623,080.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,494,529.30		
2220	SSI DISABLED WITH Q M	272,422.20	182,362.18	293,693.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		748,478.08		
2310	SSI BLIND NON-MEDIC
A	12,525.00	6,005.79	13,810.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,341.65		
2320	SSI BLIND WITH QMB	335.08	6,421.99	8,018.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,775.50		
4311	SOBRA CHILD <1 M & F	697.99	3,413.73	4,065.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,177.39		
4312	SOBRA CHILD 01-05 M	84,847.46	78,017.20	132,552.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295,417.35		
4313	SOBRA CHILD 06-13 M	1,946,261.69	1,711,753.70	2,141,655.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,799,671.35		
4314	SOBRA CHILD 14-20 MA	627,970.65	708,102.87	883,452.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,219,526.08		
4315	SOBRA CHILD 14-20 FE	998,234.53	914,646.46	1,087,806.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,000,687.05		
5015	SOBRA PREG 14-20 FE M	3,278.24	2,027.10	7,703.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,008.71		
5017	SOBRA PREG 21-44 FE
M	123,360.35	133,963.53	111,567.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368,891.16		
SUBTOTAL:	7,986,374.23	7,942,316.90	9,613,019.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,541,710.53		

1107	TANF EXPANDED 21-44	0.00	37.22	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	95.24	2,825.54	636.74	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	5.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	4,291.30	3,116.32	11,400.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	150,464.88	172,162.28	236,032.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	290,841.09	309,930.99	535,130.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	156,393.42	107,630.94	162,823.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	8,290.05	10,593.08	12,340.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	40,868.90	21,762.10	8,958.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
37.22	
3,557.52	
5.16	
18,808.52	
558,659.44	
1,135,902.19	
426,847.94	
31,224.01	
71,589.51	

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	12,122.71	8,778.37	12,439.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,340.24		
1129	TANF EXPANDED 65+ M
&	644.34	2,501.67	1,255.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,401.55		
2400	SSI AGED EXPANDED WI	442.80	442.80	680.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,566.40		
2420	SSI AGED EXPANDED
WI	30,641.77	21,083.87	28,740.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,466.63		
2600	SSI DISABLED EXPAND E	0.00	72.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.26		
2610	SSI DISABLED EXPAND
E	3,274.87	1,138.41	3,688.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,101.88		
2620	SSI DISABLED EXPAND E	46,298.74	30,206.09	48,063.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,568.30		
SUBTOTAL:	744,670.11	692,281.94	1,062,196.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,499,148.77		

3514	ADULT 40-100% MALE 1	10,038.11	6,591.57	4,422.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	13,080.63	10,050.94	17,242.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	96,278.29	154,314.73	183,904.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	82,978.62	104,713.12	117,691.46	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	82,924.60	99,666.40	146,397.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	502.62	1,172.78	1,507.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	479.00	141.70	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	182,327.26	275,741.34	189,987.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	101,639.99	70,417.91	193,855.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	3,114,052.74	2,947,900.92	3,890,571.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,884,961.31	1,472,686.76	1,991,630.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	1,853,706.77	1,593,328.65	1,898,477.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,422,969.94	6,736,726.82	8,635,690.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
21,052.60	
40,374.49	
434,497.88	
305,383.20	
328,988.75	
3,183.26	
620.70	
648,055.68	
365,913.59	
9,952,525.62	
5,349,278.46	
5,345,512.76	
22,795,386.99	

3908	NEWLY ELIGIBLE M&F 4	659.34	136.83	670.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	-399.88	11,204.19	1,404.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	3,139.31	6,363.67	17,446.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	105,054.12	122,406.42	121,054.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	37,204.00	38,075.01	39,222.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	37,918.72	28,319.56	78,701.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	183,575.61	206,505.68	258,500.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,466.26	
12,208.82	
26,949.57	
348,515.30	
114,501.53	
144,940.14	
648,581.62	

4413	SOBRA 100-133% M&F
6	74,321.05	52,735.46	98,524.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	12,411.47	19,114.63	238,232.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	47,307.68	21,577.80	26,753.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	134,040.20	93,427.89	363,510.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
225,581.09	
269,758.23	
95,639.31	
590,978.63	

1,719.40

8710	SSI DISABLED FREEDO M	665.04	1,054.36	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	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

479.00

FFS TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	665.04	1,054.36	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,198.40		

52,078,004.94

16,472,295.13	15,672,313.59	19,933,396.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	5,845.37	23,058.04	37,624.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,528.36		
1017	TANF 21-44 FEMALE N O	19,969.29	32,704.70	57,587.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,261.37		
1018	TANF 45-64 M & F NON	5,094.30	9,249.68	17,529.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,873.97		
2210	SSI DISABLED NON-ME D	91,974.79	90,886.53	231,219.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414,080.95		
2220	SSI DISABLED WITH Q
M	2,816.00	1,408.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,224.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	14,164.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,164.74		
5017	SOBRA PREG 21-44 FE
M	2,959.48	0.00	5,943.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,902.83		
SUBTOTAL:	128,659.23	157,306.95	364,070.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		650,036.22		

3516	ADULT 40-100% MALE 2	8,301.74	21,895.67	23,332.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	16,825.85	9,061.94	6,661.76	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	2,219.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	182,372.02	306,323.87	381,788.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	206,918.63	106,672.08	114,031.53	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	57,492.12	100,591.93	97,743.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	471,910.36	544,545.49	625,777.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

53,529.90	
32,549.55	
2,219.61	
870,484.83	
427,622.24	
255,827.55	
1,642,233.68	

3916	NEWLY ELIGIBLE MALE	24,443.39	35,034.19	27,447.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	7,625.11	11,472.38	16,210.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	5,620.87	7,119.57	10,689.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	37,689.37	53,626.14	54,347.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

86,924.87	
35,308.07	
23,429.80	
145,662.74	

1116	TANF EXPANDED 21-44	4,245.25	5,012.64	10,923.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	8,408.85	4,528.02	6,792.40	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	3,330.88	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	1,408.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	1,408.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,062.10	9,540.66	22,454.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
20,181.23	
19,729.27	
3,330.88	
1,408.00	
1,408.00	
46,057.38	

TOTAL:	652,321.06	765,019.24	1,066,649.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,483,990.02		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	57.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.36		
1018	TANF 45-64 M & F NON	70.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.08		
2100	SSI AGED WITH MEDIC A	162,739.34	14,576.78	123,537.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		300,853.30		
2110	SSI AGED NON-MEDICA
R	128,802.10	132,314.60	259,968.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		521,085.14		
2120	SSI AGED WITH QMB	8.25	0.00	9.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.96		
2200	SSI DISABLED WITH M E	33,272.30	45,153.97	25,391.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103,817.33		
2210	SSI DISABLED NON-ME
D	298.48	27,666.88	32,456.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,422.09		
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		
5017	SOBRA PREG 21-44 FE
M	3,450.13	10,314.26	4,557.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,322.24		
SUBTOTAL:	328,698.04	230,026.49	445,920.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,004,645.50		

3516	ADULT 40-100% MALE 2	57.36	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	3,276.00	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	12,993.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	443.29	182.28	8,880.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	268,736.40	447,744.68	385,725.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	13,631.48	7,784.46	7,427.66	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	335,740.99	493,846.09	581,492.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	634,879.50	949,557.51	983,525.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
57.36	
3,276.00	
12,993.98	
9,505.90	
1,102,206.62	
28,843.60	
1,411,079.16	
2,567,962.62	

3908	NEWLY ELIGIBLE M&F 4	0.00	11,510.95	57.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	14,264.86	7,961.78	39,603.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	15,907.04	18,011.41	84,999.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30,171.90	37,484.14	124,660.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,568.31	
61,829.74	
118,918.26	
192,316.31	

3,764,924.43

993,749.44	1,217,068.14	1,554,106.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2220	SSI DISABLED WITH Q M	89.00	0.00	1,436.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,525.15		
SUBTOTAL:	89.00	0.00	1,436.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,525.15		

3716	ADULT <40% EXP MALE	6,643.51	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	9,430.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,643.51	0.00	9,430.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,643.51	
9,430.37	
16,073.88	

