Douglas A. Ducey, Governor Jami Snyder, Director

December 30, 2020

The Honorable Karen Fann Arizona State Senate
1700 W. Washington
Phoenix, AZ 85007

The Honorable Russell “Rusty” Bowers Speaker of the House
Arizona House of Representatives 1700 W. Washington
Phoenix, AZ 85007

SUBJECT: FY 2021 Appropriation Status Report for the Period Ended November 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
November 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, as well as another potential extension in January, will significantly impact the FY21 projections. Due to the increased FMAP and corresponding enrollment increases from the MOE, AHCCCS is projecting a state match surplus and federal funds shortfall compared to the appropriation. However, the amounts will depend upon administrative adjustment activity and the possible extension of the PHE. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

Enrollment Update – November 2020 enrollment is 2,106,979 members, a 22,295 member increase over the prior month. Enrollment for December 2020 increased to 2,125,915 members, a 18,936 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 246,955 members or 13.1%.

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

The Honorable Karen Fann
The Honorable Russell “Rusty” Bowers December 30, 2020
Page 2

Major December 2020 changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 4,862; Supplemental Security Income – increase of 1,209; Prop 204 Restoration - increase of 3,915; Adult Expansion – increase of 6,510; Medicare Cost Sharing
– increase of 169; KidsCare – increase of 1,679; and Federal Emergency Services – increase of 651.

Tobacco Funds Revenue Update - Tobacco tax collections through November 2020 are $1.0 million less 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 November 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 November 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	$	93,636,400	$	37,835,201	$	37,835,201	$		-	$	93,636,400	$	-	
AHCCCS Prop 204 Administration	14,577,600	9,343,389	9,343,389			-	14,577,600		-	
DES Eligibility	91,874,500	30,525,525	30,525,525			-	91,874,500		-	
DES Prop 204 Eligibility	44,358,700	11,804,241	11,804,241			-	44,358,700		-	
ADOA Data Center	19,325,800	2,750,118	2,750,118			-	19,325,800		-	
School District Suicide Prevention Coordinator	100,000	45,996	45,996			-	100,000		-	
TOTAL ADMINISTRATION	 	263,873,000 		 	92,304,471 		 	92,304,471 		 	-			 	263,873,000 		 	-			

Traditional Medicaid Services	5,639,928,200	2,320,680,432	2,320,680,432		5,639,928,200	-	
Proposition 204 Services	4,670,376,000	2,000,015,454	2,000,015,454		4,670,376,000	-	
ACA Adult Expansion	587,108,200	274,060,159	274,060,159		587,108,200	-	
KidsCare Services	92,088,200	41,758,219	41,758,219		92,088,200	-	
ALTCS Services	1,966,345,300	764,456,650	764,456,650		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		84,747,127		84,747,127		-		197,732,200		-	
Behavioral Health Services - in Schools	10,003,300		4,168,042		4,168,042		-		10,003,300		-	
Targeted Investment Program	70,000,000		42,451		42,451		-		70,000,000		-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		31,186,648		31,186,648		-		77,646,900		-	
Supported Housing	5,324,800		2,218,667		2,218,667		-		5,324,800		-	
Crisis Services	16,391,300		6,773,458		6,773,458		-		16,391,300		-	
TOTAL PROGRAMMATIC	 	13,751,402,700 		 	5,672,227,819 		 	5,672,227,819 		 	-			 	13,751,402,700 		 	-		

-
-
-
-
-
-
-

TOTAL EXPENDITURES

  $	14,015,275,700 

  $	5,764,532,289 

  $	5,764,532,289 

  $	-	

  $ 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	
$	
63,893,300	
$	23,247,159	
$	23,247,159	
-	$	63,893,300	
$	
-	
Proposition 204 - Administrative Expenditures		21,552,000	6,436,333	6,436,333	-	21,552,000		-	
Programmatic Expenditures
Traditional Medicaid Services	
1,174,102,800	
436,417,241	
436,417,241		
-	1,174,102,800	
-	
Proposition 204 Services	206,211,500	140,887,154	140,887,154		-	206,211,500	-	
ACA Adult Expansion	22,361,600	8,217,881	8,217,881		-	22,361,600	-	
KidsCare Services	16,214,400	4,183,982	4,183,982		-	16,214,400	-	
ALTCS Services	265,435,600	110,725,396	110,725,396		-	265,435,600	-	
DSH and Rural Hospitals	8,846,200	-	-	-	8,846,200	-	
CMDP	59,250,900	20,128,524	20,128,524	-	59,250,900	-	
Behavior Health Services - in Schools	3,000,000	1,250,000	1,250,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	31,186,648	31,186,648	-	77,646,900	-	
Supported Housing	5,324,800	2,218,667	2,218,667	-	5,324,800	-	
Crisis Services	14,141,100	5,835,875	5,835,875	-	14,141,100	-	
Voluntary Political Subdivision Programs	 	6,000,000 	 	- 	 	- 	 	- 	 	6,000,000 	 	- 	
TOTAL GF EXPENDITURES	1,943,981,100	790,734,858	790,734,858	-	1,943,981,100	-	
	FEDERAL		
Administrative Expenditures	140,381,700	47,749,470	47,749,470		-	140,381,700	-	
Proposition 204 - Administrative Expenditures	33,286,000	13,701,948	13,701,948		-	33,286,000	-	
Programmatic Expenditures
Traditional Medicaid Services	
3,567,195,100	
1,397,275,318	
1,397,275,318		
-	3,567,195,100	
-	
Proposition 204 Services	3,939,570,800	1,746,852,916	1,746,852,916		-	3,939,570,800	-	
ACA Adult Expansion	520,086,200	243,665,388	243,665,388		-	520,086,200	-	
KidsCare Services	63,360,400	37,489,279	37,489,279		-	63,360,400	-	
ALTCS Services and Nursing Facility Assessment	1,255,443,608	510,830,365	510,830,365		-	1,255,443,608	-	
DSH and Rural Hospitals	24,853,300	-	-	-	24,853,300	-	
CMDP	138,481,300	64,618,604	64,618,604	-	138,481,300	-	
Behavior Health Services - in Schools	7,003,300	2,918,042	2,918,042	-	7,003,300	-	
Targeted Investment Program	48,313,300	42,451	42,451	-	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	4,168,987,712	4,168,987,712	-	10,007,203,808	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF Programmatic Expenditures
Traditional Medicaid Services Acute Care	4,037,400

46,161,700	1,009,350

19,091,250	1,009,350

19,091,250	-

-	4,037,400

46,161,700	-

-	
ALTCS Services	 	290,276,100 	 	61,704,293 	 	61,704,293 	 	- 	 	290,276,100 	 	- 	
TOTAL COUNTY EXPENDITURES	340,475,200	81,804,893	81,804,893
.	-	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	27,437,627	27,437,627	-	65,627,200	-	
Proposition 204 Services - Emergency Health Services	16,216,300	8,108,150	8,108,150	-	16,216,300	-	
Proposition 204 Services - Proposition 204 Protection	34,797,900	17,398,950	17,398,950	-	34,797,900	-	
Proposition 204 Services - ATLSF	 	102,000,000 	 	- 	 	- 	 	- 	 	102,000,000 	 	- 	
TOTAL TOBACCO EXPENDITURES	218,641,400	52,944,727	52,944,727	-	218,641,400	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program	722,600	160,211	160,211	-	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	58,399,417	58,399,417	-	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	381,456,263	381,456,263	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	8,729,300	3,157,667	3,157,667	-	8,729,300	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	16,737,702	16,737,702	-	36,422,000	-	
Proposition 204 Services - Hospital Assessment	364,184,700	86,768,284	86,768,284	-	364,184,700	-	
Proposition 204 Services - IGA Fund	7,394,800	-	-	-	7,394,800	-	
ACA Adult Expansion - Hospital Assessment	44,035,900	22,176,890	22,176,890	-	44,035,900	-	
ACA Adult Expansion - IGA Fund	624,500	-	-	-	624,500	-	
Traditional Medicaid Services - TPL	194,700	599,943	599,943	-	194,700	-	
ALTCS Services - TPL	-	774,152	774,152	-	-	-	
ALTCS Services - Nursing Facility Assessment	110,038,692	60,527,076	60,527,076	-	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	84,958	84,958	-	12,151,300	-	
Freedom to Work Premiums	31,200	3,373	3,373	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	937,583	937,583	-	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	670,060,100	670,060,100	-	1,504,974,192	-	
	TOTAL		
Administrative Expenditures	263,873,000	92,304,471	92,304,471	-	263,873,000	-	
Acute Care	11,785,057,400	4,907,771,169	4,907,771,169	-	11,785,057,400	-	
Long Term Care	 	1,966,345,300 	 	764,456,650 	 	764,456,650 	 	- 	 	1,966,345,300 	 	- 	
TOTAL EXPENDITURES	  $	14,015,275,700 	  $	5,764,532,289 	  $	5,764,532,289 	  $	- 	  $	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 November 30, 2020

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,278,203,900	$	469,132,281	$	460,914,400	
Proposition 204 Services & Administrative	227,763,500	147,323,486	147,323,486	
KidsCare Services	16,214,400.00	4,183,981.82	4,183,982	
ALTCS Services	265,435,600	110,725,396	110,725,396	
Behavioral Health Traditional Medicaid Services	 	156,363,700 	 	59,369,713 	 	59,369,713 	
TOTAL	1,943,981,100	790,734,858	782,516,977	

FEDERAL:
Acute & Administrative	8,549,918,500	3,556,049,465	3,554,009,854	
KidsCare Services	63,360,400	37,489,279	39,058,079	
ALTCS Services	1,255,443,608	510,830,365	556,856,701	
Behavioral Health Traditional Medicaid Services	 	138,481,300 	 	64,618,604 	 	67,538,046 	
TOTAL	10,007,203,808	4,168,987,712	4,217,462,680	

COUNTY:				
Acute & Administrative	50,199,100		20,100,600		20,514,984	
ALTCS Services	 	290,276,100 		 	61,704,293 		 	101,957,340 	
TOTAL	340,475,200		81,804,893		122,472,324	

TOBACCO FUNDS:						
Traditional Medicaid Services	65,627,200		27,437,627		27,437,627	
Proposition 204 Services	 	153,014,200 		 	25,507,100 		 	25,507,100 	
TOTAL	218,641,400		52,944,727		52,944,727	

OTHER:

Administrative	722,600	160,211	160,211	
Traditional Medicaid Services - IGA Fund	73,818,600	-	-	
Acute Care - Prescription Drug Rebate Program	712,796,900	439,855,680	439,855,680	
Long Term Care - Prescription Drug Rebate Program	45,151,300	19,895,369	19,895,369	
Hospital Assessment	416,239,900	108,945,175	240,032,861	
ALTCS - Nursing Facility Assessment	110,038,692	60,527,076	13,290,171	
Acute TPL - Note 1	194,700	599,943	599,943	
LTC TPL - Note 1	-	774,152	774,152	
KidsCare Services - IGA Fund	362,100	-	-	
KidsCare TPL - Note 1	-	-	(25.00)	
Member Premiums - CHIP	12,151,300	84,958	84,958	
Member Premiums - Freedom to Work	31,200	3,373	3,373	
Targeted Investment Program	21,686,700	-	21,270	
Behavioral Health Traditional Medicaid Services	2,250,200	937,583	649,226	
Voluntary Political Subdivision - State Match	 	109,530,000 	 	38,276,580 	 	76,553,160 	
TOTAL	1,504,974,192	670,060,100	791,920,350	

TOTAL REVENUE

$	14,015,275,700

$	5,764,532,289

$	5,967,317,057

BUDGET

BUDGET YTD

RECEIPTS YTD

Appropriation Status Report
Footnotes

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

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

$	1,225,030	$

1,847,909	$

6,027,230	$

8,060,099

LTC	1,078,452	729,831	4,188,930	3,704,266
KidsCare	505	19,435	2,200	66,614

Total TPL Collections

  $	2,303,987 

  $	2,597,175 

  $	10,218,360 

  $	11,830,979 

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	112,341	$	189,873	$	599,943	$	1,014,734	
LTC		200,246	153,712		774,152	724,963	
KidsCare		5	(803)		(25)	(311)	
Total Expenditure Offsets	  $	312,592 		  $	342,782 		  $	1,374,070 		  $	1,739,386 	

November 2020

November 2019

July 1, 2020	July 1, 2019
November 30, 2020	November 30, 2019

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

`

FY 21 Total

1,226.0
1,120.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2020	$	946,359	
	Revenues	6,933,045	
	Transfers-In	 	1,547,870 	
	Total Revenues	 	8,480,914 	
	Expenditures	5,011,955	
	Transfers-out	 	1,104,000 	
	Total Expenditures	 	6,115,955 	
	Ending Balance November 30, 2020	  $ 3,311,318 	

Of the $3,311,318 ending balance, $2,663,722 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through December 2020.

Summary of Voluntary Political Subdivision Contribution Expenditures:

Note 4:

As of November 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	351,881,470	353,701,009	354,741,418	406,871,637	0	0	0	0	0	0	0	1,818,410,298	
CAPITATION - AIMHS	428,410	430,948	434,545	439,294	438,317	0	0	0	0	0	0	0	2,171,514	
CAPITATION - LTC	290,925,965	290,572,481	290,613,426	291,310,327	297,689,756	0	0	0	0	0	0	0	1,461,111,955	
MENTAL HEALTH - CHILD	2,277	1,446	-719	426	-229	0	0	0	0	0	0	0	3,202	
MENTAL HEALTH - ADULT	380,807	355,992	348,738	344,658	398,620	0	0	0	0	0	0	0	1,828,814	
MENTAL HEALTH - GENERAL	13,950	10,451	3,406	836	967	0	0	0	0	0	0	0	29,610	
MENTAL HEALTH - CMDP	12,276,585	12,457,764	12,481,448	12,396,743	14,327,617	0	0	0	0	0	0	0	63,940,158	
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	4,785,609	4,808,366	6,134,651	6,138,831	0	0	0	0	0	0	0	26,618,613	
FEE FOR SERVICE - ACUTE	50,202,211	38,405,117	51,220,096	43,859,109	42,719,705	0	0	0	0	0	0	0	226,406,237	
FFS - PRIOR QUARTER COVERAGE	525,804	279,896	272,648	224,685	225,795	0	0	0	0	0	0	0	1,528,827	
EMERGENCY SERVICES - FEDERAL	3,758,804	3,482,081	4,181,075	4,408,707	3,916,805	0	0	0	0	0	0	0	19,747,471	
FFS MEDICAID IN PUBLIC SCHOOLS	512,731	226,028	162,718	568,047	957,644	0	0	0	0	0	0	0	2,427,169	
QMB - FEE FOR SERVICE	560,175	366,857	563,570	394,826	460,050	0	0	0	0	0	0	0	2,345,478	
INPATIENT INMATES FFS	328,698	230,026	445,921	384,796	482,211	0	0	0	0	0	0	0	1,871,652	
FFS TRBHA FEE FOR SERVICE	8,121,079	8,036,799	9,977,009	8,180,725	8,716,132	0	0	0	0	0	0	0	43,031,745	
STATE ONLY TRBHA FFS	128,659	157,307	364,070	114,279	73,010	0	0	0	0	0	0	0	837,325	
MARICOPA CTY INMATES FFS	17,312	13,478	6,406	50,010	13,220	0	0	0	0	0	0	0	100,426	
COCONINO COUNTY INMATES FFS	89	0	1,436	0	14	0	0	0	0	0	0	0	1,539	
PIMA COUNTY INMATES FFS	88	8,271	6,438	13,837	5,116	0	0	0	0	0	0	0	33,750	
PINAL COUNTY INMATES FFS	0	0	0	0	241	0	0	0	0	0	0	0	241	
YAVAPAI COUNTY INMATES FFS	11,214	0	342	0	0	0	0	0	0	0	0	0	11,557	
MOHAVE COUNTY INMATES FFS	0	743	423	511	4,285	0	0	0	0	0	0	0	5,962	
FEE FOR SERVICE - LTC	14,021,711	10,337,795	14,428,013	11,083,271	10,538,401	0	0	0	0	0	0	0	60,409,190	
LFFS - PRIOR QUARTER COVERAGE	-2,222	-5,829	269	455	0	0	0	0	0	0	0	0	-7,326	
YAVAPAI COUNTY INMATES LTC FEE	0	0	0	0	175	0	0	0	0	0	0	0	175	
LFFS MEDICAID IN PUBLIC SCHOOLS	607,580	255,441	189,102	555,825	962,374	0	0	0	0	0	0	0	2,570,323	
REINSURANCE - ACC	13,590,647	16,229,687	13,339,168	13,014,204	17,219,450	0	0	0	0	0	0	0	73,393,156	
REINSURANCE - LTC	3,391,581	8,020,729	5,953,416	10,269,378	5,459,164	0	0	0	0	0	0	0	33,094,268	
SMIB - ACC	17,512,926	17,842,202	17,823,376	17,941,257	17,904,353	0	0	0	0	0	0	0	89,024,115	
HIB - ACC	939,024	1,014,832	1,018,218	1,051,512	1,033,457	0	0	0	0	0	0	0	5,057,041	
Q1	3,107,017	3,143,330	3,119,658	3,147,957	3,112,879	0	0	0	0	0	0	0	15,630,841	
SMIB - LTC	4,303,885	4,303,643	4,201,672	4,175,331	4,167,946	0	0	0	0	0	0	0	21,152,477	
HIB - LTC	386,148	405,365	393,182	388,427	387,023	0	0	0	0	0	0	0	1,960,146	
SUBTOTAL	782,051,320	773,268,185	790,056,274	785,195,501	844,224,966	0	0	0	0	0	0	0	3,974,796,246	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL
TITLE XIX PROP 204
CAPITATION - ACC	310,760,657	313,246,192	318,874,940	322,756,090	374,876,940	0	0	0	0	0	0	0	1,640,514,819	
CAPITATION - AIMHS	201,435	202,551	206,196	210,948	215,167	0	0	0	0	0	0	0	1,036,297	
MENTAL HEALTH - ADULT	317,445	317,963	340,079	298,623	390,448	0	0	0	0	0	0	0	1,664,559	
MENTAL HEALTH - GENERAL	17,947	11,505	478	-1,659	0	0	0	0	0	0	0	0	28,272	
MENTAL HEALTH - CMDP	2,525	2,654	2,654	2,654	2,654	0	0	0	0	0	0	0	13,140	
MENTAL HEALTH - RBHA CRISIS	4,685,074	4,742,887	4,834,851	6,627,923	6,744,349	0	0	0	0	0	0	0	27,635,084	
FEE FOR SERVICE - ACUTE	52,697,715	41,638,572	57,754,561	46,769,742	43,098,179	0	0	0	0	0	0	0	241,958,769	
FFS - PRIOR QUARTER COVERAGE	6,219	-925	-4,174	-6,052	-427	0	0	0	0	0	0	0	-5,359	
EMERGENCY SERVICES - FEDERAL	3,940,111	3,229,763	4,570,583	4,287,997	4,308,781	0	0	0	0	0	0	0	20,337,235	
FFS MEDICAID IN PUBLIC SCHOOLS	680	191	79	285	737	0	0	0	0	0	0	0	1,971	
INPATIENT INMATES FFS	634,880	949,558	983,526	703,647	1,013,900	0	0	0	0	0	0	0	4,285,510	
FFS TRBHA FEE FOR SERVICE	8,167,640	7,429,009	9,697,887	8,791,752	6,964,617	0	0	0	0	0	0	0	41,050,905	
STATE ONLY TRBHA FFS	485,972	554,086	648,232	384,912	390,178	0	0	0	0	0	0	0	2,463,381	
COCONINO COUNTY INMATES FFS	6,644	0	9,430	406	3,688	0	0	0	0	0	0	0	20,167	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	274	0	0	0	0	0	0	0	274	
PINAL COUNTY INMATES FFS	1,098	2,454	207	6,841	9,852	0	0	0	0	0	0	0	20,453	
PIMA COUNTY INMATES FFS	12,600	43,980	17,411	16,589	18,826	0	0	0	0	0	0	0	109,407	
MOHAVE COUNTY INMATES FFS	9,593	3,912	17,882	7,260	93	0	0	0	0	0	0	0	38,740	
MARICOPA CTY INMATES FFS	90,234	55,621	48,405	235,553	145,540	0	0	0	0	0	0	0	575,353	
REINSURANCE - ACC	5,981,687	7,802,788	9,070,700	8,760,856	9,365,138	0	0	0	0	0	0	0	40,981,169	
SMIB - ACC	7,812,901	7,964,388	7,976,982	8,063,683	8,087,145	0	0	0	0	0	0	0	39,905,099	
HIB - ACC	5,038	5,496	5,038	6,412	9,618	0	0	0	0	0	0	0	31,602	
SUBTOTAL	395,838,095	388,202,645	415,055,946	407,924,464	455,645,696	0	0	0	0	0	0	0	2,062,666,846	

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	52,055,416	60,925,963	0	0	0	0	0	0	0	251,509,894	
CAPITATION - AIMHS	20,082	21,970	22,899	25,231	27,092	0	0	0	0	0	0	0	117,274	
MENTAL HEALTH - ADULT	19,939	20,808	20,121	23,216	21,019	0	0	0	0	0	0	0	105,104	
MENTAL HEALTH - GENERAL	2,244	0	0	0	0	0	0	0	0	0	0	0	2,244	
MENTAL HEALTH - CMDP	818	818	818	818	818	0	0	0	0	0	0	0	4,090	
MENTAL HEALTH - RBHA CRISIS	868,177	932,013	967,642	1,379,030	1,459,650	0	0	0	0	0	0	0	5,606,511	
FEE FOR SERVICE - ACUTE	4,511,179	3,414,251	4,698,882	4,575,291	4,574,511	0	0	0	0	0	0	0	21,774,115	
FFS - PRIOR QUARTER COVERAGE	229	-303	-429	-100	0	0	0	0	0	0	0	0	-603	
EMERGENCY SERVICES - FEDERAL	5,996,983	5,467,005	8,309,800	6,955,426	7,193,409	0	0	0	0	0	0	0	33,922,623	
FFS MEDICAID IN PUBLIC SCHOOLS	63	15	0	32	129	0	0	0	0	0	0	0	239	
INPATIENT INMATES FFS	30,172	37,484	124,660	55,689	68,900	0	0	0	0	0	0	0	316,906	
STATE ONLY TRBHA FFS	37,689	53,626	54,347	35,653	40,260	0	0	0	0	0	0	0	221,576	
FFS TRBHA FEE FOR SERVICE	183,576	206,506	258,500	229,702	250,898	0	0	0	0	0	0	0	1,129,181	
PIMA COUNTY INMATES FFS	0	5,778	5,789	91	248	0	0	0	0	0	0	0	11,906	
MOHAVE COUNTY INMATES FFS	0	0	0	0	3,713	0	0	0	0	0	0	0	3,713	
MARICOPA CTY INMATES FFS	6,097	364	27,113	15,499	922	0	0	0	0	0	0	0	49,994	
REINSURANCE - ACC	746,102	1,535,864	1,471,110	1,139,421	1,741,339	0	0	0	0	0	0	0	6,633,836	
SMIB - ACC	2,314	236	6,507	5,061	6,796	0	0	0	0	0	0	0	20,913	
	55,903,926	58,281,231	64,433,213	66,495,476	76,315,669	0	0	0	0	0	0	0	321,429,516	
	1,233,793,341	1,219,752,061	1,269,545,434	1,259,615,441	1,376,186,332	0	0	0	0	0	0	0	6,358,892,608	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - RBHA CRISIS	0	0	0	25	25	0	0	0	0	0	0	0	50	
KidsCare - CAPITATION	7,336,023	7,539,106	7,723,214	7,942,714	9,458,482	0	0	0	0	0	0	0	39,999,539	
KidsCare - FEE FOR SERVICE	191,287	101,072	201,058	172,782	146,459	0	0	0	0	0	0	0	812,658	
KidsCare - MENTAL HEALTH	88,620	91,499	92,875	99,387	103,052	0	0	0	0	0	0	0	475,433	
KidsCare - REINSURANCE	232,715	302,606	167,450	496,241	289,831	0	0	0	0	0	0	0	1,488,842	
KidsCare - TRANSPLANT REIN	4,465	11,869	0	23,265	0	0	0	0	0	0	0	0	39,598	

7,853,110	8,046,152	8,184,597	8,734,413	9,997,850	0	0	0	0	0	0	0	42,816,121	

TOTAL TITLE XXI

1,241,646,451	1,227,798,213	1,277,730,031	1,268,349,854	1,386,184,181	0	0	0	0	0	0	0	6,401,708,729	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending November 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	127.65	127.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		638.25		
1005	TANF 14-20 FEMALE WI	125.69	125.69	125.69	125.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		502.76		
1006	TANF 21-44 MALE WITH	34,208.35	30,410.95	37,883.34	39,337.41	47,710.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,550.33		
1007	TANF 21-44 FEMALE WI	64,050.55	74,207.68	73,586.15	76,449.02	72,930.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		361,223.88		
1008	TANF 45-64 M & F WIT	91,922.90	99,173.42	93,750.55	90,483.60	98,517.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		473,848.01		
1009	TANF 65+ M & F WITH	18,619.51	17,597.69	17,920.88	19,023.08	24,533.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,694.75		
100F	TANF 21-44 MALE WITH	0.00	0.00	858.25	729.32	89.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,676.98		
100G	TANF 21-44 FEMALE WI	493.97	707.73	0.00	326.30	184.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,712.84		
100H	TANF 45-64 M & F WIT	3,381.21	922.03	977.36	75.15	4,236.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,592.11		
100J	TANF 65+ M & F WITH	36.22	106.99	0.00	1,282.97	97.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,524.05		
1011	TANF <1 M & F NON-ME	5,800,131.50	5,837,957.54	5,940,435.30	6,032,199.20	7,141,473.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,752,196.97		
1012	TANF 01-05 M & F NON	4,305,066.80	4,486,437.41	4,619,810.01	4,681,638.39	5,282,547.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,375,500.34		
1013	TANF 06-13 M & F NON	7,643,444.07	7,874,959.92	7,972,435.26	8,062,238.71	9,276,109.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,829,187.81		
1014	TANF 14-20 MALE NON-	2,428,936.37	2,530,935.63	2,576,408.21	2,637,263.09	3,036,109.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,209,652.53		
1015	TANF 14-20 FEMALE N O	2,918,645.44	3,046,827.74	3,099,777.20	3,153,966.53	3,652,365.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,871,582.84		
1016	TANF 21-44 MALE NON-	11,717,475.03	11,784,940.59	11,852,048.67	11,788,419.76	13,567,599.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,710,483.61		
1017	TANF 21-44 FEMALE N O	39,060,744.01	39,509,188.92	39,757,271.15	39,544,932.92	45,410,006.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,282,143.22		
1018	TANF 45-64 M & F NON	9,758,890.39	9,880,559.18	9,896,900.28	9,912,090.83	11,319,036.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,767,477.09		
1019	TANF 65+ M & F NON-M	44,019.24	45,810.05	46,464.82	47,664.09	53,240.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		237,198.69		
101A	TANF < 1 M & F NON-M	242,715.00	230,273.70	229,936.22	250,087.61	307,332.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,260,345.29		
101B	TANF 01-05 M & F NON	9,697.81	18,957.60	16,218.37	18,400.47	19,357.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,631.43		
101C	TANF 06-13 M & F NON	9,633.07	14,592.66	14,361.81	11,161.25	8,456.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,205.10		
101D	TANF 14-20 MALE NON-	7,290.83	6,053.54	8,279.74	5,207.72	9,634.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,466.39		
101E	TANF 14-20 FEMALE N O	10,602.38	10,128.91	8,502.02	29,581.84	10,086.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,902.04		
101F	TANF 21-44 MALE NON-	174,219.43	160,889.34	171,949.09	178,346.77	161,372.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		846,776.84		
101G	TANF 21-44 FEMALE N O	334,883.85	299,235.14	294,091.37	307,923.17	338,672.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,574,805.53		
101H	TANF 44-64 M & F NON	95,620.69	91,303.95	75,456.95	96,663.15	102,267.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		461,311.78		
101J	TANF 65+ N & F NON-M	591.24	157.47	0.00	255.22	194.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,198.29		
1023	TANF 06-13 M & F WIT	105.59	105.59	105.59	105.59	105.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		527.95		
1024	TANF 14-20 MALE WITH	395.17	395.17	395.17	395.17	935.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,515.96		
1025	TANF 14-20 FEMALE WI	1,970.08	1,809.68	160.40	160.40	160.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,260.96		
1026	TANF 21-44 MALE WITH	27,495.43	31,970.87	29,841.30	25,812.41	32,787.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,907.13		
1027	TANF 21-44 FEMALE WI	51,398.03	51,936.61	48,965.83	54,053.71	60,856.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		267,210.56		
1028	TANF 45-64 M & F WIT	47,878.93	52,321.27	56,029.67	56,243.02	61,965.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,437.91		
1029	TANF 65+ M & F WITH	9,549.56	10,101.57	10,252.16	10,132.18	13,022.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,057.72		
102F	TANF 21-44 MALE WITH	0.00	0.00	5.35	0.00	38.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.24		

