Douglas A. Ducey, Governor Jami Snyder, Director

May 28, 2021

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 April 30, 2021

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 April 30, 2021.

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 (PHE) 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. On April 15, 2021, the Department of Health and Human Services extended the expiration date for the PHE to July 14, 2021. As a result, the temporary FMAP increase will continue until at least September 30, 2021 and the MOE will continue until at least July 31, 2021.

Laws 2021, Chapter 64 provided supplemental appropriations in the amounts shown below to cover the increased FMAP, the increased caseloads, and the implementation of Laws 2020, Chapter 46.

CHIP Fund (Other Appropriated)	$27,177,400	
Federal Medicaid (Expenditure Authority)	$2,695,324,200	
Health Care Investment Fund (Expenditure Authority)	$249,980,000	
Hospital Assessment Fund (Expenditure Authority)	$65,860,300	
Total Funds	$3,038,341,900	

These amounts have been added to this Appropriations Status Report. Additionally, the FMAP increase is expected to generate an estimated General Fund reversion of approximately $280 million. This estimate is subject to change based on caseload growth and other factors.

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
May 28, 2021
Page 2

Enrollment Update – April 2021 enrollment is 2,200,141 members, a 14,122 member increase over the prior month. Enrollment for May 2021 increased to 2,217,132 members, a 16,911 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 2020, AHCCCS enrollment has increased by 338,172 members or 18.0%.

Major May 2021 changes by eligibility category include: 1931 for Families and
Children/SOBRA – increase of 5,139; Supplemental Security Income – increase of 902; Prop 204 Restoration - increase of 6,802; Adult Expansion – increase of 1,420; Medicare Cost Sharing – increase of 153; KidsCare – increase of 1,362; and Federal Emergency Services – increase of 1,043.

Tobacco Funds Revenue Update - Tobacco tax collections through March 2021 are $3.6 million more than the AHCCCS monthly projected flows. In April, AHCCCS received approximately $105.7 million in Tobacco Litigation Settlement funding which is about $3.7 million more than the FY21 appropriation of
$102.0 million.   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 Nancy Barto, Chairman, Senate Health and Human Services Committee The Honorable Joanne Osborne, 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 April 30, 2021

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 April 30, 2021
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	$	110,383,900	$	77,010,004	$	77,010,004	$		-	$	110,383,900	$	-	
AHCCCS Prop 204 Administration	27,616,500	16,776,154	16,776,154			-	27,616,500		-	
DES Eligibility	102,397,300	74,727,379	74,727,379			-	102,397,300		-	
DES Prop 204 Eligibility	54,881,500	27,293,603	27,293,603			-	54,881,500		-	
ADOA Data Center	19,325,800	8,073,653	8,073,653			-	19,325,800		-	
School District Suicide Prevention Coordinator	100,000	78,932	78,932			-	100,000		-	
TOTAL ADMINISTRATION	 	314,705,000  		 	203,959,726  		 	203,959,726  		 	-			 	314,705,000  		 	-			

Traditional Medicaid Services	6,911,504,863	4,759,079,784	4,759,079,784	-	6,911,504,863	-	
Proposition 204 Services	5,829,902,000	4,249,967,900	4,249,967,900	-	5,829,902,000	-	
ACA Adult Expansion	980,003,600	671,084,133	671,084,133	-	980,003,600	-	
KidsCare Services	120,492,100	96,704,157	96,704,157	-	120,492,100	-	
ALTCS Services	2,071,105,900	1,494,129,075	1,494,129,075	-	2,071,105,900	-	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	36,068,937		36,068,937		36,068,937		-		36,068,937		-	
Voluntary Political Subdivision Programs	384,758,800		215,613,590		215,613,590		-		384,758,800		-	
CMDP	220,623,000		178,964,127		178,964,127		-		220,623,000		-	
Behavioral Health Services - in Schools	18,003,300		8,336,083		8,336,083		-		18,003,300		-	
Targeted Investment Program	70,000,000		7,766,049		7,766,049		-		70,000,000		-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		63,009,351		63,009,351		-		77,646,900		-	
Supported Housing	5,324,800		4,787,924		4,787,924		-		5,324,800		-	
Crisis Services	16,391,300		13,589,613		13,589,613		-		16,391,300		-	
TOTAL PROGRAMMATIC	 	16,746,912,600  		 	11,799,100,723  		 	11,799,100,723  		 	-			 	16,746,912,600  		 	-		

TOTAL EXPENDITURES

  $ 17,061,617,600  

  $ 12,003,060,448  

  $ 12,003,060,448  

  $	-	

  $   17,061,617,600	$	-

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2021 APPROPRIATION STATUS REPORT
For the Period Ending April 30, 2021 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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	
$	49,823,815	
$	49,823,815	
-	$	63,893,300	
$	
-	
Proposition 204 - Administrative Expenditures		21,552,000	11,570,345	11,570,345	-	21,552,000		-	

Programmatic Expenditures								
Traditional Medicaid Services	1,174,102,800	939,011,492	939,011,492	-	1,174,102,800	-	
Proposition 204 Services	206,211,500	197,263,429	197,263,429	-	206,211,500	-	
ACA Adult Expansion	22,361,600	13,217,881	13,217,881	-	22,361,600	-	
KidsCare Services	16,214,400	13,311,860	13,311,860	-	16,214,400	-	
ALTCS Services	265,435,600	220,492,458	220,492,458	-	265,435,600	-	
DSH and Rural Hospitals	8,846,200	8,580,800	8,580,800	-	8,846,200	-	
CMDP	59,250,900	42,579,822	42,579,822	-	59,250,900	-	
Behavior Health Services - in Schools	3,000,000	2,500,000	2,500,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	63,009,351	63,009,351	-	77,646,900	-	
Supported Housing	5,324,800	4,787,924	4,787,924	-	5,324,800	-	
Crisis Services	14,141,100	11,714,446	11,714,446	-	14,141,100	-	
Voluntary Political Subdivision Programs	 	6,000,000  	 	- 	 	- 	 	- 	 	6,000,000  	 	- 	
TOTAL GF EXPENDITURES	1,943,981,100	1,577,863,624	1,577,863,624	-	1,943,981,100	-	
	FEDERAL		
Administrative Expenditures	165,797,700	109,710,967	109,710,967		-	165,797,700	-	
Proposition 204 - Administrative Expenditures	56,847,700	29,471,362	29,471,362		-	56,847,700	-	
Programmatic Expenditures
Traditional Medicaid Services	
4,686,869,863	
3,071,517,925	
3,071,517,925	
-	
4,686,869,863	
-	
Proposition 204 Services	4,985,358,600	3,733,690,706	3,733,690,706	-	4,985,358,600	-	
ACA Adult Expansion	877,254,200	604,538,257	604,538,257	-	877,254,200	-	
KidsCare Services	90,537,800	83,297,147	83,297,147	-	90,537,800	-	
ALTCS Services and Nursing Facility Assessment	1,350,352,408	1,023,744,343	1,023,744,343	-	1,350,352,408	-	
DSH and Rural Hospitals	32,309,837	27,488,137	27,488,137	-	32,309,837	-	
CMDP	159,831,900	136,384,305	136,384,305	-	159,831,900	-	
Behavior Health Services - in Schools	7,003,300	5,836,083	5,836,083	-	7,003,300	-	
Targeted Investment Program	48,313,300	5,606,217	5,606,217	-	48,313,300	-	
Voluntary Political Subdivision Programs	 	269,228,800  	 	157,493,685  	 	157,493,685  	 	- 	 	269,228,800  	 	- 	
TOTAL FEDERAL EXPENDITURES	12,729,705,408	8,988,779,133	8,988,779,133	-	12,729,705,408	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF Programmatic Expenditures
Traditional Medicaid Services Acute Care	4,037,400

46,161,700	3,028,050

38,182,500	3,028,050

38,182,500	-

-	4,037,400

46,161,700	-

-	
ALTCS Services	 	290,276,100  	 	125,718,653  	 	125,718,653  	 	- 	 	290,276,100  	 	- 	
TOTAL COUNTY EXPENDITURES	340,475,200	166,929,203	166,929,203
.	-	340,475,200	-	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2021 APPROPRIATION STATUS REPORT
For the Period Ending April 30, 2021 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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	49,220,400	49,220,400	-	65,627,200	-	
Proposition 204 Services - Emergency Health Services	16,216,300	12,162,225	12,162,225	-	16,216,300	-	
Proposition 204 Services - Proposition 204 Protection	34,797,900	26,098,425	26,098,425	-	34,797,900	-	
Proposition 204 Services - ATLSF	 	102,000,000  	 	102,000,000  	 	102,000,000  	 	- 	 	102,000,000  	 	- 	
TOTAL TOBACCO EXPENDITURES	218,641,400	189,481,050	189,481,050	-	218,641,400	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program	722,600	355,186	355,186	-	722,600	-	
Health Care Investment Fund	1,854,300	-	-	-	1,854,300	-	
Programmatic Expenditures							
Traditional Medicaid Services - IGA Fund	73,818,600	2,142,900	2,142,900	-	73,818,600	-	
Traditional Medicaid Services - Health Care Investment Fund	151,901,900	-	-	-	151,901,900	-	
Acute Care - Prescription Drug Rebate Program State Match	140,158,600	116,798,833	116,798,833	-	140,158,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	541,089,942	541,089,942	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	8,729,300	6,315,333	6,315,333	-	8,729,300	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	29,386,483	29,386,483	-	36,422,000	-	
Proposition 204 Services - Hospital Assessment	400,270,000	178,753,114	178,753,114	-	400,270,000	-	
Proposition 204 Services - IGA Fund	7,394,800	-	-	-	7,394,800	-	
Proposition 204 Services - Health Care Investment Fund	77,652,900	-	-	-	77,652,900	-	
ACA Adult Expansion - Hospital Assessment	73,810,900	53,327,996	53,327,996	-	73,810,900	-	
ACA Adult Expansion - IGA Fund	624,500	-	-	-	624,500	-	
ACA Adult Expansion - Health Care Investment Fund	5,952,400	-	-	-	5,952,400	-	
Traditional Medicaid Services - TPL	194,700	1,109,915	1,109,915	-	194,700	-	
ALTCS Services - TPL	-	1,571,850	1,571,850	-	-	-	
ALTCS Services - Nursing Facility Assessment	110,038,692	86,899,954	86,899,954	-	110,038,692	-	
ALTCS Services - Health Care Investment Fund	9,851,800	-	-	-	9,851,800	-	
CMDP - Health Care Investment Fund	1,540,200	-	-	-	1,540,200	-	
Targeted Investment Program	21,686,700	2,159,833	2,159,833	-	21,686,700	-	
Children's Behavioral Health Services	8,000,000	-	-	-	8,000,000	-	
KidsCare Services - IGA Fund	362,100	-	-	-	362,100	-	
KidsCare Services -Health Care Investment Fund	1,226,500	-	-	-	1,226,500	-	
KidsCare Services Premiums	12,151,300	95,150	95,150	-	12,151,300	-	
Freedom to Work Premiums	31,200	5,877	5,877	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	1,875,167	1,875,167	-	2,250,200	-	
Voluntary Political Subdivision Programs	 	109,530,000  	 	58,119,904  	 	58,119,904  	 	- 	 	109,530,000  	 	- 	
TOTAL OTHER EXPENDITURES	1,828,814,492	1,080,007,439	1,080,007,439	-	1,828,814,492	-	
	TOTAL		
Administrative Expenditures	314,705,000	203,959,726	203,959,726	-	314,705,000	-	
Acute Care	14,675,806,700	10,304,971,647	10,304,971,647	-	14,675,806,700	-	
Long Term Care	 	2,071,105,900  	 	1,494,129,075  	 	1,494,129,075  	 	- 	 	2,071,105,900  	 	- 	
TOTAL EXPENDITURES	  $	17,061,617,600  	  $	12,003,060,448  	  $	12,003,060,448  	  $	- 	  $	17,061,617,600  	  $	- 	

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

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,278,203,900	$	1,013,133,988	$	999,916,108	
Proposition 204 Services & Administrative	227,763,500	208,833,774	208,833,774	
KidsCare Services	16,214,400.00	13,311,859.75	13,311,860	
ALTCS Services	265,435,600	220,492,458	220,492,458	
Behavioral Health Traditional Medicaid Services	 	156,363,700  	 	122,091,543  	 	122,091,543  	
TOTAL	1,943,981,100	1,577,863,624	1,564,645,743	

FEDERAL:
Acute & Administrative	11,128,983,300	7,745,353,338	7,740,418,130	
KidsCare Services	90,537,800	83,297,147	86,790,326	
ALTCS Services	1,350,352,408	1,023,744,343	1,089,986,620	
Behavioral Health Traditional Medicaid Services	 	159,831,900  	 	136,384,305  	 	142,247,869  	
TOTAL	12,729,705,408	8,988,779,133	9,059,442,945	

COUNTY:				
Acute & Administrative	50,199,100		41,210,550		41,542,707	
ALTCS Services	 	290,276,100  		 	125,718,653  		 	254,893,350  	
TOTAL	340,475,200		166,929,203		296,436,057	

TOBACCO FUNDS:						
Traditional Medicaid Services	65,627,200		49,220,400		49,220,400	
Proposition 204 Services	 	153,014,200  		 	140,260,650  		 	140,260,650  	
TOTAL	218,641,400		189,481,050		189,481,050	

OTHER:

Administrative	2,576,900	355,186	355,186	
Traditional Medicaid Services - IGA Fund	73,818,600	2,142,900	2,142,900	
Acute Care - Prescription Drug Rebate Program	712,796,900	657,888,775	657,888,775	
Long Term Care - Prescription Drug Rebate Program	45,151,300	35,701,817	35,701,817	
Hospital Assessment	482,100,200	232,081,110	391,117,858	
Health Care Investment Fund	237,047,400	-	-	
ALTCS	119,890,492	86,899,954	21,948,681	
Acute TPL - Note 1	194,700	1,109,915	1,109,915	
LTC TPL - Note 1	-	1,571,850	1,571,850	
KidsCare Services	1,588,600	-	-	
KidsCare TPL - Note 1	-	-	(780.00)	
Member Premiums - CHIP	12,151,300	95,150	95,150	
Member Premiums - Freedom to Work	31,200	5,877	5,877	
Targeted Investment Program	21,686,700	2,159,833	11,269,001	
Children's Behavioral Health Services	8,000,000	-	8,000,000	
Behavioral Health Traditional Medicaid Services	2,250,200	1,875,167	1,277,241	
Voluntary Political Subdivision - State Match	 	109,530,000  	 	58,119,904  	 	117,214,796  	
TOTAL	1,828,814,492	1,080,007,439	1,249,698,266	

TOTAL REVENUE

$	17,061,617,600

$	12,003,060,448

$	12,359,704,061

BUDGET

BUDGET YTD

RECEIPTS YTD

Appropriation Status Report
Footnotes

_.;_. :  HCCCS
Arizona Health Care Cost Contai nment  System

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

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

$	1,287,707	$

943,159	$

11,429,341	$

14,685,427

LTC	938,871	535,827	8,758,904	6,744,007
KidsCare	1,318	1,542	23,231	81,229

Total TPL Collections

  $	2,227,896  

  $	1,480,528  

  $	20,211,476  

  $	21,510,663  

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	145,650	$	119,183	$	1,109,915	$	1,612,963	
LTC		164,364	109,037	1,571,850	1,348,829	
KidsCare		22	(38)	(780)	(843)	
Total Expenditure Offsets	  $	310,036  		  $	228,182  		  $	2,680,985  		  $	2,960,949  	

April 2021

April 2020

July 1, 2020
April 30, 2021

July 1, 2019
April 30, 2020

Note 2:    Authorized Positions
Actual Positions as of April 30, 2021

`

FY 21 Total

1,226.0
1,151.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2020	$	946,359	
	Revenues	12,656,980	
	Transfers-In	 	1,768,193  	
	Total Revenues	 	14,425,174  	
	Expenditures	9,919,527	
	Transfers-out	 	1,404,000  	
	Total Expenditures	 	11,323,527  	
	Ending Balance April 30, 2021	  $    4,048,005  	

Of the $4,048,005 ending balance, $3,332,846 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through May 2021.