TOTAL:	6,732.51	0.00	10,866.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,599.03		

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	0.00	851.94	148.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,000.17		
1016	TANF 21-44 MALE NON-	28.54	706.35	4,086.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,821.64		
2210	SSI DISABLED NON-ME D	6,614.01	2,282.64	2,170.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,067.64		
4314	SOBRA CHILD 14-20 MA	7,370.21	5,177.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,547.36		
5017	SOBRA PREG 21-44 FE M	3,299.45	4,460.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,759.79		
SUBTOTAL:	17,312.21	13,478.42	6,405.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,196.60		

1116	TANF EXPANDED 21-44	1,392.31	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	9,614.96	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	334.41	25.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,007.27	334.41	25.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,392.31	
9,614.96	
359.78	
11,367.05	

3517	ADULT 40-100% FEMAL E	0.00	809.64	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	395.91	126.53	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	56,420.34	29,457.86	35,324.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	9,273.72	5,855.95	12,921.66	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	13,533.03	18,766.81	6.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	79,227.09	55,286.17	48,379.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
809.64	
522.44	
0.00	
121,202.28	
28,051.33	
32,306.82	
182,892.51	

3916	NEWLY ELIGIBLE MALE	6,096.69	363.74	27,112.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,096.69	363.74	27,112.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
33,573.17

33,573.17

265,029.33

113,643.26	69,462.74	81,923.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 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	742.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		742.87		
2220	SSI DISABLED WITH Q
M	0.00	0.00	423.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		423.11		
SUBTOTAL:	0.00	742.87	423.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,165.98		

3,631.89

1116	TANF EXPANDED 21-44	0.00	3,631.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	3,631.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,631.89

3716	ADULT <40% EXP MALE	0.00	0.00	3,509.05	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	9,592.71	279.80	14,372.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,592.71	279.80	17,881.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,509.05	
24,245.38	
27,754.43	

TOTAL:	9,592.71	4,654.56	18,305.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,552.30		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	8.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.25		
2110	SSI AGED NON-MEDICA
R	0.00	0.00	6,419.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,419.85		
2210	SSI DISABLED NON-ME D	80.07	8,270.74	18.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,369.21		
SUBTOTAL:	88.32	8,270.74	6,438.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,797.31		

3516	ADULT 40-100% MALE 2	0.00	1,019.08	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	4,774.28	38,972.56	357.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	4,411.68	3,521.31	10,052.68	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	3,414.32	467.28	7,001.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,600.28	43,980.23	17,411.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,019.08	
44,104.01	
17,985.67	
10,882.75	
73,991.51	

3918	NEWLY ELIGIBLE M&F 4	0.00	5,777.85	5,788.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	5,777.85	5,788.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,566.44

11,566.44

100,355.26

12,688.60	58,028.82	29,637.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2420	SSI AGED EXPANDED WI	163.89	2,230.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,394.44		
SUBTOTAL:	163.89	2,230.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,394.44		

216.96

1,148.62

3714	ADULT <40% EXP MALE	717.38	223.84	207.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	216.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	934.34	223.84	207.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,365.58

TOTAL:	1,098.23	2,454.39	207.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,760.02		

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1017	TANF 21-44 FEMALE N O	11,214.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,214.23		
2120	SSI AGED WITH QMB	0.00	0.00	342.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		342.37		
SUBTOTAL:	11,214.23	0.00	342.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,556.60		

11,556.60

11,214.23	0.00	342.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	479.00	1,916.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,395.00		
2100	SSI AGED WITH MEDIC A	3,330,616.47	2,456,192.60	3,516,340.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,303,149.61		
2110	SSI AGED NON-MEDICA
R	187,328.99	149,799.02	235,218.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572,346.19		
2120	SSI AGED WITH QMB	5,085,234.28	3,558,600.50	5,247,830.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,891,665.23		
2200	SSI DISABLED WITH M E	555,517.35	422,232.69	592,574.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,570,324.32		
2210	SSI DISABLED NON-ME
D	3,676,881.67	2,853,162.88	3,642,622.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,172,666.96		
2220	SSI DISABLED WITH Q M	1,181,251.47	893,296.91	1,183,450.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,257,999.29		
2310	SSI BLIND NON-MEDIC
A	479.00	492.39	1,044.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,016.19		
2320	SSI BLIND WITH QMB	0.00	17.38	2,606.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,624.29		
SUBTOTAL:	14,017,309.23	10,334,273.37	14,423,604.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,775,187.08		

8720	SSI DISABLED FREEDO M	4,401.60	3,521.28	4,408.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,401.60	3,521.28	4,408.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,331.77

12,331.77

TOTAL:	14,021,710.83	10,337,794.65	14,428,013.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,787,518.85		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	-1,208.55	-7,088.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-8,296.60		
2200	SSI DISABLED WITH M
E	-93.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-93.00		
2210	SSI DISABLED NON-ME D	-920.78	1,259.49	269.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		608.16		
SUBTOTAL:	-2,222.33	-5,828.56	269.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,781.44		

0.00

0.00

0.00

0.00

TOTAL:

-2,222.33

-5,828.56

269.45

0.00

0.00

0.00

0.00

0.00

-7,781.44

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	21,449.83	11,693.41	6,272.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,415.86		
1013	TANF 06-13 M & F NON	45,652.16	16,990.31	15,315.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,958.18		
1014	TANF 14-20 MALE NON-	4,083.21	1,462.24	1,486.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,032.01		
1015	TANF 14-20 FEMALE N O	3,673.46	1,597.88	1,159.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,431.04		
2210	SSI DISABLED NON-ME
D	123,882.31	60,436.07	35,826.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,145.36		
2310	SSI BLIND NON-MEDIC A	2,716.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,716.64		
4312	SOBRA CHILD 01-05 M	101,401.93	44,462.78	26,948.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172,812.90		
4313	SOBRA CHILD 06-13 M	149,379.80	64,797.33	55,814.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269,991.84		
4314	SOBRA CHILD 14-20 MA	15,372.03	5,852.75	3,740.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,965.41		
4315	SOBRA CHILD 14-20 FE	6,104.83	2,259.18	2,434.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,798.08		
SUBTOTAL:	473,716.20	209,551.95	148,999.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		832,267.32		

3914	NEWLY ELIGIBLE MALE	53.27	14.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	9.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	63.06	14.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

67.84	
9.79	
77.63	

4413	SOBRA 100-133% M&F
6	35,057.25	14,906.93	12,516.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,658.53	1,194.12	775.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,298.91	375.48	427.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39,014.69	16,476.53	13,718.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

62,480.43	
4,627.68	
2,101.99	
69,210.10	

3515	ADULT 40-100% FEMAL E	27.18	33.33	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	337.33	0.00	78.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	157.49	147.28	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	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	157.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	679.51	190.61	78.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
60.51	
416.09	
304.77	
10.00	
157.51	
948.88	

TOTAL:	513,473.46	226,233.66	162,796.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		902,503.93		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	17,740.79	7,670.21	4,112.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,523.58		
2200	SSI DISABLED WITH M E	774.73	316.00	263.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,353.85		
2210	SSI DISABLED NON-ME
D	587,639.52	246,975.00	184,726.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,019,341.22		
2220	SSI DISABLED WITH Q M	1,089.49	424.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,513.72		
2310	SSI BLIND NON-MEDIC
A	335.75	55.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391.25		
SUBTOTAL:	607,580.28	255,440.94	189,102.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,052,123.62		

189,102.40

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

1,052,123.62

TOTAL:

607,580.28

255,440.94

ACC REINSURANCE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	-2,605.54	-805.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,411.44		
1011	TANF <1 M & F NON-ME	480,434.84	2,224,804.45	720,496.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,425,735.67		
1012	TANF 01-05 M & F NON	37,196.19	202,649.53	96,281.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		336,127.42		
1013	TANF 06-13 M & F NON	241,018.88	227,000.67	175,147.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		643,167.20		
1014	TANF 14-20 MALE NON-	185,768.53	101,928.26	117,286.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		404,983.40		
1015	TANF 14-20 FEMALE N O	67,973.73	116,298.84	58,224.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		242,497.55		
1016	TANF 21-44 MALE NON-	172,317.95	239,808.12	303,605.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		715,731.16		
1017	TANF 21-44 FEMALE N O	403,162.64	313,990.42	496,728.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,213,881.91		
1018	TANF 45-64 M & F NON	403,812.03	193,025.91	212,646.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		809,484.24		
1019	TANF 65+ M & F NON-M	0.00	0.00	30,392.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,392.69		
2100	SSI AGED WITH MEDIC A	-1,749.83	39,482.84	51,580.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,313.54		
2110	SSI AGED NON-MEDICA
R	24,771.85	240,105.43	67,897.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332,774.90		
2200	SSI DISABLED WITH M E	53,684.93	538,549.83	19,150.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611,385.28		
2210	SSI DISABLED NON-ME
D	5,330,188.46	6,117,760.41	5,324,232.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,772,181.63		
2310	SSI BLIND NON-MEDIC A	12,975.28	34,269.50	26,913.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,158.33		
4311	SOBRA CHILD <1 M & F	2,498,117.33	2,731,667.40	1,902,761.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,132,546.29		
4312	SOBRA CHILD 01-05 M	1,603,767.69	471,995.20	700,534.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,776,297.01		
4313	SOBRA CHILD 06-13 M	393,530.06	1,103,420.81	1,375,296.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,872,247.07		
4314	SOBRA CHILD 14-20 MA	866,162.72	613,892.46	732,587.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,212,642.79		
4315	SOBRA CHILD 14-20 FE	41,106.92	116,339.99	360,104.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		517,551.58		
5015	SOBRA PREG 14-20 FE M	2,839.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,839.10		
5017	SOBRA PREG 21-44 FE
M	49,769.88	12,363.53	10,220.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,353.53		
SUBTOTAL:	12,864,243.64	15,638,547.70	12,782,089.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,284,880.85		

118.17

3100	TRANSPLANT OPTION 1	134.39	-16.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	134.39	-16.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

118.17

1106	TANF EXPANDED 21-44	0.76	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	3.08	31.67	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	6.83	95.63	11.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	192,649.96	315,409.98	173,146.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	407,414.66	317,876.10	350,750.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	-8,008.80	128,198.41	178,292.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	12,604.44	8,481.20	6,982.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	0.00	1,937.58	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	2,701.12	-71,013.92	9,869.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND
E	91,569.18	26,200.30	107,032.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.76	
34.75	
113.88	
681,206.16	
1,076,040.86	
298,482.43	
28,067.87	
1,937.58	
-58,443.68	
224,802.33	

ACC REINSURANCE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	698,941.23	727,216.95	826,084.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,252,242.94		

3907	NEWLY ELIGIBLE FEMA L	0.00	5,257.34	595.68	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	644.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	51,012.41	4,404.17	40,493.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	247,454.55	522,183.94	728,791.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	30,506.87	357,384.91	305,336.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	417,128.40	646,633.95	395,248.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	746,102.23	1,535,864.31	1,471,109.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,853.02	
644.15	
95,909.91	
1,498,429.92	
693,228.52	
1,459,010.83	
3,753,076.35	

4413	SOBRA 100-133% M&F
6	294,812.82	246,412.43	216,055.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	102,547.39	274,951.01	298,082.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	10,385.08	726.93	36,590.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	407,745.29	522,090.37	550,728.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

757,280.58	
675,580.93	
47,702.95	
1,480,564.46	

4518	BC PATIENT FEMALE 4 5	0.00	0.00	1,584.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	1,584.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,584.30

1,584.30

3508	ADULT 40-100% M&F 45	199.90	8,524.08	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	115,035.49	66,519.22	5,269.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3515	ADULT 40-100% FEMAL E	-3,007.18	54,380.63	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	274,884.97	115,059.74	319,637.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3517	ADULT 40-100% FEMAL E	116,406.01	123,334.39	13,269.55	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	715,832.53	287,779.09	1,275,065.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3705	ADULT <40% EXP FEMA L	0.00	0.00	34,949.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3706	ADULT <40% EXP MALE	1,080.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3707	ADULT <40% EXP FEMA L	10,795.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3708	ADULT <40% EXP M&F
4	6,823.85	15,674.18	828.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3714	ADULT <40% EXP MALE	208,077.28	161,980.95	208,821.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3715	ADULT <40% EXP FEMA L	184.66	103,301.82	-1,282.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3716	ADULT <40% EXP MALE	1,647,714.64	2,238,358.92	2,890,458.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3717	ADULT <40% EXP FEMA L	387,571.91	448,285.58	594,969.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3718	ADULT <40% EXP M&F
4	1,801,145.04	3,452,244.98	2,902,488.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
3719	ADULT <40% EXP M&F 6	0.00	127.95	139.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
SUBTOTAL:	5,282,745.33	7,075,571.53	8,244,614.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 
8,723.98	
186,824.06	
51,373.45	
709,582.16	
253,009.95	
2,278,676.70	
34,949.77	
1,080.51	
10,795.72	
23,326.18	
578,879.54	
102,204.08	
6,776,532.33	
1,430,827.11	
8,155,878.44	
267.80	
20,602,931.78	

8710	SSI DISABLED FREEDO M	318,524.01	68,836.44	4,993.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	318,524.01	68,836.44	4,993.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

392,354.26

392,354.26

ACC REINSURANCE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
S000	STATE-ONLY BHS	0.00	228.23	-228.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	228.23	-228.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

TOTAL:	20,318,436.12	25,568,339.31	23,880,977.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,767,753.11		

LONG TERM CARE REINSURANCE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	69,901.43	86,772.10	131,865.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		288,538.92		
2100	SSI AGED WITH MEDIC A	60,397.22	169,241.05	240,471.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		470,110.02		
2110	SSI AGED NON-MEDICA
R	11,714.39	67,113.76	57,237.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,065.94		
2200	SSI DISABLED WITH M E	275,434.62	431,387.49	427,970.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,134,792.87		
2210	SSI DISABLED NON-ME
D	2,845,203.33	7,270,389.52	5,088,943.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,204,536.24		
2300	SSI BLIND WITH MEDIC	0.00	-4,174.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-4,174.91		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	6,927.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,927.33		
SUBTOTAL:	3,262,650.99	8,020,729.01	5,953,416.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,236,796.41		

8710	SSI DISABLED FREEDO M	128,929.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	128,929.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
128,929.98

128,929.98

17,365,726.39

3,391,580.97	8,020,729.01	5,953,416.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC SMIB
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	53,412.00	71,522.40	69,263.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194,197.50		
1010	TANF NON-MEDICARE	723.00	867.60	578.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,169.00		
1020	TANF WITH QMB	41,334.30	44,476.10	48,151.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133,962.20		
2100	SSI AGED WITH MEDIC A	52,524.10	61,427.70	56,665.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,616.80		
2110	SSI AGED NON-MEDICA
R	584,914.80	589,054.90	584,770.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,758,740.20		
2120	SSI AGED WITH QMB	5,007,483.40	5,125,560.00	5,141,705.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,274,749.10		
2200	SSI DISABLED WITH M E	113,156.40	98,272.00	93,790.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		305,218.50		
2210	SSI DISABLED NON-ME
D	488,752.00	495,625.10	497,089.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,481,466.40		
2220	SSI DISABLED WITH Q M	4,085,066.00	4,232,863.20	4,229,921.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,547,850.90		
2300	SSI BLIND WITH MEDIC	-126.40	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.80		
2310	SSI BLIND NON-MEDIC A	4,338.00	4,338.00	4,627.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,303.20		
2320	SSI BLIND WITH QMB	39,729.50	40,488.00	40,488.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,705.50		
4320	SOBRA CHILD WITH Q MB	1,012.20	1,301.40	1,012.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,325.80		
5020	SOBRA PREGNANT WO
MAN	4,627.20	4,048.80	4,048.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,724.80		
8020	QMB ONLY	920,312.10	947,778.90	934,294.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,802,385.10		
8040	SLMB	5,934,242.50	6,014,077.30	6,023,078.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,971,397.80		
8888	SMIB ONLY NOT ELIGIB	-25,842.80	-13,500.40	-27,654.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-66,997.80		
9999	SMIB ONLY NOT ELIGIB	152,609.30	62,699.50	57,203.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,512.70		
SUBTOTAL:	17,458,267.60	17,781,045.10	17,759,177.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,998,490.50		