ACC CAPITATION - AMOUNTS
For The Period Ending November 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	1.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.32		
102H	TANF 44-64 M & F WIT	48.17	0.00	0.00	89.20	23.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.37		
102J	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	7.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.78		
2100	SSI AGED WITH MEDIC A	698,506.23	694,456.55	720,278.90	704,092.75	803,007.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,620,341.46		
210Z	SSI AGED WITH MEDIC
A	28,553.28	28,195.70	38,318.15	39,628.76	32,168.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,864.79		
2110	SSI AGED NON-MEDICA R	9,047,239.54	9,208,276.25	9,378,951.72	9,457,003.26	10,904,872.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,996,343.39		
211Z	SSI AGED NON-MEDICA
R	78,808.00	103,916.29	95,545.46	134,773.51	133,598.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		546,641.57		
2120	SSI AGED WITH QMB	5,666,161.42	5,728,081.35	5,803,203.87	5,802,179.46	6,768,606.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,768,232.51		
212Z	SSI AGED WITH QMB P P	2,614.05	3,303.39	2,838.15	6,793.64	3,769.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,318.87		
2200	SSI DISABLED WITH M
E	1,988,850.90	1,937,214.60	1,946,245.23	1,961,254.15	2,162,196.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,995,761.30		
220Z	SSI DISABLED WITH M E	55,243.94	52,261.49	40,385.46	35,454.14	42,355.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225,700.49		
2210	SSI DISABLED NON-ME
D	74,206,259.51	74,247,747.94	74,375,463.22	74,268,860.45	86,039,593.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		383,137,924.15		
221Z	SSI DISABLED NON-ME D	911,078.19	674,713.13	566,425.39	609,686.10	809,063.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,570,966.53		
2220	SSI DISABLED WITH Q
M	16,027,790.55	16,001,034.33	16,063,323.26	16,015,781.06	17,935,038.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,042,967.25		
222Z	SSI DISABLED WITH Q M	15,718.28	19,520.65	12,647.71	46,279.62	29,645.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123,811.92		
2300	SSI BLIND WITH MEDIC	8,075.33	8,235.73	8,367.20	8,125.45	9,386.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,190.32		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	1,602.23	70.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,672.41		
2310	SSI BLIND NON-MEDIC A	648,301.31	652,238.19	657,275.80	656,702.16	778,583.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,393,100.88		
231Z	SSI BLIND NON-MEDIC
A	1,042.60	1,030.24	13,566.07	0.00	6,658.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,297.80		
2320	SSI BLIND WITH QMB	46,856.10	46,839.73	48,573.59	48,384.98	55,829.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246,483.70		
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	391.68	441.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,750.80		
4303	SOBRA CHILD 06-13 M	702.38	829.23	923.94	452.12	481.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,389.23		
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	34.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		362.78		
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	141.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183.09		
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	19,351,457.83	22,511,797.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,044,257.65		
4312	SOBRA CHILD 01-05 M	32,694,361.76	32,840,690.29	33,105,834.02	33,256,672.51	38,979,284.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,876,842.78		
4313	SOBRA CHILD 06-13 M	42,216,382.06	42,241,870.63	42,486,916.98	42,607,846.89	49,860,065.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		219,413,081.73		
4314	SOBRA CHILD 14-20 MA	12,240,593.41	12,293,676.11	12,420,470.10	12,509,821.83	14,548,210.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,012,771.54		
4315	SOBRA CHILD 14-20 FE	12,176,873.29	12,221,437.80	12,371,672.36	12,402,886.43	14,396,718.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,569,588.26		
431A	SOBRA CHILD < 1 M &	190,018.19	129,565.61	150,896.98	192,135.55	185,992.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		848,609.32		
431B	SOBRA CHILD 01-05 M	357,231.33	341,141.31	291,594.58	359,644.58	358,264.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,707,876.45		
431C	SOBRA CHILD 6-13 M&F	411,494.30	425,568.07	345,925.32	432,911.95	415,639.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,031,539.24		

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431D	SOBRA CHILD 14-20 MA	122,376.81	112,205.00	113,616.44	123,940.23	133,160.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		605,299.14		
431E	SOBRA CHILD 14-20 FE	118,636.97	119,719.33	94,933.92	130,882.72	138,931.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		603,104.83		
4322	SOBRA CHILD 01-05 M	160.40	160.40	160.40	160.40	160.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		802.00		
4323	SOBRA CHILD 06-13 M	260.49	406.10	92.17	0.00	164.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		923.19		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	106.78	0.00	118.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.21		
4325	SOBRA CHILD 14-20 FE	506.54	624.97	486.96	486.96	592.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,698.11		
5005	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	39.35	305.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345.09		
5007	SOBRA PREG 21-44 FE
M	6,893.89	7,623.51	6,516.39	5,660.79	12,035.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,729.86		
5008	SOBRA PREG 45-64 FE M	772.43	-2,574.76	0.00	0.00	100.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,701.48		
500E	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	134.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134.92		
500G	SOBRA PREG 21-44 FE M	1,139.63	1,754.50	140.76	2,991.67	976.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,003.30		
500H	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	125.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125.69		
5013	SOBRA PREG 09-13 FE M	379.13	187.31	219.28	374.62	423.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,583.64		
5015	SOBRA PREG 14-20 FE
M	514,099.93	500,676.68	497,532.46	467,127.47	552,643.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,532,079.65		
5017	SOBRA PREG 21-44 FE M	6,245,141.22	6,059,840.82	6,088,763.58	5,882,723.90	7,004,693.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,281,162.57		
5018	SOBRA PREG 45-64 FE
M	23,254.58	21,297.41	20,401.14	21,487.38	24,937.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,377.96		
501E	SOBRA PREG 14-20 FE M	34,772.38	24,122.66	28,034.33	27,340.33	36,472.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,742.30		
501G	SOBRA PREG 21-44 FE
M	332,215.06	294,512.36	280,017.88	302,429.47	308,992.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,518,167.62		
501H	SOBRA PREG 45-64 FE M	124.37	1,264.57	668.29	640.96	1,140.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,838.65		
5027	SOBRA PREG 21-44 FE
M	16,055.18	10,460.69	13,278.20	14,384.83	15,177.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,356.69		
5028	SOBRA PREG 45-64 FE M	160.40	1,653.54	1,653.54	1,779.23	1,779.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,025.94		
502G	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	24.33	1,214.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,238.91		
SUBTOTAL:	322,044,951.03	323,005,239.42	324,486,165.66	325,026,567.15	376,119,714.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,670,682,637.28		

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

82.50

82.50

9910	TANF & SOBRA CHILDR E	2,653,886.93	2,708,690.82	2,766,144.10	2,927,996.08	2,400,892.22	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	18,705.38	37,334.63	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	148,352.14	100,096.89	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	11,156,337.47	11,387,798.75	11,428,360.74	10,490,745.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,646,245.76	14,001,587.81	14,315,148.36	14,523,414.34	13,029,068.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
13,457,610.15	
136,643.87	
589,629.80	
56,331,581.36	
70,515,465.18	

1106	TANF EXPANDED 21-44	77,768.11	78,146.70	73,692.25	81,573.09	84,965.67	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	157,777.57	190,123.46	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	406,396.68	454,946.00	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	109,666.03	126,177.48	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	1,716.60	654.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
396,145.82	
836,482.15	
2,053,850.37	
556,678.49	
5,925.43	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110G	TANF EXPANDED 21-44	6,731.98	2,857.45	2,388.62	5,456.38	8,375.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,809.58		
110H	TANF EXPANDED 45-64	7,835.95	5,499.45	4,291.27	11,084.75	10,641.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,353.02		
110J	TANF EXPANDED 65+ M
&	4,476.66	2,261.04	5,133.05	4,275.18	4,203.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,349.37		
1112	TANF EXPANDED 01-05	0.00	0.00	187.31	187.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		374.62		
1113	TANF EXPANDED 06-13	962.28	962.28	962.28	1,151.55	1,129.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,167.42		
1114	TANF EXPANDED 14-20	41,812.36	42,972.62	43,640.81	42,110.37	50,811.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221,348.09		
1115	TANF EXPANDED 14-20	245,785.25	250,520.44	256,430.37	264,097.07	312,140.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,328,973.20		
1116	TANF EXPANDED 21-44	9,715,076.07	9,724,629.10	9,940,380.65	10,107,781.07	12,262,715.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,750,582.48		
1117	TANF EXPANDED 21-44	26,803,534.08	26,868,260.63	27,405,588.13	28,007,100.56	34,131,407.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143,215,890.88		
1118	TANF EXPANDED 45-64	9,455,016.18	9,492,588.64	9,737,788.78	9,797,115.53	11,717,319.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,199,828.43		
1119	TANF EXPANDED 65+ M
&	35,524.37	34,975.43	37,615.22	39,676.64	47,892.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,684.15		
111D	TANF EXPANDED 14-20	781.60	2,173.88	446.08	1,575.08	855.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,832.02		
111E	TANF EXPANDED 14-20	1,592.49	2,017.46	1,880.38	1,778.42	3,911.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,179.93		
111F	TANF EXPANDED 21-44	204,286.43	216,747.68	178,596.92	267,272.49	219,031.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,085,935.36		
111G	TANF EXPANDED 21-44	314,523.46	325,930.93	289,036.07	388,784.82	342,880.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,661,155.83		
111H	TANF EXPANDED 45-64	134,829.59	136,379.99	135,303.77	174,601.39	133,298.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		714,412.96		
111J	TANF EXPANDED 65+ M
&	775.08	800.34	488.36	885.08	169.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,118.52		
1126	TANF EXPANDED 21-44	289,842.11	294,104.27	293,697.14	281,613.34	331,202.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,490,459.79		
1127	TANF EXPANDED 21-44	803,571.42	783,127.12	776,510.17	768,029.59	846,689.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,977,928.22		
1128	TANF EXPANDED 45-64	908,788.13	921,716.91	944,743.19	963,077.78	1,077,010.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,815,336.88		
1129	TANF EXPANDED 65+ M
&	270,502.44	281,316.18	282,575.29	276,403.32	319,920.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,430,718.11		
112F	TANF EXPANDED 21-44	64.30	182.53	62.60	1,369.82	3,110.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,790.09		
112G	TANF EXPANDED 21-44	2,530.28	286.18	170.72	416.89	398.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,802.64		
112H	TANF EXPANDED 45-64	313.22	2,624.51	245.12	456.09	898.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,537.79		
112J	TANF EXPANDED 65+ M
&	427.57	76.34	590.44	558.14	244.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,897.07		
2400	SSI AGED EXPANDED WI	59,433.58	63,276.71	67,610.87	85,462.54	95,262.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		371,046.52		
240Z	SSI AGED EXPANDED
WI	18,916.28	18,046.02	14,866.51	28,399.79	28,340.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,568.60		
2410	SSI AGED EXPANDED N O	155,456.35	151,213.66	151,779.83	160,996.73	185,473.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		804,919.58		
241Z	SSI AGED EXPANDED N
O	4,444.93	2,379.28	5,357.08	10,154.41	9,213.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,549.54		
2420	SSI AGED EXPANDED WI	5,535,744.02	5,575,749.40	5,645,158.08	5,688,116.51	6,712,980.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,157,748.37		
242Z	SSI AGED EXPANDED
WI	2,030.09	1,629.65	4,124.86	3,366.00	5,587.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,737.61		
2520	SSI BLIND EXPANDED W	286.09	286.09	286.09	286.09	286.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,430.45		
2600	SSI DISABLED EXPAND
E	194,699.39	166,838.62	163,278.37	182,564.90	182,659.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		890,040.90		
260Z	SSI DISABLED EXPAND E	36,315.12	32,400.31	29,174.27	37,120.13	31,861.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,870.83		
2610	SSI DISABLED EXPAND
E	2,051,318.55	2,017,118.33	1,979,774.95	1,957,883.40	2,322,271.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,328,367.20		
261Z	SSI DISABLED EXPAND E	15,724.76	28,275.67	17,046.21	35,429.78	24,112.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,588.79		

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2620	SSI DISABLED EXPAND E	10,570,975.06	10,696,009.10	10,699,499.79	10,763,682.22	12,094,969.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,825,135.23		
262Z	SSI DISABLED EXPAND
E	7,115.96	4,322.14	7,130.69	7,290.87	11,264.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,124.44		
SUBTOTAL:	68,644,037.26	68,894,037.05	69,873,450.66	71,124,742.00	84,387,409.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		362,923,676.77		

3506	ADULT 40-100% MALE 2	15,405.42	19,886.36	22,180.64	26,374.81	19,321.06	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	13,028.81	18,598.03	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	212,737.55	213,144.92	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	86,715.13	100,484.02	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	2,408.65	186.44	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	455.60	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	864.41	2,746.41	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	3,929,731.28	4,611,990.20	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	4,172,515.54	4,902,104.03	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	15,834,616.99	18,879,614.08	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	13,308,157.91	15,843,296.28	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	26,976,713.65	32,156,529.40	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	4,448.81	5,783.53	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	45,334.09	60,163.94	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	72,387.24	58,746.12	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	705,433.46	506,077.91	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	486,760.78	364,290.85	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	891,240.40	642,096.19	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	5,874.37	10,877.37	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	3,239.69	5,643.74	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	4,152.84	3,158.94	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	16,808.86	16,993.10	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	3,324.47	4,986.13	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	
352G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	996.68	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	478.82	43.90	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	
3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	791.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

103,168.29	
69,164.39	
815,843.89	
393,205.21	
5,631.15	
581.21	
9,065.89	
3,133.62	
20,062,819.42	
21,400,716.98	
79,043,602.57	
66,730,210.25	
137,203,227.50	
20,647.11	
240,310.39	
294,062.05	
2,547,763.25	
1,835,899.97	
3,344,434.56	
35,507.67	
15,500.70	
16,185.51	
64,671.51	
16,704.48	
3,654.50	
996.68	
1,695.68	
19.29	
791.60	

9911	SB PAYMENT FOR TAN F	1,278,492.03	1,359,933.00	1,569,448.58	1,401,101.49	1,178,175.60	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	
SUBTOTAL:	1,284,613.86	1,359,933.00	1,569,448.58	1,401,101.49	1,178,175.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,787,150.70	
6,121.83	
6,793,272.53	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3706	ADULT <40% EXP MALE	70,944.72	74,012.52	70,943.16	76,066.53	82,562.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		374,529.01		
3707	ADULT <40% EXP FEMA L	35,324.86	37,339.03	35,225.70	40,577.84	47,161.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,629.26		
3708	ADULT <40% EXP M&F
4	220,500.37	206,912.60	217,991.28	261,456.19	284,462.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,191,323.21		
3709	ADULT <40% EXP M&F 6	20,600.74	26,685.04	27,833.71	32,640.41	38,306.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,066.05		
370F	ADULT <40% EXP MALE	1,776.23	855.45	54.98	191.66	1,157.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,035.48		
370G	ADULT <40% EXP FEMA L	2,636.84	0.00	0.00	0.00	199.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,836.60		
370H	ADULT <40% EXP M&F
4	5,140.31	933.14	1,378.20	640.04	2,469.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,561.28		
370J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	1,005.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,005.26		
3714	ADULT <40% EXP MALE	7,441,757.35	7,568,978.26	7,725,785.29	7,767,888.35	9,003,114.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,507,523.26		
3715	ADULT <40% EXP FEMA L	6,902,700.42	7,006,543.99	7,261,661.58	7,291,412.50	8,455,958.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,918,277.45		
3716	ADULT <40% EXP MALE	59,638,001.41	60,135,860.91	61,353,361.79	61,316,264.75	70,237,862.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		312,681,351.47		
3717	ADULT <40% EXP FEMA L	35,463,329.02	35,943,875.13	36,591,901.64	36,486,336.21	41,741,866.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186,227,308.52		
3718	ADULT <40% EXP M&F
4	65,114,653.61	65,609,703.54	66,355,399.84	66,216,320.93	76,760,820.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		340,056,898.85		
3719	ADULT <40% EXP M&F 6	5,512.35	5,531.31	2,599.38	4,040.23	3,898.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,581.67		
371D	ADULT <40% EXP MALE	102,373.25	109,467.88	80,941.40	119,256.26	130,095.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		542,134.69		
371E	ADULT <40% EXP FEMA L	113,577.21	96,289.88	83,381.93	74,753.01	84,962.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		452,964.71		
371F	ADULT <40% EXP MALE	1,168,212.37	998,214.87	798,037.45	1,024,881.27	1,259,540.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,248,886.89		
371G	ADULT <40% EXP FEMA L	601,167.45	611,816.20	489,530.95	673,601.10	648,399.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,024,515.57		
371H	ADULT <40% EXP M&F
4	1,053,904.90	947,039.82	703,531.66	993,710.86	1,050,643.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,748,830.72		
371J	ADULT <40% EXP M&F 6	584.18	1,263.02	2,135.90	0.00	2,830.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,813.41		
3726	ADULT <40% EXP MALE	10,048.37	12,088.47	11,869.20	12,761.36	12,482.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,250.12		
3727	ADULT <40% EXP FEMA L	6,319.38	6,966.57	10,120.61	7,529.76	7,080.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,016.58		
3728	ADULT <40% EXP M&F
4	33,140.51	41,676.52	41,169.06	45,224.96	45,067.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,278.20		
3729	ADULT <40% EXP M&F 6	0.00	0.00	1,173.22	1,173.22	1,173.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,519.66		
372F	ADULT <40% EXP MALE	96.33	0.00	22.16	334.03	190.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		643.06		
372G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	142.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.58		
372H	ADULT <40% EXP M&F
4	230.94	668.53	0.00	2,533.17	228.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,661.01		
SUBTOTAL:	239,963,208.43	242,065,543.62	246,339,300.13	249,254,945.14	288,330,802.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,265,953,799.89		

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	5,149.52	5,149.52	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	53,039.51	70,177.57	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	45,408.36	56,472.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,279.81	
18,566.47	
248,951.46	
183,531.09	

9935	BIRTH SUPP PAYMENT A	210,618.24	235,915.07	156,084.40	223,301.55	285,584.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	658,178.96	690,763.66	936,655.73	752,000.17	694,966.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	868,797.20	926,678.73	1,092,740.13	975,301.72	980,551.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,111,504.17	
3,732,565.47	
4,844,069.64	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3908	NEWLY ELIGIBLE M&F 4	340,120.37	429,700.06	499,442.22	584,811.10	648,185.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,502,258.77		
3909	NEWLY ELIGIBLE M&F
6	192,067.80	222,525.48	275,579.58	319,172.48	390,902.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,400,247.80		
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		938.17		
390G	NEWLY ELIGIBLE FEMA L	622.45	0.00	2,317.28	0.00	620.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,560.42		
390H	NEWLY ELIGIBLE M&F
4	239.56	712.18	0.00	6,199.33	206.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,357.99		
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	326.50	5,170.08	515.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,011.74		
3914	NEWLY ELIGIBLE MALE	1,899,896.05	2,049,996.66	2,145,102.51	2,349,332.05	2,707,531.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,151,859.12		
3915	NEWLY ELIGIBLE FEMA L	2,054,295.81	2,241,233.43	2,302,459.09	2,500,005.82	2,891,549.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,989,543.84		
3916	NEWLY ELIGIBLE MALE	10,088,476.23	10,938,561.26	11,379,189.42	12,271,400.40	14,312,323.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,989,951.21		
3917	NEWLY ELIGIBLE FEMA L	13,851,533.45	14,904,369.11	15,598,169.06	16,835,925.24	19,970,399.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,160,396.73		
3918	NEWLY ELIGIBLE M&F
4	13,941,720.12	14,662,403.58	15,065,023.96	15,840,419.78	18,624,493.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,134,060.95		
3919	NEWLY ELIGIBLE M&F 6	13,663.01	17,931.30	20,405.76	25,307.77	26,981.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,289.46		
391D	NEWLY ELIGIBLE MALE	13,184.76	8,885.91	11,360.15	13,647.16	16,653.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,731.29		
391E	NEWLY ELIGIBLE FEMA L	16,950.75	13,468.02	18,341.54	23,649.15	18,869.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,278.94		
391F	NEWLY ELIGIBLE MALE	135,369.09	130,953.43	131,414.33	170,114.12	184,510.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		752,361.91		
391G	NEWLY ELIGIBLE FEMA L	181,738.61	169,552.74	163,822.96	220,989.09	205,993.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		942,096.53		
391H	NEWLY ELIGIBLE M&F
4	182,177.20	163,889.96	174,697.01	225,336.67	205,745.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		951,846.81		
391J	NEWLY ELIGIBLE M&F 6	469.96	0.00	0.00	1,641.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,111.84		
3926	NEWLY ELIGIBLE MALE	0.00	429.33	429.33	858.13	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,291.55		
3927	NEWLY ELIGIBLE FEMA L	410.47	410.47	410.47	410.47	410.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,052.35		
3928	NEWLY ELIGIBLE M&F
4	8,251.79	6,959.14	4,453.54	3,489.05	4,585.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,738.97		
3929	NEWLY ELIGIBLE M&F 6	6,936.70	8,708.80	11,214.40	14,098.44	17,562.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,521.11		
SUBTOTAL:	42,987,752.35	46,045,074.67	47,888,017.45	51,515,575.60	60,362,416.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248,798,836.33		

2,711,057.29

9939	BIRTH SUPP PAYMENT N	490,509.99	539,722.93	577,436.35	539,840.82	563,547.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	490,509.99	539,722.93	577,436.35	539,840.82	563,547.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,711,057.29

4403	SOBRA 100-133% M&F
6	131.47	131.47	-4.19	125.69	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	38.20	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	192.25	379.56	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	7,818,343.56	9,271,514.46	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	2,339,817.74	2,771,932.40	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	2,314,842.88	2,737,070.82	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	94,406.07	78,823.45	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	33,219.88	23,438.22	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	29,525.85	26,824.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

384.44	
275.06	
1,335.87	
39,822,167.73	
11,876,650.00	
11,721,751.07	
192.25	
419,397.49	
121,652.90	
120,711.06	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4424	SOBRA 100-133% MALE	0.00	0.00	253.23	228.39	134.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		616.42		
SUBTOTAL:	11,959,101.84	12,267,905.41	12,317,268.42	12,630,740.51	14,910,118.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,085,134.29		

9944	BIRTH SUPP PAYMENT S	55,894.09	49,462.55	68,820.88	49,405.12	62,514.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	55,894.09	49,462.55	68,820.88	49,405.12	62,514.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
286,096.99

286,096.99

4517	BC PATIENT FEMALE 2 1	9,097.90	8,834.23	7,900.73	8,080.65	9,388.70	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	49,639.77	57,868.07	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	1,434.26	1,416.05	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	3.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4 5	1,456.34	73.35	56.78	1,557.56	1,919.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451J	BC PATIENT FEMALE 6
5	728.94	112.04	290.00	149.40	401.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	4,041.35	3,675.43	3,675.43	3,813.77	4,809.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	3,442.67	3,376.09	3,098.68	2,754.69	3,242.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	1,031.24	71.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	71,516.53	68,951.84	65,580.23	68,461.34	79,121.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
43,302.21	
260,179.18	
5,158.67	
1,212.64	
5,063.34	
1,681.74	
20,015.45	
15,915.08	
1,103.11	
353,631.42	

8600	SSI BLIND FREEDOM/W O	138.01	138.01	138.01	138.01	174.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	1,157.06	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	131.47	165.93	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	1,617,999.09	1,735,140.60	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	22,948.41	11,544.30	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	430,461.81	512,519.36	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	5,561.87	18,754.64	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	364,612.98	390,329.46	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	959.83	1,298.19	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	2,442,813.47	2,671,083.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
726.09	
1,157.06	
691.81	
8,240,270.57	
188,298.92	
2,251,056.66	
60,567.70	
1,718,571.42	
25,909.86	
12,487,250.09	

3,710,435,010.20

705,453,681.98	711,712,460.09	721,041,402.68	729,552,925.20	842,674,540.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1005	TANF 14-20 FEMALE WI	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1006	TANF 21-44 MALE WITH	92.99	97.90	104.66	114.77	113.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		523.32		
1007	TANF 21-44 FEMALE WI	145.30	153.47	155.45	158.47	157.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		770.57		
1008	TANF 45-64 M & F WIT	255.43	265.88	252.84	268.38	270.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,312.98		
1009	TANF 65+ M & F WITH	140.77	131.12	132.19	139.69	148.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		692.00		
100F	TANF 21-44 MALE WITH	0.00	0.00	0.33	0.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.09		
100G	TANF 21-44 FEMALE WI	4.07	3.26	0.00	2.64	0.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.79		
100H	TANF 45-64 M & F WIT	5.44	4.13	0.82	0.51	3.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.16		
100J	TANF 65+ M & F WITH	0.22	0.83	0.00	9.27	0.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.08		
1011	TANF <1 M & F NON-ME	9,967.97	10,033.35	10,215.41	10,365.23	10,578.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,160.24		
1012	TANF 01-05 M & F NON	22,748.91	23,698.77	24,378.23	24,702.21	24,372.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,900.22		
1013	TANF 06-13 M & F NON	40,609.15	41,832.31	42,322.08	42,810.00	42,807.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210,380.83		
1014	TANF 14-20 MALE NON-	12,185.14	12,707.76	12,916.79	13,207.97	13,352.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,370.02		
1015	TANF 14-20 FEMALE N O	14,651.75	15,257.59	15,479.10	15,735.15	15,972.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,096.46		
1016	TANF 21-44 MALE NON-	29,701.60	29,950.91	30,106.97	29,962.86	29,545.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,268.19		
1017	TANF 21-44 FEMALE N O	97,525.08	98,767.87	99,402.21	98,825.42	97,392.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		491,913.55		
1018	TANF 45-64 M & F NON	24,328.23	24,621.10	24,701.08	24,726.98	24,438.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,815.70		
1019	TANF 65+ M & F NON-M	106.20	110.31	111.99	115.25	116.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		559.75		
101A	TANF < 1 M & F NON-M	408.59	392.69	383.85	421.02	439.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,046.05		
101B	TANF 01-05 M & F NON	50.14	93.74	86.90	93.82	80.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		404.80		
101C	TANF 06-13 M & F NON	39.75	62.71	66.29	58.28	26.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253.60		
101D	TANF 14-20 MALE NON-	35.79	20.42	37.63	26.42	23.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144.00		
101E	TANF 14-20 FEMALE N O	42.02	48.07	34.57	69.68	34.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228.96		
101F	TANF 21-44 MALE NON-	454.24	407.09	422.47	475.99	308.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,068.44		
101G	TANF 21-44 FEMALE N O	853.19	772.51	698.93	802.90	642.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,769.80		
101H	TANF 44-64 M & F NON	252.90	239.96	197.12	227.87	216.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,134.27		
101J	TANF 65+ N & F NON-M	1.41	0.41	0.00	0.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.56		
1023	TANF 06-13 M & F WIT	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1024	TANF 14-20 MALE WITH	3.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
1025	TANF 14-20 FEMALE WI	3.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1026	TANF 21-44 MALE WITH	77.86	83.00	78.26	79.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		402.12		
1027	TANF 21-44 FEMALE WI	125.63	134.24	120.36	128.99	134.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		644.11		
1028	TANF 45-64 M & F WIT	141.96	154.96	155.19	145.92	161.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		759.82		
1029	TANF 65+ M & F WITH	60.00	63.99	65.00	65.00	73.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		326.99		
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 November 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	0.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.73		
102J	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	4,402.33	4,355.48	4,357.54	4,400.47	4,413.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,928.84		
210Z	SSI AGED WITH MEDIC
A	169.67	173.31	137.41	212.10	151.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		843.60		
2110	SSI AGED NON-MEDICA R	7,270.07	7,396.14	7,535.71	7,598.51	7,670.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,471.06		
211Z	SSI AGED NON-MEDICA
R	62.71	82.74	77.48	108.98	90.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		422.16		
2120	SSI AGED WITH QMB	34,634.33	34,813.15	35,177.05	35,203.19	35,582.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,410.66		
212Z	SSI AGED WITH QMB P P	16.83	21.69	12.66	33.68	19.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.39		
2200	SSI DISABLED WITH M
E	3,956.99	3,848.61	3,898.41	3,962.70	3,956.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,623.47		
220Z	SSI DISABLED WITH M E	113.49	98.84	94.51	124.53	75.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		507.31		
2210	SSI DISABLED NON-ME
D	53,599.11	53,645.97	53,764.31	53,666.54	53,988.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268,664.29		
221Z	SSI DISABLED NON-ME D	681.38	520.46	454.89	480.68	544.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,682.04		
2220	SSI DISABLED WITH Q
M	27,326.19	27,348.70	27,447.82	27,358.83	27,508.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,990.39		
222Z	SSI DISABLED WITH Q M	34.06	46.23	10.53	40.27	32.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163.44		
2300	SSI BLIND WITH MEDIC	31.00	32.00	33.00	31.24	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.24		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	12.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.19		
2310	SSI BLIND NON-MEDIC A	508.77	511.94	515.61	515.38	520.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,571.88		
231Z	SSI BLIND NON-MEDIC
A	0.86	0.83	10.96	0.00	4.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.34		
2320	SSI BLIND WITH QMB	239.00	239.00	240.89	239.72	241.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,199.61		
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	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.78		
4303	SOBRA CHILD 06-13 M	5.67	7.00	7.55	3.87	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.09		
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	1.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.44		
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	33,290.65	32,751.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167,883.24		
4312	SOBRA CHILD 01-05 M	170,887.21	171,552.77	172,827.65	173,596.73	174,740.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		863,604.39		
4313	SOBRA CHILD 06-13 M	221,804.59	221,802.86	222,997.40	223,637.96	224,258.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,114,500.89		
4314	SOBRA CHILD 14-20 MA	63,319.53	63,590.59	64,243.95	64,706.68	65,180.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321,041.23		
4315	SOBRA CHILD 14-20 FE	62,977.93	63,153.10	63,923.41	64,163.10	64,530.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318,747.68		
431A	SOBRA CHILD < 1 M &	319.74	215.94	255.21	324.96	263.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,379.03		
431B	SOBRA CHILD 01-05 M	1,808.16	1,704.58	1,492.02	1,877.06	1,303.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,185.63		
431C	SOBRA CHILD 6-13 M&F	2,057.63	2,155.03	1,747.51	2,264.80	1,599.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,824.22		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431D	SOBRA CHILD 14-20 MA	601.41	556.54	569.42	637.79	519.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,885.15		
431E	SOBRA CHILD 14-20 FE	594.22	592.22	474.55	659.54	513.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,833.99		
4322	SOBRA CHILD 01-05 M	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4323	SOBRA CHILD 06-13 M	2.00	3.00	0.73	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.73		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.73	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.73		
4325	SOBRA CHILD 14-20 FE	4.00	5.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
5005	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.22	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.22		
5007	SOBRA PREG 21-44 FE
M	30.43	26.35	31.22	23.69	22.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134.21		
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		
500E	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.77		
500G	SOBRA PREG 21-44 FE M	1.34	4.36	0.96	5.17	3.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.28		
500H	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
5013	SOBRA PREG 09-13 FE M	2.00	1.00	1.16	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.16		
5015	SOBRA PREG 14-20 FE
M	2,610.55	2,511.48	2,498.96	2,351.48	2,311.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,283.92		
5017	SOBRA PREG 21-44 FE M	16,020.96	15,581.20	15,626.31	15,147.90	14,968.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,345.25		
5018	SOBRA PREG 45-64 FE
M	53.65	53.95	51.26	48.12	45.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252.77		
501E	SOBRA PREG 14-20 FE M	156.70	121.80	140.80	144.01	158.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		721.66		
501G	SOBRA PREG 21-44 FE
M	871.36	768.53	729.64	809.62	642.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,821.57		
501H	SOBRA PREG 45-64 FE M	0.32	3.02	1.73	1.86	2.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.12		
5027	SOBRA PREG 21-44 FE
M	32.00	31.00	33.32	32.77	29.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.91		
5028	SOBRA PREG 45-64 FE M	1.00	2.00	2.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
502G	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.19	1.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.35		
SUBTOTAL:	966,646.72	971,682.15	977,538.93	981,480.96	980,201.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,877,550.58		