Summary of Voluntary Political Subdivision Contribution Expenditures:

Note 4:

As of April 30, 2021 Expenditures
Appropriation	State Match	Federal	Total

DSH Voluntary	$	27,137,600		$	461,302		$	1,066,694		$	1,527,996	
GME Voluntary	357,621,200		57,658,602		156,426,991		214,085,594	
Total Voluntary Political Subdivision Program Expenditures	$	384,758,800		$	58,119,904		$	157,493,685		$	215,613,590	

Appropriation Status Report
Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending April 30, 2021

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	417,658,124	375,187,277	376,267,981	378,758,607	392,040,916	0	0	3,758,323,203	
CAPITATION - AIMHS	428,410	430,948	434,545	439,294	438,317	437,642	458,914	460,191	461,879	464,794	0	0	4,454,935	
CAPITATION - LTC	290,925,965	290,572,481	290,613,426	291,310,327	297,689,756	348,410,570	307,994,268	309,007,593	309,527,935	309,783,806	0	0	3,045,836,127	
MENTAL HEALTH - CHILD	2,277	1,446	-719	426	-229	753	-1,499	-56	753	0	0	0	3,152	
MENTAL HEALTH - ADULT	380,807	355,992	348,738	344,658	398,620	353,710	340,199	341,143	340,202	353,383	0	0	3,557,451	
MENTAL HEALTH - GENERAL	13,950	10,451	3,406	836	967	-1,644	-241	0	0	-14	0	0	27,710	
MENTAL HEALTH - CMDP	12,276,585	12,457,764	12,481,448	12,396,743	14,327,617	16,963,555	14,007,971	13,821,510	13,928,664	7,601	0	0	122,669,458	
MENTAL HEALTH - DD	32,246	18,226	-2,175	0	0	-12,214	-5,587	0	0	0	0	0	30,496	
MENTAL HEALTH - RBHA CRISIS	4,751,155	4,785,609	4,808,366	6,134,651	6,138,831	6,162,825	6,185,139	6,219,084	6,246,651	6,275,246	0	0	57,707,558	
FEE FOR SERVICE - ACUTE	50,202,211	38,405,117	51,220,096	43,859,109	42,719,705	36,053,450	25,848,395	44,112,208	81,238,510	49,010,150	0	0	462,668,951	
FFS - PRIOR QUARTER COVERAGE	525,804	279,896	272,648	224,685	225,795	200,267	222,179	325,449	240,939	188,541	0	0	2,706,202	
EMERGENCY SERVICES - FEDERAL	3,758,804	3,482,081	4,181,075	4,408,707	3,916,805	3,899,676	4,191,209	3,697,979	4,782,015	2,812,294	0	0	39,130,643	
FFS MEDICAID IN PUBLIC SCHOOLS	512,731	226,028	162,718	568,047	957,644	1,133,728	874,679	515,590	1,768,158	786,243	0	0	7,505,566	
QMB - FEE FOR SERVICE	560,175	366,857	563,570	394,826	460,050	584,575	367,346	506,543	603,099	395,540	0	0	4,802,581	
INPATIENT INMATES FFS	328,698	230,026	445,921	384,796	482,211	199,519	278,404	241,115	539,845	571,576	0	0	3,702,111	
FFS TRBHA FEE FOR SERVICE	8,121,079	8,036,799	9,977,009	8,180,725	8,716,132	9,483,464	8,946,164	8,559,286	12,756,692	10,539,789	0	0	93,317,140	
STATE ONLY TRBHA FFS	128,659	157,307	364,070	114,279	73,010	127,608	130,466	125,146	244,642	166,749	0	0	1,631,937	
MARICOPA CTY INMATES FFS	17,312	13,478	6,406	50,010	13,220	27,565	19,829	2,322	63,255	1,468	0	0	214,865	
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	7,470	10,684	23	13,615	223	0	0	65,765	
PINAL COUNTY INMATES FFS	0	0	0	0	241	6,249	0	387	6,628	0	0	0	13,506	
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	12,383,020	11,197,117	12,514,892	15,642,387	11,208,835	0	0	123,355,442	
LFFS - PRIOR QUARTER COVERAGE	-2,222	-5,829	269	455	0	177	239	-91	120	1,493	0	0	-5,388	
YAVAPAI COUNTY INMATES LTC FEE	0	0	0	0	175	8	225	0	0	0	0	0	407	
LFFS MEDICAID IN PUBLIC SCHOOLS	607,580	255,441	189,102	555,825	962,374	1,156,712	877,361	598,300	1,615,277	797,945	0	0	7,615,918	
REINSURANCE - ACC	13,590,647	16,229,687	13,339,168	13,014,204	17,219,450	17,270,494	12,554,848	13,007,134	15,303,361	15,290,612	0	0	146,819,605	
REINSURANCE - LTC	3,391,581	8,020,729	5,953,416	10,269,378	5,459,164	6,998,024	6,916,480	4,135,031	4,342,339	6,902,348	0	0	62,388,489	
SMIB - ACC	17,512,926	17,842,202	17,823,376	17,941,257	17,904,353	18,200,837	18,700,177	18,743,340	18,761,854	18,861,610	0	0	182,291,933	
HIB - ACC	939,024	1,014,832	1,018,218	1,051,512	1,033,457	1,059,744	1,096,312	1,074,029	1,075,240	1,035,481	0	0	10,397,847	
Q1	3,107,017	3,143,330	3,119,658	3,147,957	3,112,879	3,117,301	3,056,259	3,068,457	3,169,160	3,165,928	0	0	31,207,945	
SMIB - LTC	4,303,885	4,303,643	4,201,672	4,175,331	4,167,946	4,170,638	4,265,862	4,200,436	4,132,546	4,107,708	0	0	42,029,667	
HIB - LTC	386,148	405,365	393,182	388,427	387,023	393,527	397,032	395,294	373,962	370,482	0	0	3,890,442	
SUBTOTAL	782,051,320	773,268,185	790,056,274	785,195,501	844,224,966	906,447,375	804,117,706	821,940,315	875,938,332	835,140,748	0	0	8,218,380,723	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending April 30, 2021

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	370,907,540	347,640,715	350,213,561	354,647,198	358,340,504	0	0	3,422,264,338	
CAPITATION - AIMHS	201,435	202,551	206,196	210,948	215,167	217,206	229,828	231,038	232,950	236,991	0	0	2,184,311	
MENTAL HEALTH - ADULT	317,445	317,963	340,079	298,623	390,448	378,932	330,726	340,655	334,997	346,507	0	0	3,396,375	
MENTAL HEALTH - GENERAL	17,947	11,505	478	-1,659	0	-4,819	0	867	1,449	-275	0	0	25,494	
MENTAL HEALTH - CMDP	2,525	2,654	2,654	2,654	2,654	3,652	2,987	2,011	0	0	0	0	21,790	
MENTAL HEALTH - RBHA CRISIS	4,685,074	4,742,887	4,834,851	6,627,923	6,744,349	6,811,259	6,910,504	6,990,003	7,049,526	7,138,466	0	0	62,534,842	
FEE FOR SERVICE - ACUTE	52,697,715	41,638,572	57,754,561	46,769,742	43,098,179	42,434,725	31,628,182	54,451,553	90,043,232	58,263,806	0	0	518,780,267	
FFS - PRIOR QUARTER COVERAGE	6,219	-925	-4,174	-6,052	-427	0	-795	-215	971	0	0	0	-5,399	
EMERGENCY SERVICES - FEDERAL	3,940,111	3,229,763	4,570,583	4,287,997	4,308,781	4,112,806	3,364,109	4,748,338	4,209,552	3,152,674	0	0	39,924,715	
FFS MEDICAID IN PUBLIC SCHOOLS	680	191	79	285	737	868	193	313	1,236	939	0	0	5,520	
INPATIENT INMATES FFS	634,880	949,558	983,526	703,647	1,013,900	457,268	543,642	621,533	1,313,644	566,614	0	0	7,788,211	
FFS TRBHA FEE FOR SERVICE	8,167,640	7,429,009	9,697,887	8,791,752	6,964,617	8,828,814	7,589,288	8,163,070	12,105,891	8,985,666	0	0	86,723,634	
STATE ONLY TRBHA FFS	485,972	554,086	648,232	384,912	390,178	370,201	293,075	577,702	670,341	472,446	0	0	4,847,146	
COCONINO COUNTY INMATES FFS	6,644	0	9,430	406	3,688	0	1,174	15,728	0	4,576	0	0	41,645	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	274	1,371	18,776	11,329	1,131	4,783	0	0	37,665	
PINAL COUNTY INMATES FFS	1,098	2,454	207	6,841	9,852	763	6,638	0	12,066	2,311	0	0	42,232	
PIMA COUNTY INMATES FFS	12,600	43,980	17,411	16,589	18,826	7,970	22,623	22,136	18,728	77,455	0	0	258,320	
MOHAVE COUNTY INMATES FFS	9,593	3,912	17,882	7,260	93	5,397	16,851	14,421	5,830	7,310	0	0	88,549	
MARICOPA CTY INMATES FFS	90,234	55,621	48,405	235,553	145,540	74,940	112,796	44,809	240,956	93,932	0	0	1,142,786	
REINSURANCE - ACC	5,981,687	7,802,788	9,070,700	8,760,856	9,365,138	7,166,894	9,025,950	5,588,671	8,860,327	7,313,817	0	0	78,936,829	
SMIB - ACC	7,812,901	7,964,388	7,976,982	8,063,683	8,087,145	8,162,727	8,459,883	8,458,273	8,516,888	8,600,037	0	0	82,102,908	
HIB - ACC	5,038	5,496	5,038	6,412	9,618	1,374	5,652	3,980	5,652	4,710	0	0	52,970	
SUBTOTAL	395,838,095	388,202,645	415,055,946	407,924,464	455,645,696	449,939,890	416,202,799	440,499,776	488,272,566	453,613,269	0	0	4,311,195,147	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending April 30, 2021

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	74,349,422	66,796,726	68,670,405	71,596,651	71,816,024	0	0	604,739,122	
CAPITATION - AIMHS	20,082	21,970	22,899	25,231	27,092	28,529	31,474	32,631	34,469	35,405	0	0	279,782	
MENTAL HEALTH - ADULT	19,939	20,808	20,121	23,216	21,019	21,469	16,537	26,585	20,021	25,247	0	0	214,963	
MENTAL HEALTH - GENERAL	2,244	0	0	0	0	0	0	0	-141	-295	0	0	1,807	
MENTAL HEALTH - CMDP	818	818	818	818	818	1,008	881	881	85	0	0	0	6,946	
MENTAL HEALTH - RBHA CRISIS	868,177	932,013	967,642	1,379,030	1,459,650	1,538,245	1,620,737	1,675,087	1,737,694	1,753,659	0	0	13,931,933	
FEE FOR SERVICE - ACUTE	4,511,179	3,414,251	4,698,882	4,575,291	4,574,511	3,992,435	3,317,077	6,167,012	10,417,153	5,488,310	0	0	51,156,101	
FFS - PRIOR QUARTER COVERAGE	229	-303	-429	-100	0	76	0	0	0	0	0	0	-527	
EMERGENCY SERVICES - FEDERAL	5,996,983	5,467,005	8,309,800	6,955,426	7,193,409	6,920,907	6,508,794	7,395,918	6,378,460	5,713,172	0	0	66,839,874	
FFS MEDICAID IN PUBLIC SCHOOLS	63	15	0	32	129	245	87	0	238	46	0	0	855	
INPATIENT INMATES FFS	30,172	37,484	124,660	55,689	68,900	17,401	31,847	40,932	89,601	11,394	0	0	508,079	
STATE ONLY TRBHA FFS	37,689	53,626	54,347	35,653	40,260	24,164	26,788	74,251	10,238	48,911	0	0	405,926	
FFS TRBHA FEE FOR SERVICE	183,576	206,506	258,500	229,702	250,898	314,982	416,776	293,481	383,397	324,754	0	0	2,862,570	
PIMA COUNTY INMATES FFS	0	5,778	5,789	91	248	0	0	3,239	0	0	0	0	15,144	
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	10,038	883	6,414	6,200	0	0	73,530	
REINSURANCE - ACC	746,102	1,535,864	1,471,110	1,139,421	1,741,339	802,108	1,156,146	1,229,801	1,365,257	1,439,090	0	0	12,626,238	
SMIB - ACC	2,314	236	6,507	5,061	6,796	7,230	7,402	8,561	9,942	12,615	0	0	66,663	
	55,903,926	58,281,231	64,433,213	66,495,476	76,315,669	88,018,219	79,941,309	85,619,666	92,049,478	86,674,532	0	0	753,732,720	
	1,233,793,341	1,219,752,061	1,269,545,434	1,259,615,441	1,376,186,332	1,444,405,485	1,300,261,814	1,348,059,757	1,456,260,377	1,375,428,550	0	0	13,283,308,590	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - CMDP	0	0	0	0	0	127	0	0	0	0	0	0	127	
MENTAL HEALTH - RBHA CRISIS	0	0	0	25	25	25	39	55	52	39	0	0	261	
FFS - PRIOR QUARTER COVERAGE	0	0	0	0	0	0	52	0	0	0	0	0	52	
KidsCare - CAPITATION	7,336,023	7,539,106	7,723,214	7,942,714	9,458,482	10,401,924	9,479,964	9,725,978	9,951,502	10,169,820	0	0	89,728,728	
KidsCare - FEE FOR SERVICE	191,287	101,072	201,058	172,782	146,459	140,107	152,504	152,293	286,381	174,377	0	0	1,718,320	
KidsCare - MENTAL HEALTH	88,620	91,499	92,875	99,387	103,052	106,330	113,556	114,325	113,338	113,143	0	0	1,036,124	
KidsCare - REINSURANCE	232,715	302,606	167,450	496,241	289,831	342,210	117,894	435,762	317,078	239,516	0	0	2,941,302	
KidsCare - TRANSPLANT REIN	4,465	11,869	0	23,265	0	0	8,176	0	0	345,802	0	0	393,577	