3520	ADULT 40-100% FOR FI	2,458.20	1,301.40	1,735.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	3,615.00	4,771.80	7,808.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,073.20	6,073.20	9,543.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,494.80	
16,195.20	
21,690.00	

3920	NEWLY ELIGIBLE FOR F	2,313.60	235.60	6,507.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,313.60	235.60	6,507.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,056.20

9,056.20

1100	TANF EXPANDED FPR FI	245,986.80	252,086.80	233,269.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR
FI	289.20	289.20	289.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	999,695.00	1,010,007.70	1,014,129.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED
WI	21,556.00	22,548.50	25,686.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N O	1,012.20	1,012.20	1,003.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	4,119,225.10	4,206,588.20	4,224,675.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	144.60	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	35,293.00	39,602.20	23,416.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	2,383,626.10	2,426,035.80	2,444,825.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,806,828.00	7,958,315.20	7,967,438.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
731,342.60	
867.60	
3,023,831.80	
69,790.60	
3,027.50	
12,550,489.10	
433.80	
98,311.30	
7,254,487.10	
23,732,581.40	

ACC SMIB
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8620	SSI BLIND FREEDOM/W O	144.60	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433.80		
8720	SSI DISABLED FREEDO
M	54,514.20	61,012.10	64,054.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		179,580.30		
SUBTOTAL:	54,658.80	61,156.70	64,198.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,014.10		

TOTAL:	25,328,141.20	25,806,825.80	25,806,865.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,941,832.20		

ACC HIB
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	0.00	458.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		458.00		
1020	TANF WITH QMB	458.00	458.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		916.00		
2100	SSI AGED WITH MEDIC A	1,328.00	1,832.00	1,374.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,534.00		
2110	SSI AGED NON-MEDICA
R	0.00	1,374.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,374.00		
2120	SSI AGED WITH QMB	638,046.60	712,477.40	698,452.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,048,976.00		
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	1,374.00	1,374.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,748.00		
2220	SSI DISABLED WITH Q M	292,661.40	301,870.60	317,862.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		912,394.20		
2320	SSI BLIND WITH QMB	3,000.00	2,084.00	3,458.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,542.00		
8020	QMB ONLY	6,847.80	7,007.80	6,091.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,947.40		
9999	SMIB ONLY NOT ELIGIB	-4,692.20	-14,104.00	-9,020.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-27,816.60		
SUBTOTAL:	939,023.60	1,014,831.80	1,018,217.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,972,073.00		

1120	TANF EXPANDED FOR FI	458.00	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	4,580.00	5,496.00	5,038.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,038.00	5,496.00	5,038.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
458.00	
15,114.00	
15,572.00	

1,023,255.60

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

2,987,645.00

TOTAL:

944,061.60

1,020,327.80

Q1
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	3,101,840.80	3,130,613.00	3,114,944.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,347,398.10		
9999	SMIB ONLY NOT ELIGIB	5,176.20	12,716.80	4,713.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,606.80		
SUBTOTAL:	3,107,017.00	3,143,329.80	3,119,658.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,370,004.90		

TOTAL:	3,107,017.00	3,143,329.80	3,119,658.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,370,004.90		

LTC SMIB
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	144.60	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433.80		
1010	TANF NON-MEDICARE	0.00	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289.20		
1020	TANF WITH QMB	289.20	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		578.40		
2100	SSI AGED WITH MEDIC A	1,126,718.00	1,111,814.50	1,067,152.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,305,684.50		
2110	SSI AGED NON-MEDICA
R	246,457.10	249,967.40	235,625.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		732,049.70		
2120	SSI AGED WITH QMB	1,351,665.40	1,356,116.10	1,326,552.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,034,334.10		
2200	SSI DISABLED WITH M E	396,138.30	394,263.10	387,700.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,178,102.30		
2210	SSI DISABLED NON-ME
D	10,411.20	10,555.80	10,845.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,812.00		
2220	SSI DISABLED WITH Q M	1,167,867.40	1,176,443.50	1,169,313.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,513,624.80		
2300	SSI BLIND WITH MEDIC	433.80	289.20	433.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,156.80		
2310	SSI BLIND NON-MEDIC A	144.60	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433.80		
2320	SSI BLIND WITH QMB	433.80	433.80	433.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,301.40		
SUBTOTAL:	4,300,703.40	4,300,461.80	4,198,635.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,799,800.80		

9,399.00

4,201,672.20

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

12,809,199.80

8720	SSI DISABLED FREEDO M	3,181.20	3,181.20	3,036.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,181.20	3,181.20	3,036.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,399.00

TOTAL:

4,303,884.60

4,303,643.00

LTC HIB
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	252.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252.00		
2120	SSI AGED WITH QMB	387,600.40	394,738.80	385,097.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,167,437.00		
2220	SSI DISABLED WITH Q M	-1,704.00	10,626.00	8,084.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,006.00		
SUBTOTAL:	386,148.40	405,364.80	393,181.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,184,695.00		

TOTAL:	386,148.40	405,364.80	393,181.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,184,695.00		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	2,832.34	455.00	27.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,314.80		
1007	TANF 21-44 FEMALE WI	479.00	1,103.94	1,157.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,740.54		
1008	TANF 45-64 M & F WIT	8,767.23	-910.29	5,272.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,129.01		
1009	TANF 65+ M & F WITH	986.51	3,063.18	3,790.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,840.18		
1011	TANF <1 M & F NON-ME	461,027.80	365,528.50	585,976.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,412,532.66		
1012	TANF 01-05 M & F NON	184,699.98	125,380.18	209,789.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		519,869.63		
1013	TANF 06-13 M & F NON	280,888.33	237,331.61	258,132.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		776,352.84		
1014	TANF 14-20 MALE NON-	95,294.65	80,813.56	107,335.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283,443.72		
1015	TANF 14-20 FEMALE N O	213,030.75	145,779.58	176,320.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		535,130.52		
1016	TANF 21-44 MALE NON-	1,177,989.73	962,823.76	1,299,810.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,440,623.67		
1017	TANF 21-44 FEMALE N O	4,972,790.03	3,889,893.65	4,776,934.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,639,617.77		
1018	TANF 45-64 M & F NON	2,275,148.69	1,482,300.13	2,216,826.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,974,275.04		
1019	TANF 65+ M & F NON-M	15,796.27	10,852.49	15,650.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,299.64		
1026	TANF 21-44 MALE WITH	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		958.00		
1027	TANF 21-44 FEMALE WI	3.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.40		
1028	TANF 45-64 M & F WIT	3,521.84	1,872.66	3,233.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,627.85		
1029	TANF 65+ M & F WITH	292.98	1,924.55	1,814.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,031.63		
2100	SSI AGED WITH MEDIC A	64,634.29	62,083.72	80,244.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,962.65		
2110	SSI AGED NON-MEDICA
R	173,482.40	97,035.25	135,410.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		405,927.66		
2120	SSI AGED WITH QMB	342,909.69	213,466.09	401,178.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		957,553.80		
2200	SSI DISABLED WITH M E	238,117.73	322,298.77	284,942.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		845,358.81		
2210	SSI DISABLED NON-ME
D	5,265,752.86	3,391,013.01	5,234,629.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,891,395.83		
2220	SSI DISABLED WITH Q M	511,611.84	318,762.10	584,682.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,415,056.59		
2300	SSI BLIND WITH MEDIC	1,532.50	506.14	2,480.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,519.04		
2310	SSI BLIND NON-MEDIC A	69,578.89	33,696.39	68,573.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,848.33		
2320	SSI BLIND WITH QMB	10,798.66	4,826.98	7,965.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,591.63		
4311	SOBRA CHILD <1 M & F	1,382,791.01	1,137,325.32	1,342,518.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,862,634.58		
4312	SOBRA CHILD 01-05 M	1,754,908.77	1,316,963.45	1,987,017.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,058,889.62		
4313	SOBRA CHILD 06-13 M	2,770,782.14	2,137,159.12	3,132,409.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,040,350.48		
4314	SOBRA CHILD 14-20 MA	826,137.69	690,281.33	845,508.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,361,927.98		
4315	SOBRA CHILD 14-20 FE	1,138,041.48	963,645.72	1,261,033.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,362,720.42		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	1,148.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,148.13		
5013	SOBRA PREG 09-13 FE
M	479.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,437.00		
5015	SOBRA PREG 14-20 FE M	149,844.64	168,483.13	235,339.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		553,667.30		
5017	SOBRA PREG 21-44 FE
M	1,254,267.06	1,120,613.96	1,358,338.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,733,219.48		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5027	SOBRA PREG 21-44 FE M	85.40	0.00	5.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.56		
SUBTOTAL:	25,650,263.58	19,287,330.98	26,625,496.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,563,090.79		