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

5.00

5.00

9910	TANF & SOBRA CHILDR E	427.00	437.00	446.00	472.00	387.00	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	3.00	6.00	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	24.00	16.00	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	1,796.00	1,833.00	1,841.00	1,690.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,359.00	2,255.00	2,305.00	2,340.00	2,099.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,169.00	
22.00	
95.00	
9,072.00	
11,358.00	

1106	TANF EXPANDED 21-44	227.00	225.92	225.15	235.16	232.29	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	418.40	433.34	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	1,322.09	1,346.47	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	783.59	793.48	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	11.99	0.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,145.52	
2,087.23	
6,551.32	
3,869.93	
30.88	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
110G	TANF EXPANDED 21-44	16.14	17.36	8.32	15.69	8.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.34		
110H	TANF EXPANDED 45-64	26.62	24.59	20.10	21.56	16.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109.54		
110J	TANF EXPANDED 65+ M
&	29.91	16.58	35.00	29.87	28.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.77		
1112	TANF EXPANDED 01-05	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1113	TANF EXPANDED 06-13	5.00	5.00	5.00	6.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.00		
1114	TANF EXPANDED 14-20	222.16	227.73	231.77	223.59	229.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,135.16		
1115	TANF EXPANDED 14-20	1,271.74	1,297.44	1,327.55	1,354.17	1,355.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,606.64		
1116	TANF EXPANDED 21-44	25,405.97	25,442.76	25,998.25	26,415.31	26,944.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,206.91		
1117	TANF EXPANDED 21-44	68,847.72	68,996.75	70,356.88	71,863.02	73,769.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		353,833.79		
1118	TANF EXPANDED 45-64	24,345.36	24,411.74	25,022.65	25,166.57	25,452.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,398.91		
1119	TANF EXPANDED 65+ M
&	93.93	92.74	99.73	105.57	113.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		504.97		
111D	TANF EXPANDED 14-20	3.85	11.16	2.18	8.88	2.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.64		
111E	TANF EXPANDED 14-20	8.59	10.15	9.59	9.28	13.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.58		
111F	TANF EXPANDED 21-44	527.07	554.56	476.99	721.70	473.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,753.77		
111G	TANF EXPANDED 21-44	799.18	794.50	755.43	1,024.24	673.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,046.57		
111H	TANF EXPANDED 45-64	349.43	359.79	348.87	446.08	270.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,774.40		
111J	TANF EXPANDED 65+ M
&	2.06	2.00	1.26	2.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.73		
1126	TANF EXPANDED 21-44	722.06	727.52	731.20	710.57	721.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,613.11		
1127	TANF EXPANDED 21-44	1,603.40	1,607.75	1,616.90	1,609.06	1,600.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,037.74		
1128	TANF EXPANDED 45-64	2,621.04	2,658.82	2,699.09	2,729.75	2,729.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,438.09		
1129	TANF EXPANDED 65+ M
&	1,690.93	1,729.98	1,748.02	1,769.92	1,798.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,737.38		
112F	TANF EXPANDED 21-44	0.51	1.32	0.46	10.63	2.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.50		
112G	TANF EXPANDED 21-44	1.89	1.69	1.22	2.08	1.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.14		
112H	TANF EXPANDED 45-64	2.83	3.78	1.76	4.14	3.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.20		
112J	TANF EXPANDED 65+ M
&	3.16	0.58	4.22	4.47	0.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.12		
2400	SSI AGED EXPANDED WI	316.62	315.33	357.77	433.30	447.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,870.69		
240Z	SSI AGED EXPANDED
WI	124.04	118.66	103.52	193.94	150.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		690.84		
2410	SSI AGED EXPANDED N O	126.45	121.59	121.94	130.58	135.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		635.86		
241Z	SSI AGED EXPANDED N
O	3.74	1.86	4.02	8.29	6.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.68		
2420	SSI AGED EXPANDED WI	27,810.16	28,078.05	28,360.82	28,477.16	28,952.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,678.68		
242Z	SSI AGED EXPANDED
WI	15.79	12.67	16.48	25.22	24.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94.55		
2520	SSI BLIND EXPANDED W	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
2600	SSI DISABLED EXPAND
E	399.04	387.48	389.19	441.66	428.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,045.82		
260Z	SSI DISABLED EXPAND E	70.71	74.48	62.08	69.12	61.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338.17		
2610	SSI DISABLED EXPAND
E	1,609.01	1,581.73	1,552.13	1,534.93	1,546.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,824.68		
261Z	SSI DISABLED EXPAND E	12.50	23.37	14.40	30.05	14.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.07		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2620	SSI DISABLED EXPAND E	16,636.88	16,747.92	16,787.51	16,809.91	16,860.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,843.04		
262Z	SSI DISABLED EXPAND
E	16.92	14.28	10.74	12.95	12.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.80		
SUBTOTAL:	178,461.58	179,154.57	181,997.55	185,195.90	187,667.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		912,476.76		

3506	ADULT 40-100% MALE 2	17.00	21.63	24.12	28.06	22.00	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	15.00	17.00	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	289.79	286.80	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	124.00	135.99	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	0.93	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	1.35	1.06	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	5,912.32	5,980.99	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	6,260.97	6,337.15	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	22,836.09	23,931.27	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	19,249.36	20,113.29	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	39,989.83	40,891.97	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	7.00	8.00	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	68.14	79.12	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	110.12	72.25	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	1,037.89	689.23	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	711.35	473.83	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	1,341.09	843.71	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	10.00	16.00	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	2.00	4.00	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	1.61	2.00	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	19.00	20.00	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	5.00	8.00	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	
352G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.38	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	0.29	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	
3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

112.81	
75.50	
1,096.15	
554.12	
3.89	
0.22	
6.86	
4.59	
29,204.18	
31,125.68	
110,634.66	
93,793.96	
196,806.79	
31.30	
347.58	
426.92	
3,681.52	
2,632.70	
4,872.65	
54.70	
11.58	
8.60	
76.00	
26.00	
1.41	
0.38	
1.77	
0.03	
1.00	

9911	SB PAYMENT FOR TAN F	206.00	219.00	253.00	226.00	190.00	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	
SUBTOTAL:	207.00	219.00	253.00	226.00	190.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,094.00	
1.00	
1,095.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3706	ADULT <40% EXP MALE	65.26	66.99	67.72	72.12	72.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		344.48		
3707	ADULT <40% EXP FEMA L	27.25	28.00	26.75	29.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147.00		
3708	ADULT <40% EXP M&F
4	261.27	253.17	272.70	325.64	341.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,454.62		
3709	ADULT <40% EXP M&F 6	31.00	40.00	40.00	48.08	54.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213.08		
370F	ADULT <40% EXP MALE	0.95	0.99	0.03	0.09	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.89		
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		1.73		
370H	ADULT <40% EXP M&F
4	3.91	1.41	2.12	1.01	2.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.01		
370J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	1.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.50		
3714	ADULT <40% EXP MALE	11,053.83	11,244.89	11,488.75	11,559.82	11,682.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,030.26		
3715	ADULT <40% EXP FEMA L	10,253.38	10,408.82	10,790.14	10,828.38	10,936.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,217.35		
3716	ADULT <40% EXP MALE	81,347.38	82,165.91	83,817.78	83,862.39	84,144.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415,338.27		
3717	ADULT <40% EXP FEMA L	47,777.98	48,506.24	49,403.48	49,379.80	49,457.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,524.64		
3718	ADULT <40% EXP M&F
4	90,788.49	91,545.33	92,557.09	92,363.75	92,631.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		459,886.17		
3719	ADULT <40% EXP M&F 6	7.00	7.00	4.00	6.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.00		
371D	ADULT <40% EXP MALE	144.10	161.65	121.70	186.68	147.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		761.64		
371E	ADULT <40% EXP FEMA L	165.29	140.83	123.09	111.42	93.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		634.04		
371F	ADULT <40% EXP MALE	1,606.51	1,390.67	1,091.87	1,515.05	1,505.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,109.62		
371G	ADULT <40% EXP FEMA L	864.79	874.26	692.27	961.90	740.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,134.06		
371H	ADULT <40% EXP M&F
4	1,532.85	1,349.05	1,020.61	1,444.35	1,234.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,581.59		
371J	ADULT <40% EXP M&F 6	1.00	2.00	3.00	0.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
3726	ADULT <40% EXP MALE	8.00	11.22	10.68	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53.90		
3727	ADULT <40% EXP FEMA L	7.00	8.00	9.99	9.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.99		
3728	ADULT <40% EXP M&F
4	34.00	45.95	43.00	49.73	53.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		226.44		
3729	ADULT <40% EXP M&F 6	0.00	0.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
372F	ADULT <40% EXP MALE	0.06	0.00	0.03	0.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.60		
372G	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		
372H	ADULT <40% EXP M&F
4	0.32	0.99	0.00	4.40	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.77		
SUBTOTAL:	337,007.15	340,209.02	346,246.67	350,796.19	353,100.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,727,359.20		

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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	44.12	55.77	58.00	71.00	92.00	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	54.00	63.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3.00	
8.26	
320.89	
217.89	

9935	BIRTH SUPP PAYMENT A	34.00	38.00	25.00	36.00	46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	106.00	111.00	151.00	121.00	112.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	140.00	149.00	176.00	157.00	158.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
179.00	
601.00	
780.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3908	NEWLY ELIGIBLE M&F 4	667.68	818.49	919.22	1,076.97	1,177.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,659.55		
3909	NEWLY ELIGIBLE M&F
6	416.57	489.92	615.59	712.70	853.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,087.95		
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		2.19		
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		2.35		
390H	NEWLY ELIGIBLE M&F
4	0.57	1.57	0.00	11.23	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.40		
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.83	12.61	0.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.37		
3914	NEWLY ELIGIBLE MALE	4,343.06	4,693.16	4,912.59	5,363.27	5,634.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,946.59		
3915	NEWLY ELIGIBLE FEMA L	4,680.17	5,098.94	5,243.82	5,690.96	5,965.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,679.01		
3916	NEWLY ELIGIBLE MALE	21,942.82	23,709.36	24,635.82	26,538.89	28,013.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,840.70		
3917	NEWLY ELIGIBLE FEMA L	30,421.79	32,719.36	34,193.85	36,849.49	39,250.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173,435.46		
3918	NEWLY ELIGIBLE M&F
4	30,261.50	31,823.14	32,676.26	34,354.05	35,792.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164,907.11		
3919	NEWLY ELIGIBLE M&F 6	32.00	42.00	47.99	59.00	63.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243.99		
391D	NEWLY ELIGIBLE MALE	30.13	20.32	25.30	32.09	29.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137.14		
391E	NEWLY ELIGIBLE FEMA L	38.63	25.82	41.44	52.52	30.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188.83		
391F	NEWLY ELIGIBLE MALE	308.08	288.17	291.62	390.67	335.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,613.98		
391G	NEWLY ELIGIBLE FEMA L	384.30	361.56	371.61	509.50	338.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,965.81		
391H	NEWLY ELIGIBLE M&F
4	398.00	367.30	378.20	515.08	367.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,026.20		
391J	NEWLY ELIGIBLE M&F 6	1.00	0.00	0.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
3926	NEWLY ELIGIBLE MALE	0.00	1.00	1.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
3927	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
3928	NEWLY ELIGIBLE M&F
4	19.00	16.00	10.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.00		
3929	NEWLY ELIGIBLE M&F 6	16.00	20.00	26.00	33.00	41.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.00		
SUBTOTAL:	94,039.60	100,589.52	104,492.12	112,344.03	118,063.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		529,528.67		

437.00

9939	BIRTH SUPP PAYMENT N	79.00	87.00	93.00	87.00	91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	79.00	87.00	93.00	87.00	91.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

437.00

4403	SOBRA 100-133% M&F
6	1.00	1.00	-0.04	1.00	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	0.32	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	1.00	2.00	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	41,515.38	42,021.70	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	12,374.70	12,597.84	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	12,155.06	12,384.68	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	496.24	270.80	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	175.33	84.78	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	156.37	109.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.96	
2.32	
7.00	
204,305.85	
60,807.08	
59,453.69	
1.00	
2,011.60	
589.91	
591.28	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4424	SOBRA 100-133% MALE	0.00	0.00	2.00	1.67	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.67		
SUBTOTAL:	63,325.74	64,946.16	65,156.10	66,877.07	67,472.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327,777.36		

4517	BC PATIENT FEMALE 2 1	24.57	23.72	21.53	22.00	21.00	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	132.05	131.62	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	3.61	3.65	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	
451H	BC PATIENT FEMALE 4 5	3.40	0.18	0.13	4.03	4.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451J	BC PATIENT FEMALE 6
5	1.82	0.28	0.86	0.37	1.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	5.00	4.00	4.00	4.35	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	9.00	8.80	8.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	2.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	183.87	177.73	168.94	176.05	173.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

112.82	
669.82	
13.24	
3.12	
12.08	
4.38	
22.35	
39.80	
2.64	
880.25	

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO
M	2,191.36	2,199.68	2,207.03	2,212.61	2,218.74	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	57.66	15.22	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	323.25	323.81	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	4.79	10.79	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	479.28	484.70	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	7.54	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,991.80	3,049.32	3,050.34	3,087.13	3,056.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.00	
1.00	
5.00	
11,029.42	
241.21	
1,622.78	
44.32	
2,265.56	
20.62	
15,234.91	

9944	BIRTH SUPP PAYMENT S	9.00	8.00	11.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9.00	8.00	11.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
46.00

46.00

TOTAL:	1,645,451.46	1,662,527.47	1,681,489.65	1,702,776.33	1,712,283.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,404,528.73		

ACUTE CAPITATION - AMERICAN INDIAN A - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.18		
1018	TANF 45-64 M & F NON	15.18	15.18	15.18	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.90		
2110	SSI AGED NON-MEDICA R	0.00	15.18	15.18	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.72		
2120	SSI AGED WITH QMB	0.00	0.00	15.18	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.54		
2220	SSI DISABLED WITH Q M	0.00	15.18	15.18	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.72		
4312	SOBRA CHILD 01-05 M	15.18	15.18	15.18	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.90		
4313	SOBRA CHILD 06-13 M	0.00	15.18	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.54		
SUBTOTAL:	30.36	75.90	91.08	91.08	91.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		379.50		

1117	TANF EXPANDED 21-44	0.00	15.18	15.18	15.18	15.18	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	15.18	15.18	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	30.36	30.36	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	15.18	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15.18	75.90	75.90	75.90	75.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
60.72	
60.72	
136.62	
60.72	
318.78	

3516	ADULT 40-100% MALE 2	0.00	15.18	15.18	15.18	15.18	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	15.18	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	30.36	30.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	30.36	45.54	45.54	60.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
60.72	
15.18	
15.18	
91.08	
182.16	

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

 
60.72	
60.72	
121.44	

1,001.88

45.54	212.52	242.88	242.88	258.06	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 November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1018	TANF 45-64 M & F NON	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2110	SSI AGED NON-MEDICA R	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
2120	SSI AGED WITH QMB	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2220	SSI DISABLED WITH Q M	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4312	SOBRA CHILD 01-05 M	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4313	SOBRA CHILD 06-13 M	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	2.00	5.00	6.00	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		

3516	ADULT 40-100% MALE 2	0.00	1.00	1.00	1.00	1.00	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	1.00	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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	2.00	3.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00	
1.00	
1.00	
6.00	
12.00	

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

4.00	
4.00	
8.00	

1117	TANF EXPANDED 21-44	0.00	1.00	1.00	1.00	1.00	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	1.00	1.00	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	2.00	2.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1.00	5.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
4.00	
4.00	
9.00	
4.00	
21.00	

TOTAL:	3.00	14.00	16.00	16.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.00		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 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	17.46	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157.14		
1009	TANF 65+ M & F WITH	69.84	87.30	87.30	69.84	52.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		366.66		
1011	TANF <1 M & F NON-ME	1,571.40	1,571.40	1,693.62	1,711.08	1,536.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,083.98		
1012	TANF 01-05 M & F NON	2,636.46	2,531.70	2,566.62	2,758.68	2,828.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,321.98		
1013	TANF 06-13 M & F NON	2,688.84	2,811.06	3,055.50	3,055.50	2,828.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,439.42		
1014	TANF 14-20 MALE NON-	506.34	628.56	698.40	733.32	750.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,317.40		
1015	TANF 14-20 FEMALE N O	1,257.12	1,292.04	1,169.82	1,082.52	1,117.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,918.94		
1016	TANF 21-44 MALE NON-	3,265.02	3,299.94	3,422.16	3,369.78	3,282.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,639.38		
1017	TANF 21-44 FEMALE N O	11,226.78	11,261.70	11,296.62	11,209.32	11,314.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,308.50		
1018	TANF 45-64 M & F NON	4,225.32	4,172.94	4,103.10	4,295.16	4,138.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,934.54		
1019	TANF 65+ M & F NON-M	34.92	34.92	34.92	34.92	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.60		
1028	TANF 45-64 M & F WIT	17.46	34.92	69.84	52.38	52.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		226.98		
1029	TANF 65+ M & F WITH	17.46	17.46	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.30		
2100	SSI AGED WITH MEDIC A	122.22	122.22	139.68	139.68	139.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		663.48		
2110	SSI AGED NON-MEDICA
R	174.60	192.06	209.52	244.44	261.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,082.52		
2120	SSI AGED WITH QMB	1,693.62	1,676.16	1,658.70	1,641.24	1,658.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,328.42		
2200	SSI DISABLED WITH M E	576.18	593.64	646.02	611.10	558.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,985.66		
2210	SSI DISABLED NON-ME
D	10,004.58	9,847.44	9,725.22	9,760.14	9,969.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,307.04		
2220	SSI DISABLED WITH Q M	3,561.84	3,544.38	3,474.54	3,544.38	3,614.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,739.36		
2300	SSI BLIND WITH MEDIC	0.00	0.00	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.38		
2310	SSI BLIND NON-MEDIC A	87.30	87.30	69.84	69.84	69.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.12		
2320	SSI BLIND WITH QMB	17.46	17.46	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.30		
4311	SOBRA CHILD <1 M & F	5,045.94	4,923.72	5,150.70	5,028.48	4,836.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,985.26		
4312	SOBRA CHILD 01-05 M	24,758.28	25,351.92	25,247.16	25,212.24	25,631.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,200.88		
4313	SOBRA CHILD 06-13 M	23,710.68	23,815.44	23,955.12	23,763.06	24,094.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,339.10		
4314	SOBRA CHILD 14-20 MA	5,674.50	5,709.42	5,884.02	6,006.24	6,058.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,332.80		
4315	SOBRA CHILD 14-20 FE	5,953.86	6,023.70	6,023.70	6,128.46	6,198.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,328.02		
5015	SOBRA PREG 14-20 FE M	244.44	157.14	174.60	157.14	174.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		907.92		
5017	SOBRA PREG 21-44 FE
M	1,030.14	907.92	942.84	907.92	1,047.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,836.42		
SUBTOTAL:	110,207.52	110,748.78	111,586.86	111,656.70	112,337.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		556,537.50		

1107	TANF EXPANDED 21-44	17.46	17.46	17.46	17.46	17.46	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	139.68	139.68	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	226.98	226.98	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	17.46	17.46	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	122.22	104.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
87.30	
715.86	
1,012.68	
104.76	
453.96	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 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	1,728.54	1,798.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,904.60		
1117	TANF EXPANDED 21-44	5,639.58	5,622.12	5,709.42	5,849.10	5,622.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,442.34		
1118	TANF EXPANDED 45-64	2,898.36	2,950.74	2,985.66	2,811.06	2,880.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,526.72		
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	122.22	104.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611.10		
1127	TANF EXPANDED 21-44	69.84	52.38	52.38	52.38	52.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		279.36		
1128	TANF EXPANDED 45-64	419.04	488.88	488.88	488.88	541.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,426.94		
1129	TANF EXPANDED 65+ M
&	331.74	331.74	331.74	366.66	349.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,711.08		
2400	SSI AGED EXPANDED WI	52.38	34.92	34.92	34.92	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192.06		
2410	SSI AGED EXPANDED N
O	17.46	17.46	17.46	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.30		
2420	SSI AGED EXPANDED WI	2,409.48	2,426.94	2,409.48	2,444.40	2,479.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,169.62		
2600	SSI DISABLED EXPAND
E	34.92	17.46	17.46	52.38	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157.14		
2610	SSI DISABLED EXPAND E	261.90	244.44	226.98	174.60	157.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,065.06		
2620	SSI DISABLED EXPAND
E	1,012.68	1,082.52	1,134.90	1,117.44	1,134.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,482.44		
SUBTOTAL:	15,679.08	15,591.78	15,696.54	15,783.84	15,714.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,465.24		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	69.84	69.84	104.76	104.76	139.68	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	34.92	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

34.92	
488.88	
174.60	

3508	ADULT 40-100% M&F 45	34.92	34.92	34.92	34.92	52.38	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	17.46	17.46	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	244.44	244.44	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	384.12	366.66	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	1,274.58	1,292.04	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	960.30	995.22	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	3,404.70	3,352.32	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	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	17.46	17.46	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	890.46	942.84	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	890.46	960.30	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	9,742.68	9,760.14	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	5,569.74	5,552.28	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	11,855.34	11,995.02	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	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	33,872.40	33,680.34	34,588.26	35,304.12	35,566.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
192.06	
87.30	
1,204.74	
1,658.70	
6,180.84	
4,993.56	
17,058.42	
34.92	
52.38	
34.92	
4,277.70	
4,225.32	
47,561.04	
27,551.88	
57,862.44	
34.92	
173,011.14	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	104.76	122.22	104.76	139.68	139.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611.10		
3915	NEWLY ELIGIBLE FEMA L	192.06	226.98	209.52	174.60	192.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		995.22		
3916	NEWLY ELIGIBLE MALE	1,204.74	1,309.50	1,309.50	1,414.26	1,466.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,704.64		
3917	NEWLY ELIGIBLE FEMA L	1,606.32	1,798.38	1,798.38	1,972.98	2,217.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,393.48		
3918	NEWLY ELIGIBLE M&F
4	2,619.00	2,741.22	2,741.22	2,950.74	3,160.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,212.44		
SUBTOTAL:	5,831.64	6,303.06	6,303.06	6,809.40	7,368.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,615.28		

4413	SOBRA 100-133% M&F
6	2,444.40	2,252.34	2,304.72	2,234.88	2,199.96	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	698.40	820.62	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	646.02	646.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,649.14	3,492.00	3,579.30	3,579.30	3,666.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,436.30	
3,579.30	
2,950.74	
17,966.34	

4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	17.46	17.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 

34.92

34.92

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

 
436.50	
87.30	
87.30	
611.10	

859,241.52

169,362.00	169,938.18	171,876.24	173,273.04	174,792.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending November 30, 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	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1009	TANF 65+ M & F WITH	4.00	5.00	5.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
1011	TANF <1 M & F NON-ME	90.00	90.00	97.00	98.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		463.00		
1012	TANF 01-05 M & F NON	151.00	145.00	147.00	158.00	162.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		763.00		
1013	TANF 06-13 M & F NON	154.00	161.00	175.00	175.00	162.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		827.00		
1014	TANF 14-20 MALE NON-	29.00	36.00	40.00	42.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190.00		
1015	TANF 14-20 FEMALE N O	72.00	74.00	67.00	62.00	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		339.00		
1016	TANF 21-44 MALE NON-	187.00	189.00	196.00	193.00	188.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		953.00		
1017	TANF 21-44 FEMALE N O	643.00	645.00	647.00	642.00	648.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,225.00		
1018	TANF 45-64 M & F NON	242.00	239.00	235.00	246.00	237.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,199.00		
1019	TANF 65+ M & F NON-M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1028	TANF 45-64 M & F WIT	1.00	2.00	4.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1029	TANF 65+ M & F WITH	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2100	SSI AGED WITH MEDIC A	7.00	7.00	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.00		
2110	SSI AGED NON-MEDICA
R	10.00	11.00	12.00	14.00	15.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.00		
2120	SSI AGED WITH QMB	97.00	96.00	95.00	94.00	95.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		477.00		
2200	SSI DISABLED WITH M E	33.00	34.00	37.00	35.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.00		
2210	SSI DISABLED NON-ME
D	573.00	564.00	557.00	559.00	571.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,824.00		
2220	SSI DISABLED WITH Q M	204.00	203.00	199.00	203.00	207.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,016.00		
2300	SSI BLIND WITH MEDIC	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2310	SSI BLIND NON-MEDIC A	5.00	5.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4311	SOBRA CHILD <1 M & F	289.00	282.00	295.00	288.00	277.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,431.00		
4312	SOBRA CHILD 01-05 M	1,418.00	1,452.00	1,446.00	1,444.00	1,468.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,228.00		
4313	SOBRA CHILD 06-13 M	1,358.00	1,364.00	1,372.00	1,361.00	1,380.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,835.00		
4314	SOBRA CHILD 14-20 MA	325.00	327.00	337.00	344.00	347.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,680.00		
4315	SOBRA CHILD 14-20 FE	341.00	345.00	345.00	351.00	355.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,737.00		
5015	SOBRA PREG 14-20 FE M	14.00	9.00	10.00	9.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.00		
5017	SOBRA PREG 21-44 FE
M	59.00	52.00	54.00	52.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277.00		
SUBTOTAL:	6,312.00	6,343.00	6,391.00	6,395.00	6,434.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,875.00		

1107	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	10.00	7.00	8.00	8.00	8.00	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	13.00	13.00	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	1.00	1.00	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	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5.00	
41.00	
58.00	
6.00	
26.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending November 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	99.00	103.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		510.00		
1117	TANF EXPANDED 21-44	323.00	322.00	327.00	335.00	322.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,629.00		
1118	TANF EXPANDED 45-64	166.00	169.00	171.00	161.00	165.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		832.00		
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	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.00		
1127	TANF EXPANDED 21-44	4.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
1128	TANF EXPANDED 45-64	24.00	28.00	28.00	28.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139.00		
1129	TANF EXPANDED 65+ M
&	19.00	19.00	19.00	21.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98.00		
2400	SSI AGED EXPANDED WI	3.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
2410	SSI AGED EXPANDED N
O	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2420	SSI AGED EXPANDED WI	138.00	139.00	138.00	140.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		697.00		
2600	SSI DISABLED EXPAND
E	2.00	1.00	1.00	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
2610	SSI DISABLED EXPAND E	15.00	14.00	13.00	10.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61.00		
2620	SSI DISABLED EXPAND
E	58.00	62.00	65.00	64.00	65.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.00		
SUBTOTAL:	898.00	893.00	899.00	904.00	900.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,494.00		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	4.00	4.00	6.00	6.00	8.00	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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
28.00	
10.00	