7,853,110	8,046,152	8,184,597	8,734,413	9,997,850	10,990,723	9,872,186	10,428,414	10,668,350	11,042,697	0	0	95,818,492	

TOTAL TITLE XXI

1,241,646,451	1,227,798,213	1,277,730,031	1,268,349,854	1,386,184,181	1,455,396,208	1,310,134,000	1,358,488,172	1,466,928,727	1,386,471,247	0	0	13,379,127,082	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67.59	0.00	0.00		67.59		
1004	TANF 14-20 MALE WITH	127.65	127.65	127.65	127.65	127.65	470.04	134.32	134.32	276.02	0.00	0.00	0.00		1,652.95		
1005	TANF 14-20 FEMALE WI	125.69	125.69	125.69	125.69	0.00	9.45	0.00	0.00	117.20	117.20	0.00	0.00		746.61		
1006	TANF 21-44 MALE WITH	34,208.35	30,410.95	37,883.34	39,337.41	47,710.28	49,628.68	40,896.28	40,193.61	34,634.18	34,562.87	0.00	0.00		389,465.95		
1007	TANF 21-44 FEMALE WI	64,050.55	74,207.68	73,586.15	76,449.02	72,930.48	62,007.45	71,099.66	51,862.65	54,765.21	47,511.91	0.00	0.00		648,470.76		
1008	TANF 45-64 M & F WIT	91,922.90	99,173.42	93,750.55	90,483.60	98,517.54	111,975.22	105,131.56	105,044.89	95,031.57	84,984.08	0.00	0.00		976,015.33		
1009	TANF 65+ M & F WITH	18,619.51	17,597.69	17,920.88	19,023.08	24,533.59	23,085.65	23,857.05	22,765.47	22,781.72	21,423.97	0.00	0.00		211,608.61		
100A	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	161.35	0.00	0.00		161.35		
100D	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	112.14	0.00	0.00	0.00	0.00	0.00	0.00		112.14		
100F	TANF 21-44 MALE WITH	0.00	0.00	858.25	729.32	89.41	93.04	0.00	163.59	0.00	222.09	0.00	0.00		2,155.70		
100G	TANF 21-44 FEMALE WI	493.97	707.73	0.00	326.30	184.84	170.18	0.00	49.07	213.61	0.00	0.00	0.00		2,145.70		
100H	TANF 45-64 M & F WIT	3,381.21	922.03	977.36	75.15	4,236.36	160.53	0.00	56.90	2,530.02	82.16	0.00	0.00		12,421.72		
100J	TANF 65+ M & F WITH	36.22	106.99	0.00	1,282.97	97.87	140.60	0.00	76.98	74.11	0.00	0.00	0.00		1,815.74		
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	7,191,133.24	6,544,882.08	6,679,047.95	6,768,029.42	7,225,148.37	0.00	0.00		65,160,438.03		
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	5,429,521.19	4,694,959.31	4,678,659.13	4,599,340.30	4,557,135.35	0.00	0.00		47,335,115.62		
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	9,892,191.22	8,727,355.53	8,730,592.49	8,677,009.02	8,604,965.30	0.00	0.00		85,461,301.37		
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	3,293,653.21	2,931,793.72	2,962,822.44	2,993,459.19	3,004,907.95	0.00	0.00		28,396,289.04		
1015	TANF 14-20 FEMALE N	2,918,645.44	3,046,827.74	3,099,777.20	3,153,966.53	3,652,365.93	3,929,299.90	3,509,710.69	3,565,886.37	3,578,536.05	3,593,147.28	0.00	0.00		34,048,163.13		
	O																
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	14,226,318.65	12,618,535.52	12,736,880.40	12,808,449.26	12,933,114.93	0.00	0.00		126,033,782.37		
1017	TANF 21-44 FEMALE N	39,060,744.01	39,509,188.92	39,757,271.15	39,544,932.92	45,410,006.22	47,441,663.39	41,921,296.20	42,445,546.53	42,895,745.14	43,252,020.63	0.00	0.00		421,238,415.11		
	O																
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	11,888,708.44	10,594,181.48	10,777,128.24	10,903,493.27	11,014,804.79	0.00	0.00		105,945,793.31		
1019	TANF 65+ M & F NON-M	44,019.24	45,810.05	46,464.82	47,664.09	53,240.49	54,442.44	50,003.64	53,799.67	54,028.18	56,028.88	0.00	0.00		505,501.50		
101A	TANF < 1 M & F NON-M	242,715.00	230,273.70	229,936.22	250,087.61	307,332.76	357,729.20	260,467.47	257,515.86	240,832.43	243,832.54	0.00	0.00		2,620,722.79		
101B	TANF 01-05 M & F NON	9,697.81	18,957.60	16,218.37	18,400.47	19,357.18	13,830.28	7,062.34	13,392.87	17,107.85	12,536.81	0.00	0.00		146,561.58		
101C	TANF 06-13 M & F NON	9,633.07	14,592.66	14,361.81	11,161.25	8,456.31	4,153.21	9,628.74	4,571.96	4,905.14	3,280.47	0.00	0.00		84,744.62		
101D	TANF 14-20 MALE NON-	7,290.83	6,053.54	8,279.74	5,207.72	9,634.56	4,562.58	5,639.89	3,106.60	7,644.33	2,893.47	0.00	0.00		60,313.26		
101E	TANF 14-20 FEMALE N	10,602.38	10,128.91	8,502.02	29,581.84	10,086.89	10,592.52	3,735.10	5,116.84	3,496.33	5,779.96	0.00	0.00		97,622.79		
	O																
101F	TANF 21-44 MALE NON-	174,219.43	160,889.34	171,949.09	178,346.77	161,372.21	168,000.56	134,242.14	120,134.06	155,517.93	115,427.87	0.00	0.00		1,540,099.40		
101G	TANF 21-44 FEMALE N	334,883.85	299,235.14	294,091.37	307,923.17	338,672.00	319,070.76	261,644.65	209,289.83	293,897.39	239,332.21	0.00	0.00		2,898,040.37		
	O																
101H	TANF 44-64 M & F NON	95,620.69	91,303.95	75,456.95	96,663.15	102,267.04	105,345.12	95,782.71	72,502.67	89,503.03	80,241.74	0.00	0.00		904,687.05		
101J	TANF 65+ N & F NON-M	591.24	157.47	0.00	255.22	194.36	589.18	1,012.90	0.00	0.00	666.53	0.00	0.00		3,466.90		
1023	TANF 06-13 M & F WIT	105.59	105.59	105.59	105.59	105.59	182.06	131.08	131.08	131.08	131.08	0.00	0.00		1,234.33		
1024	TANF 14-20 MALE WITH	395.17	395.17	395.17	395.17	935.28	474.70	856.20	856.20	443.51	270.28	0.00	0.00		5,416.85		
1025	TANF 14-20 FEMALE WI	1,970.08	1,809.68	160.40	160.40	160.40	83.36	134.72	134.72	134.72	134.72	0.00	0.00		4,883.20		
1026	TANF 21-44 MALE WITH	27,495.43	31,970.87	29,841.30	25,812.41	32,787.12	33,476.59	42,735.33	36,771.69	37,048.85	34,732.46	0.00	0.00		332,672.05		
1027	TANF 21-44 FEMALE WI	51,398.03	51,936.61	48,965.83	54,053.71	60,856.38	50,151.70	51,868.22	62,116.34	58,182.66	58,861.10	0.00	0.00		548,390.58		

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	47,878.93	52,321.27	56,029.67	56,243.02	61,965.02	54,278.57	52,871.34	56,230.24	63,457.07	68,803.73	0.00	0.00		570,078.86		
1029	TANF 65+ M & F WITH	9,549.56	10,101.57	10,252.16	10,132.18	13,022.25	13,020.30	13,249.01	13,532.69	14,124.80	14,438.21	0.00	0.00		121,422.73		
102F	TANF 21-44 MALE WITH	0.00	0.00	5.35	0.00	38.89	4.03	1,554.43	0.00	99.95	56.80	0.00	0.00		1,759.45		
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	109.50	0.00	0.00	0.00	0.00	0.00	0.00		269.87		
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	698,506.23	694,456.55	720,278.90	704,092.75	803,007.03	733,984.71	734,884.92	743,969.44	745,473.59	759,065.94	0.00	0.00		7,337,720.06		
	A																
210Z	SSI AGED WITH MEDIC	28,553.28	28,195.70	38,318.15	39,628.76	32,168.90	32,000.86	27,894.14	56,023.64	77,711.80	27,987.19	0.00	0.00		388,482.42		
	A																
2110	SSI AGED NON-MEDICA	9,047,239.54	9,208,276.25	9,378,951.72	9,457,003.26	10,904,872.62	11,027,642.30	10,205,029.77	10,380,252.83	10,573,916.45	10,763,411.43	0.00	0.00		100,946,596.17		
	R																
211Z	SSI AGED NON-MEDICA	78,808.00	103,916.29	95,545.46	134,773.51	133,598.31	142,957.70	141,656.10	201,751.93	156,307.30	168,569.97	0.00	0.00		1,357,884.57		
	R																
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	6,417,721.98	6,115,510.22	6,149,588.43	6,214,354.12	6,286,844.27	0.00	0.00		60,952,251.53		
212Z	SSI AGED WITH QMB P	2,614.05	3,303.39	2,838.15	6,793.64	3,769.64	4,034.75	4,086.48	1,844.33	3,224.92	3,786.02	0.00	0.00		36,295.37		
	P																
2200	SSI DISABLED WITH M	1,988,850.90	1,937,214.60	1,946,245.23	1,961,254.15	2,162,196.42	2,067,034.94	2,120,369.25	2,107,233.99	2,091,306.46	2,102,459.79	0.00	0.00		20,484,165.73		
	E																
220Z	SSI DISABLED WITH M	55,243.94	52,261.49	40,385.46	35,454.14	42,355.46	35,463.83	30,849.98	51,880.15	76,467.04	14,551.45	0.00	0.00		434,912.94		
	E																
2210	SSI DISABLED NON-ME	74,206,259.51	74,247,747.94	74,375,463.22	74,268,860.45	86,039,593.03	83,295,053.05	77,681,885.25	77,916,719.13	77,793,327.75	78,162,934.33	0.00	0.00		777,987,843.66		
	D																
221Z	SSI DISABLED NON-ME	911,078.19	674,713.13	566,425.39	609,686.10	809,063.72	743,639.61	655,797.61	906,379.82	922,395.55	930,064.76	0.00	0.00		7,729,243.88		
	D																
2220	SSI DISABLED WITH Q	16,027,790.55	16,001,034.33	16,063,323.26	16,015,781.06	17,935,038.05	16,697,481.85	16,134,181.54	16,178,907.21	16,181,592.29	16,188,407.71	0.00	0.00		163,423,537.85		
	M																
222Z	SSI DISABLED WITH Q	15,718.28	19,520.65	12,647.71	46,279.62	29,645.66	52,897.56	12,857.87	49,962.07	18,800.82	14,137.72	0.00	0.00		272,467.96		
	M																
2300	SSI BLIND WITH MEDIC	8,075.33	8,235.73	8,367.20	8,125.45	9,386.61	5,836.39	8,521.44	6,317.97	6,048.93	5,925.87	0.00	0.00		74,840.92		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	1,602.23	70.18	0.41	0.00	0.00	0.00	0.00	0.00	0.00		1,672.82		
2310	SSI BLIND NON-MEDIC	648,301.31	652,238.19	657,275.80	656,702.16	778,583.42	751,970.23	695,230.04	689,276.13	692,661.32	689,656.63	0.00	0.00		6,911,895.23		
	A																
231Z	SSI BLIND NON-MEDIC	1,042.60	1,030.24	13,566.07	0.00	6,658.89	129.48	236.72	8,638.42	8,264.94	15,325.84	0.00	0.00		54,893.20		
	A																
2320	SSI BLIND WITH QMB	46,856.10	46,839.73	48,573.59	48,384.98	55,829.30	54,815.25	51,788.38	53,936.54	55,591.35	58,220.59	0.00	0.00		520,835.81		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	83.62	0.00	0.00	0.00		83.62		
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	411.81	268.02	328.75	194.62	0.00	0.00	0.00		4,954.00		
4303	SOBRA CHILD 06-13 M	702.38	829.23	923.94	452.12	481.56	534.51	272.78	407.10	372.44	407.50	0.00	0.00		5,383.56		
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	1.22	0.00	0.00	0.00	0.00	0.00	0.00		184.31		
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	21,852,324.21	19,601,254.24	19,364,696.24	19,150,673.50	19,826,449.45	0.00	0.00		200,839,655.29		
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	41,586,930.82	36,650,218.30	36,873,983.78	37,234,039.28	42,031,454.11	0.00	0.00		365,253,469.07		
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	52,872,613.39	46,377,119.82	46,590,866.74	46,881,391.88	51,612,379.31	0.00	0.00		463,747,452.87		
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	15,547,872.91	13,741,237.33	13,839,967.75	13,966,154.82	15,372,323.58	0.00	0.00		136,480,327.93		