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

0.00

1106	TANF EXPANDED 21-44	3,449.22	2,456.28	5,305.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	1,495.62	2,650.65	1,179.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	22,534.78	14,660.12	18,395.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	24,627.45	14,126.14	26,378.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	479.00	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	19,340.12	7,687.57	2,085.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	20,932.02	36,988.35	47,861.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	666,818.56	414,380.34	680,595.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	2,355,669.29	1,701,284.92	2,248,453.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,600,613.57	1,139,270.53	1,469,651.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	11,587.12	13,358.17	5,471.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	4,910.70	5,871.25	6,081.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	11,844.40	10,977.19	14,175.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	48,690.03	35,791.38	56,299.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	44,086.51	30,330.82	61,293.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	13,125.49	6,724.46	11,450.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	18,866.29	14,905.92	16,903.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	286,357.53	181,598.46	335,861.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	5,240.90	6,423.21	7,096.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	79,539.43	37,645.54	75,232.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	157,341.19	106,840.18	191,309.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,397,549.22	3,783,971.48	5,281,082.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,211.12	
5,325.64	
55,590.48	
65,132.13	
479.00	
29,113.13	
105,782.22	
1,761,794.50	
6,305,407.47	
4,209,535.77	
30,417.12	
16,863.17	
36,997.43	
140,780.88	
135,710.36	
31,300.40	
50,676.16	
803,817.62	
18,760.39	
192,417.21	
455,490.97	
14,462,603.17	

3508	ADULT 40-100% M&F 45	4,749.49	3,044.59	3,367.43	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	1,081.04	1,067.08	2,480.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	55,655.89	59,644.76	42,361.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	68,981.94	63,411.33	71,635.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	579,433.68	415,747.60	617,290.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	509,454.89	424,835.64	628,892.63	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	1,758,347.75	1,285,345.22	1,996,255.22	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	958.00	479.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	5.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,161.51	
4,628.52	
157,662.44	
204,028.43	
1,612,472.17	
1,563,183.16	
5,039,948.19	
2,395.00	
5.16	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3528	ADULT 40-100% M&F 45	0.00	45.61	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		524.61		
3706	ADULT <40% EXP MALE	804.69	451.18	2,510.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,766.37		
3707	ADULT <40% EXP FEMA L	0.00	2,685.20	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,164.20		
3708	ADULT <40% EXP M&F
4	5,758.15	2,913.43	3,250.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,922.39		
3709	ADULT <40% EXP M&F 6	92.75	455.00	84.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		632.73		
3714	ADULT <40% EXP MALE	196,306.17	183,586.66	188,675.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		568,568.44		
3715	ADULT <40% EXP FEMA L	311,743.87	248,388.04	288,045.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		848,177.40		
3716	ADULT <40% EXP MALE	5,096,082.76	3,433,566.03	5,237,756.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,767,405.00		
3717	ADULT <40% EXP FEMA L	2,830,538.66	2,155,568.38	2,672,114.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,658,221.65		
3718	ADULT <40% EXP M&F
4	7,151,333.82	5,480,862.38	7,158,543.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,790,740.00		
3719	ADULT <40% EXP M&F 6	2,451.46	24.00	63.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,538.96		
3726	ADULT <40% EXP MALE	455.00	479.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,892.00		
3727	ADULT <40% EXP FEMA L	936.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		936.72		
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:	18,575,171.89	13,762,600.13	18,916,203.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,253,975.05		

3908	NEWLY ELIGIBLE M&F 4	3,715.72	6,270.63	9,915.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	3,720.34	1,820.75	4,426.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	28,552.16	34,187.66	17,902.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	42,858.76	38,635.33	58,592.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	435,087.68	344,992.87	435,758.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	778,864.23	651,565.50	737,757.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,268,382.21	1,028,170.27	1,420,090.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	479.00	958.00	3,353.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	489.26	479.00	566.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	239.25	0.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,562,388.61	2,107,080.01	2,688,842.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19,901.57	
9,967.24	
80,642.72	
140,087.08	
1,215,839.00	
2,168,187.21	
3,716,643.27	
4,790.00	
1,534.79	
718.25	
7,358,311.13	

4413	SOBRA 100-133% M&F
6	268,764.47	149,124.80	243,206.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	77,334.28	65,345.20	64,800.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	106,732.39	90,920.58	104,065.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	452,831.14	305,390.58	412,072.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
661,095.82	
207,479.49	
301,718.92	
1,170,294.23	

4517	BC PATIENT FEMALE 2 1	479.00	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	3,297.43	958.00	3,353.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,776.43	958.00	3,353.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

8,087.43

7,608.43

479.00

8700

SSI DISABLED FREEDO M

7,365.17

3,199.17

11,015.35

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

21,579.69

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	13,811.11	6,905.41	10,003.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,719.95		
8720	SSI DISABLED FREEDO
M	3,819.95	597.17	2,231.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,649.02		
SUBTOTAL:	24,996.23	10,701.75	23,250.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,948.66		

0.00

53,950,300.43

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

145,875,310.46

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

TOTAL:

52,666,977.10

39,258,032.93

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	30,466.04	32,532.59	46,352.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,351.26		
8040	SLMB	8.80	15.80	148.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173.02		
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:	30,474.84	32,548.39	46,501.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,524.28		

TOTAL:	30,474.84	32,548.39	46,501.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,524.28		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	21.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.31		
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	8.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.97		
1011	TANF <1 M & F NON-ME	47,656.61	14,781.13	4,283.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,721.36		
1012	TANF 01-05 M & F NON	178.37	0.00	-43.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134.52		
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-	70.93	92.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163.79		
1015	TANF 14-20 FEMALE N O	320.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320.79		
1016	TANF 21-44 MALE NON-	2,461.05	5,953.60	3,099.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,513.72		
1017	TANF 21-44 FEMALE N O	10,550.22	4,750.51	23,956.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,257.12		
1018	TANF 45-64 M & F NON	3,043.28	23,696.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,739.37		
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	1,934.75	901.85	382.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,218.77		
2110	SSI AGED NON-MEDICA
R	135,338.97	11,318.42	46,363.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193,020.63		
2120	SSI AGED WITH QMB	554.79	1,883.86	84.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,523.50		
2200	SSI DISABLED WITH M E	1,221.33	2,336.37	1,746.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,304.19		
2210	SSI DISABLED NON-ME
D	401,433.67	623,439.40	19,509.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,044,382.83		
2220	SSI DISABLED WITH Q M	1,482.16	1,102.71	1,030.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,615.28		
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	1,089,561.88	4,402.69	13,849.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,107,814.44		
4312	SOBRA CHILD 01-05 M	3,632.61	1,568.94	12,843.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,045.27		
4313	SOBRA CHILD 06-13 M	3,206.57	510.76	4,684.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,401.68		
4314	SOBRA CHILD 14-20 MA	1,438.36	4,864.53	6,125.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,428.46		
4315	SOBRA CHILD 14-20 FE	1,022.13	919.34	8,921.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,863.12		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	9,538.67	2,430.46	-701.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,268.13		
5017	SOBRA PREG 21-44 FE
M	16,547.82	23,491.79	11,070.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,109.82		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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:	1,731,203.93	728,445.31	157,227.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,616,877.07		