3508	ADULT 40-100% M&F 45	2.00	2.00	2.00	2.00	3.00	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	1.00	1.00	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	14.00	14.00	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	22.00	21.00	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	73.00	74.00	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	55.00	57.00	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	195.00	192.00	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	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	1.00	1.00	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	51.00	54.00	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	51.00	55.00	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	558.00	559.00	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	319.00	318.00	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	679.00	687.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,940.00	1,929.00	1,981.00	2,022.00	2,037.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11.00	
5.00	
69.00	
95.00	
354.00	
286.00	
977.00	
2.00	
3.00	
2.00	
245.00	
242.00	
2,724.00	
1,578.00	
3,314.00	
2.00	
9,909.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	6.00	7.00	6.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.00		
3915	NEWLY ELIGIBLE FEMA L	11.00	13.00	12.00	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.00		
3916	NEWLY ELIGIBLE MALE	69.00	75.00	75.00	81.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.00		
3917	NEWLY ELIGIBLE FEMA L	92.00	103.00	103.00	113.00	127.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		538.00		
3918	NEWLY ELIGIBLE M&F
4	150.00	157.00	157.00	169.00	181.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		814.00		
SUBTOTAL:	334.00	361.00	361.00	390.00	422.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,868.00		

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

2.00

2.00

4413	SOBRA 100-133% M&F
6	140.00	129.00	132.00	128.00	126.00	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	40.00	47.00	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	37.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	209.00	200.00	205.00	205.00	210.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
655.00	
205.00	
169.00	
1,029.00	

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

 
25.00	
5.00	
5.00	
35.00	

TOTAL:	9,700.00	9,733.00	9,844.00	9,924.00	10,011.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,212.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending November 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 November 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 November 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 November 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 November 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 November 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 November 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	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.10		
1008	TANF 45-64 M & F WIT	52.10	26.05	52.10	52.10	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		234.45		
1009	TANF 65+ M & F WITH	78.15	78.15	78.15	52.10	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		312.60		
1011	TANF <1 M & F NON-ME	1,276.45	1,224.35	1,094.10	1,068.05	911.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,574.70		
1012	TANF 01-05 M & F NON	3,490.70	3,699.10	3,803.30	4,819.25	4,480.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,292.95		
1013	TANF 06-13 M & F NON	5,001.60	5,183.95	5,157.90	6,095.70	5,757.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,196.20		
1014	TANF 14-20 MALE NON-	1,302.50	1,354.60	1,458.80	1,693.25	1,589.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,398.20		
1015	TANF 14-20 FEMALE N O	2,448.70	2,474.75	2,631.05	3,021.80	2,891.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,467.85		
1016	TANF 21-44 MALE NON-	8,935.15	9,325.90	9,664.55	10,550.25	10,420.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,895.85		
1017	TANF 21-44 FEMALE N O	33,891.05	33,969.20	34,828.85	42,409.40	41,367.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186,465.90		
1018	TANF 45-64 M & F NON	11,566.20	11,696.45	11,878.80	14,770.35	14,379.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,291.40		
1019	TANF 65+ M & F NON-M	26.05	52.10	52.10	52.10	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		234.45		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.10		
1029	TANF 65+ M & F WITH	26.05	26.05	26.05	52.10	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182.35		
2100	SSI AGED WITH MEDIC A	1,745.35	1,771.40	1,771.40	2,136.10	2,214.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,638.50		
2110	SSI AGED NON-MEDICA
R	703.35	755.45	755.45	963.85	937.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,115.90		
2120	SSI AGED WITH QMB	7,033.50	7,189.80	7,294.00	10,628.40	10,732.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,878.30		
2200	SSI DISABLED WITH M E	4,662.95	4,689.00	4,871.35	5,783.10	5,835.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,841.60		
2210	SSI DISABLED NON-ME
D	24,200.45	24,330.70	24,408.85	30,712.95	30,791.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,444.05		
2220	SSI DISABLED WITH Q M	10,810.75	10,758.65	10,836.80	14,952.70	14,978.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,337.65		
2300	SSI BLIND WITH MEDIC	26.05	26.05	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.25		
2310	SSI BLIND NON-MEDIC A	442.85	416.80	416.80	547.05	547.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,370.55		
2320	SSI BLIND WITH QMB	182.35	182.35	182.35	286.55	286.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,120.15		
4311	SOBRA CHILD <1 M & F	3,829.35	3,464.65	2,969.70	2,865.50	2,500.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,630.00		
4312	SOBRA CHILD 01-05 M	41,237.15	41,185.05	41,393.45	49,599.20	49,573.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,988.00		
4313	SOBRA CHILD 06-13 M	58,820.90	59,211.65	59,862.90	69,032.50	69,631.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316,559.60		
4314	SOBRA CHILD 14-20 MA	15,708.15	15,760.25	15,838.40	18,391.30	18,417.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,115.45		
4315	SOBRA CHILD 14-20 FE	16,385.45	16,619.90	16,984.60	19,954.30	19,902.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89,846.45		
5013	SOBRA PREG 09-13 FE M	26.05	26.05	26.05	52.10	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156.30		
5015	SOBRA PREG 14-20 FE
M	182.35	182.35	234.45	312.60	338.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,250.40		
5017	SOBRA PREG 21-44 FE M	2,344.50	2,474.75	2,631.05	4,037.75	4,141.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,630.00		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.15		
SUBTOTAL:	256,436.20	258,155.50	261,255.45	314,996.60	312,938.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,403,782.40		

260.50

1106	TANF EXPANDED 21-44	52.10	52.10	52.10	52.10	52.10	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	52.10	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

260.50

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	208.40	182.35	208.40	286.55	260.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,146.20		
1109	TANF EXPANDED 65+ M
&	260.50	286.55	286.55	286.55	286.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,406.70		
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	52.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.10		
1115	TANF EXPANDED 14-20	260.50	260.50	260.50	364.70	416.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,563.00		
1116	TANF EXPANDED 21-44	4,454.55	4,454.55	4,194.05	4,793.20	5,079.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,976.10		
1117	TANF EXPANDED 21-44	13,415.75	13,363.65	13,363.65	17,766.10	18,938.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,847.50		
1118	TANF EXPANDED 45-64	7,085.60	7,215.85	7,320.05	9,378.00	9,664.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,664.05		
1119	TANF EXPANDED 65+ M
&	26.05	26.05	26.05	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.25		
1126	TANF EXPANDED 21-44	208.40	208.40	234.45	260.50	234.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,146.20		
1127	TANF EXPANDED 21-44	286.55	286.55	286.55	312.60	312.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,484.85		
1128	TANF EXPANDED 45-64	807.55	833.60	859.65	1,068.05	963.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,532.70		
1129	TANF EXPANDED 65+ M
&	755.45	755.45	755.45	1,146.20	1,198.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,610.85		
2400	SSI AGED EXPANDED WI	26.05	26.05	26.05	182.35	234.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		494.95		
2410	SSI AGED EXPANDED N
O	130.25	130.25	130.25	182.35	156.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		729.40		
2420	SSI AGED EXPANDED WI	4,220.10	4,141.95	4,141.95	6,720.90	6,746.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,971.85		
2610	SSI DISABLED EXPAND
E	208.40	182.35	182.35	234.45	208.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,015.95		
2620	SSI DISABLED EXPAND E	1,901.65	1,953.75	1,953.75	3,021.80	3,021.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,852.75		
SUBTOTAL:	34,359.95	34,412.05	34,333.90	46,134.55	47,905.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		197,146.40		

3908	NEWLY ELIGIBLE M&F 4	104.20	104.20	130.25	208.40	234.45	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	208.40	260.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

547.05

781.50

3509	ADULT 40-100% M&F 65	26.05	26.05	26.05	52.10	52.10	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	1,094.10	1,015.95	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	1,276.45	1,328.55	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	3,047.85	3,230.20	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	2,891.55	3,126.00	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	7,007.45	7,424.25	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	26.05	26.05	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	156.30	156.30	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	4,011.70	4,168.00	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	4,819.25	4,767.15	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	33,344.00	33,969.20	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	17,661.90	18,052.65	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	38,215.35	38,501.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	90,445.60	91,722.05	93,727.90	113,604.05	115,844.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
182.35	
4,793.20	
5,991.50	
12,920.80	
11,722.50	
29,202.05	
52.10	
442.85	
19,094.65	
21,803.85	
155,101.70	
79,504.60	
164,505.75	
26.05	
505,343.95	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	338.65	364.70	364.70	364.70	494.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,927.70		
3915	NEWLY ELIGIBLE FEMA L	442.85	573.10	625.20	833.60	807.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,282.30		
3916	NEWLY ELIGIBLE MALE	2,162.15	2,396.60	2,657.10	3,282.30	3,412.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,910.70		
3917	NEWLY ELIGIBLE FEMA L	3,308.35	3,751.20	3,985.65	6,069.65	6,486.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,601.30		
3918	NEWLY ELIGIBLE M&F
4	4,636.90	4,975.55	5,236.05	7,398.20	7,971.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,218.00		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.10		
SUBTOTAL:	11,019.15	12,191.40	13,025.00	18,391.30	19,693.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,320.65		

4413	SOBRA 100-133% M&F
6	4,610.85	4,558.75	4,272.20	5,314.20	5,522.60	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	1,615.10	1,589.05	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	1,693.25	1,823.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,372.15	7,476.35	7,033.50	8,622.55	8,935.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
24,278.60	
7,528.45	
7,632.65	
39,439.70	

4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	26.05	26.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
52.10

52.10

8700	SSI DISABLED FREEDO M	26.05	26.05	26.05	104.20	104.20	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	78.15	78.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	78.15	78.15	78.15	182.35	182.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
286.55	
312.60	
599.15	

2,220,684.35

399,711.20	404,035.50	409,453.90	501,957.45	505,526.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending November 30, 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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1008	TANF 45-64 M & F WIT	2.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1009	TANF 65+ M & F WITH	3.00	3.00	3.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1011	TANF <1 M & F NON-ME	49.00	47.00	42.00	41.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		214.00		
1012	TANF 01-05 M & F NON	134.00	142.00	146.00	185.00	172.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		779.00		
1013	TANF 06-13 M & F NON	192.00	199.00	198.00	234.00	221.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,044.00		
1014	TANF 14-20 MALE NON-	50.00	52.00	56.00	65.00	61.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284.00		
1015	TANF 14-20 FEMALE N O	94.00	95.00	101.00	116.00	111.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		517.00		
1016	TANF 21-44 MALE NON-	343.00	358.00	371.00	405.00	400.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,877.00		
1017	TANF 21-44 FEMALE N O	1,301.00	1,304.00	1,337.00	1,628.00	1,588.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,158.00		
1018	TANF 45-64 M & F NON	444.00	449.00	456.00	567.00	552.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,468.00		
1019	TANF 65+ M & F NON-M	1.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1029	TANF 65+ M & F WITH	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
2100	SSI AGED WITH MEDIC A	67.00	68.00	68.00	82.00	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		370.00		
2110	SSI AGED NON-MEDICA
R	27.00	29.00	29.00	37.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.00		
2120	SSI AGED WITH QMB	270.00	276.00	280.00	408.00	412.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,646.00		
2200	SSI DISABLED WITH M E	179.00	180.00	187.00	222.00	224.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		992.00		
2210	SSI DISABLED NON-ME
D	929.00	934.00	937.00	1,179.00	1,182.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,161.00		
2220	SSI DISABLED WITH Q M	415.00	413.00	416.00	574.00	575.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,393.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2310	SSI BLIND NON-MEDIC A	17.00	16.00	16.00	21.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.00		
2320	SSI BLIND WITH QMB	7.00	7.00	7.00	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.00		
4311	SOBRA CHILD <1 M & F	147.00	133.00	114.00	110.00	96.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		600.00		
4312	SOBRA CHILD 01-05 M	1,583.00	1,581.00	1,589.00	1,904.00	1,903.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,560.00		
4313	SOBRA CHILD 06-13 M	2,258.00	2,273.00	2,298.00	2,650.00	2,673.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,152.00		
4314	SOBRA CHILD 14-20 MA	603.00	605.00	608.00	706.00	707.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,229.00		
4315	SOBRA CHILD 14-20 FE	629.00	638.00	652.00	766.00	764.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,449.00		
5013	SOBRA PREG 09-13 FE M	1.00	1.00	1.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
5015	SOBRA PREG 14-20 FE
M	7.00	7.00	9.00	12.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.00		
5017	SOBRA PREG 21-44 FE M	90.00	95.00	101.00	155.00	159.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		600.00		
5018	SOBRA PREG 45-64 FE
M	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
SUBTOTAL:	9,844.00	9,910.00	10,029.00	12,092.00	12,013.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,888.00		

10.00

1106	TANF EXPANDED 21-44	2.00	2.00	2.00	2.00	2.00	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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	8.00	7.00	8.00	11.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.00		
1109	TANF EXPANDED 65+ M
&	10.00	11.00	11.00	11.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.00		
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1115	TANF EXPANDED 14-20	10.00	10.00	10.00	14.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.00		
1116	TANF EXPANDED 21-44	171.00	171.00	161.00	184.00	195.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		882.00		
1117	TANF EXPANDED 21-44	515.00	513.00	513.00	682.00	727.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,950.00		
1118	TANF EXPANDED 45-64	272.00	277.00	281.00	360.00	371.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,561.00		
1119	TANF EXPANDED 65+ M
&	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1126	TANF EXPANDED 21-44	8.00	8.00	9.00	10.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.00		
1127	TANF EXPANDED 21-44	11.00	11.00	11.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.00		
1128	TANF EXPANDED 45-64	31.00	32.00	33.00	41.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.00		
1129	TANF EXPANDED 65+ M
&	29.00	29.00	29.00	44.00	46.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177.00		
2400	SSI AGED EXPANDED WI	1.00	1.00	1.00	7.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
2410	SSI AGED EXPANDED N
O	5.00	5.00	5.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.00		
2420	SSI AGED EXPANDED WI	162.00	159.00	159.00	258.00	259.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		997.00		
2610	SSI DISABLED EXPAND
E	8.00	7.00	7.00	9.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.00		
2620	SSI DISABLED EXPAND E	73.00	75.00	75.00	116.00	116.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		455.00		
SUBTOTAL:	1,319.00	1,321.00	1,318.00	1,771.00	1,839.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,568.00		

3908	NEWLY ELIGIBLE M&F 4	4.00	4.00	5.00	8.00	9.00	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	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

21.00

30.00

3509	ADULT 40-100% M&F 65	1.00	1.00	1.00	2.00	2.00	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	42.00	39.00	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	49.00	51.00	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	117.00	124.00	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	111.00	120.00	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	269.00	285.00	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	1.00	1.00	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	6.00	6.00	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	154.00	160.00	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	185.00	183.00	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	1,280.00	1,304.00	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	678.00	693.00	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	1,467.00	1,478.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,472.00	3,521.00	3,598.00	4,361.00	4,447.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7.00	
184.00	
230.00	
496.00	
450.00	
1,121.00	
2.00	
17.00	
733.00	
837.00	
5,954.00	
3,052.00	
6,315.00	
1.00	
19,399.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	13.00	14.00	14.00	14.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74.00		
3915	NEWLY ELIGIBLE FEMA L	17.00	22.00	24.00	32.00	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126.00		
3916	NEWLY ELIGIBLE MALE	83.00	92.00	102.00	126.00	131.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		534.00		
3917	NEWLY ELIGIBLE FEMA L	127.00	144.00	153.00	233.00	249.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		906.00		
3918	NEWLY ELIGIBLE M&F
4	178.00	191.00	201.00	284.00	306.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,160.00		
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
SUBTOTAL:	423.00	468.00	500.00	706.00	756.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,853.00		

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

2.00

2.00

4413	SOBRA 100-133% M&F
6	177.00	175.00	164.00	204.00	212.00	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	62.00	61.00	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	65.00	70.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	283.00	287.00	270.00	331.00	343.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
932.00	
289.00	
293.00	
1,514.00	

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

 
11.00	
12.00	
23.00	

TOTAL:	15,344.00	15,510.00	15,718.00	19,269.00	19,406.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,247.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending November 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	3,438.80	3,997.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,752.20		
1010	TANF NON-MEDICARE	3,291,897.58	3,285,053.48	3,288,548.72	3,306,465.97	3,375,616.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,547,582.59		
1020	TANF WITH QMB	9,680.62	4,840.31	4,840.31	4,840.31	5,398.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,600.06		
2100	SSI AGED WITH MEDIC A	36,886,150.06	36,257,168.41	36,003,911.48	36,034,477.60	36,272,170.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,453,878.28		
210Z	SSI AGED WITH MEDIC
A	1,298,077.28	1,402,442.60	1,257,963.40	1,581,824.80	1,265,210.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,805,518.83		
2110	SSI AGED NON-MEDICA R	3,936,251.45	3,919,215.33	3,905,281.54	3,844,314.05	3,846,434.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,451,497.17		
211Z	SSI AGED NON-MEDICA
R	58,332.16	48,168.31	33,594.18	79,175.95	120,089.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		339,359.60		
2120	SSI AGED WITH QMB	29,860,178.07	29,597,269.68	29,251,347.96	29,094,365.17	29,447,335.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,250,496.06		
212Z	SSI AGED WITH QMB P P	52,730.40	29,814.20	66,471.69	48,436.02	47,234.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,686.35		
2200	SSI DISABLED WITH M
E	17,059,477.72	17,032,420.82	16,952,713.58	17,010,018.04	17,352,020.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,406,650.61		
220Z	SSI DISABLED WITH M E	98,578.03	155,770.48	142,184.45	146,143.08	109,406.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		652,082.61		
2210	SSI DISABLED NON-ME
D	162,684,114.64	163,041,594.79	163,677,617.83	164,231,246.48	169,081,414.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		822,715,987.97		
221Z	SSI DISABLED NON-ME D	35,551.37	116,027.59	170,841.19	178,006.17	232,484.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		732,910.69		
2220	SSI DISABLED WITH Q
M	34,878,015.83	34,889,678.58	35,047,772.64	34,970,006.24	35,712,723.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,498,196.96		
222Z	SSI DISABLED WITH Q M	6,530.37	27,041.24	249.93	368.96	6,478.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,668.61		
2300	SSI BLIND WITH MEDIC	13,493.19	13,493.19	18,333.50	18,333.50	23,173.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,827.19		
2310	SSI BLIND NON-MEDIC A	87,574.55	94,928.07	94,586.84	105,994.80	128,773.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		511,858.21		
2320	SSI BLIND WITH QMB	13,529.94	13,596.77	14,463.63	17,446.82	17,562.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,599.16		
SUBTOTAL:	290,273,602.06	289,931,962.65	289,934,161.67	290,674,902.76	297,047,524.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,457,862,153.15		

8700	SSI DISABLED FREEDO M	259,279.78	247,188.10	270,149.86	246,516.30	253,566.44	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	265,969.54	263,464.57	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	122,938.58	125,200.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	652,362.84	640,518.58	679,264.26	635,424.42	642,231.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,276,700.48	
1,324,056.84	
27,249.16	
621,795.61	
3,249,802.09	

1,461,111,955.24

290,925,964.90	290,572,481.23	290,613,425.93	291,310,327.18	297,689,756.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending November 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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1010	TANF NON-MEDICARE	674.29	672.89	673.13	677.17	676.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,373.64		
1020	TANF WITH QMB	2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2100	SSI AGED WITH MEDIC A	11,098.06	10,918.90	10,833.93	10,836.05	10,806.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,493.67		
210Z	SSI AGED WITH MEDIC
A	373.44	404.87	364.02	461.37	361.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,964.90		
2110	SSI AGED NON-MEDICA R	554.21	552.90	548.01	540.06	529.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,724.83		
211Z	SSI AGED NON-MEDICA
R	8.27	6.41	4.89	10.89	15.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.84		
2120	SSI AGED WITH QMB	9,354.00	9,262.01	9,160.70	9,097.54	9,115.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,990.04		
212Z	SSI AGED WITH QMB P P	14.65	8.61	18.56	13.25	13.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.01		
2200	SSI DISABLED WITH M
E	4,238.21	4,227.15	4,206.93	4,222.19	4,217.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,111.70		
220Z	SSI DISABLED WITH M E	28.56	44.79	40.99	42.67	31.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188.21		
2210	SSI DISABLED NON-ME
D	31,815.64	31,895.15	32,020.73	32,121.78	32,152.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,006.00		
221Z	SSI DISABLED NON-ME D	4.68	15.55	23.26	24.58	29.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97.32		
2220	SSI DISABLED WITH Q
M	8,199.32	8,200.99	8,238.64	8,213.75	8,223.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,076.58		
222Z	SSI DISABLED WITH Q M	1.67	8.46	0.06	0.09	1.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
2300	SSI BLIND WITH MEDIC	3.00	3.00	4.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
2310	SSI BLIND NON-MEDIC A	15.95	17.58	18.00	20.00	23.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.39		
2320	SSI BLIND WITH QMB	3.35	4.00	5.09	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.44		
SUBTOTAL:	66,390.30	66,245.26	66,162.94	66,293.39	66,211.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		331,303.57		

8700	SSI DISABLED FREEDO M	62.00	59.00	61.99	58.73	60.00	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	39.00	37.99	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	28.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	129.99	127.41	131.98	125.73	125.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
301.72	
194.52	
3.86	
141.00	
641.10	

TOTAL:	66,520.29	66,372.67	66,294.92	66,419.12	66,337.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		331,944.67		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending November 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	0.00	0.00	0.00	0.00	-347.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-347.68		
1012	TANF 01-05 M & F NON	0.00	338.30	0.00	404.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		743.17		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	-752.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-752.82		
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	-140.72	-164.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148.61		
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	1,286.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		343.72		
4314	SOBRA CHILD 14-20 MA	0.00	676.60	0.00	-372.13	283.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		588.21		
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	425.96	-228.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,727.94		

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

3,201.56

2,277.37	1,446.13	-718.99	425.96	-228.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	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		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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:	Cu0.0r0	ren0.0t0	an0.d00	pr0i.00	or m0.00	ont0h.00	da0.0t0	a is0.00	und0.00	er r0e.00	vis0i.00	on. 0.00		0.00		

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 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	42,850.40	41,357.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,030.68		
1014	TANF 14-20 MALE NON-	0.00	166.11	0.00	166.11	343.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		675.53		
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		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	505.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		505.74		
1017	TANF 21-44 FEMALE N O	37,014.36	1,152.57	6,630.70	-529.82	6,675.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,943.77		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	1,325.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,325.23		
2100	SSI AGED WITH MEDIC A	0.00	957.65	4,527.59	0.00	440.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,925.72		
2120	SSI AGED WITH QMB	1,493.14	4,206.47	1,649.28	3,768.58	4,030.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,148.41		
2200	SSI DISABLED WITH M E	12,359.84	10,710.56	13,285.32	10,710.56	11,599.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,665.36		
220Z	SSI DISABLED WITH M
E	0.00	2,574.76	0.00	5,816.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,391.04		
2210	SSI DISABLED NON-ME D	193,855.87	191,768.29	188,680.16	193,415.19	226,777.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		994,496.56		
221Z	SSI DISABLED NON-ME
D	2,237.23	2,574.76	398.17	2,823.93	5,378.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,412.91		
2220	SSI DISABLED WITH Q M	91,009.08	94,482.21	78,859.66	75,456.21	88,696.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		428,503.75		
2310	SSI BLIND NON-MEDIC
A	1,649.28	1,649.28	1,649.28	1,649.28	2,155.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,752.14		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	1,054.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,054.90		
4315	SOBRA CHILD 14-20 FE	0.00	1,411.97	96.33	0.00	109.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,618.25		
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	1,649.28	1,649.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,947.84		
5010	SOBRA PREGNANT WO
MAN	4,224.04	4,224.04	2,574.76	4,224.04	5,873.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,120.20		
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		
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	473.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		473.12		
SUBTOTAL:	380,720.68	355,991.96	348,738.40	342,000.04	398,446.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,825,897.13		

1100	TANF EXPANDED FPR FI	5,873.32	4,224.04	2,574.76	2,574.76	2,574.76	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	505.74	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	505.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	0.00	0.00	0.00	1,444.97	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	14,576.78	14,576.78	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	444.26	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	7,952.44	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	2,847.37	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	4,791.70	7,366.46	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	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	444.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
17,821.64	
505.74	
505.74	
1,444.97	
73,085.58	
444.26	
6,866.19	
2,847.37	
319.22	
23,234.70	
1,276.86	
444.26	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2420	SSI AGED EXPANDED WI	6,642.66	6,642.66	6,642.66	6,642.66	7,531.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,101.82		
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		-962.49		
260Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	198.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198.73		
2620	SSI DISABLED EXPAND
E	25,031.96	28,174.38	28,631.08	25,031.96	36,892.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143,762.20		
262Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	505.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		505.74		
SUBTOTAL:	54,303.49	59,335.04	55,354.89	55,062.83	82,346.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		306,402.53		

390H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	49.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR
F	16,740.02	18,233.16	20,807.92	20,807.92	20,807.92	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	161.39	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	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	2,408.29	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	23,216.21	21,019.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

49.77	
97,396.94	
3,851.88	
1,396.81	
2,408.29	
105,103.69	

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	83.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	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

83.06

3510	ADULT 40-100% FOR FI	39,398.90	45,272.22	42,697.46	41,048.18	41,048.18	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	444.26	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	1,011.48	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	7,261.32	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	1,936.85	3,478.70	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	1,544.86	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	
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	
3710	AHC CARE EXPANDED FO	177,292.68	182,956.16	174,306.40	185,584.62	205,047.38	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	429.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	24,035.00	8,914.24	19,170.16	1,789.37	19,195.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,340.71	12,707.58	1,012.66	415.28	13,303.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	12,179.55	166.11	30,343.41	6,913.80	18,772.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
371E	ADULT <40% EXP FEMA L	0.00	0.00	429.13	1,539.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	1,869.87	0.00	649.03	3,903.66	443.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA L	3,146.98	0.00	4,205.44	0.00	1,029.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F
4	561.88	638.43	8,153.41	0.00	-4,479.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	263,141.57	258,628.19	284,724.45	243,560.25	308,101.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
209,464.94	
444.26	
7,544.54	
10,548.00	
5,415.55	
581.40	
4,526.61	
85.83	
1,495.02	
925,187.24	
429.16	
73,104.72	
28,780.07	
68,375.08	
83.06	
1,968.46	
6,865.76	
8,382.32	
4,874.30	
1,358,156.32	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	85.83	0.00	0.00	83.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		168.89		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	2,574.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	505.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	2,574.76	505.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,574.76	
505.74	
3,080.50	

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	-332.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	-332.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-332.23

-332.23

3,598,476.83

718,190.73	694,763.11	708,939.06	666,497.15	810,086.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

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

For The Period Ending November 30, 2020

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

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

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

2100	SSI AGED WITH MEDIC
A
2120	SSI AGED WITH QMB

2200	SSI DISABLED WITH M
E
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
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	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	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

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

n. 0.00	0.00

4315

431E

5000

5010

5015

5017

501G

SOBRA CHILD 14-20 FE SOBRA CHILD 14-20 FE
SOBRA PREGNANT WO MAN
SOBRA PREGNANT WO
MAN
SOBRA PREG 14-20 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 21-44 FE
M

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

SUBTOTAL:

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
110F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
260Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
262Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

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

Current and prior month data is under revision.

390H	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	
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	
391H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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	

0.00

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending November 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		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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

 
0.00

0.00

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending November 30, 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	836.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,621.95		
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	-0.67	1,460.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,788.84		
2220	SSI DISABLED WITH Q M	916.89	0.00	334.20	0.00	282.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,533.21		
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	-775.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-248.46		
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	835.75	966.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,609.52		

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	-198.01	-0.24	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	-1,460.63	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	-1,658.64	-0.24	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	
9,605.06	
2,870.03	
4,614.27	
-23.14	
40.94	
22,161.45	

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 November 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		

60,124.99

34,141.06	21,955.96	3,884.19	-822.89	966.67	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 November 30, 2020

RATE CODE	DESCRIPTION

1015

1016

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

1017

1018

101E

2100

210Z

2110

2120

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

TANF 14-20 FEMALE N O
SSI AGED WITH MEDIC
A
SSI AGED WITH MEDIC
A
SSI AGED NON-MEDICA
R
SSI AGED WITH QMB

2200

2210

2220

4312

SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SOBRA CHILD 01-05 M

4314

SOBRA CHILD 14-20 MA

5017

SOBRA PREG 21-44 FE M
SOBRA PREG 14-20 FE

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

data is

0.00

0.00

under re

0.00

0.00

visio

0.00

n.