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	15,407,341.24	13,600,280.42	13,704,160.20	13,815,657.02	15,149,596.12	0.00	0.00		135,246,623.26		
431A	SOBRA CHILD < 1 M &	190,018.19	129,565.61	150,896.98	192,135.55	185,992.99	204,551.52	172,111.89	151,109.20	159,801.74	145,870.96	0.00	0.00		1,682,054.63		
431B	SOBRA CHILD 01-05 M	357,231.33	341,141.31	291,594.58	359,644.58	358,264.65	323,222.73	281,837.30	231,424.64	292,720.07	242,022.60	0.00	0.00		3,079,103.79		
431C	SOBRA CHILD 6-13 M&F	411,494.30	425,568.07	345,925.32	432,911.95	415,639.60	394,653.89	305,153.85	294,996.00	381,226.91	259,334.16	0.00	0.00		3,666,904.05		
431D	SOBRA CHILD 14-20 MA	122,376.81	112,205.00	113,616.44	123,940.23	133,160.66	118,701.95	95,113.16	95,715.95	108,309.34	80,274.78	0.00	0.00		1,103,414.32		
431E	SOBRA CHILD 14-20 FE	118,636.97	119,719.33	94,933.92	130,882.72	138,931.89	118,178.37	92,744.83	109,294.57	103,757.30	75,584.47	0.00	0.00		1,102,664.37		
4322	SOBRA CHILD 01-05 M	160.40	160.40	160.40	160.40	160.40	83.36	134.72	134.72	134.72	134.72	0.00	0.00		1,424.24		
4323	SOBRA CHILD 06-13 M	260.49	406.10	92.17	0.00	164.43	144.59	135.14	135.14	135.14	135.14	0.00	0.00		1,608.34		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	106.78	0.00	118.43	-1.23	0.00	136.94	136.94	136.94	0.00	0.00		634.80		
4325	SOBRA CHILD 14-20 FE	506.54	624.97	486.96	486.96	592.68	621.12	531.68	531.68	531.68	531.68	0.00	0.00		5,445.95		
5005	SOBRA PREG 14-20 FE	0.00	0.00	0.00	39.35	305.74	308.11	0.00	0.00	0.00	0.00	0.00	0.00		653.20		
	M																
5007	SOBRA PREG 21-44 FE	6,893.89	7,623.51	6,516.39	5,660.79	12,035.28	13,644.22	10,722.25	10,032.37	10,085.93	11,450.08	0.00	0.00		94,664.71		
	M																
5008	SOBRA PREG 45-64 FE	772.43	-2,574.76	0.00	0.00	100.85	0.00	1,672.47	1,851.66	0.00	0.00	0.00	0.00		1,822.65		
	M																
500E	SOBRA PREG 14-20 FE	0.00	0.00	0.00	134.92	0.00	-6.30	0.00	0.00	0.00	0.00	0.00	0.00		128.62		
	M																
500G	SOBRA PREG 21-44 FE	1,139.63	1,754.50	140.76	2,991.67	976.74	214.59	193.30	169.07	8.72	127.46	0.00	0.00		7,716.44		
	M																
500H	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	125.69	0.00	182.52	38.49	0.00	0.00	0.00	0.00		346.70		
	M																
5013	SOBRA PREG 09-13 FE	379.13	187.31	219.28	374.62	423.30	440.56	600.92	721.46	958.82	1,026.05	0.00	0.00		5,331.45		
	M																
5015	SOBRA PREG 14-20 FE	514,099.93	500,676.68	497,532.46	467,127.47	552,643.11	547,419.27	465,257.41	456,318.48	458,770.50	462,351.37	0.00	0.00		4,922,196.68		
	M																
5017	SOBRA PREG 21-44 FE	6,245,141.22	6,059,840.82	6,088,763.58	5,882,723.90	7,004,693.05	6,969,745.57	5,986,174.98	5,977,035.38	5,886,386.49	5,813,316.25	0.00	0.00		61,913,821.24		
	M																
5018	SOBRA PREG 45-64 FE	23,254.58	21,297.41	20,401.14	21,487.38	24,937.45	23,026.50	23,323.51	26,562.60	29,762.02	28,000.18	0.00	0.00		242,052.77		
	M																
501C	SOBRA PREG 09-13 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	48.06	0.00	0.00	0.00		48.06		
	M																
501E	SOBRA PREG 14-20 FE	34,772.38	24,122.66	28,034.33	27,340.33	36,472.60	35,878.71	33,916.50	28,323.21	32,903.16	28,840.22	0.00	0.00		310,604.10		
	M																
501G	SOBRA PREG 21-44 FE	332,215.06	294,512.36	280,017.88	302,429.47	308,992.85	347,429.27	320,063.36	279,163.59	305,016.63	284,560.47	0.00	0.00		3,054,400.94		
	M																
501H	SOBRA PREG 45-64 FE	124.37	1,264.57	668.29	640.96	1,140.46	643.77	3,010.45	1,047.33	1,147.26	1,631.40	0.00	0.00		11,318.86		
	M																
5025	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	141.70	0.00	0.00	0.00	0.00	0.00		141.70		
	M																
5027	SOBRA PREG 21-44 FE	16,055.18	10,460.69	13,278.20	14,384.83	15,177.79	11,028.45	8,768.64	15,542.40	15,323.62	17,758.60	0.00	0.00		137,778.40		
	M																
5028	SOBRA PREG 45-64 FE	160.40	1,653.54	1,653.54	1,779.23	1,779.23	2,204.56	2,010.82	4,468.43	4,468.43	4,468.43	0.00	0.00		24,646.61		
	M																
502G	SOBRA PREG 21-44 FE	0.00	0.00	0.00	24.33	1,214.58	11.01	0.00	298.25	0.00	0.00	0.00	0.00		1,548.17		
	M																
SUBTOTAL:	322,044,951.03	323,005,239.42	324,486,165.66	325,026,567.15	376,119,714.02	383,173,278.48	345,171,685.33	347,268,258.50	348,932,685.83	362,953,342.22	0.00	0.00		3,458,181,887.64		

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	2,793,506.21	2,341,963.46	2,310,227.94	2,603,488.69	2,412,145.72	0.00	0.00	
9920	SSI W/MEDICARE KICK	24,617.35	43,221.43	12,765.08	18,705.38	37,334.63	22,061.89	44,856.59	32,344.98	19,197.32	38,728.13	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	108,231.76	130,071.82	122,220.34	104,073.28	52,256.49	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	12,882,471.97	10,760,018.43	9,747,755.60	10,101,028.41	9,458,065.63	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	15,806,271.83	13,276,910.30	12,212,548.86	12,827,787.70	11,961,195.97	0.00	0.00	

25,918,942.17	
293,832.78	
1,106,483.49	
109,280,921.40	
136,600,179.84	

3100	TRANSPLANT OPTION 1	16.50	16.50	16.50	16.50	16.50	16.50	16.50	16.50	16.50	16.50	0.00	0.00	

165.00

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	16.50	16.50	16.50	16.50	16.50	16.50	16.50	16.50	16.50	16.50	0.00	0.00		165.00		

1106	TANF EXPANDED 21-44	77,768.11	78,146.70	73,692.25	81,573.09	84,965.67	75,471.72	70,477.10	67,254.17	65,270.91	66,003.00	0.00	0.00	
1107	TANF EXPANDED 21-44	159,772.71	164,213.11	164,595.30	157,777.57	190,123.46	170,357.64	162,063.06	168,121.54	160,833.70	165,687.84	0.00	0.00	
1108	TANF EXPANDED 45-64	397,181.59	393,412.43	401,913.67	406,396.68	454,946.00	429,322.31	425,885.51	421,012.56	422,930.71	426,637.42	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	106,088.51	105,903.72	108,842.75	109,666.03	126,177.48	124,224.33	121,726.10	116,631.16	118,216.29	120,788.73	0.00	0.00	
110F	TANF EXPANDED 21-44	1,182.86	1,804.71	566.35	1,716.60	654.91	1,006.35	914.49	930.08	1,102.94	383.97	0.00	0.00	
110G	TANF EXPANDED 21-44	6,731.98	2,857.45	2,388.62	5,456.38	8,375.15	11,845.19	4,422.51	1,810.55	2,357.19	3,888.27	0.00	0.00	
110H	TANF EXPANDED 45-64	7,835.95	5,499.45	4,291.27	11,084.75	10,641.60	10,731.15	4,016.21	51,021.25	9,208.97	1,982.74	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	4,476.66	2,261.04	5,133.05	4,275.18	4,203.44	5,300.37	1,859.90	4,715.41	5,463.49	1,385.35	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	187.31	187.31	0.00	10.99	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	962.28	962.28	962.28	1,151.55	1,129.03	1,378.32	1,174.92	829.87	629.04	629.04	0.00	0.00	
1114	TANF EXPANDED 14-20	41,812.36	42,972.62	43,640.81	42,110.37	50,811.93	52,139.78	40,708.67	44,058.22	45,282.88	46,052.61	0.00	0.00	
1115	TANF EXPANDED 14-20	245,785.25	250,520.44	256,430.37	264,097.07	312,140.07	324,545.65	278,047.48	272,292.06	279,529.70	276,833.49	0.00	0.00	
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	12,625,064.11	11,194,280.36	11,231,548.00	11,307,024.70	11,259,808.73	0.00	0.00	
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	35,168,513.80	31,360,852.52	31,556,582.18	31,725,182.99	31,724,021.10	0.00	0.00	
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	11,975,823.42	10,703,318.00	10,755,539.25	10,819,916.34	10,841,257.92	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	35,524.37	34,975.43	37,615.22	39,676.64	47,892.49	50,266.19	47,947.69	46,544.83	50,335.30	49,777.50	0.00	0.00	
111D	TANF EXPANDED 14-20	781.60	2,173.88	446.08	1,575.08	855.38	1,597.77	546.66	428.47	618.75	438.33	0.00	0.00	
111E	TANF EXPANDED 14-20	1,592.49	2,017.46	1,880.38	1,778.42	3,911.18	1,760.56	1,082.79	1,851.45	1,738.34	1,546.61	0.00	0.00	
111F	TANF EXPANDED 21-44	204,286.43	216,747.68	178,596.92	267,272.49	219,031.84	223,543.32	178,032.83	164,985.53	204,138.63	124,998.78	0.00	0.00	
111G	TANF EXPANDED 21-44	314,523.46	325,930.93	289,036.07	388,784.82	342,880.55	328,548.42	246,321.63	226,144.89	285,198.18	185,523.11	0.00	0.00	
111H	TANF EXPANDED 45-64	134,829.59	136,379.99	135,303.77	174,601.39	133,298.22	163,830.23	147,894.76	113,854.40	129,358.64	76,784.03	0.00	0.00	
111J	TANF EXPANDED 65+ M
&	775.08	800.34	488.36	885.08	169.66	1,009.90	0.00	912.12	413.44	0.00	0.00	0.00	
1125	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	141.70	141.70	141.70	0.00	0.00	
1126	TANF EXPANDED 21-44	289,842.11	294,104.27	293,697.14	281,613.34	331,202.93	302,294.75	304,925.95	309,494.10	307,293.01	316,190.47	0.00	0.00	
1127	TANF EXPANDED 21-44	803,571.42	783,127.12	776,510.17	768,029.59	846,689.92	809,416.71	797,750.67	812,640.82	801,800.66	799,187.41	0.00	0.00	
1128	TANF EXPANDED 45-64	908,788.13	921,716.91	944,743.19	963,077.78	1,077,010.87	990,583.10	974,092.23	971,079.68	986,651.65	977,384.99	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	270,502.44	281,316.18	282,575.29	276,403.32	319,920.88	292,521.57	276,975.91	279,451.14	282,203.00	291,032.05	0.00	0.00	
112F	TANF EXPANDED 21-44	64.30	182.53	62.60	1,369.82	3,110.84	193.83	2,433.66	358.43	96.69	62.69	0.00	0.00	
112G	TANF EXPANDED 21-44	2,530.28	286.18	170.72	416.89	398.57	5,032.58	290.60	211.05	135.21	379.75	0.00	0.00	
112H	TANF EXPANDED 45-64	313.22	2,624.51	245.12	456.09	898.85	244.14	296.77	533.95	498.61	1,075.95	0.00	0.00	
112J	TANF EXPANDED 65+ M
&	427.57	76.34	590.44	558.14	244.58	459.87	593.65	398.65	452.79	135.14	0.00	0.00	
2400	SSI AGED EXPANDED WI	59,433.58	63,276.71	67,610.87	85,462.54	95,262.82	91,180.96	77,611.24	94,839.14	84,479.42	84,275.39	0.00	0.00	
240Z	SSI AGED EXPANDED
WI	18,916.28	18,046.02	14,866.51	28,399.79	28,340.00	30,758.37	20,303.30	62,871.31	59,519.91	23,816.74	0.00	0.00	
2410	SSI AGED EXPANDED N O	155,456.35	151,213.66	151,779.83	160,996.73	185,473.01	182,791.63	173,237.48	182,603.58	185,236.65	185,505.08	0.00	0.00	

740,622.72	
1,663,545.93	
4,179,638.88	
1,158,265.10	
10,263.26	
50,133.29	
116,313.34	
39,073.89	
385.61	
9,808.61	
449,590.25	
2,760,221.58	
109,368,308.38	
304,751,043.47	
105,295,683.36	
440,555.66	
9,462.00	
19,159.68	
1,981,634.45	
2,932,892.06	
1,346,135.02	
5,453.98	
425.10	
3,030,658.07	
7,998,724.49	
9,715,128.53	
2,852,901.78	
7,935.39	
9,851.83	
7,187.21	
3,937.17	
803,432.67	
305,838.23	
1,714,294.00	