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

0.00

1106	TANF EXPANDED 21-44	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	827.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	13,142.76	8,667.59	3,754.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	2,926.00	2,023.77	11,445.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	743.54	2,547.77	36,753.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	222.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	238.23	2,257.17	1,162.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	216.54	21.31	6.66	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	39.34	119.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	133,775.92	0.00	76.32	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	151.53	113.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	151,042.99	16,535.78	53,654.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
827.30	
0.00	
0.00	
0.00	
0.00	
25,565.22	
16,395.01	
40,044.58	
0.00	
0.00	
0.00	
222.87	
0.00	
3,657.88	
0.00	
244.51	
158.45	
133,852.24	
265.39	
221,233.45	

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	140.28	4,000.79	3,021.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	93,185.54	8,783.97	31,764.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	2,012.50	4,884.64	3,470.25	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	25,124.04	15,511.89	22,938.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
7,162.66	
133,734.28	
10,367.39	
63,574.23	
0.00	
0.00	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3707	ADULT <40% EXP FEMA L	5,201.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,201.56		
3708	ADULT <40% EXP M&F
4	0.00	0.00	41.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.68		
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3714	ADULT <40% EXP MALE	0.00	1,476.69	4,393.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,870.61		
3715	ADULT <40% EXP FEMA L	2,166.89	361.54	1,379.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,908.34		
3716	ADULT <40% EXP MALE	226,474.25	117,784.32	153,008.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		497,266.70		
3717	ADULT <40% EXP FEMA L	36,163.97	65,186.57	26,135.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,485.69		
3718	ADULT <40% EXP M&F
4	131,866.31	54,563.94	131,702.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318,132.40		
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 FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	522,335.34	272,554.35	377,855.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,172,745.54		

3908	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	522.61	259.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	22.28	0.00	18,781.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	27,302.98	3,464.78	9,800.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	3,199.26	1,188.81	2,125.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	3,337.44	19,937.54	14,069.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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:	33,861.96	25,113.74	45,036.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
782.06	
18,804.07	
40,567.82	
6,513.80	
37,344.79	
0.00	
0.00	
0.00	
104,012.54	

4413	SOBRA 100-133% M&F
6	1,723.43	235.48	2,162.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	321.12	360.49	735.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,104.51	3,007.59	260.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,149.06	3,603.56	3,158.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4,121.28	
1,416.99	
4,372.76	
9,911.03	

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	239.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	239.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

239.31

239.31

0.00

8700

SSI DISABLED FREEDO M

305.49

0.02

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

305.51

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	0.00	0.00	64.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.76		
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	305.49	0.02	64.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		370.27		

0.00

637,237.68

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

4,125,389.21

S000	STATE-ONLY BHS	6,610.59	-6,610.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,610.59	-6,610.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

TOTAL:

2,448,509.36

1,039,642.17

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	528,545.05	333,937.23	516,724.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,379,206.57		
8040	SLMB	81.79	311.97	259.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		653.21		
8050	QI1	175.98	1.85	76.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		254.15		
SUBTOTAL:	528,802.82	334,251.05	517,060.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,380,113.93		

TOTAL:	528,802.82	334,251.05	517,060.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,380,113.93		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	479.00	1,916.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,395.00		
2100	SSI AGED WITH MEDIC A	266,079.56	234,408.52	196,721.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		697,209.81		
2110	SSI AGED NON-MEDICA
R	28,192.26	13,746.42	25,768.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,706.69		
2120	SSI AGED WITH QMB	250,820.13	171,461.90	292,915.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		715,197.62		
2200	SSI DISABLED WITH M E	33,409.98	20,684.24	36,391.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,485.43		
2210	SSI DISABLED NON-ME
D	801,056.57	582,866.97	787,325.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,171,249.15		
2220	SSI DISABLED WITH Q M	115,571.37	75,938.00	124,823.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316,332.91		
2310	SSI BLIND NON-MEDIC
A	479.00	492.39	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,929.39		
2320	SSI BLIND WITH QMB	0.00	17.38	21.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.94		
SUBTOTAL:	1,495,608.87	1,100,094.82	1,466,841.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,062,544.94		

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

4,062,544.94

1,495,608.87	1,100,094.82	1,466,841.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending September 30, 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	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	41,898.28	24,031.58	1,334.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,264.26		
2110	SSI AGED NON-MEDICA
R	441.64	634.60	20.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,096.60		
2120	SSI AGED WITH QMB	62.97	19.40	88.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170.76		
2200	SSI DISABLED WITH M E	4,906.83	16,206.71	237.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,350.84		
2210	SSI DISABLED NON-ME
D	44,870.39	36,856.53	39,258.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,985.78		
2220	SSI DISABLED WITH Q M	3,634.92	1,629.28	2,794.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,058.55		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	95,815.03	79,378.10	43,733.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218,926.79		

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

 
0.00

0.00

TOTAL:	95,815.03	79,378.10	43,733.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218,926.79		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	4,573.24	1,673.10	4,816.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,063.32		
1007	TANF 21-44 FEMALE WI	1,920.61	1,372.74	291.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,584.89		
1008	TANF 45-64 M & F WIT	7,282.96	3,604.16	3,970.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,857.27		
1009	TANF 65+ M & F WITH	2,939.37	379.98	4,575.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,894.57		
1011	TANF <1 M & F NON-ME	634,706.45	295,612.73	796,508.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,726,827.44		
1012	TANF 01-05 M & F NON	117,610.19	58,544.34	109,868.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,023.24		
1013	TANF 06-13 M & F NON	161,558.71	120,366.13	212,330.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		494,255.28		
1014	TANF 14-20 MALE NON-	83,960.49	35,044.51	40,234.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,239.04		
1015	TANF 14-20 FEMALE N O	189,887.25	134,325.90	224,101.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		548,314.54		
1016	TANF 21-44 MALE NON-	963,942.03	1,024,074.63	1,286,021.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,274,037.68		
1017	TANF 21-44 FEMALE N O	3,169,657.70	2,694,879.11	3,108,970.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,973,507.25		
1018	TANF 45-64 M & F NON	1,581,210.06	1,337,225.47	1,641,236.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,559,672.25		
1019	TANF 65+ M & F NON-M	1,991.69	1,861.25	1,841.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,694.68		
1026	TANF 21-44 MALE WITH	0.00	0.00	8,171.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,171.26		
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	12,559.06	1,177.47	11,931.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,668.52		
1029	TANF 65+ M & F WITH	2,751.80	1,032.42	601.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,385.38		
2100	SSI AGED WITH MEDIC A	127,917.46	112,965.89	154,623.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		395,506.95		
2110	SSI AGED NON-MEDICA
R	82,396.22	87,388.83	111,960.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281,745.94		
2120	SSI AGED WITH QMB	423,535.31	287,246.13	387,331.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,098,112.80		
2200	SSI DISABLED WITH M E	367,814.33	227,632.48	341,524.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		936,971.49		
2210	SSI DISABLED NON-ME
D	6,668,489.74	5,155,417.18	6,741,200.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,565,107.20		
2220	SSI DISABLED WITH Q M	1,280,507.32	906,913.57	1,312,718.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,500,138.99		
2300	SSI BLIND WITH MEDIC	75.74	167.54	32.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		275.71		
2310	SSI BLIND NON-MEDIC A	82,843.21	59,625.10	80,658.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,126.34		
2320	SSI BLIND WITH QMB	14,835.59	19,732.97	29,174.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,742.56		
4311	SOBRA CHILD <1 M & F	814,131.23	1,007,677.65	740,565.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,562,374.13		
4312	SOBRA CHILD 01-05 M	1,005,758.92	1,055,286.32	958,237.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,019,282.91		
4313	SOBRA CHILD 06-13 M	1,595,690.76	1,386,958.88	1,794,704.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,777,354.27		
4314	SOBRA CHILD 14-20 MA	871,236.80	482,124.72	1,586,773.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,940,135.10		
4315	SOBRA CHILD 14-20 FE	842,681.59	721,641.34	792,887.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,357,210.16		
5007	SOBRA PREG 21-44 FE M	0.00	-869.63	79.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-789.83		
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	120,759.94	84,122.10	86,748.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		291,630.42		
5017	SOBRA PREG 21-44 FE
M	850,122.88	552,251.75	1,112,517.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,514,892.59		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	131.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131.02		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 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:	22,085,348.65	17,857,456.76	23,687,339.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,630,145.36		