0.00

0.00

501E

0.00

0.00

0.00

0.00

M
SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

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	

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	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending November 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		

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending November 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	524,258.31	531,797.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,478,681.58		
1011	TANF <1 M & F NON-ME	18,250.52	22,539.27	32,615.10	15,545.58	52,944.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141,895.12		
1012	TANF 01-05 M & F NON	1,830.78	-799.39	7,686.18	-16,879.18	25,702.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,541.37		
1013	TANF 06-13 M & F NON	2,624.03	9,884.36	17,196.09	7,358.19	12,112.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,174.94		
1014	TANF 14-20 MALE NON-	1,158.73	2,879.58	5,007.88	-647.35	4,536.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,934.98		
1015	TANF 14-20 FEMALE N O	3,215.93	3,304.16	4,542.04	3,111.21	7,728.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,901.53		
101B	TANF 01-05 M & F NON	0.00	-1,017.84	441.06	27.27	1,376.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		827.35		
101C	TANF 06-13 M & F NON	9,263.82	0.00	33.93	0.00	1,654.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,952.68		
101D	TANF 14-20 MALE NON-	101.78	0.00	0.00	0.00	312.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		413.90		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	27.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.27		
2210	SSI DISABLED NON-ME
D	408,654.27	424,352.66	423,589.32	410,028.60	437,491.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,104,116.52		
221Z	SSI DISABLED NON-ME D	-2,347.06	-560.34	-667.67	-2,849.73	3,772.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,652.27		
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	1,635.96	1,635.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,325.71		
4310	SOBRA CHILD NON-ME
DI	11,486,063.32	11,314,030.73	11,474,882.63	11,389,831.57	11,530,567.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,195,375.35		
4311	SOBRA CHILD <1 M & F	39,388.90	49,308.13	69,495.86	47,599.12	172,293.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		378,085.19		
4312	SOBRA CHILD 01-05 M	-77,519.72	24,412.60	-11,511.06	-28,260.56	560,837.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		467,959.00		
4313	SOBRA CHILD 06-13 M	-99,853.49	28,110.86	-44,630.93	-28,342.05	570,798.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		426,082.54		
4314	SOBRA CHILD 14-20 MA	-29,493.13	2,805.33	-32,320.28	-1,909.91	130,680.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,762.51		
4315	SOBRA CHILD 14-20 FE	-18,582.82	5,555.02	-24,766.46	-6,396.00	157,086.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,896.20		
431A	SOBRA CHILD < 1 M &	4,160.74	7,257.75	1,436.41	5,948.23	3,869.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,673.00		
431B	SOBRA CHILD 01-05 M	16,416.41	14,807.75	2,042.33	17,443.93	13,306.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,017.41		
431C	SOBRA CHILD 6-13 M&F	16,098.60	30,558.45	10,758.92	12,166.77	26,075.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,658.72		
431D	SOBRA CHILD 14-20 MA	1,389.83	2,961.87	3,442.84	7,121.24	11,555.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,470.85		
431E	SOBRA CHILD 14-20 FE	5,207.63	3,738.27	4,760.32	3,944.09	25,023.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,674.20		
5010	SOBRA PREGNANT WO MAN	5,714.89	6,932.59	9,586.39	10,404.37	11,840.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,478.71		
5015	SOBRA PREG 14-20 FE
M	0.00	-168.22	0.00	0.00	2,730.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,562.40		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	364.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		364.55		
SUBTOTAL:	12,247,672.27	12,427,829.73	12,449,744.41	12,371,139.66	14,298,123.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,794,509.49		

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

4,089.90

4,089.90

3710	AHC CARE EXPANDED FO	1,635.96	2,653.80	2,653.80	2,653.80	2,653.80	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	2,653.80	2,653.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,251.16	
361.17	
527.73	
13,140.06	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4410	SOBRA 100-133% FOR F	22,851.99	22,237.27	20,201.59	18,365.77	16,529.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,186.57		
4413	SOBRA 100-133% M&F
6	1,710.46	6,970.68	8,115.40	2,686.51	8,482.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,965.88		
4414	SOBRA 100-133% MALE	2,248.94	330.73	163.60	2,577.05	1,350.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,670.88		
4415	SOBRA 100-133% FEMA L	2,101.36	395.80	3,223.33	1,894.72	3,130.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,745.85		
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	79.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.05		
SUBTOTAL:	28,912.75	29,934.48	31,703.92	25,603.10	29,493.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,648.23		

63,957,387.68

12,484,920.11	12,400,214.54	14,331,089.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

12,279,927.86

12,461,235.99

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP

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

For The Period Ending November 30, 2020

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

1012	TANF 01-05 M & F NON

1013	TANF 06-13 M & F NON

1014	TANF 14-20 MALE NON-

1015	TANF 14-20 FEMALE N
O
101B	TANF 01-05 M & F NON

101C	TANF 06-13 M & F NON

101D	TANF 14-20 MALE NON-

101E	TANF 14-20 FEMALE N
O
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
2310	SSI BLIND NON-MEDIC
A
4310	SOBRA CHILD NON-ME
DI

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

n. 0.00	0.00

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

4311

4312

4313

4314

4315

431A

431B

431C

431D

431E

5010

5015

501E

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

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

SUBTOTAL:

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		
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		
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		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending November 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 November 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		

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 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	11.59	11.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.92		
1004	TANF 14-20 MALE WITH	2.74	2.74	2.74	4.18	4.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.58		
1005	TANF 14-20 FEMALE WI	8.79	8.79	8.79	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.97		
1006	TANF 21-44 MALE WITH	757.08	843.75	873.72	1,395.68	1,417.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,287.66		
1007	TANF 21-44 FEMALE WI	1,148.91	1,198.02	1,236.36	1,940.40	1,892.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,416.07		
1008	TANF 45-64 M & F WIT	2,224.32	2,273.07	2,170.83	3,354.27	3,433.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,456.36		
1009	TANF 65+ M & F WITH	1,453.62	1,368.54	1,396.89	1,761.23	1,910.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,890.64		
100H	TANF 45-64 M & F WIT	0.00	0.00	0.00	17.27	5.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.95		
100J	TANF 65+ M & F WITH	0.00	0.00	0.00	27.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.20		
1010	TANF NON-MEDICARE	1,513.89	1,522.87	1,530.54	1,698.96	1,685.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,951.27		
1011	TANF <1 M & F NON-ME	17,524.33	17,720.42	17,977.97	18,748.57	19,216.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,187.98		
1012	TANF 01-05 M & F NON	41,559.69	43,158.68	44,336.78	44,787.11	44,237.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218,079.63		
1013	TANF 06-13 M & F NON	74,475.95	76,508.88	77,270.23	78,027.08	77,859.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384,142.10		
1014	TANF 14-20 MALE NON-	46,352.86	48,408.65	49,479.57	63,037.32	64,017.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271,295.46		
1015	TANF 14-20 FEMALE N O	70,065.73	72,493.21	73,478.73	93,801.79	95,609.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		405,448.90		
1016	TANF 21-44 MALE NON-	286,728.72	289,965.21	290,793.96	381,398.57	377,375.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,626,261.77		
1017	TANF 21-44 FEMALE N O	943,158.63	957,428.07	962,937.12	1,280,678.05	1,263,182.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,407,384.57		
1018	TANF 45-64 M & F NON	237,180.33	240,443.73	241,435.89	320,683.79	317,563.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,357,306.94		
1019	TANF 65+ M & F NON-M	1,090.95	1,132.92	1,164.09	1,609.02	1,612.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,609.90		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	2.49	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.32		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.83		
101D	TANF 14-20 MALE NON-	0.00	0.00	0.00	5.68	11.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.04		
101E	TANF 14-20 FEMALE N O	0.00	0.00	0.00	25.79	30.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.66		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	182.52	283.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		465.57		
101G	TANF 21-44 FEMALE N O	0.00	0.00	0.00	295.22	278.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		573.33		
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	104.43	54.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158.48		
1020	TANF WITH QMB	20.37	11.58	11.58	11.59	11.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.71		
1023	TANF 06-13 M & F WIT	2.74	2.74	2.74	4.18	4.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.58		
1024	TANF 14-20 MALE WITH	21.73	21.73	21.73	26.02	26.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117.23		
1025	TANF 14-20 FEMALE WI	17.58	8.79	8.79	13.60	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62.36		
1026	TANF 21-44 MALE WITH	631.98	645.60	602.85	940.47	1,000.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,821.22		
1027	TANF 21-44 FEMALE WI	1,027.86	1,126.14	971.16	1,606.63	1,698.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,429.95		
1028	TANF 45-64 M & F WIT	1,226.46	1,331.52	1,349.07	1,792.97	2,025.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,725.61		
1029	TANF 65+ M & F WITH	616.38	634.38	648.75	843.49	944.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,687.25		
102H	TANF 44-64 M & F WIT	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.60		
2100	SSI AGED WITH MEDIC A	139,858.53	137,184.75	135,820.08	174,153.40	177,373.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		764,390.56		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC A	0.00	0.00	0.00	1,316.42	671.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,988.17		
2110	SSI AGED NON-MEDICA
R	74,282.82	75,580.74	76,795.26	104,227.52	105,621.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		436,508.20		
2120	SSI AGED WITH QMB	416,017.41	417,094.59	418,032.84	531,062.49	537,484.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,319,691.69		
212Z	SSI AGED WITH QMB P P	0.00	0.00	0.00	496.85	358.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		855.08		
2200	SSI DISABLED WITH M
E	71,832.38	71,039.81	71,388.26	101,638.41	102,480.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		418,379.21		
220Z	SSI DISABLED WITH M E	0.00	0.00	0.00	453.31	284.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		737.86		
2210	SSI DISABLED NON-ME
D	497,259.09	498,233.77	498,770.01	756,361.99	761,835.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,012,460.11		
221Z	SSI DISABLED NON-ME D	0.00	0.00	0.00	348.14	389.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		737.68		
2220	SSI DISABLED WITH Q
M	283,547.52	283,698.51	284,153.29	435,345.08	437,311.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,724,055.89		
222Z	SSI DISABLED WITH Q M	0.00	0.00	0.00	351.51	266.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617.75		
2300	SSI BLIND WITH MEDIC	317.64	326.43	351.60	487.51	495.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,978.61		
2310	SSI BLIND NON-MEDIC A	4,496.64	4,503.52	4,523.15	6,167.70	6,214.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,905.51		
231Z	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.60		
2320	SSI BLIND WITH QMB	2,450.94	2,435.37	2,451.75	3,187.52	3,205.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,730.60		
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	16.38	5.84	5.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.07		
4303	SOBRA CHILD 06-13 M	10.96	17.80	21.90	12.54	12.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		75.74		
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	57,617.14	57,008.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289,487.33		
4312	SOBRA CHILD 01-05 M	307,647.78	309,622.43	311,363.75	314,613.62	316,789.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,560,037.04		
4313	SOBRA CHILD 06-13 M	405,453.91	406,204.52	409,021.56	408,771.56	410,246.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,039,698.05		
4314	SOBRA CHILD 14-20 MA	207,687.12	208,776.60	211,648.39	252,887.94	254,602.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,135,602.62		
4315	SOBRA CHILD 14-20 FE	211,543.83	211,668.46	213,887.32	255,979.41	256,333.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,149,412.29		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	1.66	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.49		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	1.66	7.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.16		
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	26.71	20.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.55		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	121.49	88.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209.83		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	96.52	53.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150.15		
4322	SOBRA CHILD 01-05 M	1.36	1.36	1.36	0.83	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.74		
4323	SOBRA CHILD 06-13 M	2.72	5.46	1.36	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.37		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	2.74	0.00	0.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.45		
4325	SOBRA CHILD 14-20 FE	25.85	27.32	27.37	28.07	28.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.68		
5005	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	25.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.19		
5007	SOBRA PREG 21-44 FE
M	258.87	206.55	285.24	272.73	265.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,288.43		
500G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.60		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE M	4.19	4.30	7.13	3.79	3.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.49		
5015	SOBRA PREG 14-20 FE
M	21,816.24	21,187.06	20,711.01	25,710.00	25,229.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,653.49		
5017	SOBRA PREG 21-44 FE M	146,781.51	144,124.83	144,011.01	189,108.61	188,191.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		812,217.25		
5018	SOBRA PREG 45-64 FE
M	448.26	457.05	462.63	594.53	555.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,518.21		
501E	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	38.79	25.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.69		
501G	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	63.75	58.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121.82		
5027	SOBRA PREG 21-44 FE M	256.44	270.03	286.83	383.77	368.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,565.58		
5028	SOBRA PREG 45-64 FE
M	17.58	17.58	17.58	46.48	46.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145.70		
502G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	27.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.20		
SUBTOTAL:	4,579,833.46	4,609,412.17	4,631,258.29	5,920,849.65	5,921,433.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,662,786.70		

1106	TANF EXPANDED 21-44	1,918.77	1,901.97	1,925.55	2,823.15	2,929.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	3,377.31	3,350.52	3,346.14	5,159.34	5,355.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	11,446.20	11,088.69	11,155.77	16,201.76	16,457.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	7,541.79	7,727.49	7,848.15	9,923.38	10,141.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	0.00	0.00	0.00	40.80	40.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	0.00	0.00	0.00	44.47	38.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	44.47	30.87	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	0.83	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	11.56	10.73	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	2,827.86	2,904.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	12,100.24	12,246.55	12,634.78	17,051.57	17,132.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	238,739.25	239,841.90	245,166.93	324,012.20	332,026.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	652,361.52	654,421.89	666,647.64	902,331.72	928,880.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	233,628.21	234,349.74	240,186.39	317,094.08	321,240.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	980.31	989.88	1,027.02	1,354.52	1,462.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111E	TANF EXPANDED 14-20	0.00	0.00	0.00	19.28	19.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	195.15	184.53	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	224.24	257.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111H	TANF EXPANDED 45-64	0.00	0.00	0.00	77.58	38.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	5,821.38	5,882.04	5,927.94	8,514.05	8,680.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	12,463.98	12,562.26	12,708.45	19,888.76	19,782.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,498.91	
20,588.73	
66,350.22	
43,182.29	
13.60	
81.60	
83.26	
75.34	
2.19	
47.16	
12,289.42	
71,165.86	
1,379,786.62	
3,804,643.22	
1,346,498.87	
5,814.70	
38.56	
379.68	
482.10	
116.37	
13.60	
34,825.63	
77,405.54	

3100	TRANSPLANT OPTION 1	4.80	4.80	4.80	5.68	5.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4.80	4.80	4.80	5.68	5.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25.76

25.76

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1128	TANF EXPANDED 45-64	23,018.61	23,289.18	23,649.48	34,074.12	34,088.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138,119.96		
1129	TANF EXPANDED 65+ M
&	17,478.51	17,974.95	18,052.89	22,905.63	23,319.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99,731.31		
112F	TANF EXPANDED 21-44	0.00	0.00	0.00	28.86	25.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.05		
112G	TANF EXPANDED 21-44	0.00	0.00	0.00	40.80	27.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.00		
112H	TANF EXPANDED 45-64	0.00	0.00	0.00	54.05	34.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.59		
112J	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	63.98	23.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.16		
2400	SSI AGED EXPANDED WI	2,198.04	2,297.10	2,639.49	4,168.98	4,391.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,694.94		
240Z	SSI AGED EXPANDED
WI	0.00	0.00	0.00	145.23	164.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		309.74		
2410	SSI AGED EXPANDED N O	1,276.38	1,223.25	1,200.45	1,622.77	1,717.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,040.58		
2420	SSI AGED EXPANDED
WI	256,763.58	259,681.14	261,436.05	344,322.99	349,311.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,471,515.48		
242Z	SSI AGED EXPANDED WI	0.00	0.00	0.00	396.44	373.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		769.58		
2520	SSI BLIND EXPANDED
W	17.58	17.58	17.58	27.20	27.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107.14		
2600	SSI DISABLED EXPAND E	2,905.74	2,871.84	2,794.77	4,695.85	4,641.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,909.41		
260Z	SSI DISABLED EXPAND
E	0.00	0.00	0.00	274.97	166.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441.49		
2610	SSI DISABLED EXPAND E	13,819.14	13,651.29	13,377.27	17,933.85	18,215.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,997.11		
2620	SSI DISABLED EXPAND
E	117,410.01	118,277.28	118,655.28	202,018.14	202,902.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		759,262.90		
262Z	SSI DISABLED EXPAND E	0.00	0.00	0.00	193.37	136.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		329.99		
SUBTOTAL:	1,617,412.73	1,625,838.23	1,652,643.08	2,260,835.20	2,307,181.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,463,910.90		

3506	ADULT 40-100% MALE 2	128.22	156.18	179.76	321.56	294.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	97.86	115.44	118.23	170.19	189.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	1,464.54	1,575.60	1,532.43	3,538.09	3,442.09	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	988.38	1,451.78	1,616.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	0.00	0.00	0.00	19.28	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	54,211.41	55,890.45	74,957.77	75,822.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	57,788.40	58,194.33	59,178.45	79,053.22	80,327.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	190,807.23	194,505.99	204,045.48	285,013.39	301,503.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	161,763.39	165,486.84	172,039.38	240,163.57	252,488.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	348,455.88	351,664.68	359,824.26	481,943.16	496,024.57	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	88.94	98.52	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	61.74	34.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	17.27	19.28	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	1,177.34	729.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	453.66	253.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	443.85	342.62	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	38.79	61.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,080.43	
691.19	
11,552.75	
5,691.80	
19.28	
315,148.45	
334,541.84	
1,175,875.13	
991,941.34	
2,037,912.55	
372.83	
96.28	
36.55	
1,906.94	
706.88	
786.47	
173.45	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3527	ADULT 40-100% FEMAL E	4.80	4.80	0.00	13.60	25.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.39		
3528	ADULT 40-100% M&F 45	88.29	94.29	121.44	243.87	269.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		817.18		
3529	ADULT 40-100% M&F 65	22.38	38.76	42.75	60.08	88.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252.91		
352G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.60		
352H	ADULT 40-100% M&F 45	0.00	0.00	0.00	25.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.19		
3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.60		
3706	ADULT <40% EXP MALE	463.80	472.59	512.55	909.10	949.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,307.94		
3707	ADULT <40% EXP FEMA L	141.84	170.19	158.61	366.04	463.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,299.81		
3708	ADULT <40% EXP M&F
4	2,051.13	2,017.17	2,270.01	4,031.38	4,244.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,614.18		
3709	ADULT <40% EXP M&F 6	298.02	381.51	410.67	594.18	650.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,334.85		
370F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	11.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.59		
370H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	11.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.59		
3714	ADULT <40% EXP MALE	108,326.43	110,706.57	112,937.91	149,401.97	152,045.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		633,418.32		
3715	ADULT <40% EXP FEMA L	99,812.34	101,749.14	105,598.59	140,735.20	142,422.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		590,317.80		
3716	ADULT <40% EXP MALE	766,708.20	780,770.91	794,516.55	1,094,785.41	1,105,414.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,542,195.74		
3717	ADULT <40% EXP FEMA L	440,857.62	449,652.90	458,141.52	638,474.33	642,157.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,629,283.65		
3718	ADULT <40% EXP M&F
4	832,800.54	843,593.64	853,079.10	1,162,060.67	1,168,879.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,860,413.72		
3719	ADULT <40% EXP M&F 6	52.74	55.53	35.16	73.68	54.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271.51		
371D	ADULT <40% EXP MALE	0.00	0.00	0.00	214.89	195.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		410.62		
371E	ADULT <40% EXP FEMA L	0.00	0.00	0.00	65.99	50.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.37		
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	2,612.12	2,613.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,225.93		
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	1,103.33	1,058.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,162.12		
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	1,459.06	1,353.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,812.31		
3726	ADULT <40% EXP MALE	49.53	83.49	83.49	151.26	147.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		515.01		
3727	ADULT <40% EXP FEMA L	42.75	51.54	63.12	98.52	81.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		337.18		
3728	ADULT <40% EXP M&F
4	266.07	384.72	335.19	601.87	684.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,272.75		
3729	ADULT <40% EXP M&F 6	0.00	0.00	25.17	30.87	30.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86.91		
372F	ADULT <40% EXP MALE	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.60		
372H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	22.95	11.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.54		
SUBTOTAL:	3,067,661.76	3,117,048.27	3,182,208.15	4,367,087.95	4,437,166.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,171,173.07		

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	27.20	27.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	308.43	407.49	404.28	895.15	1,117.15	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	634.63	750.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	6,100.62	7,320.66	8,082.60	12,967.30	14,144.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
26.37	
77.56	
3,132.50	
2,167.92	
48,615.75	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3909	NEWLY ELIGIBLE M&F 6	3,880.74	4,533.12	5,770.68	8,561.31	10,218.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,964.71		
390H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.60		
3914	NEWLY ELIGIBLE MALE	41,282.46	44,627.58	46,656.78	67,833.98	71,410.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271,811.66		
3915	NEWLY ELIGIBLE FEMA L	44,199.27	48,238.71	49,500.84	72,022.58	75,448.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289,410.28		
3916	NEWLY ELIGIBLE MALE	205,392.54	222,209.34	230,776.62	331,475.21	351,343.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,341,197.69		
3917	NEWLY ELIGIBLE FEMA L	285,434.55	307,647.78	321,376.26	462,680.43	494,429.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,871,568.77		
3918	NEWLY ELIGIBLE M&F
4	280,711.11	296,004.21	303,941.64	420,095.77	438,924.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,739,676.82		
3919	NEWLY ELIGIBLE M&F 6	288.48	369.18	439.08	729.95	773.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,600.41		
391D	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	5.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.68		
391E	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	5.68	5.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.36		
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	283.16	194.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		477.50		
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	119.35	109.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		229.00		
391H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	138.51	115.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253.84		
3926	NEWLY ELIGIBLE MALE	0.00	8.79	8.79	25.19	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56.37		
3927	NEWLY ELIGIBLE FEMA L	11.58	11.58	11.58	11.59	11.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.92		
3928	NEWLY ELIGIBLE M&F
4	171.78	152.22	97.08	110.46	121.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		653.36		
3929	NEWLY ELIGIBLE M&F 6	160.17	202.92	258.06	392.77	487.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,501.89		
SUBTOTAL:	868,176.60	932,012.79	967,642.26	1,379,029.50	1,459,649.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,606,510.96		

4517	BC PATIENT FEMALE 2 1	201.75	187.38	178.59	249.55	237.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	1,239.21	1,274.37	1,203.27	1,544.23	1,557.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	8.79	8.79	13.60	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451H	BC PATIENT FEMALE 4
5	0.00	0.00	0.00	38.79	38.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451J	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	24.96	48.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	31.17	26.37	26.37	54.40	65.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,055.23	
6,818.91	
44.78	
77.58	
73.10	
204.30	

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	4.18	5.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	70,892.26	72,845.42	73,219.06	73,227.28	74,151.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	39,394.30	40,697.82	40,945.35	50,269.37	51,430.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	38,473.55	39,680.84	39,991.29	49,407.33	50,687.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	1.66	5.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	2.49	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	4.18	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	1.54	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	148,768.42	153,231.03	154,165.37	172,918.03	176,282.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
9.58	
2.94	
18.77	
364,335.39	
222,737.47	
218,240.62	
7.50	
3.32	
4.18	
5.20	
805,364.97	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4618	CC PATIENT FEMALE 4 5	90.27	90.27	78.69	91.18	91.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441.59		
SUBTOTAL:	1,562.40	1,587.18	1,495.71	2,016.71	2,053.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,715.49		

6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	11.59	11.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	13.60	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	25.19	25.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8600	SSI BLIND FREEDOM/W O	8.79	8.79	8.79	13.60	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	13.60	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	11.59	11.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO
M	15,056.52	15,234.33	15,259.50	28,097.70	28,228.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	85.27	69.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	3,013.47	2,974.35	2,990.70	4,519.54	4,516.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	2,895.96	3,145.26	3,171.21	6,119.61	6,203.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	13.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,986.32	21,374.31	21,441.78	38,860.91	39,057.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
53.57	
13.60	
57.92	
101,876.80	
154.93	
18,014.66	
21,535.26	
13.60	
141,720.34	

	23.18	
	27.20	
	50.38	
TOTAL:			10,304,406.49	10,460,508.78	10,610,859.44	14,141,628.82	14,342,855.04	0.00	0.00	0.00	0.00	0.00	0.00		0.00			59,860,258.57	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending November 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	
100H	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	
100J	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

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

n. 0.00

0.00

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

1018	TANF 21-44 FEMALE N O
TANF 45-64 M & F NON	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

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

101F	TANF 14-20 FEMALE N O
TANF 21-44 MALE NON-	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
101G

101H	TANF 21-44 FEMALE N O
TANF 44-64 M & F NON	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
102H	TANF 44-64 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	
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	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS

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

For The Period Ending November 30, 2020

RATE CODE	DESCRIPTION 210Z	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R
2120	SSI AGED WITH QMB

212Z	SSI AGED WITH QMB P
P
2200	SSI DISABLED WITH M
E
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
221Z	SSI DISABLED NON-ME
D
2220	SSI DISABLED WITH Q
M
222Z	SSI DISABLED WITH Q
M
2300	SSI BLIND WITH MEDIC

2310	SSI BLIND NON-MEDIC
A
231Z	SSI BLIND NON-MEDIC
A
2320	SSI BLIND WITH QMB

0.00

0.00

0.00

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	
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	
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	
5005

5007	SOBRA PREG 14-20 FE M
SOBRA PREG 21-44 FE	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	

500G	M
SOBRA PREG 21-44 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	
	M															

4301	SOBRA CHILD <1 M & F

4302

SOBRA CHILD 01-05 M

Cu0.00rren0.00t an0.0d0

0.00

0.00

0.00

pr0i.00or m0.00 ont0h.00

0.00	0.00

0.00

0.00

0.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

0.00

0.00

n. 0.00	0.00

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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		
501G	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		
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		
502G	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		

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

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	
110F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	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	
110J	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	
111E	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	
111F	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
111H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111J	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending November 30, 2020

RATE CODE	DESCRIPTION

1128

TANF EXPANDED 45-64

1129

112F

TANF EXPANDED 65+ M
&
TANF EXPANDED 21-44

112G

112H

TANF EXPANDED 21-44

TANF EXPANDED 45-64

112J

2400

240Z

2410

2420

242Z

2520

2600

260Z

2610

TANF EXPANDED 65+ M
&
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI AGED EXPANDED N
O
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI BLIND EXPANDED
W
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

data is

0.00

0.00

under re

0.00

0.00

visio

0.00

n.

0.00

0.00

2620

262Z

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

E
SUBTOTAL:

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	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	
350F	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	
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	
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	
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
0.00	
0.00	
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

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

For The Period Ending November 30, 2020

RATE CODE	DESCRIPTION 3527	ADULT 40-100% FEMAL
E
3528	ADULT 40-100% M&F 45

3529	ADULT 40-100% M&F 65

352G	ADULT 40-100% FEMAL
E
352H	ADULT 40-100% M&F 45

3704	ADULT <40% EXP MALE

3706	ADULT <40% EXP MALE

3707	ADULT <40% EXP FEMA
L
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
370F	ADULT <40% EXP MALE

370H	ADULT <40% EXP M&F
4
3714	ADULT <40% EXP MALE

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

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

da0.0t0 a is0.00 und0.00er r0e.00   vis0i.0o0

n. 0.00	0.00

3717

3718

3719

371D

371E

371F

371G

371H

3726

3727

3728

3729

372F

372H

ADULT <40% EXP FEMA L
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6
ADULT <40% EXP MALE

ADULT <40% EXP FEMA L
ADULT <40% EXP MALE

ADULT <40% EXP FEMA L
ADULT <40% EXP M&F
4
ADULT <40% EXP MALE

ADULT <40% EXP FEMA L
ADULT <40% EXP M&F
4
ADULT <40% EXP M&F
6
ADULT <40% EXP MALE

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:

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	

0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending November 30, 2020

RATE CODE	DESCRIPTION

3909

390H

3914

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

3915

3916

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

3917

3918

3919

391D

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

391E

391F

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

391G

391H

3926

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

3927

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

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

data is

0.00

0.00

under re

0.00

0.00

visio

0.00

n.

0.00

0.00

3928

3929

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

6
SUBTOTAL:

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

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
0.00	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	
441C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
451H	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	
451J	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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		
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	
8610	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	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
872Z	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	
0.00	
0.00	
0.00	

0.00

0.00

0.00

6014	KIDS 14-19 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	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

Current and prior month data is under revision.