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
241Z	SSI AGED EXPANDED N	4,444.93	2,379.28	5,357.08	10,154.41	9,213.84	9,696.95	27,539.62	1,928.57	5,933.16	8,144.33	0.00	0.00		84,792.17		
	O																
2420	SSI AGED EXPANDED	5,535,744.02	5,575,749.40	5,645,158.08	5,688,116.51	6,712,980.36	6,375,256.72	6,095,112.00	6,118,892.74	6,216,983.11	6,322,273.31	0.00	0.00		60,286,266.25		
	WI																
242Z	SSI AGED EXPANDED	2,030.09	1,629.65	4,124.86	3,366.00	5,587.01	6,979.34	2,198.27	1,970.21	3,348.59	3,769.38	0.00	0.00		35,003.40		
	WI																
2520	SSI BLIND EXPANDED	286.09	286.09	286.09	286.09	286.09	237.40	269.86	135.14	135.14	135.14	0.00	0.00		2,343.13		
	W																
2600	SSI DISABLED EXPAND	194,699.39	166,838.62	163,278.37	182,564.90	182,659.62	201,584.84	192,435.96	169,463.65	160,993.36	169,755.48	0.00	0.00		1,784,274.19		
	E																
260Z	SSI DISABLED EXPAND	36,315.12	32,400.31	29,174.27	37,120.13	31,861.00	24,109.76	27,401.20	47,537.10	26,036.65	21,366.34	0.00	0.00		313,321.88		
	E																
2610	SSI DISABLED EXPAND	2,051,318.55	2,017,118.33	1,979,774.95	1,957,883.40	2,322,271.97	2,241,299.16	2,037,129.01	2,064,443.71	2,024,163.76	2,104,287.61	0.00	0.00		20,799,690.45		
	E																
261Z	SSI DISABLED EXPAND	15,724.76	28,275.67	17,046.21	35,429.78	24,112.37	60,095.26	20,837.88	42,045.36	22,684.10	25,867.56	0.00	0.00		292,118.95		
	E																
2620	SSI DISABLED EXPAND	10,570,975.06	10,696,009.10	10,699,499.79	10,763,682.22	12,094,969.06	11,340,992.39	11,083,767.76	11,109,223.03	11,164,392.58	11,135,545.87	0.00	0.00		110,659,056.86		
	E																
262Z	SSI DISABLED EXPAND	7,115.96	4,322.14	7,130.69	7,290.87	11,264.78	8,722.17	4,934.35	32,006.84	24,267.07	8,756.80	0.00	0.00		115,811.67		
	E																
SUBTOTAL:	68,644,037.26	68,894,037.05	69,873,450.66	71,124,742.00	84,387,409.80	84,720,743.02	77,111,710.56	77,549,337.89	77,992,197.95	77,853,517.75	0.00	0.00		758,151,183.94		

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	1,557,118.17	1,137,700.73	1,220,408.86	1,275,385.32	1,518,810.86	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	6,398.60	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,751.60	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	1,557,118.17	1,137,700.73	1,220,408.86	1,288,535.52	1,518,810.86	0.00	0.00	

13,496,574.64	
12,520.43	
6,751.60	
13,515,846.67	

3506	ADULT 40-100% MALE 2	15,405.42	19,886.36	22,180.64	26,374.81	19,321.06	20,794.65	21,501.61	27,268.00	26,260.81	25,248.23	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	17,997.26	21,410.75	24,131.08	26,527.48	27,950.93	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	176,356.59	237,804.21	210,655.88	165,214.58	204,053.16	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	115,150.45	115,482.12	111,177.70	126,172.51	141,051.58	0.00	0.00	
350F	ADULT 40-100% MALE 2	0.00	1,269.76	1,766.30	2,408.65	186.44	39.06	814.75	2,036.83	1,604.92	1,981.03	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	125.61	0.00	0.00	455.60	0.00	0.00	476.08	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	1,389.94	459.51	0.00	10,052.92	702.23	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	4,371,919.42	4,099,945.35	4,123,883.67	4,148,017.40	4,209,702.55	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	4,738,798.70	4,477,399.16	4,463,185.97	4,484,365.49	4,580,273.42	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	19,202,104.12	18,414,934.88	18,746,471.18	19,135,557.73	19,298,332.12	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	15,931,440.37	15,155,812.46	15,409,266.38	15,578,624.92	15,683,843.82	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	31,585,779.66	29,710,364.97	29,991,283.13	30,143,703.77	30,207,140.85	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	4,391.00	3,328.29	3,325.05	3,297.63	4,525.64	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	57,651.10	44,841.74	31,277.21	52,659.64	25,707.86	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	71,459.11	58,805.01	46,044.68	66,283.26	40,478.23	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	645,857.71	477,930.46	355,411.00	418,268.77	311,678.62	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	477,240.67	383,152.15	256,455.65	289,868.72	221,717.83	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	983,911.07	761,168.37	535,553.93	576,716.19	468,177.62	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	7,993.81	2,117.11	16,529.57	3,143.66	3,676.32	0.00	0.00	

224,241.59	
187,181.89	
1,809,928.31	
1,002,239.57	
12,107.74	
1,057.29	
21,670.49	
3,133.62	
41,016,287.81	
44,144,739.72	
173,841,002.60	
144,489,198.20	
288,841,499.88	
39,514.72	
452,447.94	
577,132.34	
4,756,909.81	
3,464,334.99	
6,669,961.74	
68,968.14	

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3524	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	752.39	752.39	752.39	752.39	752.39	0.00	0.00		3,761.95		
3526	ADULT 40-100% MALE 2	1,217.63	2,159.95	3,239.69	3,239.69	5,643.74	5,074.89	4,935.35	4,233.40	4,935.35	4,935.35	0.00	0.00		39,615.04		
3527	ADULT 40-100% FEMAL	3,129.78	3,169.19	2,574.76	4,152.84	3,158.94	3,973.73	3,889.25	3,266.50	3,447.65	674.17	0.00	0.00		31,436.81		
	E																
3528	ADULT 40-100% M&F 45	8,193.63	9,430.50	13,245.42	16,808.86	16,993.10	24,552.66	24,572.82	21,257.39	21,856.76	25,150.06	0.00	0.00		182,061.20		
3529	ADULT 40-100% M&F 65	1,994.61	3,145.30	3,253.97	3,324.47	4,986.13	5,862.31	7,344.61	12,045.36	11,890.58	12,569.53	0.00	0.00		66,416.87		
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		3,654.50		
352G	ADULT 40-100% FEMAL	0.00	0.00	0.00	996.68	0.00	6.80	0.00	0.00	339.65	0.00	0.00	0.00		1,343.13		
	E																
352H	ADULT 40-100% M&F 45	1,149.10	0.00	23.86	478.82	43.90	133.41	181.15	1,374.56	0.00	0.00	0.00	0.00		3,384.80		
352J	ADULT 40-100% M&F 65	0.00	0.00	19.29	0.00	0.00	663.28	0.00	0.00	0.00	0.00	0.00	0.00		682.57		
3704	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	791.60	-39.21	0.00	0.00	0.00	0.00	0.00	0.00		752.39		
3706	ADULT <40% EXP MALE	70,944.72	74,012.52	70,943.16	76,066.53	82,562.08	93,535.95	84,090.55	83,656.86	86,689.21	92,030.26	0.00	0.00		814,531.84		
3707	ADULT <40% EXP FEMA	35,324.86	37,339.03	35,225.70	40,577.84	47,161.83	52,383.92	54,511.67	58,553.02	39,678.61	65,694.89	0.00	0.00		466,451.37		
	L																
3708	ADULT <40% EXP M&F	220,500.37	206,912.60	217,991.28	261,456.19	284,462.77	299,282.68	332,890.78	339,722.17	338,456.74	383,464.21	0.00	0.00		2,885,139.79		
	4																
3709	ADULT <40% EXP M&F	20,600.74	26,685.04	27,833.71	32,640.41	38,306.15	38,460.51	36,052.78	41,349.16	36,664.05	46,693.58	0.00	0.00		345,286.13		
	6																
370F	ADULT <40% EXP MALE	1,776.23	855.45	54.98	191.66	1,157.16	3,518.75	985.81	433.70	12,298.06	1,299.45	0.00	0.00		22,571.25		
370G	ADULT <40% EXP FEMA	2,636.84	0.00	0.00	0.00	199.76	0.00	1,535.19	4,825.17	1,673.77	518.96	0.00	0.00		11,389.69		
	L																
370H	ADULT <40% EXP M&F	5,140.31	933.14	1,378.20	640.04	2,469.59	6,477.18	3,146.24	27,202.15	6,839.65	1,419.65	0.00	0.00		55,646.15		
	4																
370J	ADULT <40% EXP M&F	0.00	0.00	0.00	1,005.26	0.00	23.88	95.23	629.53	0.00	0.00	0.00	0.00		1,753.90		
	6																
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	8,789,938.43	8,419,060.95	8,528,046.17	8,682,318.60	8,857,104.09	0.00	0.00		82,783,991.50		
3715	ADULT <40% EXP FEMA	6,902,700.42	7,006,543.99	7,261,661.58	7,291,412.50	8,455,958.96	8,230,522.14	7,790,092.04	7,898,973.58	8,000,853.78	8,166,365.42	0.00	0.00		77,005,084.41		
	L																
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	68,901,189.20	65,549,493.17	66,751,945.47	67,622,405.25	69,062,792.68	0.00	0.00		650,569,177.24		
3717	ADULT <40% EXP FEMA	35,463,329.02	35,943,875.13	36,591,901.64	36,486,336.21	41,741,866.52	40,851,751.99	38,841,348.52	39,323,991.08	39,793,141.27	40,671,793.56	0.00	0.00		385,709,334.94		
	L																
3718	ADULT <40% EXP M&F	65,114,653.61	65,609,703.54	66,355,399.84	66,216,320.93	76,760,820.93	74,094,911.35	70,030,018.27	70,773,796.45	71,336,305.61	72,594,526.72	0.00	0.00		698,886,457.25		
	4																
3719	ADULT <40% EXP M&F	5,512.35	5,531.31	2,599.38	4,040.23	3,898.40	3,559.23	3,256.86	4,970.78	4,110.62	6,608.40	0.00	0.00		44,087.56		
	6																
371D	ADULT <40% EXP MALE	102,373.25	109,467.88	80,941.40	119,256.26	130,095.90	90,288.33	95,206.44	72,353.17	94,365.69	69,863.60	0.00	0.00		964,211.92		
371E	ADULT <40% EXP FEMA	113,577.21	96,289.88	83,381.93	74,753.01	84,962.68	98,508.72	96,308.24	69,477.66	81,191.97	84,089.64	0.00	0.00		882,540.94		
	L																
371F	ADULT <40% EXP MALE	1,168,212.37	998,214.87	798,037.45	1,024,881.27	1,259,540.93	1,286,124.62	1,113,494.03	903,801.38	1,141,071.30	961,838.43	0.00	0.00		10,655,216.65		
371G	ADULT <40% EXP FEMA	601,167.45	611,816.20	489,530.95	673,601.10	648,399.87	822,990.78	708,172.00	483,288.97	641,183.44	541,264.97	0.00	0.00		6,221,415.73		
	L																
371H	ADULT <40% EXP M&F	1,053,904.90	947,039.82	703,531.66	993,710.86	1,050,643.48	1,302,429.08	1,079,109.32	819,002.68	996,059.53	827,935.74	0.00	0.00		9,773,367.07		
	4																
371J	ADULT <40% EXP M&F	584.18	1,263.02	2,135.90	0.00	2,830.31	37.02	0.00	23,922.82	10,553.23	0.00	0.00	0.00		41,326.48		
	6																
3726	ADULT <40% EXP MALE	10,048.37	12,088.47	11,869.20	12,761.36	12,482.72	14,692.22	13,961.92	16,119.28	21,083.11	18,985.76	0.00	0.00		144,092.41		
3727	ADULT <40% EXP FEMA	6,319.38	6,966.57	10,120.61	7,529.76	7,080.26	6,460.81	8,546.41	3,611.06	4,879.46	4,201.51	0.00	0.00		65,715.83		
	L																
3728	ADULT <40% EXP M&F	33,140.51	41,676.52	41,169.06	45,224.96	45,067.15	51,957.88	49,812.05	47,447.09	46,950.30	51,975.54	0.00	0.00		454,421.06		
	4																
3729	ADULT <40% EXP M&F	0.00	0.00	1,173.22	1,173.22	1,173.22	2,458.85	3,206.69	2,529.08	1,916.42	2,532.14	0.00	0.00		16,162.84		
	6																
372F	ADULT <40% EXP MALE	96.33	0.00	22.16	334.03	190.54	28.08	266.98	0.00	0.00	0.00	0.00	0.00		938.12		
372G	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	142.58	0.00	0.00	0.00	171.42	0.00	0.00	0.00		314.00		
	L																

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
372H	ADULT <40% EXP M&F 4	230.94	668.53	0.00	2,533.17	228.37	154.73	0.00	698.65	521.94	0.00	0.00	0.00		5,036.33		
372J	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	0.00	218.48	0.00	0.00	0.00	0.00	0.00	0.00		218.48		
SUBTOTAL:	239,963,208.43	242,065,543.62	246,339,300.13	249,254,945.14	288,330,802.57	283,493,159.76	268,343,610.61	270,677,709.72	274,300,945.81	278,013,322.74	0.00	0.00		2,640,782,548.53		

9935	BIRTH SUPP PAYMENT A	210,618.24	235,915.07	156,084.40	223,301.55	285,584.91	324,364.06	273,360.42	194,648.93	227,211.72	214,137.24	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	658,178.96	690,763.66	936,655.73	752,000.17	694,966.95	812,155.16	774,332.90	571,455.92	838,307.14	740,715.84	0.00	0.00	
SUBTOTAL:	868,797.20	926,678.73	1,092,740.13	975,301.72	980,551.86	1,136,519.22	1,047,693.32	766,104.85	1,065,518.86	954,853.08	0.00	0.00	