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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

0.00

1106	TANF EXPANDED 21-44	7,269.85	298.34	5,218.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	11,248.86	3,136.91	6,273.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	26,649.73	22,080.21	39,100.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	14,139.96	21,135.76	44,872.94	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	366.88	1,322.00	549.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	19,168.85	8,058.38	22,338.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	662,679.18	445,720.42	482,022.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,035,686.92	998,043.43	1,398,012.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	935,668.87	655,642.66	711,948.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	5,930.20	2,640.40	1,683.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	8,990.76	10,590.46	8,823.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	53,609.42	28,798.36	126,916.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	83,777.23	47,340.21	80,778.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	43,823.71	26,209.78	39,383.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	7,302.67	11,896.35	9,991.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	16,665.50	12,631.63	4,392.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	441,581.69	275,347.49	421,861.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	5,827.66	4,955.23	10,107.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	112,670.42	65,539.21	55,150.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	296,268.26	199,455.26	379,638.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,789,326.62	2,840,842.49	3,849,063.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,787.08	
20,659.31	
87,830.28	
80,148.66	
0.00	
2,238.22	
49,566.06	
1,590,421.97	
3,431,742.88	
2,303,259.85	
10,254.42	
28,404.40	
209,323.79	
211,896.37	
109,416.49	
29,190.17	
33,690.03	
1,138,790.86	
20,890.00	
233,359.81	
875,361.57	
10,479,232.22	

3508	ADULT 40-100% M&F 45	7,823.30	13,500.93	4,052.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	48.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	11,068.05	24,808.91	25,627.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	55,500.73	76,627.83	53,567.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	607,958.28	636,287.55	878,251.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	431,461.36	308,116.11	609,347.37	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	1,816,977.25	1,389,102.77	1,550,893.01	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	164.48	328.96	1,798.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25,376.72	
48.11	
61,504.14	
185,696.41	
2,122,496.93	
1,348,924.84	
4,756,973.03	
2,292.39	
0.00	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3528	ADULT 40-100% M&F 45	2,862.31	13,571.92	2,848.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,282.44		
3706	ADULT <40% EXP MALE	57.38	86.35	1,708.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,852.66		
3707	ADULT <40% EXP FEMA L	0.00	684.81	127.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		812.57		
3708	ADULT <40% EXP M&F
4	2,187.53	4,691.21	48,985.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,864.14		
3709	ADULT <40% EXP M&F 6	605.22	45.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		650.89		
3714	ADULT <40% EXP MALE	353,676.97	240,624.10	246,783.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		841,084.11		
3715	ADULT <40% EXP FEMA L	162,511.44	114,009.53	241,281.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		517,802.24		
3716	ADULT <40% EXP MALE	8,341,319.42	7,438,446.61	10,304,097.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,083,863.76		
3717	ADULT <40% EXP FEMA L	3,534,124.56	3,597,125.52	4,446,436.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,577,686.56		
3718	ADULT <40% EXP M&F
4	8,932,369.89	6,988,768.45	10,831,898.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,753,037.33		
3719	ADULT <40% EXP M&F 6	1,068.32	106,447.32	1,986.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,502.57		
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 FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F
4	552.34	8,792.98	26,960.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,306.29		
SUBTOTAL:	24,262,288.83	20,962,067.53	29,276,701.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,501,058.13		

3908	NEWLY ELIGIBLE M&F 4	10,016.89	12,890.32	13,458.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	3,863.03	1,025.42	4,456.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	26,065.60	22,466.51	44,089.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	15,683.28	7,642.00	58,075.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	533,216.42	328,287.76	361,705.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	404,707.40	216,150.60	319,306.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	921,318.96	692,866.60	1,162,324.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	132.56	861.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	57.18	595.65	724.84	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:	1,914,928.76	1,282,057.42	1,965,002.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
36,365.44	
9,344.68	
92,621.76	
81,401.04	
1,223,210.00	
940,164.14	
2,776,510.12	
994.02	
1,377.67	
0.00	
5,161,988.87	

4413	SOBRA 100-133% M&F
6	79,561.09	97,234.17	143,584.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	63,466.22	36,422.17	49,832.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	35,059.44	41,821.87	55,640.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	178,086.75	175,478.21	249,057.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
320,379.64	
149,720.94	
132,521.61	
602,622.19	

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	6,741.91	1,649.82	16,106.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,741.91	1,649.82	16,106.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

24,498.53

24,498.53

0.00

8700

SSI DISABLED FREEDO M

19,266.93

11,931.03

19,448.70

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

50,646.66

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8710	SSI DISABLED FREEDO M	17,233.38	7,817.72	3,782.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,833.73		
8720	SSI DISABLED FREEDO
M	22,396.77	20,915.69	19,546.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,858.53		
SUBTOTAL:	58,897.08	40,664.44	42,777.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,338.92		

0.00

59,086,000.86

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

154,541,884.22

S000	STATE-ONLY BHS	0.00	48.09	-48.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	48.09	-48.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

TOTAL:

52,295,618.60

43,160,264.76

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 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	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	3,022,638.63	2,197,752.50	3,318,284.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,538,675.54		
2110	SSI AGED NON-MEDICA
R	158,695.09	135,418.00	209,429.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		503,542.90		
2120	SSI AGED WITH QMB	4,834,351.18	3,387,119.20	4,954,826.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,176,296.85		
2200	SSI DISABLED WITH M E	517,200.54	385,341.74	555,945.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,458,488.05		
2210	SSI DISABLED NON-ME
D	2,830,954.71	2,233,439.38	2,816,037.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,880,432.03		
2220	SSI DISABLED WITH Q M	1,062,045.18	815,729.63	1,055,833.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,933,607.83		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	86.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86.80		
2320	SSI BLIND WITH QMB	0.00	0.00	2,585.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,585.35		
SUBTOTAL:	12,425,885.33	9,154,800.45	12,913,029.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,493,715.35		

8720	SSI DISABLED FREEDO M	4,401.60	3,521.28	4,408.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,401.60	3,521.28	4,408.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,331.77

12,331.77

TOTAL:	12,430,286.93	9,158,321.73	12,917,438.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,506,047.12		

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	25.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.53		
8040	SLMB	768.43	57.18	8.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		834.20		
8050	QI1	47.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.94		
SUBTOTAL:	841.90	57.18	8.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		907.67		

0.00

0.00

0.00

0.00

TOTAL:

841.90

57.18

8.59

0.00

0.00

0.00

0.00

0.00

907.67

KidsCare - CAPITATION AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	174,491.07	172,577.29	175,116.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		522,185.35		
6012	KIDS 1-5 M & F NON-M	1,800,811.10	1,831,909.98	1,869,166.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,501,887.85		
6013	KIDS 6-13 M & F NON-	3,466,599.08	3,566,682.54	3,676,408.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,709,690.22		
6014	KIDS 14-19 MALE NON-	935,140.73	970,724.10	997,580.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,903,445.45		
6015	KIDS 14-19 FEMALE NO	940,472.58	978,761.40	1,004,941.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,924,174.98		
9960	KIDSCARE KICK PAYME N	18,508.35	18,450.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,959.27		
SUBTOTAL:	7,336,022.91	7,539,106.23	7,723,213.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,598,343.12		

TOTAL:	7,336,022.91	7,539,106.23	7,723,213.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,598,343.12		

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	295.03	291.32	294.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		881.13		
6012	KIDS 1-5 M & F NON-M	9,545.70	9,706.14	9,896.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,148.57		
6013	KIDS 6-13 M & F NON-	18,395.31	18,912.65	19,476.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,784.35		
6014	KIDS 14-19 MALE NON-	4,949.42	5,141.98	5,271.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,363.17		
6015	KIDS 14-19 FEMALE NO	4,967.01	5,155.01	5,290.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,412.44		
9960	KIDSCARE KICK PAYME N	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
SUBTOTAL:	38,155.47	39,210.10	40,230.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117,595.66		