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	5,378.39	5,755.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,511.80		
1007	TANF 21-44 FEMALE WI	2,399.61	2,476.68	1,470.45	963.42	926.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,236.35		
1008	TANF 45-64 M & F WIT	16,050.19	2,693.87	9,242.22	6,204.84	6,251.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,442.71		
1009	TANF 65+ M & F WITH	3,934.85	3,443.16	8,365.71	8,977.18	703.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,424.05		
1011	TANF <1 M & F NON-ME	1,143,390.86	675,922.36	1,386,768.24	1,038,330.39	1,012,131.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,256,543.48		
1012	TANF 01-05 M & F NON	302,488.54	183,924.52	319,614.33	276,361.86	211,619.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,294,008.55		
1013	TANF 06-13 M & F NON	442,447.04	357,697.74	470,463.34	388,182.19	350,844.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,009,634.60		
1014	TANF 14-20 MALE NON-	179,326.07	115,950.93	147,569.55	177,009.38	140,974.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		760,830.37		
1015	TANF 14-20 FEMALE N O	403,238.79	280,105.48	400,421.58	369,405.06	424,042.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,877,213.15		
1016	TANF 21-44 MALE NON-	2,144,392.81	1,992,851.99	2,588,930.27	2,492,570.64	2,048,345.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,267,090.99		
1017	TANF 21-44 FEMALE N O	8,152,997.95	6,589,523.27	7,909,860.92	6,956,770.12	6,614,624.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,223,776.62		
1018	TANF 45-64 M & F NON	3,859,402.03	2,843,221.69	3,858,062.94	3,264,101.76	3,065,080.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,889,869.21		
1019	TANF 65+ M & F NON-M	17,787.96	12,713.74	17,492.62	26,877.72	23,881.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,753.57		
1026	TANF 21-44 MALE WITH	958.00	0.00	8,171.26	8,540.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,669.96		
1027	TANF 21-44 FEMALE WI	3.40	0.00	0.00	0.00	147.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150.77		
1028	TANF 45-64 M & F WIT	16,080.90	3,050.13	15,165.34	9,217.35	6,136.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,650.58		
1029	TANF 65+ M & F WITH	3,044.78	2,956.97	2,415.26	7,334.78	5,687.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,439.75		
2100	SSI AGED WITH MEDIC A	194,486.50	175,951.46	235,250.41	146,935.14	151,740.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		904,364.50		
2110	SSI AGED NON-MEDICA
R	391,217.59	195,742.50	293,734.14	194,552.87	317,396.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,392,643.47		
2120	SSI AGED WITH QMB	766,999.79	502,596.08	788,594.23	648,763.75	704,020.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,410,974.84		
2200	SSI DISABLED WITH M E	607,153.39	552,267.62	628,213.48	501,317.00	479,718.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,768,670.19		
2210	SSI DISABLED NON-ME
D	12,335,676.27	9,169,869.59	11,995,340.00	10,537,334.58	9,042,453.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,080,673.92		
2220	SSI DISABLED WITH Q M	1,793,601.32	1,226,778.38	1,898,431.16	1,578,101.37	1,438,425.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,935,338.13		
2300	SSI BLIND WITH MEDIC	1,608.24	673.68	2,512.83	3,636.12	1,795.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,226.14		
2310	SSI BLIND NON-MEDIC A	152,422.10	93,321.49	149,231.08	113,600.43	132,231.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		640,806.61		
2320	SSI BLIND WITH QMB	25,634.25	24,559.95	37,139.99	23,276.74	13,811.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,422.57		
4311	SOBRA CHILD <1 M & F	3,286,484.12	2,149,405.66	2,096,933.37	1,915,298.65	1,973,036.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,421,157.83		
4312	SOBRA CHILD 01-05 M	2,764,300.30	2,373,818.71	2,958,098.79	2,805,266.22	3,878,655.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,780,139.13		
4313	SOBRA CHILD 06-13 M	4,369,679.47	3,524,628.76	4,931,798.20	4,281,492.04	4,489,857.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,597,455.86		
4314	SOBRA CHILD 14-20 MA	1,698,812.85	1,177,270.58	2,438,408.11	1,375,762.11	1,624,040.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,314,294.42		
4315	SOBRA CHILD 14-20 FE	1,981,745.20	1,686,206.40	2,062,842.10	1,870,597.80	1,974,760.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,576,152.34		
5007	SOBRA PREG 21-44 FE M	0.00	-869.63	1,227.93	3,933.81	3,507.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,799.98		
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	275,451.33	215,187.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,347,204.73		
5017	SOBRA PREG 21-44 FE
M	2,120,937.76	1,696,357.50	2,481,926.63	1,794,581.26	1,573,705.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,667,508.67		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	131.02	2,231.25	998.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,360.94		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	142.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232.69		
SUBTOTAL:	49,466,816.16	37,873,233.05	50,470,064.01	43,108,358.25	41,932,639.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,851,110.47		

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	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	-0.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	-0.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
-0.30	
-0.30	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	856.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	12,572.79	16,545.52	7,419.92	17,347.58	9,955.60	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	15,731.77	1,738.61	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	91,045.23	75,893.29	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	122,783.98	90,132.21	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	1,199,354.45	1,566,080.21	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	901,656.75	882,923.68	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	2,921,477.14	2,529,402.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

856.76	
63,841.41	
22,147.01	
386,105.10	
609,803.69	
6,634,138.04	
4,707,055.82	
15,311,374.91	

1106	TANF EXPANDED 21-44	10,719.07	2,754.62	10,524.51	4,113.87	2,913.63	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	4,698.46	4,399.14	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	44,944.46	38,201.61	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	32,620.04	36,396.95	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	479.00	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	900.23	958.00	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	76,246.39	68,058.34	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	877,072.78	833,312.95	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	3,058,429.83	3,111,122.85	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	2,142,527.78	1,935,715.10	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	3,786.00	3,674.97	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	14,105.59	15,832.91	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	66,421.55	61,981.26	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	106,263.54	106,646.11	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	82,007.61	96,822.45	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	27,197.38	22,731.64	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	25,061.75	25,532.33	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	574,278.79	491,847.75	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	7,391.71	26,602.77	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	236,797.14	90,254.57	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	490,368.08	395,860.73	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	7,875,711.98	7,368,866.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
31,025.70	
35,082.55	
227,394.13	
214,297.78	
958.00	
33,209.58	
299,653.01	
5,088,167.42	
15,923,098.04	
10,631,083.08	
48,132.51	
75,206.07	
374,724.03	
565,809.77	
423,956.91	
114,077.47	
134,960.27	
3,008,979.53	
73,803.32	
886,680.97	
2,217,346.74	
40,407,646.88	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3519	ADULT 40-100% M&F 65	1,122.48	807.96	2,756.95	1,979.53	1,780.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,447.32		
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		5.16		
3528	ADULT 40-100% M&F 45	2,862.31	13,617.53	3,327.21	9,088.64	5,407.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,302.96		
3706	ADULT <40% EXP MALE	862.07	537.53	4,219.43	2,641.24	5,047.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,307.31		
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	20,799.69	32,882.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,510.40		
3709	ADULT <40% EXP M&F 6	697.97	500.67	84.98	169.42	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,932.04		
3714	ADULT <40% EXP MALE	549,983.14	425,687.45	439,852.57	575,005.01	388,057.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,378,586.06		
3715	ADULT <40% EXP FEMA L	476,422.20	362,759.11	530,706.67	563,869.62	525,585.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,459,343.48		
3716	ADULT <40% EXP MALE	13,663,876.43	10,989,796.96	15,694,862.07	12,861,276.25	11,117,075.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,326,887.27		
3717	ADULT <40% EXP FEMA L	6,400,827.19	5,817,880.47	7,144,686.24	6,548,974.08	5,707,235.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,619,603.02		
3718	ADULT <40% EXP M&F
4	16,215,570.02	12,524,194.77	18,122,144.94	13,020,323.85	12,771,869.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,654,103.07		
3719	ADULT <40% EXP M&F 6	3,519.78	106,471.32	2,050.43	645.01	1,059.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,746.00		
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	19,860.83	15,851.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,018.41		
SUBTOTAL:	43,359,796.06	34,997,222.01	48,570,760.65	38,894,030.07	35,729,313.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,551,122.29		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	315.07	1,218.50	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	86.42	412.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	13,732.61	19,160.95	23,373.45	18,672.60	19,129.25	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	12,691.27	13,763.07	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	49,496.21	48,590.06	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	64,522.02	79,450.98	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	923,623.17	939,115.93	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	1,153,122.28	1,501,423.89	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	2,348,490.51	1,962,781.42	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	4,214.46	7,313.70	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	57.18	651.12	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	660.22	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	4,575,291.19	4,574,510.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,533.57	
499.10	
94,068.86	
45,766.26	
272,132.81	
384,265.19	
4,342,355.92	
5,769,411.32	
10,841,770.11	
17,312.18	
3,620.76	
1,378.47	
21,774,114.55	

4413	SOBRA 100-133% M&F
6	350,048.99	246,594.45	388,953.30	358,715.26	389,766.96	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	131,387.01	133,833.98	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	193,892.85	178,259.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	634,066.95	484,472.35	664,288.15	683,995.12	701,860.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,734,078.96	
623,838.41	
810,765.32	
3,168,682.69	

4517

BC PATIENT FEMALE 2 1

479.00

0.00

0.00

0.00

479.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

958.00

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4518	BC PATIENT FEMALE 4 5	10,039.34	2,607.82	19,699.11	15,646.80	10,347.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,340.19		
SUBTOTAL:	10,518.34	2,607.82	19,699.11	15,646.80	10,826.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,298.19		

8700	SSI DISABLED FREEDO M	26,937.59	15,130.22	30,464.05	12,339.35	34,548.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	31,044.49	14,723.13	13,850.82	40,287.34	29,099.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	26,216.72	21,512.86	21,777.97	-1,518.26	4,414.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	84,198.80	51,366.21	66,092.84	51,108.43	68,062.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
119,420.19	
129,004.82	
72,403.77	
320,828.78	

S000	STATE-ONLY BHS	6,610.59	-6,562.50	-48.09	0.00	6,317.30	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	6,317.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,317.30

6,317.30

490,139,120.85

107,411,105.06	83,457,939.86	113,673,538.97	95,204,141.84	90,392,395.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 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	1,935.70	456.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,774.02		
1012	TANF 01-05 M & F NON	647.22	136.59	0.00	443.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,227.10		
1013	TANF 06-13 M & F NON	1,255.10	0.00	9,406.29	240.35	224.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,126.18		
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	950.19	965.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,204.15		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	521.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		521.98		
1017	TANF 21-44 FEMALE N O	31,834.14	12,820.33	6,592.11	7,094.24	32,763.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,104.56		
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	843.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		892.00		
4311	SOBRA CHILD <1 M & F	60,059.97	30,560.13	36,385.04	81,057.95	40,352.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248,415.77		
4312	SOBRA CHILD 01-05 M	96,645.58	29,504.41	14,980.14	15,786.95	9,360.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166,277.87		
4313	SOBRA CHILD 06-13 M	28,540.89	41,368.11	21,037.74	9,508.29	9,250.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,705.94		
4314	SOBRA CHILD 14-20 MA	15,316.91	13,767.28	31,611.58	5,386.94	11,173.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,255.81		
4315	SOBRA CHILD 14-20 FE	35,626.01	10,194.98	22,640.89	15,683.31	6,051.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,196.88		
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	12,164.49	17,204.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,320.70		
5017	SOBRA PREG 21-44 FE M	118,243.42	110,937.05	85,990.10	71,271.89	87,059.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		473,501.83		
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	222,366.75	215,385.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,375,863.22		

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	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	-136.78	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	-427.00	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	-152.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-100.14	0.00	0.00	-289.14	-427.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
33.48	
-136.78	
-427.00	
-112.02	
-173.96	
-816.28	

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	-510.93	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	-4,957.51	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	-136.91	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	-157.69	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	-5,763.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
-670.80	
-660.75	
-1,150.71	
-718.45	
5,655.56	
-3,494.20	
-3,503.75	
-4,543.10	

3916

NEWLY ELIGIBLE MALE

0.00

0.00

0.00

-100.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

-100.00

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		-7.47		
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		-495.49		
SUBTOTAL:	228.78	-302.72	-429.02	-100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-602.96		

4413	SOBRA 100-133% M&F
6	3,690.96	1,766.09	4,790.07	1,024.30	3,142.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	103,321.39	13,115.92	6,531.34	780.45	6,459.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	5,061.43	1,478.57	480.90	513.00	807.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	112,073.78	16,360.58	11,802.31	2,317.75	10,409.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14,413.98	
130,208.57	
8,341.12	
152,963.67	

TOTAL:	532,251.37	278,668.20	268,045.07	218,532.32	225,367.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,522,864.55		

FEDERAL EMERGENCY SERVICES
For The Period Ending November 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	5,413.13	2,744.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,482.62		
1012	TANF 01-05 M & F NON	29,766.61	5,058.03	27,650.24	11,021.48	9,272.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,768.69		
1013	TANF 06-13 M & F NON	48,909.26	269,034.29	84,803.20	98,338.33	62,944.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		564,029.73		
1014	TANF 14-20 MALE NON-	142,120.31	36,400.94	76,985.27	225,065.73	75,386.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		555,959.23		
1015	TANF 14-20 FEMALE N O	193,775.73	243,632.31	169,948.20	224,563.08	239,176.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,071,095.96		
1016	TANF 21-44 MALE NON-	398.83	20.28	0.00	209.94	419.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,048.93		
1017	TANF 21-44 FEMALE N O	1,503,087.87	1,418,081.95	1,807,767.82	1,641,076.56	1,758,788.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,128,802.87		
1018	TANF 45-64 M & F NON	14,122.04	726.72	4,499.74	8,809.39	4,651.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,809.46		
2100	SSI AGED WITH MEDIC A	27,107.23	11,301.18	14,673.08	9,365.03	57,953.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,400.38		
2110	SSI AGED NON-MEDICA
R	1,748,492.75	1,469,447.90	1,954,407.98	2,156,559.09	1,681,396.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,010,304.30		
2200	SSI DISABLED WITH M E	7,695.04	2,242.16	2,186.04	1,055.36	1,510.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,688.82		
2210	SSI DISABLED NON-ME
D	43,003.05	25,262.16	37,324.27	26,198.68	22,405.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,193.53		
2220	SSI DISABLED WITH Q M	0.00	872.61	829.45	1,030.81	153.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,886.76		
SUBTOTAL:	3,758,804.16	3,482,080.53	4,181,075.29	4,408,706.61	3,916,804.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,747,471.28		

3906	NEWLY ELIGIBLE MALE	27.16	0.00	0.00	210.25	106.48	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	5,763.32	10,876.34	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	81,367.29	21,903.46	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	41,078.30	38,429.84	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	1,678,384.76	1,639,015.64	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	607,775.50	719,647.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

343.89	
34,184.66	
217,047.82	
224,171.24	
7,655,822.08	
2,966,765.77	

1107	TANF EXPANDED 21-44	4,466.01	104.64	3,762.29	4,739.12	4,817.71	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	1,599.25	1,822.00	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	159.61	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	21,267.81	28,364.80	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	713,009.24	674,802.37	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	1,916,520.19	1,864,899.02	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	1,599,598.92	1,723,133.90	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	25,812.60	4,455.76	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	14.10	8.52	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	2,653.47	1,721.32	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	48.84	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	2,574.32	4,755.26	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	4,287,997.47	4,308,780.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
17,889.77	
4,637.85	
69.44	
4,303.57	
85,284.16	
4,200,567.29	
8,642,892.24	
7,240,647.62	
98,489.34	
171.94	
7,433.63	
21,232.74	
13,015.20	
600.51	
20,337,235.30	

FEDERAL EMERGENCY SERVICES
For The Period Ending November 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	4,531,338.83	4,765,007.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,775,995.19		
3919	NEWLY ELIGIBLE M&F
6	6,763.68	14,681.00	18,917.68	9,507.32	-1,577.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,292.57		
SUBTOTAL:	5,996,983.35	5,467,004.70	8,309,800.13	6,955,425.57	7,193,409.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,922,623.22		

74,007,329.80

13,695,898.84	12,178,848.34	17,061,458.15	15,652,129.65	15,418,994.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE
For The Period Ending November 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	394,600.58	460,018.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,343,258.13		
8040	SLMB	859.02	384.95	416.46	223.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,884.27		
8050	QI1	223.92	1.85	76.32	1.50	31.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		335.52		
SUBTOTAL:	560,175.21	366,856.62	563,569.70	394,825.92	460,050.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,345,477.92		

TOTAL:	560,175.21	366,856.62	563,569.70	394,825.92	460,050.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,345,477.92		

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 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		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	8.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.01		
1011	TANF <1 M & F NON-ME	2,229.05	682.70	1,916.00	1,117.60	1,508.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,453.44		
1012	TANF 01-05 M & F NON	6,130.49	6,317.48	6,021.42	8,420.77	5,043.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,933.77		
1013	TANF 06-13 M & F NON	185,370.72	142,831.84	95,609.79	111,919.80	86,340.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		622,072.96		
1014	TANF 14-20 MALE NON-	61,620.57	53,913.40	60,192.12	53,420.91	26,399.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,546.63		
1015	TANF 14-20 FEMALE N O	117,992.97	113,226.00	123,239.60	81,482.04	291,370.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		727,311.01		
1016	TANF 21-44 MALE NON-	620,695.88	661,887.71	508,772.72	544,819.32	554,579.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,890,754.84		
1017	TANF 21-44 FEMALE N O	1,377,131.11	1,347,188.67	2,150,745.77	1,860,697.10	1,618,408.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,354,171.17		
1018	TANF 45-64 M & F NON	215,528.64	200,049.81	187,946.09	205,377.01	318,056.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,126,957.61		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	-182.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-182.44		
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	18,666.50	6,326.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,907.57		
2110	SSI AGED NON-MEDICA
R	3,465.84	2,684.56	4,610.40	3,382.34	2,526.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,669.42		
2120	SSI AGED WITH QMB	32,438.17	3,015.69	22,662.12	36,255.22	13,600.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,971.48		
2200	SSI DISABLED WITH M E	30,039.85	40,301.42	111,308.73	65,026.37	47,099.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293,775.86		
2210	SSI DISABLED NON-ME
D	1,255,916.44	1,615,532.63	1,623,080.23	1,668,643.25	1,710,373.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,873,546.44		
2220	SSI DISABLED WITH Q M	272,422.20	182,362.18	293,693.70	298,895.88	324,477.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,371,851.45		
2310	SSI BLIND NON-MEDIC
A	12,525.00	6,005.79	13,810.86	10,763.03	4,693.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,797.77		
2320	SSI BLIND WITH QMB	335.08	6,421.99	8,018.43	5,962.24	3,829.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,567.09		
4311	SOBRA CHILD <1 M & F	697.99	3,413.73	4,065.67	6,904.39	3,975.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,057.51		
4312	SOBRA CHILD 01-05 M	84,847.46	78,017.20	132,552.69	102,131.77	87,345.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		484,894.39		
4313	SOBRA CHILD 06-13 M	1,946,261.69	1,711,753.70	2,141,655.96	1,621,868.76	1,864,057.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,285,598.00		
4314	SOBRA CHILD 14-20 MA	627,970.65	708,102.87	883,452.56	554,719.48	786,315.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,560,560.88		
4315	SOBRA CHILD 14-20 FE	998,234.53	914,646.46	1,087,806.06	751,126.20	734,615.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,486,428.88		
5015	SOBRA PREG 14-20 FE M	3,278.24	2,027.10	7,703.37	4,535.80	13,940.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,484.96		
5017	SOBRA PREG 21-44 FE
M	123,360.35	133,963.53	111,567.28	53,007.63	63,736.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		485,634.90		
SUBTOTAL:	7,986,374.23	7,942,316.90	9,613,019.40	8,068,960.97	8,568,626.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,179,298.21		

1107	TANF EXPANDED 21-44	0.00	37.22	0.00	26.79	33.49	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	606.96	78.54	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	24.44	5.16	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	912.66	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	223,385.34	160,482.48	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	498,290.49	278,238.77	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	114,741.68	95,514.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
97.50	
4,243.02	
34.76	
19,721.18	
942,527.26	
1,912,431.45	
637,104.58	

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	8,290.05	10,593.08	12,340.88	5,518.00	-5,426.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,315.23		
1127	TANF EXPANDED 21-44	40,868.90	21,762.10	8,958.51	5,716.20	-46,919.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,386.66		
1128	TANF EXPANDED 45-64	12,122.71	8,778.37	12,439.16	5,011.05	4,664.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,015.49		
1129	TANF EXPANDED 65+ M
&	644.34	2,501.67	1,255.54	2,503.31	6,614.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,518.99		
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	12,662.60	20,609.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,738.64		
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	1,228.51	878.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,209.38		
2620	SSI DISABLED EXPAND E	46,298.74	30,206.09	48,063.47	25,851.79	70,098.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		220,518.55		
SUBTOTAL:	744,670.11	692,281.94	1,062,196.72	896,479.82	584,872.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,980,501.35		

3908	NEWLY ELIGIBLE M&F 4	659.34	136.83	670.09	1,410.10	2,418.04	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	1,437.00	958.00	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	11,764.36	12,189.94	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	119,805.83	104,417.20	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	50,246.64	73,368.40	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	45,037.65	57,502.82	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	43.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	183,575.61	206,505.68	258,500.33	229,701.58	250,897.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,294.40	
14,603.82	
50,903.87	
572,738.33	
238,116.57	
247,480.61	
43.38	
1,129,180.98	

4413	SOBRA 100-133% M&F
6	74,321.05	52,735.46	98,524.58	71,072.61	90,508.89	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	16,466.58	28,092.40	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	21,775.92	28,902.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

387,162.59	
314,317.21	
146,317.65	

3514	ADULT 40-100% MALE 1	10,038.11	6,591.57	4,422.92	2,290.33	2,528.07	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	24,148.78	5,798.85	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	145,070.76	148,256.14	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	93,138.93	77,049.90	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	95,738.72	91,319.79	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	2,752.16	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	192,777.65	195,859.86	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	112,467.39	138,098.53	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	3,629,572.78	2,968,258.80	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	2,062,325.07	1,411,485.67	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	1,537,577.16	1,338,180.98	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	164.48	155.65	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	7,895,272.05	6,379,744.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
25,871.00	
70,322.12	
727,824.78	
475,572.03	
516,047.26	
5,935.42	
620.70	
1,036,693.19	
616,479.51	
16,550,357.20	
8,823,089.20	
8,221,270.90	
320.13	
37,070,403.44	

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	134,040.20	93,427.89	363,510.54	109,315.11	147,503.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		847,797.45		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	1.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	665.04	1,054.36	0.00	2,449.17	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	
SUBTOTAL:	665.04	1,054.36	479.00	2,449.17	1.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1.85	
4,168.57	
479.00	
4,649.42	

85,211,830.85

19,933,396.22	17,202,178.70	15,931,647.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

16,472,295.13

15,672,313.59

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending November 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	7,259.82	5,880.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,669.03		
1017	TANF 21-44 FEMALE N O	19,969.29	32,704.70	57,587.38	37,280.52	26,460.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174,002.79		
1018	TANF 45-64 M & F NON	5,094.30	9,249.68	17,529.99	3,363.52	6,825.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,062.53		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	-1,364.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,364.00		
2210	SSI DISABLED NON-ME
D	91,974.79	90,886.53	231,219.63	64,967.52	35,206.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		514,255.31		
2220	SSI DISABLED WITH Q M	2,816.00	1,408.00	0.00	1,408.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,632.00		
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	114,279.38	73,009.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		837,325.23		

3516	ADULT 40-100% MALE 2	8,301.74	21,895.67	23,332.49	6,369.94	21,838.65	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	5,886.16	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	2,219.61	754.67	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	206,633.92	223,016.99	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	77,584.81	58,750.29	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	71,052.77	52,615.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	471,910.36	544,545.49	625,777.83	369,747.21	356,975.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

81,738.49	
38,435.71	
5,193.89	
1,300,135.74	
563,957.34	
379,495.49	
2,368,956.66	

3916	NEWLY ELIGIBLE MALE	24,443.39	35,034.19	27,447.29	24,675.52	26,025.15	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	10,977.43	8,291.39	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	5,943.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	37,689.37	53,626.14	54,347.23	35,652.95	40,259.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

137,625.54	
54,576.89	
29,373.15	
221,575.58	

1116	TANF EXPANDED 21-44	4,245.25	5,012.64	10,923.34	2,522.64	13,454.16	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	11,234.18	16,932.01	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	1,408.00	2,816.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,062.10	9,540.66	22,454.62	15,164.82	33,202.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
36,158.03	
47,895.46	
3,330.88	
1,408.00	
5,632.00	
94,424.37	

TOTAL:	652,321.06	765,019.24	1,066,649.72	534,844.36	503,447.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,522,281.84		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending November 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	152,337.26	170,994.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		624,184.81		
2110	SSI AGED NON-MEDICA
R	128,802.10	132,314.60	259,968.44	159,816.72	249,391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		930,292.86		
2120	SSI AGED WITH QMB	8.25	0.00	9.71	0.00	26.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.12		
2200	SSI DISABLED WITH M E	33,272.30	45,153.97	25,391.06	59,972.74	59,597.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,387.33		
2210	SSI DISABLED NON-ME
D	298.48	27,666.88	32,456.73	634.16	749.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,805.26		
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	12,034.92	1,452.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,810.04		
SUBTOTAL:	328,698.04	230,026.49	445,920.97	384,795.80	482,210.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,871,651.86		

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	5,611.59	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	970.88	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	14,272.59	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	262,081.54	457,684.63	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	25,788.16	22,632.31	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	410,166.04	518,339.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	634,879.50	949,557.51	983,525.61	703,647.33	1,013,899.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
57.36	
8,887.59	
13,964.86	
23,778.49	
1,821,972.79	
77,264.07	
2,339,584.75	
4,285,509.91	

3908	NEWLY ELIGIBLE M&F 4	0.00	11,510.95	57.36	600.35	107.63	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	31,741.97	35,455.73	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	4,588.77	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	18,758.05	33,337.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30,171.90	37,484.14	124,660.27	55,689.14	68,900.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
12,276.29	
129,027.44	
4,588.77	
171,013.37	
316,905.87	

6,474,067.64

993,749.44	1,217,068.14	1,554,106.85	1,144,132.27	1,565,010.94	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 November 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	13.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,539.08		
SUBTOTAL:	89.00	0.00	1,436.15	0.00	13.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,539.08		

3716	ADULT <40% EXP MALE	6,643.51	0.00	0.00	128.76	21.88	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	277.17	3,665.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,643.51	0.00	9,430.37	405.93	3,687.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,794.15	
13,373.23	
20,167.38	

TOTAL:	6,732.51	0.00	10,866.52	405.93	3,701.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,706.46		

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 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	6,370.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,370.68		
1016	TANF 21-44 MALE NON-	28.54	706.35	4,086.75	43,152.93	4,561.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,535.61		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	6,390.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,390.58		
2210	SSI DISABLED NON-ME
D	6,614.01	2,282.64	2,170.99	486.47	1,660.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,214.65		
4314	SOBRA CHILD 14-20 MA	7,370.21	5,177.15	0.00	0.00	607.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,154.76		
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	50,009.91	13,219.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,426.07		

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	570.81	6,128.49	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	570.81	6,128.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,392.31	
16,314.26	
359.78	
18,066.35	

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	188,065.10	105,487.57	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	35,811.26	12,364.07	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	11,105.75	21,560.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	79,227.09	55,286.17	48,379.25	234,982.11	139,411.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
809.64	
522.44	
0.00	
414,754.95	
76,226.66	
64,972.80	
557,286.49	

3916	NEWLY ELIGIBLE MALE	6,096.69	363.74	27,112.74	0.00	921.78	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	15,499.33	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	15,499.33	921.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
34,494.95	
15,499.33	
49,994.28	

725,773.19

113,643.26	69,462.74	81,923.33	301,062.16	159,681.70	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 November 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	446.40	4,285.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,474.68		
2220	SSI DISABLED WITH Q
M	0.00	0.00	423.11	64.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		487.37		
SUBTOTAL:	0.00	742.87	423.11	510.66	4,285.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,962.05		

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

3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	70.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	6,254.24	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	1,006.09	22.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,592.71	279.80	17,881.92	7,260.33	92.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

70.08	
3,509.05	
6,254.24	
25,274.30	
35,107.67	

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	3,713.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	3,713.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,713.42

3,713.42

TOTAL:	9,592.71	4,654.56	18,305.03	7,770.99	8,091.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,415.03		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 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	13,837.24	5,115.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,322.26		
SUBTOTAL:	88.32	8,270.74	6,438.25	13,837.24	5,115.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,750.36		

3516	ADULT 40-100% MALE 2	0.00	1,019.08	0.00	0.00	6,512.73	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	7,208.49	4,090.03	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	5,067.09	7,326.03	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	4,313.76	897.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,600.28	43,980.23	17,411.00	16,589.34	18,826.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,531.81	
55,402.53	
30,378.79	
16,094.17	
109,407.30	

3918	NEWLY ELIGIBLE M&F 4	0.00	5,777.85	5,788.59	90.87	248.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	5,777.85	5,788.59	90.87	248.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
11,905.50

11,905.50

155,063.16

12,688.60	58,028.82	29,637.84	30,517.45	24,190.45	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 November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	241.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241.10		
SUBTOTAL:	0.00	0.00	0.00	0.00	241.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		241.10		

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	328.57	9,851.92	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	6,280.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	934.34	223.84	207.40	6,609.12	9,851.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,148.62	
10,397.45	
6,280.55	
17,826.62	

2420	SSI AGED EXPANDED WI	163.89	2,230.55	0.00	231.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	163.89	2,230.55	0.00	231.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
2,625.94

2,625.94

TOTAL:	1,098.23	2,454.39	207.40	6,840.62	10,093.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,693.66		

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 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		

274.03

11,830.63

3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	274.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	274.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

342.37	0.00	274.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

274.03

TOTAL:

11,214.23

0.00

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending November 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	1,437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,832.00		
2100	SSI AGED WITH MEDIC A	3,330,616.47	2,456,192.60	3,516,340.54	2,423,276.39	2,320,640.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,047,066.96		
2110	SSI AGED NON-MEDICA
R	187,328.99	149,799.02	235,218.18	120,294.47	154,163.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		846,804.33		
2120	SSI AGED WITH QMB	5,085,234.28	3,558,600.50	5,247,830.45	4,000,803.94	3,613,144.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,505,613.41		
2200	SSI DISABLED WITH M E	555,517.35	422,232.69	592,574.28	442,575.93	485,649.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,498,549.65		
2210	SSI DISABLED NON-ME
D	3,676,881.67	2,853,162.88	3,642,622.41	3,148,700.46	2,918,107.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,239,474.99		
2220	SSI DISABLED WITH Q M	1,181,251.47	893,296.91	1,183,450.91	939,777.85	1,039,867.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,237,644.31		
2310	SSI BLIND NON-MEDIC
A	479.00	492.39	1,044.80	479.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,453.19		
2320	SSI BLIND WITH QMB	0.00	17.38	2,606.91	2,415.70	2,389.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,429.05		
SUBTOTAL:	14,017,309.23	10,334,273.37	14,423,604.48	11,079,760.74	10,534,920.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,389,867.89		

8720	SSI DISABLED FREEDO M	4,401.60	3,521.28	4,408.89	3,509.76	3,481.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,401.60	3,521.28	4,408.89	3,509.76	3,481.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19,322.57

19,322.57

TOTAL:	14,021,710.83	10,337,794.65	14,428,013.37	11,083,270.50	10,538,401.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,409,190.46		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 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	455.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,063.27		
SUBTOTAL:	-2,222.33	-5,828.56	269.45	455.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,326.33		

455.11

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

-7,326.33

YAVAPAI COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	175.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.22		
SUBTOTAL:	0.00	0.00	0.00	0.00	175.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.22		

TOTAL:	0.00	0.00	0.00	0.00	175.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.22		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending November 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	25,001.63	37,849.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,266.49		
1013	TANF 06-13 M & F NON	45,652.16	16,990.31	15,315.71	57,451.65	87,519.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,929.71		
1014	TANF 14-20 MALE NON-	4,083.21	1,462.24	1,486.56	4,428.17	6,494.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,955.13		
1015	TANF 14-20 FEMALE N O	3,673.46	1,597.88	1,159.70	3,922.03	6,560.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,913.39		
2210	SSI DISABLED NON-ME
D	123,882.31	60,436.07	35,826.98	106,378.59	184,120.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		510,644.77		
2310	SSI BLIND NON-MEDIC A	2,716.64	0.00	0.00	1,974.96	1,711.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,403.20		
4312	SOBRA CHILD 01-05 M	101,401.93	44,462.78	26,948.19	96,081.99	162,611.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		431,506.79		
4313	SOBRA CHILD 06-13 M	149,379.80	64,797.33	55,814.71	202,394.94	347,789.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		820,176.57		
4314	SOBRA CHILD 14-20 MA	15,372.03	5,852.75	3,740.63	12,944.99	25,606.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,516.89		
4315	SOBRA CHILD 14-20 FE	6,104.83	2,259.18	2,434.07	5,356.84	12,784.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,939.55		
SUBTOTAL:	473,716.20	209,551.95	148,999.17	515,935.79	873,049.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,221,252.49		

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	27.18	33.33	0.00	136.95	60.00	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	118.75	646.93	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	29.46	20.00	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	285.16	736.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
10.00	
257.46	
1,181.77	
354.23	
10.00	
157.51	
1,970.97	

3914	NEWLY ELIGIBLE MALE	53.27	14.57	0.00	32.49	16.00	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	113.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	63.06	14.57	0.00	32.49	129.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
116.33	
123.06	
239.39	

4413	SOBRA 100-133% M&F
6	35,057.25	14,906.93	12,516.25	48,450.64	77,223.02	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	2,336.31	5,254.71	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	1,324.38	2,116.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39,014.69	16,476.53	13,718.88	52,111.33	84,594.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
188,154.09	
12,218.70	
5,543.23	
205,916.02	

2,429,378.87

162,796.81	568,364.77	958,510.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

513,473.46

226,233.66

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending November 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	14,185.19	22,456.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,165.02		
2200	SSI DISABLED WITH M E	774.73	316.00	263.12	558.66	3,031.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,943.58		
2210	SSI DISABLED NON-ME
D	587,639.52	246,975.00	184,726.70	540,569.92	935,503.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,495,415.08		
2220	SSI DISABLED WITH Q M	1,089.49	424.23	0.00	409.41	1,271.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,194.48		
2310	SSI BLIND NON-MEDIC
A	335.75	55.50	0.00	102.26	111.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		604.51		
SUBTOTAL:	607,580.28	255,440.94	189,102.40	555,825.44	962,373.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,570,322.67		

TOTAL:	607,580.28	255,440.94	189,102.40	555,825.44	962,373.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,570,322.67		

ACC REINSURANCE
For The Period Ending November 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		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	6,382.46	-9,615.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,232.97		
1011	TANF <1 M & F NON-ME	480,434.84	2,224,804.45	720,496.38	402,399.85	946,020.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,774,156.06		
1012	TANF 01-05 M & F NON	37,196.19	202,649.53	96,281.70	57,600.45	93,430.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		487,157.88		
1013	TANF 06-13 M & F NON	241,018.88	227,000.67	175,147.65	135,216.71	272,433.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,050,817.80		
1014	TANF 14-20 MALE NON-	185,768.53	101,928.26	117,286.61	132,042.93	223,418.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		760,444.48		
1015	TANF 14-20 FEMALE N O	67,973.73	116,298.84	58,224.98	33,714.58	62,429.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338,641.47		
1016	TANF 21-44 MALE NON-	172,317.95	239,808.12	303,605.09	2,001.56	287,108.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,004,840.94		
1017	TANF 21-44 FEMALE N O	403,162.64	313,990.42	496,728.85	515,075.80	542,798.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,271,755.72		
1018	TANF 45-64 M & F NON	403,812.03	193,025.91	212,646.30	133,716.49	303,317.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,246,518.19		
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	108,557.87	23,760.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221,631.84		
2110	SSI AGED NON-MEDICA
R	24,771.85	240,105.43	67,897.62	317,685.62	191,608.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		842,068.66		
2200	SSI DISABLED WITH M E	53,684.93	538,549.83	19,150.52	1,401,916.46	49,178.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,062,480.50		
2210	SSI DISABLED NON-ME
D	5,330,188.46	6,117,760.41	5,324,232.76	3,977,811.96	7,992,327.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,742,320.91		
2310	SSI BLIND NON-MEDIC A	12,975.28	34,269.50	26,913.55	18,991.17	177,029.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270,178.87		
4311	SOBRA CHILD <1 M & F	2,498,117.33	2,731,667.40	1,902,761.56	2,479,867.39	2,778,418.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,390,831.88		
4312	SOBRA CHILD 01-05 M	1,603,767.69	471,995.20	700,534.12	665,075.87	672,817.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,114,190.10		
4313	SOBRA CHILD 06-13 M	393,530.06	1,103,420.81	1,375,296.20	1,014,224.32	903,029.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,789,501.05		
4314	SOBRA CHILD 14-20 MA	866,162.72	613,892.46	732,587.61	514,047.49	762,706.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,489,396.66		
4315	SOBRA CHILD 14-20 FE	41,106.92	116,339.99	360,104.67	524,801.78	236,905.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,279,258.55		
5015	SOBRA PREG 14-20 FE M	2,839.10	0.00	0.00	0.00	25,546.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,385.65		
5017	SOBRA PREG 21-44 FE
M	49,769.88	12,363.53	10,220.12	18,346.43	89,537.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,237.63		
SUBTOTAL:	12,864,243.64	15,638,547.70	12,782,089.51	12,459,477.19	16,624,205.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,368,563.12		

3100

TRANSPLANT OPTION 1

1,572.03

1,572.03

134.39	-16.22	0.00	0.00	1,453.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
134.39	-16.22	0.00	0.00	1,453.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

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	1,174.10	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	286,855.23	266,833.29	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	259,221.48	343,239.00	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	218,582.20	503,388.33	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	19,705.90	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	6,979.39	17,336.29	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	8,757.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.76	
1,208.85	
113.88	
1,234,894.68	
1,678,501.34	
1,020,452.96	
19,705.90	
52,383.55	
10,695.53	

ACC REINSURANCE
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2600	SSI DISABLED EXPAND E	2,701.12	-71,013.92	9,869.12	309.19	6,736.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-51,397.87		
2610	SSI DISABLED EXPAND
E	91,569.18	26,200.30	107,032.85	75,814.89	69,987.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		370,604.44		
SUBTOTAL:	698,941.23	727,216.95	826,084.76	867,468.28	1,217,452.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,337,164.02		

3508	ADULT 40-100% M&F 45	199.90	8,524.08	0.00	0.00	-8,524.08	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	35,420.40	54,141.62	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	32,525.76	1,139.36	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	343,483.49	276,649.96	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	316,829.25	362,238.64	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	796,124.27	797,207.92	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	7,265.98	-883.36	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	89,153.22	-5,113.17	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	188,920.09	326,307.90	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	41,044.21	-28,386.07	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	2,453,567.19	2,415,286.09	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	647,280.80	767,669.40	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	2,941,380.65	3,189,951.10	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	392.34	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	7,893,387.65	8,147,685.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
199.90	
276,386.08	
85,038.57	
1,329,715.61	
932,077.84	
3,872,008.89	
34,949.77	
1,080.51	
17,178.34	
107,366.23	
1,094,107.53	
114,862.22	
11,645,385.61	
2,845,777.31	
14,287,210.19	
660.14	
36,644,004.74	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	7,717.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	12,398.47	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	48,836.68	49,140.83	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	925.66	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	385,752.60	751,038.77	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	101,290.66	7,736.46	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	603,540.79	912,382.00	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	1,139,420.73	1,741,339.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,717.17	
5,853.02	
13,042.62	
193,887.42	
925.66	
2,635,221.29	
802,255.64	
2,974,933.62	
6,633,836.44	

4413	SOBRA 100-133% M&F
6	294,812.82	246,412.43	216,055.33	305,884.98	363,191.92	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	236,398.62	168,885.43	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	12,443.17	7,259.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	407,745.29	522,090.37	550,728.80	554,726.77	539,337.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,426,357.48	
1,080,864.98	
67,406.03	
2,574,628.49	

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

1,584.30

ACC REINSURANCE
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	12,436.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
8710	SSI DISABLED FREEDO
M	318,524.01	68,836.44	4,993.81	0.00	42,017.12	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	54,453.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

 
12,436.24	
434,371.38	
446,807.62	

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	
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

0.00

121,008,160.76

20,318,436.12	25,568,339.31	23,880,977.68	22,914,480.62	28,325,927.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE REINSURANCE
For The Period Ending November 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	8,637.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,637.52		
1010	TANF NON-MEDICARE	69,901.43	86,772.10	131,865.39	193,696.46	125,063.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		607,298.87		
2100	SSI AGED WITH MEDIC A	60,397.22	169,241.05	240,471.75	231,709.44	240,620.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		942,440.43		
2110	SSI AGED NON-MEDICA
R	11,714.39	67,113.76	57,237.79	60,757.45	48,712.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		245,536.01		
2200	SSI DISABLED WITH M E	275,434.62	431,387.49	427,970.76	416,500.37	497,429.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,048,722.51		
2210	SSI DISABLED NON-ME
D	2,845,203.33	7,270,389.52	5,088,943.39	9,241,961.50	4,431,222.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,877,720.34		
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	10,153,262.74	5,343,048.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,733,108.10		

8710	SSI DISABLED FREEDO M	128,929.98	0.00	0.00	116,115.14	116,115.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	128,929.98	0.00	0.00	116,115.14	116,115.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
361,160.26

361,160.26

TOTAL:	3,391,580.97	8,020,729.01	5,953,416.41	10,269,377.88	5,459,164.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,094,268.36		

ACC SMIB
For The Period Ending November 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	65,214.30	68,540.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		327,951.90		
1010	TANF NON-MEDICARE	723.00	867.60	578.40	578.40	578.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,325.80		
1020	TANF WITH QMB	41,334.30	44,476.10	48,151.80	46,127.40	46,127.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		226,217.00		
2100	SSI AGED WITH MEDIC A	52,524.10	61,427.70	56,665.00	59,124.30	55,976.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285,717.30		
2110	SSI AGED NON-MEDICA
R	584,914.80	589,054.90	584,770.50	585,051.60	582,125.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,925,917.20		
2120	SSI AGED WITH QMB	5,007,483.40	5,125,560.00	5,141,705.70	5,179,201.00	5,189,898.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,643,848.10		
2200	SSI DISABLED WITH M E	113,156.40	98,272.00	93,790.10	90,638.30	96,275.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		492,132.40		
2210	SSI DISABLED NON-ME
D	488,752.00	495,625.10	497,089.30	502,260.70	501,612.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,485,339.10		
2220	SSI DISABLED WITH Q M	4,085,066.00	4,232,863.20	4,229,921.70	4,231,086.40	4,215,256.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,994,193.60		
2300	SSI BLIND WITH MEDIC	-126.40	144.60	144.60	144.60	-289.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.20		
2310	SSI BLIND NON-MEDIC A	4,338.00	4,338.00	4,627.20	4,916.40	4,338.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,557.60		
2320	SSI BLIND WITH QMB	39,729.50	40,488.00	40,488.00	40,921.80	40,632.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		202,259.90		
4320	SOBRA CHILD WITH Q MB	1,012.20	1,301.40	1,012.20	723.00	723.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,771.80		
5020	SOBRA PREGNANT WO
MAN	4,627.20	4,048.80	4,048.80	6,507.00	3,036.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,268.40		
8000	SMIB ONLY NOT ELIGIB	0.00	0.00	0.00	0.00	-289.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-289.20		
8020	QMB ONLY	920,312.10	947,778.90	934,294.10	952,121.80	967,782.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,722,289.10		
8040	SLMB	5,934,242.50	6,014,077.30	6,023,078.00	6,037,424.30	5,985,247.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,994,069.80		
8888	SMIB ONLY NOT ELIGIB	-25,842.80	-13,500.40	-27,654.60	-24,276.80	-16,165.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-107,439.90		
9999	SMIB ONLY NOT ELIGIB	152,609.30	62,699.50	57,203.90	97,707.80	93,547.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		463,768.10		
SUBTOTAL:	17,458,267.60	17,781,045.10	17,759,177.80	17,875,472.30	17,834,953.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,708,916.20		

1100	TANF EXPANDED FPR FI	245,986.80	252,086.80	233,269.00	238,028.50	245,831.70	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	289.20	289.20	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	1,029,091.50	1,028,267.00	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	26,264.50	26,119.90	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	867.60	723.00	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	4,260,282.40	4,297,674.20	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	144.60	144.60	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	27,329.40	35,716.20	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	2,471,263.30	2,441,245.00	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	8,053,561.00	8,076,010.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,215,202.80	
1,446.00	
5,081,190.30	
122,175.00	
4,618.10	
21,108,445.70	
723.00	
161,356.90	
12,166,995.40	
39,862,153.20	

3500	ADULT 40-100% FOR FI	0.00	0.00	0.00	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	2,458.20	1,301.40	1,735.20	3,181.20	3,759.60	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	6,796.20	7,230.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,073.20	6,073.20	9,543.60	10,122.00	11,134.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
289.20	
12,435.60	
30,221.40	
42,946.20	

3900

NEWLY ELIGIBLE FOR F

0.00

0.00

0.00

723.00

433.80

0.00

0.00	0.00

0.00

0.00

0.00

0.00

1,156.80

ACC SMIB
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3920	NEWLY ELIGIBLE FOR F	2,313.60	235.60	6,507.00	4,338.00	6,362.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,756.60		
SUBTOTAL:	2,313.60	235.60	6,507.00	5,061.00	6,796.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,913.40		

8620	SSI BLIND FREEDOM/W O	144.60	144.60	144.60	144.60	144.60	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	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	54,514.20	61,012.10	64,054.00	65,495.80	69,110.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	54,658.80	61,156.70	64,198.60	65,785.00	69,400.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
723.00	
289.20	
314,186.90	
315,199.10	

128,950,128.10

25,328,141.20	25,806,825.80	25,806,865.20	26,010,001.30	25,998,294.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC HIB
For The Period Ending November 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	458.00	1,374.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,748.00		
2100	SSI AGED WITH MEDIC A	1,328.00	1,832.00	1,374.00	1,374.00	9,160.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,068.00		
2110	SSI AGED NON-MEDICA
R	0.00	1,374.00	0.00	1,374.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,748.00		
2120	SSI AGED WITH QMB	638,046.60	712,477.40	698,452.00	726,674.00	696,932.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,472,582.20		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	458.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		458.00		
2210	SSI DISABLED NON-ME
D	1,374.00	1,374.00	0.00	1,374.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,122.00		
2220	SSI DISABLED WITH Q M	292,661.40	301,870.60	317,862.20	323,094.60	322,969.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,558,458.40		
2320	SSI BLIND WITH QMB	3,000.00	2,084.00	3,458.00	2,542.00	2,542.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,626.00		
8020	QMB ONLY	6,847.80	7,007.80	6,091.80	7,649.00	6,137.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,734.00		
9999	SMIB ONLY NOT ELIGIB	-4,692.20	-14,104.00	-9,020.40	-13,028.00	-6,116.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-46,961.40		
SUBTOTAL:	939,023.60	1,014,831.80	1,018,217.60	1,051,511.60	1,033,456.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,057,041.20		

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	1,374.00	4,580.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR
FI	458.00	0.00	0.00	0.00	458.00	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	5,038.00	4,580.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,038.00	5,496.00	5,038.00	6,412.00	9,618.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
5,954.00	
916.00	
24,732.00	
31,602.00	

TOTAL:	944,061.60	1,020,327.80	1,023,255.60	1,057,923.60	1,043,074.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,088,643.20		

Q1
For The Period Ending November 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	3,139,044.10	3,100,662.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,587,104.30		
9999	SMIB ONLY NOT ELIGIB	5,176.20	12,716.80	4,713.80	8,912.60	12,217.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,736.50		
SUBTOTAL:	3,107,017.00	3,143,329.80	3,119,658.10	3,147,956.70	3,112,879.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,630,840.80		

15,630,840.80

3,107,017.00	3,143,329.80	3,119,658.10	3,147,956.70	3,112,879.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC SMIB
For The Period Ending November 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	144.60	289.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		867.60		
1010	TANF NON-MEDICARE	0.00	144.60	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433.80		
1020	TANF WITH QMB	289.20	144.60	144.60	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		867.60		
2100	SSI AGED WITH MEDIC A	1,126,718.00	1,111,814.50	1,067,152.00	1,061,789.40	1,059,040.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,426,514.30		
2110	SSI AGED NON-MEDICA
R	246,457.10	249,967.40	235,625.20	235,517.00	231,070.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,198,637.50		
2120	SSI AGED WITH QMB	1,351,665.40	1,356,116.10	1,326,552.60	1,309,380.60	1,300,707.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,644,422.10		
2200	SSI DISABLED WITH M E	396,138.30	394,263.10	387,700.90	384,275.90	382,674.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,945,052.30		
2210	SSI DISABLED NON-ME
D	10,411.20	10,555.80	10,845.00	11,857.20	13,592.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,261.60		
2220	SSI DISABLED WITH Q M	1,167,867.40	1,176,443.50	1,169,313.90	1,168,028.20	1,176,378.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,858,031.70		
2300	SSI BLIND WITH MEDIC	433.80	289.20	433.80	433.80	578.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,169.00		
2310	SSI BLIND NON-MEDIC A	144.60	144.60	144.60	144.60	144.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		723.00		
2320	SSI BLIND WITH QMB	433.80	433.80	433.80	723.00	723.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,747.40		
SUBTOTAL:	4,300,703.40	4,300,461.80	4,198,635.60	4,172,583.50	4,165,343.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,137,727.90		

14,749.20

8720	SSI DISABLED FREEDO M	3,181.20	3,181.20	3,036.60	2,747.40	2,602.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,181.20	3,181.20	3,036.60	2,747.40	2,602.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14,749.20

TOTAL:	4,303,884.60	4,303,643.00	4,201,672.20	4,175,330.90	4,167,946.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,152,477.10		

LTC HIB
For The Period Ending November 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	378,053.40	376,695.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,922,185.80		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	252.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252.00		
2220	SSI DISABLED WITH Q
M	-1,704.00	10,626.00	8,084.00	10,122.00	10,328.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,456.00		
SUBTOTAL:	386,148.40	405,364.80	393,181.80	388,427.40	387,023.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,960,145.80		

1,960,145.80

386,148.40	405,364.80	393,181.80	388,427.40	387,023.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	80.72	8.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,404.43		
1007	TANF 21-44 FEMALE WI	479.00	1,103.94	1,157.60	172.76	926.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,839.49		
1008	TANF 45-64 M & F WIT	8,767.23	-910.29	5,272.07	6,144.46	5,040.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,313.94		
1009	TANF 65+ M & F WITH	986.51	3,063.18	3,790.49	3,572.44	-310.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,102.43		
1011	TANF <1 M & F NON-ME	461,027.80	365,528.50	585,976.36	388,106.47	345,703.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,146,342.53		
1012	TANF 01-05 M & F NON	184,699.98	125,380.18	209,789.47	202,225.60	147,986.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		870,081.45		
1013	TANF 06-13 M & F NON	280,888.33	237,331.61	258,132.90	255,486.61	247,492.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,279,332.28		
1014	TANF 14-20 MALE NON-	95,294.65	80,813.56	107,335.51	102,835.97	93,386.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		479,666.18		
1015	TANF 14-20 FEMALE N O	213,030.75	145,779.58	176,320.19	169,924.94	193,520.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		898,575.91		
1016	TANF 21-44 MALE NON-	1,177,989.73	962,823.76	1,299,810.18	1,110,259.72	1,085,607.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,636,490.42		
1017	TANF 21-44 FEMALE N O	4,972,790.03	3,889,893.65	4,776,934.09	3,835,954.02	3,670,193.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,145,765.69		
1018	TANF 45-64 M & F NON	2,275,148.69	1,482,300.13	2,216,826.22	1,908,927.29	1,839,051.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,722,253.50		
1019	TANF 65+ M & F NON-M	15,796.27	10,852.49	15,650.88	24,856.64	20,583.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87,739.81		
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	4,381.92	2,927.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,937.06		
1029	TANF 65+ M & F WITH	292.98	1,924.55	1,814.10	3,656.83	2,583.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,272.39		
2100	SSI AGED WITH MEDIC A	64,634.29	62,083.72	80,244.64	50,806.57	42,479.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		300,248.54		
2110	SSI AGED NON-MEDICA
R	173,482.40	97,035.25	135,410.01	128,622.04	103,594.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		638,143.96		
2120	SSI AGED WITH QMB	342,909.69	213,466.09	401,178.02	334,494.11	295,693.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,587,741.85		
2200	SSI DISABLED WITH M E	238,117.73	322,298.77	284,942.31	213,312.02	159,020.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,217,691.58		
2210	SSI DISABLED NON-ME
D	5,265,752.86	3,391,013.01	5,234,629.96	4,031,910.63	3,551,491.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,474,797.99		
2220	SSI DISABLED WITH Q M	511,611.84	318,762.10	584,682.65	474,952.83	421,893.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,311,903.24		
2300	SSI BLIND WITH MEDIC	1,532.50	506.14	2,480.40	3,264.32	1,472.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,255.79		
2310	SSI BLIND NON-MEDIC A	69,578.89	33,696.39	68,573.05	65,030.17	59,992.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		296,870.98		
2320	SSI BLIND WITH QMB	10,798.66	4,826.98	7,965.99	11,309.28	5,219.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,120.69		
4311	SOBRA CHILD <1 M & F	1,382,791.01	1,137,325.32	1,342,518.25	998,706.89	870,760.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,732,101.64		
4312	SOBRA CHILD 01-05 M	1,754,908.77	1,316,963.45	1,987,017.40	1,993,308.15	1,768,378.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,820,576.23		
4313	SOBRA CHILD 06-13 M	2,770,782.14	2,137,159.12	3,132,409.22	2,842,156.72	2,753,461.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,635,968.43		
4314	SOBRA CHILD 14-20 MA	826,137.69	690,281.33	845,508.96	744,062.61	987,252.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,093,242.96		
4315	SOBRA CHILD 14-20 FE	1,138,041.48	963,645.72	1,261,033.22	1,113,014.87	1,086,407.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,562,143.12		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	1,148.13	951.17	109.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,208.65		
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	192,153.92	122,055.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		867,876.76		
5017	SOBRA PREG 21-44 FE
M	1,254,267.06	1,120,613.96	1,358,338.46	1,056,066.84	820,333.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,609,619.60		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	1,437.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,916.00		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	22,272,146.53	20,704,797.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,540,034.48		

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	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	4,749.49	3,044.59	3,367.43	6,745.68	1,916.68	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	15,417.85	1,738.61	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	71,227.58	49,841.70	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	65,384.38	62,064.30	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	502,761.26	506,984.36	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	523,339.16	431,621.38	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	1,743,578.50	1,337,916.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

479.00	
19,823.87	
21,784.98	
278,731.72	
331,477.11	
2,622,217.79	
2,518,143.70	
8,121,443.58	

1106	TANF EXPANDED 21-44	3,449.22	2,456.28	5,305.62	2,879.12	724.85	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	2,183.78	1,035.22	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	20,478.08	11,971.17	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	21,167.86	23,291.61	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	479.00	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	479.00	958.00	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	34,191.93	21,802.53	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	479,046.55	498,578.64	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	2,014,650.33	1,967,452.79	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	1,375,047.67	1,289,779.00	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	3,353.00	3,297.05	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	7,253.80	5,113.82	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	10,330.94	9,628.43	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	51,960.38	41,962.28	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	45,982.14	46,929.38	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	9,578.83	7,515.97	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	21,703.42	15,858.76	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	297,425.59	233,880.27	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	4,843.36	4,391.04	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	71,096.00	38,633.10	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	146,677.46	125,575.11	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	4,620,808.24	4,348,379.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
14,815.09	
8,544.64	
88,039.73	
109,591.60	
958.00	
30,550.13	
161,776.68	
2,739,419.69	
10,287,510.59	
6,874,362.44	
37,067.17	
29,230.79	
56,956.80	
234,703.54	
228,621.88	
48,395.20	
88,238.34	
1,335,123.48	
27,994.79	
302,146.31	
727,743.54	
23,431,790.43	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3519	ADULT 40-100% M&F 65	958.00	479.00	958.00	1,437.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,790.00		
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		5.16		
3528	ADULT 40-100% M&F 45	0.00	45.61	479.00	958.00	660.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,143.51		
3706	ADULT <40% EXP MALE	804.69	451.18	2,510.50	1,599.36	574.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,940.39		
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	7,741.77	5,017.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,681.83		
3709	ADULT <40% EXP M&F 6	92.75	455.00	84.98	169.42	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,281.15		
3714	ADULT <40% EXP MALE	196,306.17	183,586.66	188,675.61	201,294.46	188,343.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		958,206.03		
3715	ADULT <40% EXP FEMA L	311,743.87	248,388.04	288,045.49	273,441.97	286,117.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,407,736.90		
3716	ADULT <40% EXP MALE	5,096,082.76	3,433,566.03	5,237,756.21	3,907,453.41	3,799,519.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,474,377.76		
3717	ADULT <40% EXP FEMA L	2,830,538.66	2,155,568.38	2,672,114.61	2,508,099.05	2,334,511.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,500,831.82		
3718	ADULT <40% EXP M&F
4	7,151,333.82	5,480,862.38	7,158,543.80	5,805,766.95	5,347,048.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,943,555.31		
3719	ADULT <40% EXP M&F 6	2,451.46	24.00	63.50	479.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,496.96		
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	479.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		958.00		
SUBTOTAL:	18,575,171.89	13,762,600.13	18,916,203.03	15,637,373.80	14,356,750.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,248,099.49		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	257.69	981.33	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	3,715.72	6,270.63	9,915.22	10,095.23	8,359.73	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	4,864.34	4,919.51	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	24,247.07	23,279.03	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	50,209.04	51,152.85	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	449,378.63	401,130.42	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	691,072.76	652,933.26	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	1,356,251.28	1,119,384.38	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	3,353.00	5,269.00	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	660.22	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	2,589,729.04	2,268,069.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,239.02	
0.00	
38,356.53	
19,751.09	
128,168.82	
241,448.97	
2,066,348.05	
3,512,193.23	
6,192,278.93	
13,412.00	
1,534.79	
1,378.47	
12,216,109.90	

4413	SOBRA 100-133% M&F
6	268,764.47	149,124.80	243,206.55	252,433.32	314,497.28	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	92,558.03	89,554.16	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	98,997.57	92,290.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	452,831.14	305,390.58	412,072.51	443,988.92	496,342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
1,228,026.42	
389,591.68	
493,007.05	
2,110,625.15	

4517

BC PATIENT FEMALE 2 1

479.00

0.00

0.00

0.00

479.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

958.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4518	BC PATIENT FEMALE 4 5	3,297.43	958.00	3,353.00	5,748.00	2,032.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,388.43		
SUBTOTAL:	3,776.43	958.00	3,353.00	5,748.00	2,511.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,346.43		

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

0.00

0.00

8700	SSI DISABLED FREEDO M	7,365.17	3,199.17	11,015.35	5,903.62	7,578.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	13,811.11	6,905.41	10,003.43	10,017.05	22,789.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	3,819.95	597.17	2,231.90	2,110.53	743.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	24,996.23	10,701.75	23,250.68	18,031.20	31,111.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
35,061.56	
63,526.45	
9,503.47	
108,091.48	