2,345,226.54	
7,469,532.43	
9,814,758.97	

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	5,742.66	5,672.38	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	91,422.29	90,221.25	75,960.77	85,797.71	88,123.05	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	23,819.16	27,767.16	30,064.21	45,408.36	56,472.20	62,384.62	68,716.35	64,818.97	71,024.25	72,457.78	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	340,120.37	429,700.06	499,442.22	584,811.10	648,185.02	859,894.69	821,883.93	761,851.04	800,598.01	843,627.21	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	192,067.80	222,525.48	275,579.58	319,172.48	390,902.46	570,252.52	564,341.12	475,107.53	529,001.78	569,997.23	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	938.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17.34	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	622.45	0.00	2,317.28	0.00	620.69	0.00	0.00	0.00	629.79	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	239.56	712.18	0.00	6,199.33	206.92	87.62	173.06	6,800.13	19,812.85	450.73	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	326.50	5,170.08	515.16	38.66	1,575.80	6,975.40	0.00	388.76	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,899,896.05	2,049,996.66	2,145,102.51	2,349,332.05	2,707,531.85	3,386,127.83	3,045,092.35	3,160,077.87	3,273,609.58	3,238,044.17	0.00	0.00	
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	3,595,398.65	3,235,399.88	3,390,017.42	3,516,719.35	3,451,909.26	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	10,088,476.23	10,938,561.26	11,379,189.42	12,271,400.40	14,312,323.90	17,536,368.41	15,789,970.23	16,493,203.98	17,136,119.06	17,284,184.12	0.00	0.00	
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	24,296,082.34	22,081,689.65	22,812,507.78	23,685,219.98	24,059,879.94	0.00	0.00	
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	22,040,521.63	19,550,646.48	20,186,283.01	20,855,070.17	20,935,360.41	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	13,663.01	17,931.30	20,405.76	25,307.77	26,981.62	41,416.72	42,729.59	42,478.68	46,835.82	50,499.82	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	13,184.76	8,885.91	11,360.15	13,647.16	16,653.31	22,140.56	13,972.17	10,119.28	8,099.81	11,593.41	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	16,950.75	13,468.02	18,341.54	23,649.15	18,869.48	23,144.56	18,707.81	19,634.51	16,121.01	16,420.24	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	135,369.09	130,953.43	131,414.33	170,114.12	184,510.94	237,351.47	170,393.66	124,524.18	168,191.56	103,030.79	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	181,738.61	169,552.74	163,822.96	220,989.09	205,993.13	276,295.22	213,707.13	148,115.55	182,724.09	125,306.53	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	182,177.20	163,889.96	174,697.01	225,336.67	205,745.97	398,555.71	255,208.69	222,503.35	226,879.02	152,720.02	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	469.96	0.00	0.00	1,641.88	0.00	0.00	0.00	0.00	1,986.78	497.26	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	429.33	429.33	858.13	2,574.76	2,691.68	3,028.49	436.16	436.16	436.16	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	410.47	410.47	410.47	410.47	410.47	492.88	437.94	925.66	1,445.73	925.66	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	8,251.79	6,959.14	4,453.54	3,489.05	4,585.45	6,686.40	4,909.05	6,080.36	8,748.55	8,739.50	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	6,936.70	8,708.80	11,214.40	14,098.44	17,562.77	25,264.26	21,786.50	25,579.95	28,911.29	30,483.62	0.00	0.00	
392G	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	348.08	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	286.36	0.00	0.00	0.00	0.00	
392J	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	538.61	0.00	0.00	0.00	0.00	

1,279.81	
29,981.51	
680,476.53	
522,933.06	
6,590,113.65	
4,108,947.98	
955.51	
4,190.21	
34,682.38	
14,990.36	
27,254,810.92	
29,178,988.40	
143,229,797.01	
198,095,776.42	
181,701,942.65	
328,250.09	
129,656.52	
185,307.07	
1,555,853.57	
1,888,245.05	
2,207,713.60	
4,595.88	
11,320.20	
6,280.22	
62,902.83	
190,546.73	
348.08	
286.36	
538.61	

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	42,987,752.35	46,045,074.67	47,888,017.45	51,515,575.60	60,362,416.26	73,478,361.38	66,000,263.51	68,034,826.55	70,663,982.35	71,045,441.09	0.00	0.00		598,021,711.21		

9939	BIRTH SUPP PAYMENT N	490,509.99	539,722.93	577,436.35	539,840.82	563,547.20	871,060.67	796,462.78	635,578.00	932,669.04	770,582.67	0.00	0.00		
SUBTOTAL:	490,509.99	539,722.93	577,436.35	539,840.82	563,547.20	871,060.67	796,462.78	635,578.00	932,669.04	770,582.67	0.00	0.00		

6,717,410.45

6,717,410.45

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	-0.39	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	0.00	0.00	0.00	608.00	608.00	608.00	608.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	379.56	192.25	192.25	192.25	379.56	463.34	216.17	216.17	216.17	414.71	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	9,869,836.93	8,728,325.55	8,801,905.78	8,887,307.36	8,935,966.92	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	2,990,804.69	2,675,975.21	2,692,819.04	2,741,491.52	2,783,378.06	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	2,946,091.29	2,616,121.70	2,641,923.71	2,678,345.41	2,701,040.81	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	104,787.65	75,070.35	65,368.29	63,868.05	57,097.10	0.00	0.00	
441D	SOBRA 100-133% MALE	23,170.00	26,350.17	15,474.63	33,219.88	23,438.22	28,174.07	20,794.39	20,405.52	25,825.99	20,595.93	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	23,208.67	21,494.79	20,652.12	33,364.47	17,107.11	0.00	0.00	
4423	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	134.72	134.72	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	253.23	228.39	134.80	258.84	254.14	254.14	254.14	254.14	0.00	0.00	
SUBTOTAL:	11,959,101.84	12,267,905.41	12,317,268.42	12,630,740.51	14,910,118.11	15,963,625.09	14,138,860.30	14,244,287.49	14,431,415.83	14,516,462.78	0.00	0.00	

384.44	
274.67	
2,432.00	
2,862.43	
85,045,510.27	
25,761,118.52	
25,305,273.99	
192.25	
785,588.93	
237,448.80	
236,538.22	
269.44	
1,891.82	
137,379,785.78	

9944	BIRTH SUPP PAYMENT S	55,894.09	49,462.55	68,820.88	49,405.12	62,514.35	49,472.99	39,451.44	25,873.74	12,797.20	51,816.28	0.00	0.00	
SUBTOTAL:	55,894.09	49,462.55	68,820.88	49,405.12	62,514.35	49,472.99	39,451.44	25,873.74	12,797.20	51,816.28	0.00	0.00	

465,508.64

465,508.64

4517	BC PATIENT FEMALE 2 1	9,097.90	8,834.23	7,900.73	8,080.65	9,388.70	9,844.05	9,118.19	8,738.32	7,647.12	7,754.79	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	62,050.98	56,767.03	55,893.18	55,730.89	55,302.29	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	854.72	619.80	833.84	1,434.26	1,416.05	2,555.53	2,542.13	4,011.39	4,023.50	2,288.54	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	177.31	466.16	565.47	0.00	3.70	922.06	55.95	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	4,516.93	2,064.33	537.91	2,053.14	758.41	0.00	0.00	
451J	BC PATIENT FEMALE 6
5	728.94	112.04	290.00	149.40	401.36	3,337.54	635.51	410.69	164.62	79.69	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	4,493.16	4,209.02	4,497.58	4,560.31	4,560.31	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	2,703.01	2,448.39	2,053.39	2,053.39	2,223.79	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	1,031.24	71.87	3.32	0.00	414.02	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,655.35	0.00	0.00	
SUBTOTAL:	71,516.53	68,951.84	65,580.23	68,461.34	79,121.48	90,426.58	77,840.55	76,556.48	76,232.97	74,623.17	0.00	0.00	

86,404.68	
545,923.55	
20,579.76	
2,190.65	
14,994.06	
6,309.79	
42,335.83	
27,397.05	
1,520.45	
1,655.35	
749,311.17	

8600	SSI BLIND FREEDOM/W O	138.01	138.01	138.01	138.01	174.05	158.50	144.84	144.84	144.84	144.84	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	1,157.06	1,482.66	1,319.86	1,319.86	1,319.86	1,319.86	0.00	0.00	
8620	SSI BLIND FREEDOM/W O	131.47	131.47	131.47	131.47	165.93	162.16	141.70	141.70	141.70	141.70	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	1,661,270.43	1,634,564.60	1,600,201.07	1,582,762.02	1,596,558.18	0.00	0.00	

1,463.95	
7,919.16	
1,420.77	
16,315,626.87	

ACC CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
870Z	SSI DISABLED FREEDO	59,052.04	56,907.81	37,846.36	22,948.41	11,544.30	24,235.34	16,243.31	8,796.66	26,638.92	6,686.10	0.00	0.00		270,899.25		
	M																
8710	SSI DISABLED FREEDO	437,294.87	437,573.54	433,207.08	430,461.81	512,519.36	490,875.85	452,827.83	464,794.85	471,491.97	478,780.91	0.00	0.00		4,609,828.07		
	M																
871Z	SSI DISABLED FREEDO	5,359.78	23,115.59	7,775.82	5,561.87	18,754.64	13,332.87	9,898.68	7,989.90	23,307.33	6,505.91	0.00	0.00		121,602.39		
	M																
8720	SSI DISABLED FREEDO	296,664.18	323,529.49	343,435.31	364,612.98	390,329.46	382,843.39	366,976.92	356,286.35	368,227.30	392,849.34	0.00	0.00		3,585,754.72		
	M																
872Z	SSI DISABLED FREEDO	214.12	21,303.89	2,133.83	959.83	1,298.19	671.52	395.12	764.26	3,637.17	472.19	0.00	0.00		31,850.12		
	M																
SUBTOTAL:	2,437,037.14	2,488,306.56	2,448,009.33	2,442,813.47	2,671,083.59	2,575,032.72	2,482,512.86	2,440,439.49	2,477,671.11	2,483,459.03	0.00	0.00		24,946,365.30		

7,785,326,663.14

721,041,402.68	729,552,925.20	842,674,540.25	862,915,086.41	789,624,718.79	795,151,946.93	805,002,456.67	822,197,444.14	0.00	0.00	