117,595.66

38,155.47	39,210.10	40,230.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	523.48	519.05	545.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,587.70		
6012	KIDS 1-5 M & F NON-M	18,360.10	18,658.73	18,175.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,193.93		
6013	KIDS 6-13 M & F NON-	36,515.44	36,931.37	38,384.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,831.11		
6014	KIDS 14-19 MALE NON-	16,095.74	17,066.38	17,392.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,554.76		
6015	KIDS 14-19 FEMALE NO	17,125.52	18,323.05	18,377.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,826.17		
SUBTOTAL:	88,620.28	91,498.58	92,874.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,993.67		

TOTAL:	88,620.28	91,498.58	92,874.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272,993.67		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	302.00	300.00	316.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		918.00		
6012	KIDS 1-5 M & F NON-M	9,877.76	10,041.06	10,220.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,138.85		
6013	KIDS 6-13 M & F NON-	19,182.12	19,701.53	20,303.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,186.78		
6014	KIDS 14-19 MALE NON-	5,207.03	5,397.03	5,548.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,152.09		
6015	KIDS 14-19 FEMALE NO	5,227.03	5,431.03	5,579.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,237.09		
SUBTOTAL:	39,795.94	40,870.65	41,966.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,632.81		

41,966.22

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

122,632.81

TOTAL:

39,795.94

40,870.65

KidsCare - FEE FOR SERVICE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	12,185.87	25.59	1,926.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,137.58		
6012	KIDS 1-5 M & F NON-M	38,128.70	11,226.18	35,357.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,712.09		
6013	KIDS 6-13 M & F NON-	41,178.75	41,588.86	72,955.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,723.27		
6014	KIDS 14-19 MALE NON-	20,137.82	10,886.64	27,745.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,769.94		
6015	KIDS 14-19 FEMALE NO	79,656.09	37,344.80	63,073.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,074.88		
SUBTOTAL:	191,287.23	101,072.07	201,058.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		493,417.76		

TOTAL:	191,287.23	101,072.07	201,058.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		493,417.76		

KidsCare - REINSURANCE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	32,192.38	15,576.63	23,224.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,993.90		
6013	KIDS 6-13 M & F NON-	64,628.70	108,533.95	62,469.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		235,632.21		
6014	KIDS 14-19 MALE NON-	-0.01	178,495.68	70,224.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248,720.19		
6015	KIDS 14-19 FEMALE NO	135,893.44	0.00	11,530.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,424.30		
SUBTOTAL:	232,714.51	302,606.26	167,449.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		702,770.60		

702,770.60

232,714.51	302,606.26	167,449.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - TRANSPLANT REINSURANCE
For The Period Ending September 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
6013	KIDS 6-13 M & F NON-	4,465.07	11,868.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,333.75		
SUBTOTAL:	4,465.07	11,868.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,333.75		

TOTAL:	4,465.07	11,868.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,333.75		

0

0

0

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending September 30, 2020

RJAuTEnCeO3DE0, 202DE0SCRIPTION

JULY

AUGUST SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

1010	TANF NON-MEDICARE	663.29	661.89	661.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,986.28	
1020	TANF WITH QMB	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00	
2100	SSI AGED WITH MEDICA	277.71	272.54	275.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		825.50	
2110	SSI AGED NON-MEDICAR	10.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.00	
2120	SSI AGED WITH QMB	442.10	445.44	444.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,331.82	
2200	SSI DISABLED WITH ME	1,899.08	1,908.78	1,906.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,713.98	
2210	SSI DISABLED NON-MED	27,309.05	27,444.84	27,549.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,303.18	
221Z	SSI DISABLED NON-MED	0.00	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 QM	5,137.58	5,146.48	5,175.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,459.79	
2300	SSI BLIND WITH MEDIC	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00	
2310	SSI BLIND NON-MEDICA	12.00	13.58	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.58	
2320	SSI BLIND WITH QMB	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00	
8700	SSI DISABLED FREEDOM	32.00	31.00	42.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105.99	
8710	SSI DISABLED FREEDOM	11.00	11.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.00	
8720	SSI DISABLED FREEDOM	21.00	22.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.00	
SUBTOTAL:	35,820.81	35,972.55	36,117.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,911.12	
TOTAL:	35,820.81	35,972.55	36,117.76	0.0	0.00	0.0	0.00	0.00	0.00	0.0	0.00	0.00		107,911.12	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending September 30, 2020

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	407,381.00	423,760.10	419,922.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,251,063.41	
EPD	117,131,570.69	116,026,496.12	115,369,118.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	348,527,185.22	
TOTAL AHCCCS LTC	117,538,951.69	116,450,256.22	115,789,040.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	349,778,248.63	
DES/DD	173,387,013.21	174,122,225.01	174,824,385.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	522,333,623.43	
TOTAL DES LTC	173,387,013.21	174,122,225.01	174,824,385.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	522,333,623.43	
TOTAL LTC - CAP	290,925,964.90	290,572,481.23	290,613,425.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	872,111,872.06	

EPD/DD FEE-FOR-SERVICE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	14,021,710.83	10,337,794.65	14,428,013.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,787,518.85	
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	14,021,710.83	10,337,794.65	14,428,013.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38,787,518.85	

EPD/DD REINSURANCE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	1,710,587.65	2,650,052.78	3,133,859.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,494,499.54	
DES/DD	1,680,993.32	5,370,676.23	2,819,557.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,871,226.85	
TOTAL DES LTC	1,680,993.32	5,370,676.23	2,819,557.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,871,226.85	
TOTAL LTC - REIN	3,391,580.97	8,020,729.01	5,953,416.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,365,726.39	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	4,690,033.00	4,709,007.80	4,594,854.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,993,894.80	

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

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending September 30, 2020

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

00999155	CRS REINSURANCE ONLY	-834.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-834.25	
Subtotal	-834.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-834.25	

-834.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-834.25	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending September 30, 2020

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	

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

GRAND TOTAL

BEHAVIORAL HEALTH EXPENDITURES BY RBHA - CAPITATION AMOUNTS
For the Period Ending September 30, 2020

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

00010306	MERCY CARE - RBHA CRISIS CAP AMOUNTS	5,408,113.60	5,455,437.16	5,476,999.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,340,549.78	

00010422	AZ COMPLETE HEALTH CARE - RBHA CRISIS CAP AMOUNTS	4,029,461.70	4,082,897.14	4,134,674.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,247,032.86	

00010497	STEWARD HEALTH CHOICE AZ - RBHA CRISIS CAP AMOUNTS	866,831.19	876,606.45	886,586.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,630,023.89	

00010705	HEALTH CHOICE RBHA - CAP AMOUNTS	717.13	-141.92	702.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,277.67	

00010730	CENPATICO RBHA - CAP AMOUNTS	37,232.19	1,693.00	478.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39,403.51	

00010789	MERCY MARICOPA RBHA - CAP AMOUNTS	74,475.62	32,139.90	1,984.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,599.94	
			
Subtotal		
	10,416,831.43	10,448,631.73	10,501,424.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,366,887.65	

10,416,831.43	10,448,631.73	10,501,424.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31,366,887.65	

GRAND TOTAL

BEHAVIORAL HEALTH EXPENDITURES BY RBHA - MEMBER MONTHS
For the Period Ending September 30, 2020

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

00010306	MERCY CARE - RBHA CRISIS CAP MEMBER MONTHS	994,764.00	999,950.00	999,950.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,994,664.00	
			
00010422	AZ COMPLETE HEALTH CARE - RBHA CRISIS CAP MEMBER MONTHS	498,371.00	504,271.00	509,727.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,512,369.00	
			
00010497	STEWARD HEALTH CHOICE AZ - RBHA CRISIS CAP MEMBER MONTHS	242,165.00	244,658.00	247,195.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	734,018.00	
			
00010705	HEALTH CHOICE RBHA - CAP MEMBER MONTHS	7.67	-2.00	9.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.35	
			
00010730	CENPATICO RBHA - CAP MEMBER MONTHS	218.57	24.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	248.57	
			
00010789	MERCY MARICOPA RBHA - CAP MEMBER MONTHS	380.01	368.10	17.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	765.34	
			
Subtotal	1,735,906.25	1,749,269.10	1,756,904.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,242,080.26	

1,735,906.25	1,749,269.10	1,756,904.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,242,080.26	

GRAND TOTAL