TOTAL:	52,666,977.10	39,258,032.93	53,950,300.43	45,587,825.73	42,207,961.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		233,671,097.36		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	29,711.98	31,860.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,923.39		
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	29,711.98	31,860.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171,096.41		

29,711.98

0.00

0.00

0.00

TOTAL:

30,474.84

32,548.39

46,501.05

31,860.15

0.00

0.00

0.00

0.00

171,096.41

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	5,245.57	22,736.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,703.70		
1012	TANF 01-05 M & F NON	178.37	0.00	-43.85	0.00	95.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230.48		
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	8,551.42	1,150.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,215.33		
1017	TANF 21-44 FEMALE N O	10,550.22	4,750.51	23,956.39	203,788.44	878.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243,924.05		
1018	TANF 45-64 M & F NON	3,043.28	23,696.09	0.00	275.90	60.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,075.57		
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	70.83	2,545.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,835.22		
2110	SSI AGED NON-MEDICA
R	135,338.97	11,318.42	46,363.24	5,707.11	23,015.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221,743.08		
2120	SSI AGED WITH QMB	554.79	1,883.86	84.85	133.17	32.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,689.29		
2200	SSI DISABLED WITH M E	1,221.33	2,336.37	1,746.49	1,970.76	254.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,529.57		
2210	SSI DISABLED NON-ME
D	401,433.67	623,439.40	19,509.76	306,904.50	202,617.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,553,905.10		
2220	SSI DISABLED WITH Q M	1,482.16	1,102.71	1,030.41	-614.25	595.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,596.40		
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	223,666.09	12,037.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,343,518.46		
4312	SOBRA CHILD 01-05 M	3,632.61	1,568.94	12,843.72	166,524.97	172,903.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		357,474.03		
4313	SOBRA CHILD 06-13 M	3,206.57	510.76	4,684.35	19,833.69	11,886.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,122.28		
4314	SOBRA CHILD 14-20 MA	1,438.36	4,864.53	6,125.57	17,653.91	17,033.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,116.14		
4315	SOBRA CHILD 14-20 FE	1,022.13	919.34	8,921.65	114.72	11,833.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,811.78		
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	3,967.13	6,489.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,724.56		
5017	SOBRA PREG 21-44 FE
M	16,547.82	23,491.79	11,070.21	15,334.15	19,899.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,343.22		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 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	979,128.11	506,067.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,102,073.12		

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	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

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	
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	1,022.78	339.28	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	8,208.39	73,763.76	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	1,239.94	14,473.63	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	18,989.05	37,500.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
8,524.72	
215,706.43	
26,080.96	
120,063.61	

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	239.04	2,882.67	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	5,923.35	8,087.62	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	1,421.03	1,862.86	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	870.82	211.85	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	47.65	126.61	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	53.18	178.20	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	92,651.00	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	21.56	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	101,227.63	13,349.81	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	
28,686.93	
30,405.98	
43,328.47	
0.00	
0.00	
0.00	
222.87	
0.00	
4,740.55	
0.00	
418.77	
389.83	
226,503.24	
286.95	
335,810.89	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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	62.36	36.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140.38		
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	54,494.24	955.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,358.47		
3716	ADULT <40% EXP MALE	226,474.25	117,784.32	153,008.13	150,508.65	117,090.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		764,865.42		
3717	ADULT <40% EXP FEMA L	36,163.97	65,186.57	26,135.15	19,805.42	51,793.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,085.03		
3718	ADULT <40% EXP M&F
4	131,866.31	54,563.94	131,702.15	41,024.07	31,357.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390,514.27		
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	295,354.90	327,311.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,795,411.46		

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	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	21,961.79	4,798.30	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	17,289.64	1,242.65	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	256,969.05	16,311.56	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	296,220.48	22,352.51	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	
67,327.91	
25,046.09	
310,625.40	
0.00	
0.00	
0.00	
422,585.53	

4413	SOBRA 100-133% M&F
6	1,723.43	235.48	2,162.37	1,724.15	631.21	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	492.80	162.89	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	417.68	839.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,149.06	3,603.56	3,158.41	2,634.63	1,633.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
6,476.64	
2,072.68	
5,630.21	
14,179.53	

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

0.00

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4518	BC PATIENT FEMALE 4 5	0.00	0.00	239.31	2,502.30	307.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,049.23		
SUBTOTAL:	0.00	0.00	239.31	2,502.30	307.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,049.23		

S000	STATE-ONLY BHS	6,610.59	-6,610.59	0.00	0.00	6,317.30	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	6,317.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,317.30

6,317.30

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	
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	
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:	305.49	0.02	64.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
305.51	
64.76	
0.00	
370.27	

TOTAL:	2,448,509.36	1,039,642.17	637,237.68	1,677,068.05	877,340.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,679,797.33		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	364,888.60	428,158.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,172,253.56		
8040	SLMB	81.79	311.97	259.45	223.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		877.05		
8050	QI1	175.98	1.85	76.32	1.50	31.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287.58		
SUBTOTAL:	528,802.82	334,251.05	517,060.06	365,113.94	428,190.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,173,418.19		

365,113.94

0.00

0.00

0.00

TOTAL:

528,802.82

334,251.05

517,060.06

428,190.32

0.00

0.00

0.00

0.00

2,173,418.19

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending November 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	1,437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,832.00		
2100	SSI AGED WITH MEDIC A	266,079.56	234,408.52	196,721.73	144,847.62	122,644.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		964,702.14		
2110	SSI AGED NON-MEDICA
R	28,192.26	13,746.42	25,768.01	15,172.67	19,328.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102,207.43		
2120	SSI AGED WITH QMB	250,820.13	171,461.90	292,915.59	221,877.83	197,346.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,134,422.21		
2200	SSI DISABLED WITH M E	33,409.98	20,684.24	36,391.21	35,796.06	24,400.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,682.28		
2210	SSI DISABLED NON-ME
D	801,056.57	582,866.97	787,325.61	793,819.43	660,360.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,625,428.85		
2220	SSI DISABLED WITH Q M	115,571.37	75,938.00	124,823.54	92,502.68	84,465.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		493,301.17		
2310	SSI BLIND NON-MEDIC
A	479.00	492.39	958.00	479.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,366.39		
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	1,305,932.29	1,109,504.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,477,981.41		

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:	1,495,608.87	1,100,094.82	1,466,841.25	1,305,932.29	1,109,504.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,477,981.41		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	-17,318.68	16,523.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,469.21		
2110	SSI AGED NON-MEDICA
R	441.64	634.60	20.36	0.00	14,873.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,970.55		
2120	SSI AGED WITH QMB	62.97	19.40	88.39	68.64	4,726.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,965.55		
2200	SSI DISABLED WITH M E	4,906.83	16,206.71	237.30	0.00	25.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,376.62		
2210	SSI DISABLED NON-ME
D	44,870.39	36,856.53	39,258.86	79,291.71	22,673.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,951.01		
2220	SSI DISABLED WITH Q M	3,634.92	1,629.28	2,794.35	972.51	1,506.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,537.71		
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	63,014.18	60,329.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		342,270.65		

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

342,270.65

95,815.03	79,378.10	43,733.66	63,014.18	60,329.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 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	5,297.67	5,746.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,107.37		
1007	TANF 21-44 FEMALE WI	1,920.61	1,372.74	291.54	790.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,375.55		
1008	TANF 45-64 M & F WIT	7,282.96	3,604.16	3,970.15	60.38	1,211.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,128.77		
1009	TANF 65+ M & F WITH	2,939.37	379.98	4,575.22	5,404.74	1,013.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,312.65		
1011	TANF <1 M & F NON-ME	634,706.45	295,612.73	796,508.26	644,978.35	643,691.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,015,497.25		
1012	TANF 01-05 M & F NON	117,610.19	58,544.34	109,868.71	74,136.26	63,537.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		423,696.62		
1013	TANF 06-13 M & F NON	161,558.71	120,366.13	212,330.44	132,695.58	103,351.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		730,302.32		
1014	TANF 14-20 MALE NON-	83,960.49	35,044.51	40,234.04	74,173.41	47,587.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281,000.40		
1015	TANF 14-20 FEMALE N O	189,887.25	134,325.90	224,101.39	199,480.12	230,521.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		978,316.45		
1016	TANF 21-44 MALE NON-	963,942.03	1,024,074.63	1,286,021.02	1,373,759.50	961,588.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,609,385.24		
1017	TANF 21-44 FEMALE N O	3,169,657.70	2,694,879.11	3,108,970.44	2,917,027.66	2,943,551.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,834,086.88		
1018	TANF 45-64 M & F NON	1,581,210.06	1,337,225.47	1,641,236.72	1,354,898.57	1,225,969.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,140,540.14		
1019	TANF 65+ M & F NON-M	1,991.69	1,861.25	1,841.74	2,021.08	3,298.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,013.76		
1026	TANF 21-44 MALE WITH	0.00	0.00	8,171.26	8,540.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,711.96		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	147.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147.37		
1028	TANF 45-64 M & F WIT	12,559.06	1,177.47	11,931.99	4,835.43	3,209.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,713.52		
1029	TANF 65+ M & F WITH	2,751.80	1,032.42	601.16	3,677.95	3,104.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,167.36		
2100	SSI AGED WITH MEDIC A	127,917.46	112,965.89	154,623.60	96,057.74	106,716.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		598,280.74		
2110	SSI AGED NON-MEDICA
R	82,396.22	87,388.83	111,960.89	60,223.72	190,786.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		532,756.43		
2120	SSI AGED WITH QMB	423,535.31	287,246.13	387,331.36	314,136.47	408,294.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,820,543.70		
2200	SSI DISABLED WITH M E	367,814.33	227,632.48	341,524.68	286,034.22	320,443.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,543,449.04		
2210	SSI DISABLED NON-ME
D	6,668,489.74	5,155,417.18	6,741,200.28	6,198,519.45	5,288,344.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,051,970.83		
2220	SSI DISABLED WITH Q M	1,280,507.32	906,913.57	1,312,718.10	1,103,762.79	1,015,936.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,619,838.49		
2300	SSI BLIND WITH MEDIC	75.74	167.54	32.43	371.80	322.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		970.35		
2310	SSI BLIND NON-MEDIC A	82,843.21	59,625.10	80,658.03	48,570.26	72,239.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		343,935.63		
2320	SSI BLIND WITH QMB	14,835.59	19,732.97	29,174.00	11,967.46	8,591.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,301.88		
4311	SOBRA CHILD <1 M & F	814,131.23	1,007,677.65	740,565.25	692,925.67	1,090,237.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,345,537.73		
4312	SOBRA CHILD 01-05 M	1,005,758.92	1,055,286.32	958,237.67	645,433.10	1,937,372.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,602,088.87		
4313	SOBRA CHILD 06-13 M	1,595,690.76	1,386,958.88	1,794,704.63	1,419,501.63	1,724,509.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,921,365.15		
4314	SOBRA CHILD 14-20 MA	871,236.80	482,124.72	1,586,773.58	614,045.59	619,754.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,173,935.32		
4315	SOBRA CHILD 14-20 FE	842,681.59	721,641.34	792,887.23	757,468.21	876,519.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,991,197.44		
5007	SOBRA PREG 21-44 FE M	0.00	-869.63	79.80	2,982.64	3,398.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,591.33		
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	79,330.28	86,642.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457,603.41		
5017	SOBRA PREG 21-44 FE
M	850,122.88	552,251.75	1,112,517.96	723,180.27	733,472.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,971,545.85		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	131.02	794.25	519.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,444.94		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 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	142.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.13		
SUBTOTAL:	22,085,348.65	17,857,456.76	23,687,339.95	19,857,083.61	20,721,773.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,209,002.87		

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	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	-0.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	-0.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
-0.30	
-0.30	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	377.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	7,823.30	13,500.93	4,052.49	10,601.90	8,038.92	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	313.92	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	19,817.65	26,051.59	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	56,376.82	27,728.63	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	688,384.80	985,332.09	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	377,077.65	436,828.67	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	1,158,909.59	1,153,985.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

377.76	
44,017.54	
362.03	
107,373.38	
269,801.86	
3,796,213.82	
2,162,831.16	
7,069,867.72	

1106	TANF EXPANDED 21-44	7,269.85	298.34	5,218.89	1,234.75	2,188.78	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	2,514.68	3,363.92	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	24,466.38	26,230.44	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	11,452.18	13,105.34	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	421.23	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	42,054.46	46,255.81	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	397,787.19	331,851.64	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	1,037,856.15	1,135,582.44	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	766,059.08	644,073.24	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	433.00	377.92	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	6,851.79	10,719.09	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	56,090.61	52,352.83	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	54,303.16	64,683.83	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	36,025.47	49,893.07	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	16,747.73	15,003.82	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	3,358.33	9,673.57	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	276,805.55	257,840.87	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	2,495.17	22,033.53	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	73,050.14	51,621.47	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	343,669.06	270,285.62	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	3,153,676.11	3,007,137.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
16,210.61	
26,537.91	
138,527.10	
104,706.18	
0.00	
2,659.45	
137,876.33	
2,320,060.80	
5,605,181.47	
3,713,392.17	
11,065.34	
45,975.28	
317,767.23	
330,883.36	
195,335.03	
60,941.72	
46,721.93	
1,673,437.28	
45,418.70	
358,031.42	
1,489,316.25	
16,640,045.56	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3519	ADULT 40-100% M&F 65	164.48	328.96	1,798.95	542.53	822.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,657.32		
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		
3528	ADULT 40-100% M&F 45	2,862.31	13,571.92	2,848.21	8,130.64	4,746.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,159.45		
3706	ADULT <40% EXP MALE	57.38	86.35	1,708.93	1,041.88	4,472.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,366.92		
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	12,995.56	27,828.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,688.19		
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	373,710.55	199,714.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,414,509.42		
3715	ADULT <40% EXP FEMA L	162,511.44	114,009.53	241,281.27	235,933.41	238,512.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		992,248.11		
3716	ADULT <40% EXP MALE	8,341,319.42	7,438,446.61	10,304,097.73	8,803,314.19	7,200,466.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,087,644.09		
3717	ADULT <40% EXP FEMA L	3,534,124.56	3,597,125.52	4,446,436.48	4,021,069.61	3,320,930.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,919,686.17		
3718	ADULT <40% EXP M&F
4	8,932,369.89	6,988,768.45	10,831,898.99	7,173,532.83	7,393,463.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,320,033.49		
3719	ADULT <40% EXP M&F 6	1,068.32	106,447.32	1,986.93	166.01	580.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,249.04		
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	19,381.83	15,372.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,060.41		
SUBTOTAL:	24,262,288.83	20,962,067.53	29,276,701.77	22,961,301.37	21,045,251.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,507,611.34		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	57.38	237.17	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	86.42	412.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	10,016.89	12,890.32	13,458.23	8,577.37	10,769.52	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	7,826.93	8,843.56	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	25,249.14	25,311.03	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	14,312.98	28,298.13	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	452,282.75	533,187.21	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	444,759.88	847,247.98	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	735,270.18	827,085.48	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	861.46	2,044.70	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	57.18	651.12	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	1,689,341.67	2,284,088.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
294.55	
499.10	
55,712.33	
26,015.17	
143,181.93	
124,012.15	
2,208,679.96	
2,232,172.00	
4,338,865.78	
3,900.18	
2,085.97	
0.00	
9,135,419.12	

4413	SOBRA 100-133% M&F
6	79,561.09	97,234.17	143,584.38	104,557.79	74,638.47	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	38,336.18	44,116.93	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	94,477.60	85,128.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	178,086.75	175,478.21	249,057.23	237,371.57	203,884.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
499,575.90	
232,174.05	
312,128.06	
1,043,878.01	

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

0.00

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2020	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4518	BC PATIENT FEMALE 4 5	6,741.91	1,649.82	16,106.80	7,396.50	8,007.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,902.53		
SUBTOTAL:	6,741.91	1,649.82	16,106.80	7,396.50	8,007.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,902.53		

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

0.00

8700	SSI DISABLED FREEDO M	19,266.93	11,931.03	19,448.70	6,435.73	26,970.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	17,233.38	7,817.72	3,782.63	30,270.29	6,309.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	22,396.77	20,915.69	19,546.07	-3,628.79	3,670.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	58,897.08	40,664.44	42,777.40	33,077.23	36,950.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
84,053.12	
65,413.61	
62,900.30	
212,367.03	

TOTAL:	52,295,618.60	43,160,264.76	59,086,000.86	47,939,248.06	47,307,093.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249,788,226.16		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 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	2,295,747.45	2,181,472.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,015,895.61		
2110	SSI AGED NON-MEDICA
R	158,695.09	135,418.00	209,429.81	105,121.80	119,961.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		728,626.35		
2120	SSI AGED WITH QMB	4,834,351.18	3,387,119.20	4,954,826.47	3,778,857.47	3,411,071.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,366,225.65		
2200	SSI DISABLED WITH M E	517,200.54	385,341.74	555,945.77	406,779.87	461,222.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,326,490.75		
2210	SSI DISABLED NON-ME
D	2,830,954.71	2,233,439.38	2,816,037.94	2,275,589.32	2,235,073.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,391,095.13		
2220	SSI DISABLED WITH Q M	1,062,045.18	815,729.63	1,055,833.02	846,302.66	953,894.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,733,805.43		
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	2,415.70	2,389.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,390.11		
SUBTOTAL:	12,425,885.33	9,154,800.45	12,913,029.57	9,710,814.27	9,365,086.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,569,615.83		

8720	SSI DISABLED FREEDO M	4,401.60	3,521.28	4,408.89	3,509.76	3,481.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,401.60	3,521.28	4,408.89	3,509.76	3,481.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
19,322.57

19,322.57

53,588,938.40

12,430,286.93	9,158,321.73	12,917,438.46	9,714,324.03	9,368,567.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 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		

TOTAL:	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		

KidsCare - CAPITATION AMOUNTS
For The Period Ending November 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	181,138.61	210,661.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		913,985.10		
6012	KIDS 1-5 M & F NON-M	1,800,811.10	1,831,909.98	1,869,166.77	1,901,150.46	2,284,309.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,687,347.84		
6013	KIDS 6-13 M & F NON-	3,466,599.08	3,566,682.54	3,676,408.60	3,776,365.49	4,481,691.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,967,747.14		
6014	KIDS 14-19 MALE NON-	935,140.73	970,724.10	997,580.62	1,035,181.24	1,224,752.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,163,379.05		
6015	KIDS 14-19 FEMALE NO	940,472.58	978,761.40	1,004,941.00	1,036,585.75	1,232,555.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,193,316.00		
9960	KIDSCARE KICK PAYME N	18,508.35	18,450.92	0.00	12,292.30	24,512.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,764.32		
SUBTOTAL:	7,336,022.91	7,539,106.23	7,723,213.98	7,942,713.85	9,458,482.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,999,539.45		

39,999,539.45

7,336,022.91	7,539,106.23	7,723,213.98	7,942,713.85	9,458,482.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending November 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	306.33	302.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,490.08		
6012	KIDS 1-5 M & F NON-M	9,545.70	9,706.14	9,896.73	10,069.56	10,442.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,660.54		
6013	KIDS 6-13 M & F NON-	18,395.31	18,912.65	19,476.39	20,009.53	20,741.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,535.25		
6014	KIDS 14-19 MALE NON-	4,949.42	5,141.98	5,271.77	5,471.18	5,702.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,536.37		
6015	KIDS 14-19 FEMALE NO	4,967.01	5,155.01	5,290.42	5,477.04	5,721.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,611.30		
9960	KIDSCARE KICK PAYME N	3.00	3.00	0.00	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
SUBTOTAL:	38,155.47	39,210.10	40,230.09	41,335.64	42,914.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,845.54		

TOTAL:	38,155.47	39,210.10	40,230.09	41,335.64	42,914.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,845.54		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending November 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	551.07	548.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,687.47		
6012	KIDS 1-5 M & F NON-M	18,360.10	18,658.73	18,175.10	17,610.60	17,534.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,339.00		
6013	KIDS 6-13 M & F NON-	36,515.44	36,931.37	38,384.30	37,928.95	39,221.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188,981.12		
6014	KIDS 14-19 MALE NON-	16,095.74	17,066.38	17,392.64	21,055.70	21,135.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,746.30		
6015	KIDS 14-19 FEMALE NO	17,125.52	18,323.05	18,377.60	22,240.63	24,612.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,678.98		
SUBTOTAL:	88,620.28	91,498.58	92,874.81	99,386.95	103,052.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		475,432.87		

475,432.87

92,874.81	99,386.95	103,052.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

88,620.28

91,498.58

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending November 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	318.00	315.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,551.00		
6012	KIDS 1-5 M & F NON-M	9,877.76	10,041.06	10,220.03	10,395.03	10,775.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,308.88		
6013	KIDS 6-13 M & F NON-	19,182.12	19,701.53	20,303.13	20,834.12	21,612.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,632.99		
6014	KIDS 14-19 MALE NON-	5,207.03	5,397.03	5,548.03	5,752.03	5,989.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,893.12		
6015	KIDS 14-19 FEMALE NO	5,227.03	5,431.03	5,579.03	5,785.03	6,026.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,048.28		
SUBTOTAL:	39,795.94	40,870.65	41,966.22	43,084.21	44,717.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210,434.27		

TOTAL:	39,795.94	40,870.65	41,966.22	43,084.21	44,717.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210,434.27		

KidsCare - FEE FOR SERVICE
For The Period Ending November 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	500.01	1,522.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,160.51		
6012	KIDS 1-5 M & F NON-M	38,128.70	11,226.18	35,357.21	11,548.78	15,116.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,377.12		
6013	KIDS 6-13 M & F NON-	41,178.75	41,588.86	72,955.66	65,638.47	71,046.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292,407.89		
6014	KIDS 14-19 MALE NON-	20,137.82	10,886.64	27,745.48	29,751.16	24,120.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,641.26		
6015	KIDS 14-19 FEMALE NO	79,656.09	37,344.80	63,073.99	65,343.28	34,653.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		280,071.44		
SUBTOTAL:	191,287.23	101,072.07	201,058.46	172,781.70	146,458.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		812,658.22		

812,658.22

201,058.46	172,781.70	146,458.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

191,287.23

101,072.07

KidsCare - REINSURANCE
For The Period Ending November 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	0.00	0.00	0.00	0.00	33,763.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,763.91		
6012	KIDS 1-5 M & F NON-M	32,192.38	15,576.63	23,224.89	15,553.91	23,540.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,088.23		
6013	KIDS 6-13 M & F NON-	64,628.70	108,533.95	62,469.56	224,072.07	113,035.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		572,739.70		
6014	KIDS 14-19 MALE NON-	-0.01	178,495.68	70,224.52	225,495.71	117,693.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		591,909.09		
6015	KIDS 14-19 FEMALE NO	135,893.44	0.00	11,530.86	31,118.94	1,797.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,341.23		
SUBTOTAL:	232,714.51	302,606.26	167,449.83	496,240.63	289,830.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,488,842.16		

TOTAL:	232,714.51	302,606.26	167,449.83	496,240.63	289,830.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,488,842.16		

KidsCare - TRANSPLANT REINSURANCE
For The Period Ending November 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	0.00	0.00	0.00	23,264.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,264.66		
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	23,264.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,598.41		

39,598.41

4,465.07	11,868.68	0.00	23,264.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending November 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	666.17	664.16		0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,316.61		
1020	TANF WITH QMB	2.00	1.00	1.00	1.00	1.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
2100	SSI AGED WITH MEDICA	277.71	272.54	275.25	277.55	272.96		0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,376.01		
2110	SSI AGED NON-MEDICAR	10.00	10.00	11.00	11.00	11.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		53.00		
2120	SSI AGED WITH QMB	442.10	445.44	444.28	448.54	450.50		0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,230.86		
2200	SSI DISABLED WITH ME	1,899.08	1,908.78	1,906.12	1,919.56	1,936.87		0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,570.41		
2210	SSI DISABLED NON-MED	27,309.05	27,444.84	27,549.29	27,631.79	27,650.45		0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,585.42		
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	5,169.55	5,167.53		0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,796.87		
2300	SSI BLIND WITH MEDIC	2.00	2.00	3.00	3.00	4.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
2310	SSI BLIND NON-MEDICA	12.00	13.58	15.00	16.00	20.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		76.58		
2320	SSI BLIND WITH QMB	2.00	2.00	2.00	2.00	2.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
8700	SSI DISABLED FREEDOM	32.00	31.00	42.99	31.73	30.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		167.72		
8710	SSI DISABLED FREEDOM	11.00	11.00	10.00	10.00	10.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.00		
8720	SSI DISABLED FREEDOM	21.00	22.00	21.00	21.00	21.00		0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.00		
SUBTOTAL:	35,820.81	35,972.55	36,117.76	36,208.89	36,241.4	7	0.00	0.00	0.00	0.00	0.00	0.00	0.0		180,361.48		
TOTAL:	35,820.81	35,972.55	36,117.76	36,208.	36,241.4	7	0.0	0.00	0.00	0.00	0.0	0.00	0.00		180,361.48		

89

0

0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending November 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	416,389.21	415,371.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,082,823.74	
EPD	117,131,570.69	116,026,496.12	115,369,118.41	115,627,611.21	117,001,923.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	581,156,719.74	
TOTAL AHCCCS LTC	117,538,951.69	116,450,256.22	115,789,040.72	116,044,000.42	117,417,294.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	583,239,543.48	
DES/DD	173,387,013.21	174,122,225.01	174,824,385.21	175,266,326.76	180,272,461.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	877,872,411.76	
TOTAL DES LTC	173,387,013.21	174,122,225.01	174,824,385.21	175,266,326.76	180,272,461.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	877,872,411.76	
TOTAL LTC - CAP	290,925,964.90	290,572,481.23	290,613,425.93	291,310,327.18	297,689,756.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,461,111,955.24	

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	11,083,270.50	10,538,401.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,409,190.46	
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	11,083,270.50	10,538,401.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,409,190.46	

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	5,922,724.66	3,306,357.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,723,581.26	
DES/DD	1,680,993.32	5,370,676.23	2,819,557.30	4,346,653.22	2,152,807.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,370,687.10	
TOTAL DES LTC	1,680,993.32	5,370,676.23	2,819,557.30	4,346,653.22	2,152,807.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16,370,687.10	
TOTAL LTC - REIN	3,391,580.97	8,020,729.01	5,953,416.41	10,269,377.88	5,459,164.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,094,268.36	

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	4,563,758.30	4,554,969.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,112,622.90	

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.

144

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending November 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 November 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 November 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	5,501,005.19	5,589,599.17	8,502,953.83	8,639,433.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33,641,105.32	

00010422	AZ COMPLETE HEALTH CARE - RBHA CRISIS CAP AMOUNTS	4,029,461.70	4,082,897.14	4,134,674.02	4,639,756.11	4,693,408.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21,580,197.85	

00010497	STEWARD HEALTH CHOICE AZ - RBHA CRISIS CAP AMOUNTS	866,831.19	876,606.45	886,586.25	998,918.88	1,010,012.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,638,955.40	

00010705	HEALTH CHOICE RBHA - CAP AMOUNTS	717.13	-141.92	702.46	-1,460.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-182.96	

00010730	CENPATICO RBHA - CAP AMOUNTS	37,232.19	1,693.00	478.32	2,305.86	-512.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	41,196.72	

00010789	MERCY MARICOPA RBHA - CAP AMOUNTS	74,475.62	32,139.90	1,984.42	-1,241.49	1,250.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	108,609.10	
			
Subtotal		
	10,416,831.43	10,494,199.76	10,614,024.64	14,141,232.56	14,343,593.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,009,881.43	

10,416,831.43	10,494,199.76	10,614,024.64	14,141,232.56	14,343,593.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	60,009,881.43	

GRAND TOTAL

BEHAVIORAL HEALTH EXPENDITURES BY RBHA - MEMBER MONTHS
For the Period Ending November 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	1,008,997.00	1,022,075.00	1,064,262.00	1,076,917.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,167,015.00	
			
00010422	AZ COMPLETE HEALTH CARE - RBHA CRISIS CAP MEMBER MONTHS	498,371.00	504,271.00	509,727.00	531,249.00	536,375.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,579,993.00	
			
00010497	STEWARD HEALTH CHOICE AZ - RBHA CRISIS CAP MEMBER MONTHS	242,165.00	244,658.00	247,195.00	256,191.00	258,502.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,248,711.00	
			
00010705	HEALTH CHOICE RBHA - CAP MEMBER MONTHS	7.67	-2.00	9.68	-23.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7.96	
			
00010730	CENPATICO RBHA - CAP MEMBER MONTHS	218.57	24.00	6.00	41.54	-9.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	280.80	
			
00010789	MERCY MARICOPA RBHA - CAP MEMBER MONTHS	380.01	368.10	17.23	-40.31	25.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	750.41	
			
Subtotal	1,735,906.25	1,758,316.10	1,779,029.91	1,851,679.92	1,871,810.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,996,742.25	

1,735,906.25	1,758,316.10	1,779,029.91	1,851,679.92	1,871,810.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,996,742.25	

GRAND TOTAL