TOTAL:	705,453,681.98 711,712,460.09

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.46	0.00	0.00		0.46		
1004	TANF 14-20 MALE WITH	1.00	1.00	1.00	1.00	1.00	3.22	1.00	1.00	2.00	0.00	0.00	0.00		12.22		
1005	TANF 14-20 FEMALE WI	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00		6.00		
1006	TANF 21-44 MALE WITH	92.99	97.90	104.66	114.77	113.00	120.77	117.00	111.78	107.00	106.45	0.00	0.00		1,086.32		
1007	TANF 21-44 FEMALE WI	145.30	153.47	155.45	158.47	157.88	153.09	165.48	149.63	150.10	132.99	0.00	0.00		1,521.86		
1008	TANF 45-64 M & F WIT	255.43	265.88	252.84	268.38	270.45	297.79	303.00	288.23	288.15	275.40	0.00	0.00		2,765.55		
1009	TANF 65+ M & F WITH	140.77	131.12	132.19	139.69	148.23	150.03	157.00	149.42	149.45	139.73	0.00	0.00		1,437.63		
100A	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.11	0.00	0.00		1.11		
100D	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.77	0.00	0.00	0.00	0.00	0.00	0.00		0.77		
100F	TANF 21-44 MALE WITH	0.00	0.00	0.33	0.76	0.00	0.03	0.00	1.21	0.00	1.53	0.00	0.00		3.86		
100G	TANF 21-44 FEMALE WI	4.07	3.26	0.00	2.64	0.82	1.22	0.00	0.35	1.58	0.00	0.00	0.00		13.94		
100H	TANF 45-64 M & F WIT	5.44	4.13	0.82	0.51	3.26	0.29	0.00	0.39	18.70	0.60	0.00	0.00		34.14		
100J	TANF 65+ M & F WITH	0.22	0.83	0.00	9.27	0.76	0.96	0.00	0.57	0.54	0.00	0.00	0.00		13.15		
1011	TANF <1 M & F NON-ME	9,967.97	10,033.35	10,215.41	10,365.23	10,578.28	10,770.66	10,718.76	10,937.69	11,078.23	11,253.54	0.00	0.00		105,919.12		
1012	TANF 01-05 M & F NON	22,748.91	23,698.77	24,378.23	24,702.21	24,372.10	23,252.15	23,082.64	23,003.99	22,625.78	22,150.95	0.00	0.00		234,015.73		
1013	TANF 06-13 M & F NON	40,609.15	41,832.31	42,322.08	42,810.00	42,807.29	42,647.87	43,017.67	43,037.32	42,752.54	42,315.19	0.00	0.00		424,151.42		
1014	TANF 14-20 MALE NON-	12,185.14	12,707.76	12,916.79	13,207.97	13,352.36	13,458.22	13,601.96	13,769.46	13,832.94	13,800.64	0.00	0.00		132,833.24		
1015	TANF 14-20 FEMALE N	14,651.75	15,257.59	15,479.10	15,735.15	15,972.87	16,105.66	16,264.80	16,479.10	16,517.86	16,502.27	0.00	0.00		158,966.15		
	O																
1016	TANF 21-44 MALE NON-	29,701.60	29,950.91	30,106.97	29,962.86	29,545.85	29,807.81	29,914.24	30,274.14	30,419.76	30,720.66	0.00	0.00		300,404.80		
1017	TANF 21-44 FEMALE N	97,525.08	98,767.87	99,402.21	98,825.42	97,392.97	97,756.43	98,023.84	99,304.96	100,288.71	101,159.87	0.00	0.00		988,447.36		
	O																
1018	TANF 45-64 M & F NON	24,328.23	24,621.10	24,701.08	24,726.98	24,438.31	24,683.44	24,804.03	25,247.96	25,532.52	25,775.49	0.00	0.00		248,859.14		
1019	TANF 65+ M & F NON-M	106.20	110.31	111.99	115.25	116.00	109.29	113.63	122.99	124.13	128.86	0.00	0.00		1,158.65		
101A	TANF < 1 M & F NON-M	408.59	392.69	383.85	421.02	439.90	569.61	424.23	416.88	392.26	394.60	0.00	0.00		4,243.63		
101B	TANF 01-05 M & F NON	50.14	93.74	86.90	93.82	80.20	68.73	37.02	68.27	85.88	64.01	0.00	0.00		728.71		
101C	TANF 06-13 M & F NON	39.75	62.71	66.29	58.28	26.57	16.56	48.26	23.78	23.22	15.98	0.00	0.00		381.40		
101D	TANF 14-20 MALE NON-	35.79	20.42	37.63	26.42	23.74	11.17	27.93	15.14	29.73	14.07	0.00	0.00		242.04		
101E	TANF 14-20 FEMALE N	42.02	48.07	34.57	69.68	34.62	41.25	17.13	24.78	16.81	27.66	0.00	0.00		356.59		
	O																
101F	TANF 21-44 MALE NON-	454.24	407.09	422.47	475.99	308.65	386.67	337.26	297.95	393.59	285.32	0.00	0.00		3,769.23		
101G	TANF 21-44 FEMALE N	853.19	772.51	698.93	802.90	642.27	717.09	631.18	507.36	717.86	551.65	0.00	0.00		6,894.94		
	O																
101H	TANF 44-64 M & F NON	252.90	239.96	197.12	227.87	216.42	234.44	238.99	184.04	227.66	198.83	0.00	0.00		2,218.23		
101J	TANF 65+ N & F NON-M	1.41	0.41	0.00	0.74	0.00	1.32	2.70	0.00	0.00	1.69	0.00	0.00		8.27		
1023	TANF 06-13 M & F WIT	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
1024	TANF 14-20 MALE WITH	3.00	3.00	3.00	3.00	3.00	3.00	6.00	6.00	3.12	2.00	0.00	0.00		35.12		
1025	TANF 14-20 FEMALE WI	3.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		13.00		
1026	TANF 21-44 MALE WITH	77.86	83.00	78.26	79.00	84.00	84.79	90.92	79.00	82.40	82.46	0.00	0.00		821.69		
1027	TANF 21-44 FEMALE WI	125.63	134.24	120.36	128.99	134.89	127.10	127.60	137.99	145.00	143.00	0.00	0.00		1,324.80		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1028	TANF 45-64 M & F WIT	141.96	154.96	155.19	145.92	161.79	155.06	162.00	157.58	160.45	170.70	0.00	0.00		1,565.61		
1029	TANF 65+ M & F WITH	60.00	63.99	65.00	65.00	73.00	81.99	86.00	88.00	92.74	94.99	0.00	0.00		770.71		
102F	TANF 21-44 MALE WITH	0.00	0.00	0.03	0.00	0.00	0.03	0.96	0.00	0.74	0.43	0.00	0.00		2.19		
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	0.70	0.00	0.00	0.00	0.00	0.00	0.00		1.43		
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	4,402.33	4,355.48	4,357.54	4,400.47	4,413.02	4,482.08	4,502.13	4,489.02	4,515.24	4,554.61	0.00	0.00		44,471.92		
	A																
210Z	SSI AGED WITH MEDIC	169.67	173.31	137.41	212.10	151.11	182.17	200.11	359.49	402.91	181.71	0.00	0.00		2,169.99		
	A																
2110	SSI AGED NON-MEDICA	7,270.07	7,396.14	7,535.71	7,598.51	7,670.63	7,804.27	7,842.32	7,973.03	8,124.36	8,268.95	0.00	0.00		77,483.99		
	R																
211Z	SSI AGED NON-MEDICA	62.71	82.74	77.48	108.98	90.25	106.93	108.79	155.66	121.77	130.63	0.00	0.00		1,045.94		
	R																
2120	SSI AGED WITH QMB	34,634.33	34,813.15	35,177.05	35,203.19	35,582.94	35,828.39	35,899.03	36,143.82	36,475.39	36,735.21	0.00	0.00		356,492.50		
212Z	SSI AGED WITH QMB P	16.83	21.69	12.66	33.68	19.53	30.17	30.34	12.83	24.02	21.48	0.00	0.00		223.23		
	P																
2200	SSI DISABLED WITH M	3,956.99	3,848.61	3,898.41	3,962.70	3,956.76	4,096.25	4,223.64	4,256.05	4,221.11	4,165.30	0.00	0.00		40,585.82		
	E																
220Z	SSI DISABLED WITH M	113.49	98.84	94.51	124.53	75.94	95.23	94.58	113.97	176.11	92.47	0.00	0.00		1,079.67		
	E																
2210	SSI DISABLED NON-ME	53,599.11	53,645.97	53,764.31	53,666.54	53,988.36	54,166.20	54,139.94	54,278.17	54,216.15	54,160.57	0.00	0.00		539,625.32		
	D																
221Z	SSI DISABLED NON-ME	681.38	520.46	454.89	480.68	544.63	576.82	504.45	702.20	692.90	694.59	0.00	0.00		5,853.00		
	D																
2220	SSI DISABLED WITH Q	27,326.19	27,348.70	27,447.82	27,358.83	27,508.85	27,429.32	27,320.39	27,358.50	27,344.21	27,389.63	0.00	0.00		273,832.44		
	M																
222Z	SSI DISABLED WITH Q	34.06	46.23	10.53	40.27	32.35	38.77	18.51	35.31	28.42	18.40	0.00	0.00		302.85		
	M																
2300	SSI BLIND WITH MEDIC	31.00	32.00	33.00	31.24	33.00	32.00	34.00	36.00	34.00	33.00	0.00	0.00		329.24		
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	508.77	511.94	515.61	515.38	520.18	521.50	524.86	520.80	523.10	520.48	0.00	0.00		5,182.62		
	A																
231Z	SSI BLIND NON-MEDIC	0.86	0.83	10.96	0.00	4.69	0.00	0.19	6.49	6.35	13.49	0.00	0.00		43.86		
	A																
2320	SSI BLIND WITH QMB	239.00	239.00	240.89	239.72	241.00	239.72	236.96	234.54	232.66	236.96	0.00	0.00		2,380.45		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00	0.00		0.03		
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	3.00	2.00	2.42	1.44	0.00	0.00	0.00		35.64		
4303	SOBRA CHILD 06-13 M	5.67	7.00	7.55	3.87	3.00	3.00	2.00	3.00	2.74	3.00	0.00	0.00		40.83		
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	32,618.40	32,112.58	31,719.57	31,371.84	30,789.80	0.00	0.00		326,495.43		
4312	SOBRA CHILD 01-05 M	170,887.21	171,552.77	172,827.65	173,596.73	174,740.03	177,006.24	177,706.56	178,821.96	180,460.80	181,149.63	0.00	0.00		1,758,749.58		
4313	SOBRA CHILD 06-13 M	221,804.59	221,802.86	222,997.40	223,637.96	224,258.08	225,433.01	225,931.52	226,986.08	228,290.80	229,179.70	0.00	0.00		2,250,322.00		
4314	SOBRA CHILD 14-20 MA	63,319.53	63,590.59	64,243.95	64,706.68	65,180.48	65,745.20	66,201.80	66,662.30	67,209.19	67,622.04	0.00	0.00		654,481.76		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	62,977.93	63,153.10	63,923.41	64,163.10	64,530.14	64,948.60	65,367.46	65,897.45	66,450.93	66,844.92	0.00	0.00		648,257.04		
431A	SOBRA CHILD < 1 M &	319.74	215.94	255.21	324.96	263.18	315.65	280.81	245.08	259.56	230.04	0.00	0.00		2,710.17		
431B	SOBRA CHILD 01-05 M	1,808.16	1,704.58	1,492.02	1,877.06	1,303.81	1,446.43	1,379.00	1,131.37	1,431.03	1,174.20	0.00	0.00		14,747.66		
431C	SOBRA CHILD 6-13 M&F	2,057.63	2,155.03	1,747.51	2,264.80	1,599.25	1,770.05	1,498.29	1,450.28	1,876.08	1,231.33	0.00	0.00		17,650.25		
431D	SOBRA CHILD 14-20 MA	601.41	556.54	569.42	637.79	519.99	532.81	459.47	458.51	523.00	366.06	0.00	0.00		5,225.00		
431E	SOBRA CHILD 14-20 FE	594.22	592.22	474.55	659.54	513.46	523.89	455.86	512.84	504.30	342.33	0.00	0.00		5,173.21		
4322	SOBRA CHILD 01-05 M	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
4323	SOBRA CHILD 06-13 M	2.00	3.00	0.73	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		11.73		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	0.73	0.00	1.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00		4.73		
4325	SOBRA CHILD 14-20 FE	4.00	5.00	4.00	4.00	4.00	4.00	4.00	4.00	4.00	4.00	0.00	0.00		41.00		
5005	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.22	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		4.22		
	M																
5007	SOBRA PREG 21-44 FE	30.43	26.35	31.22	23.69	22.52	26.73	24.57	19.55	19.93	18.96	0.00	0.00		243.95		
	M																
5008	SOBRA PREG 45-64 FE	0.30	-1.00	0.00	0.00	0.00	0.00	0.64	0.71	0.00	0.00	0.00	0.00		0.65		
	M																
500E	SOBRA PREG 14-20 FE	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		
	M																
500G	SOBRA PREG 21-44 FE	1.34	4.36	0.96	5.17	3.45	1.24	1.41	1.35	0.06	0.89	0.00	0.00		20.23		
	M																
500H	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	1.00	0.00	1.35	0.28	0.00	0.00	0.00	0.00		2.63		
	M																
5013	SOBRA PREG 09-13 FE	2.00	1.00	1.16	2.00	2.00	2.00	3.00	3.60	4.77	5.00	0.00	0.00		26.53		
	M																
5015	SOBRA PREG 14-20 FE	2,610.55	2,511.48	2,498.96	2,351.48	2,311.45	2,285.83	2,205.87	2,184.03	2,198.00	2,187.16	0.00	0.00		23,344.81		
	M																
5017	SOBRA PREG 21-44 FE	16,020.96	15,581.20	15,626.31	15,147.90	14,968.88	14,850.45	14,404.99	14,331.91	14,149.16	13,995.94	0.00	0.00		149,077.70		
	M																
5018	SOBRA PREG 45-64 FE	53.65	53.95	51.26	48.12	45.79	45.51	47.83	52.28	52.30	52.87	0.00	0.00		503.56		
	M																
501C	SOBRA PREG 09-13 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.22	0.00	0.00	0.00		0.22		
	M																
501E	SOBRA PREG 14-20 FE	156.70	121.80	140.80	144.01	158.35	159.51	165.07	138.33	153.90	140.48	0.00	0.00		1,478.95		
	M																
501G	SOBRA PREG 21-44 FE	871.36	768.53	729.64	809.62	642.42	777.05	779.88	688.84	755.80	705.84	0.00	0.00		7,528.98		
	M																
501H	SOBRA PREG 45-64 FE	0.32	3.02	1.73	1.86	2.19	1.48	1.16	2.70	2.67	4.08	0.00	0.00		21.21		
	M																
5025	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00		1.00		
	M																
5027	SOBRA PREG 21-44 FE	32.00	31.00	33.32	32.77	29.82	29.99	28.00	34.83	29.12	29.00	0.00	0.00		309.85		
	M																
5028	SOBRA PREG 45-64 FE	1.00	2.00	2.00	3.00	3.00	4.00	4.00	4.00	4.00	4.00	0.00	0.00		31.00		
	M																
502G	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.19	1.16	0.00	0.00	2.20	0.00	0.00	0.00	0.00		3.55		
	M																
SUBTOTAL:	966,646.72	971,682.15	977,538.93	981,480.96	980,201.82	985,989.10	987,277.59	992,927.31	999,161.82	999,817.88	0.00	0.00		9,842,724.28		

9910	TANF & SOBRA CHILDR E	427.00	437.00	446.00	472.00	387.00	396.00	362.00	357.00	402.00	373.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	4.00	7.00	2.00	3.00	6.00	3.00	7.00	5.00	3.00	6.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	16.00	15.00	24.00	24.00	16.00	15.00	20.00	19.00	16.00	8.00	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	1,841.00	1,660.00	1,504.00	1,558.00	1,461.00	0.00	0.00	
SUBTOTAL:	2,359.00	2,255.00	2,305.00	2,340.00	2,099.00	2,255.00	2,049.00	1,885.00	1,979.00	1,848.00	0.00	0.00	

4,059.00	
46.00	
173.00	
17,096.00	
21,374.00	

3100	TRANSPLANT OPTION 1	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	

10.00

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		

1106	TANF EXPANDED 21-44	227.00	225.92	225.15	235.16	232.29	240.90	247.20	241.46	244.72	249.61	0.00	0.00	
1107	TANF EXPANDED 21-44	407.12	410.56	417.81	418.40	433.34	426.55	425.79	430.07	414.11	432.87	0.00	0.00	
1108	TANF EXPANDED 45-64	1,318.24	1,278.61	1,285.91	1,322.09	1,346.47	1,365.95	1,362.38	1,358.19	1,361.15	1,370.73	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	756.72	757.62	778.52	783.59	793.48	818.52	838.39	800.53	790.69	820.33	0.00	0.00	
110F	TANF EXPANDED 21-44	8.09	6.15	4.12	11.99	0.53	7.21	6.70	7.21	8.04	2.88	0.00	0.00	
110G	TANF EXPANDED 21-44	16.14	17.36	8.32	15.69	8.83	26.58	9.60	13.49	16.42	14.51	0.00	0.00	
110H	TANF EXPANDED 45-64	26.62	24.59	20.10	21.56	16.67	22.57	11.55	58.11	42.80	14.79	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	29.91	16.58	35.00	29.87	28.41	18.00	13.79	31.00	29.68	10.25	0.00	0.00	
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	
1113	TANF EXPANDED 06-13	5.00	5.00	5.00	6.00	5.00	6.00	5.70	4.00	3.00	3.00	0.00	0.00	
1114	TANF EXPANDED 14-20	222.16	227.73	231.77	223.59	229.91	225.38	199.96	216.87	222.85	226.64	0.00	0.00	
1115	TANF EXPANDED 14-20	1,271.74	1,297.44	1,327.55	1,354.17	1,355.74	1,379.93	1,343.14	1,308.22	1,332.00	1,306.46	0.00	0.00	
1116	TANF EXPANDED 21-44	25,405.97	25,442.76	25,998.25	26,415.31	26,944.62	27,262.58	27,308.11	27,392.42	27,574.91	27,465.79	0.00	0.00	
1117	TANF EXPANDED 21-44	68,847.72	68,996.75	70,356.88	71,863.02	73,769.42	74,640.54	75,045.31	75,514.38	75,932.28	75,926.54	0.00	0.00	
1118	TANF EXPANDED 45-64	24,345.36	24,411.74	25,022.65	25,166.57	25,452.59	25,548.03	25,713.52	25,853.69	25,991.04	26,009.94	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	93.93	92.74	99.73	105.57	113.00	113.44	120.00	116.85	125.96	125.00	0.00	0.00	
111D	TANF EXPANDED 14-20	3.85	11.16	2.18	8.88	2.57	7.46	2.66	2.09	3.07	2.12	0.00	0.00	
111E	TANF EXPANDED 14-20	8.59	10.15	9.59	9.28	13.97	7.41	5.31	9.10	8.53	7.45	0.00	0.00	
111F	TANF EXPANDED 21-44	527.07	554.56	476.99	721.70	473.45	505.26	440.72	410.03	521.26	307.56	0.00	0.00	
111G	TANF EXPANDED 21-44	799.18	794.50	755.43	1,024.24	673.22	730.37	610.54	564.07	727.28	458.04	0.00	0.00	
111H	TANF EXPANDED 45-64	349.43	359.79	348.87	446.08	270.23	380.65	368.96	282.02	327.61	192.29	0.00	0.00	
111J	TANF EXPANDED 65+ M
&	2.06	2.00	1.26	2.41	0.00	2.53	0.00	2.13	1.03	0.00	0.00	0.00	
1125	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	
1126	TANF EXPANDED 21-44	722.06	727.52	731.20	710.57	721.76	722.84	731.61	747.09	747.34	739.86	0.00	0.00	
1127	TANF EXPANDED 21-44	1,603.40	1,607.75	1,616.90	1,609.06	1,600.63	1,613.10	1,598.76	1,632.49	1,623.11	1,620.91	0.00	0.00	
1128	TANF EXPANDED 45-64	2,621.04	2,658.82	2,699.09	2,729.75	2,729.39	2,736.51	2,756.77	2,758.70	2,811.54	2,821.28	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	1,690.93	1,729.98	1,748.02	1,769.92	1,798.53	1,784.42	1,791.77	1,819.02	1,832.20	1,868.64	0.00	0.00	
112F	TANF EXPANDED 21-44	0.51	1.32	0.46	10.63	2.58	1.54	1.91	2.62	0.12	0.46	0.00	0.00	
112G	TANF EXPANDED 21-44	1.89	1.69	1.22	2.08	1.26	5.12	1.76	1.01	0.99	1.47	0.00	0.00	
112H	TANF EXPANDED 45-64	2.83	3.78	1.76	4.14	3.69	0.78	2.18	3.80	3.74	6.83	0.00	0.00	
112J	TANF EXPANDED 65+ M
&	3.16	0.58	4.22	4.47	0.69	2.96	4.44	2.95	3.36	1.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	316.62	315.33	357.77	433.30	447.67	481.93	445.36	495.93	456.67	472.17	0.00	0.00	
240Z	SSI AGED EXPANDED
WI	124.04	118.66	103.52	193.94	150.68	182.92	153.14	368.26	250.94	175.97	0.00	0.00	
2410	SSI AGED EXPANDED N O	126.45	121.59	121.94	130.58	135.30	131.97	135.46	142.41	144.42	143.92	0.00	0.00	

2,369.41	
4,216.62	
13,369.72	
7,938.39	
62.92	
146.94	
259.36	
242.49	
2.00	
47.70	
2,226.86	
13,276.39	
267,210.72	
730,892.84	
253,515.13	
1,106.22	
46.04	
89.38	
4,938.60	
7,136.87	
3,325.93	
13.42	
3.00	
7,301.85	
16,126.11	
27,322.89	
17,833.43	
22.15	
18.49	
33.53	
27.83	
4,222.75	
1,822.07	
1,334.04	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
241Z	SSI AGED EXPANDED N	3.74	1.86	4.02	8.29	6.77	6.61	22.13	1.52	4.38	6.73	0.00	0.00		66.05		
	O																
2420	SSI AGED EXPANDED	27,810.16	28,078.05	28,360.82	28,477.16	28,952.49	29,273.55	29,512.32	29,632.31	29,955.66	30,346.83	0.00	0.00		290,399.35		
	WI																
242Z	SSI AGED EXPANDED	15.79	12.67	16.48	25.22	24.39	26.54	16.55	14.28	24.59	20.78	0.00	0.00		197.29		
	WI																
2520	SSI BLIND EXPANDED	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00		17.00		
	W																
2600	SSI DISABLED EXPAND	399.04	387.48	389.19	441.66	428.45	473.41	471.90	455.31	444.23	464.28	0.00	0.00		4,354.95		
	E																
260Z	SSI DISABLED EXPAND	70.71	74.48	62.08	69.12	61.78	62.18	72.83	139.04	118.25	71.95	0.00	0.00		802.42		
	E																
2610	SSI DISABLED EXPAND	1,609.01	1,581.73	1,552.13	1,534.93	1,546.88	1,549.73	1,533.63	1,557.89	1,529.99	1,585.89	0.00	0.00		15,581.81		
	E																
261Z	SSI DISABLED EXPAND	12.50	23.37	14.40	30.05	14.75	46.92	16.44	32.84	17.91	19.95	0.00	0.00		229.13		
	E																
2620	SSI DISABLED EXPAND	16,636.88	16,747.92	16,787.51	16,809.91	16,860.82	16,971.20	17,028.71	17,122.32	17,154.70	17,112.42	0.00	0.00		169,232.39		
	E																
262Z	SSI DISABLED EXPAND	16.92	14.28	10.74	12.95	12.91	8.80	14.20	23.66	31.97	20.56	0.00	0.00		166.99		
	E																
SUBTOTAL:	178,461.58	179,154.57	181,997.55	185,195.90	187,667.16	189,820.89	190,393.20	191,571.38	192,836.54	192,450.70	0.00	0.00		1,869,549.47		

9911	SB PAYMENT FOR TAN F	206.00	219.00	253.00	226.00	190.00	224.00	176.00	188.00	197.00	235.00	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	1.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	
SUBTOTAL:	207.00	219.00	253.00	226.00	190.00	224.00	176.00	188.00	199.00	235.00	0.00	0.00	

2,114.00	
2.00	
1.00	
2,117.00	

3506	ADULT 40-100% MALE 2	17.00	21.63	24.12	28.06	22.00	23.35	25.83	28.17	27.74	27.76	0.00	0.00	
3507	ADULT 40-100% FEMAL E	13.00	15.77	14.73	15.00	17.00	16.00	19.06	23.32	23.99	26.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	169.14	177.34	173.08	289.79	286.80	211.80	328.80	286.75	224.84	277.30	0.00	0.00	
3509	ADULT 40-100% M&F 65	92.00	88.98	113.15	124.00	135.99	149.08	158.00	157.46	177.14	201.00	0.00	0.00	
350F	ADULT 40-100% MALE 2	0.00	1.34	1.62	0.93	0.00	0.03	1.16	0.77	0.99	1.23	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	0.22	0.00	0.00	0.00	0.00	0.00	0.67	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	1.89	0.61	0.00	4.20	0.93	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	5,988.47	5,978.20	6,007.81	6,045.35	6,137.79	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	6,488.36	6,492.95	6,465.91	6,503.01	6,639.79	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	25,015.88	25,638.51	26,085.31	26,611.18	26,822.77	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	20,811.77	21,149.50	21,530.49	21,758.33	21,920.50	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	42,034.36	42,369.42	42,769.98	43,023.48	43,140.94	0.00	0.00	
3519	ADULT 40-100% M&F 65	4.00	6.00	6.30	7.00	8.00	6.00	5.00	5.00	5.00	7.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	71.07	64.16	65.09	68.14	79.12	80.69	64.24	46.52	76.96	36.09	0.00	0.00	
351E	ADULT 40-100% FEMAL E	69.74	86.39	88.42	110.12	72.25	97.58	88.43	63.78	96.43	59.53	0.00	0.00	
351F	ADULT 40-100% MALE 2	625.93	710.51	617.96	1,037.89	689.23	886.01	693.28	510.16	597.92	444.85	0.00	0.00	
351G	ADULT 40-100% FEMAL E	513.83	499.01	434.68	711.35	473.83	645.80	563.55	360.94	424.36	311.53	0.00	0.00	
351H	ADULT 40-100% M&F 45	1,025.68	894.26	767.91	1,341.09	843.71	1,387.87	1,116.62	781.02	836.89	688.18	0.00	0.00	
351J	ADULT 40-100% M&F 65	16.00	7.00	5.70	10.00	16.00	13.00	3.00	25.00	5.00	6.00	0.00	0.00	

245.66	
183.87	
2,425.64	
1,396.80	
8.07	
0.89	
14.49	
4.59	
59,361.80	
63,715.70	
240,808.31	
200,964.55	
410,144.97	
59.30	
652.08	
832.67	
6,813.74	
4,938.88	
9,683.23	
106.70	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3524	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		5.00		
3526	ADULT 40-100% MALE 2	2.00	1.58	2.00	2.00	4.00	3.00	3.00	2.00	3.00	3.00	0.00	0.00		25.58		
3527	ADULT 40-100% FEMAL	1.99	2.00	1.00	1.61	2.00	3.00	3.00	2.00	2.25	1.00	0.00	0.00		19.85		
	E																
3528	ADULT 40-100% M&F 45	10.00	12.00	15.00	19.00	20.00	29.00	25.00	24.35	28.00	30.00	0.00	0.00		212.35		
3529	ADULT 40-100% M&F 65	3.00	5.00	5.00	5.00	8.00	7.82	11.00	17.00	15.03	16.00	0.00	0.00		92.85		
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		1.41		
352G	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.38	0.00	0.00	0.00	0.00	0.48	0.00	0.00	0.00		0.86		
	E																
352H	ADULT 40-100% M&F 45	1.45	0.00	0.03	0.29	0.00	0.19	0.25	2.13	0.00	0.00	0.00	0.00		4.34		
352J	ADULT 40-100% M&F 65	0.00	0.00	0.03	0.00	0.00	1.02	0.00	0.00	0.00	0.00	0.00	0.00		1.05		
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		1.00		
3706	ADULT <40% EXP MALE	65.26	66.99	67.72	72.12	72.39	73.30	69.02	70.42	70.22	72.63	0.00	0.00		700.07		
3707	ADULT <40% EXP FEMA	27.25	28.00	26.75	29.00	36.00	39.00	42.15	42.19	38.30	52.03	0.00	0.00		360.67		
	L																
3708	ADULT <40% EXP M&F	261.27	253.17	272.70	325.64	341.84	343.54	397.78	396.62	398.57	454.37	0.00	0.00		3,445.50		
	4																
3709	ADULT <40% EXP M&F	31.00	40.00	40.00	48.08	54.00	54.00	53.19	61.66	54.14	68.00	0.00	0.00		504.07		
	6																
370F	ADULT <40% EXP MALE	0.95	0.99	0.03	0.09	0.83	1.40	0.98	0.70	19.24	1.32	0.00	0.00		26.53		
370G	ADULT <40% EXP FEMA	1.73	0.00	0.00	0.00	0.00	0.00	0.93	2.29	1.37	0.83	0.00	0.00		7.15		
	L																
370H	ADULT <40% EXP M&F	3.91	1.41	2.12	1.01	2.56	5.13	1.34	35.72	3.17	1.31	0.00	0.00		57.68		
	4																
370J	ADULT <40% EXP M&F	0.00	0.00	0.00	1.50	0.00	0.00	0.16	0.92	0.00	0.00	0.00	0.00		2.58		
	6																
3714	ADULT <40% EXP MALE	11,053.83	11,244.89	11,488.75	11,559.82	11,682.97	11,853.22	12,100.14	12,253.74	12,459.54	12,701.02	0.00	0.00		118,397.92		
3715	ADULT <40% EXP FEMA	10,253.38	10,408.82	10,790.14	10,828.38	10,936.63	11,056.44	11,179.10	11,339.32	11,468.25	11,719.55	0.00	0.00		109,980.01		
	L																
3716	ADULT <40% EXP MALE	81,347.38	82,165.91	83,817.78	83,862.39	84,144.81	85,752.05	86,857.23	88,454.49	89,745.26	91,733.51	0.00	0.00		857,880.81		
3717	ADULT <40% EXP FEMA	47,777.98	48,506.24	49,403.48	49,379.80	49,457.14	50,207.38	50,874.85	51,646.44	52,241.97	53,431.27	0.00	0.00		502,926.55		
	L																
3718	ADULT <40% EXP M&F	90,788.49	91,545.33	92,557.09	92,363.75	92,631.51	93,700.72	94,436.83	95,501.96	96,329.97	98,013.82	0.00	0.00		937,869.47		
	4																
3719	ADULT <40% EXP M&F	7.00	7.00	4.00	6.00	4.00	4.77	5.00	7.70	6.09	10.00	0.00	0.00		61.56		
	6																
371D	ADULT <40% EXP MALE	144.10	161.65	121.70	186.68	147.51	121.84	134.17	100.70	136.29	100.41	0.00	0.00		1,355.05		
371E	ADULT <40% EXP FEMA	165.29	140.83	123.09	111.42	93.41	138.76	140.90	102.18	120.34	123.44	0.00	0.00		1,259.66		
	L																
371F	ADULT <40% EXP MALE	1,606.51	1,390.67	1,091.87	1,515.05	1,505.52	1,715.03	1,515.76	1,265.09	1,605.00	1,324.06	0.00	0.00		14,534.56		
371G	ADULT <40% EXP FEMA	864.79	874.26	692.27	961.90	740.84	1,063.15	981.78	688.87	844.47	734.17	0.00	0.00		8,446.50		
	L																
371H	ADULT <40% EXP M&F	1,532.85	1,349.05	1,020.61	1,444.35	1,234.73	1,790.00	1,531.79	1,164.31	1,394.45	1,159.45	0.00	0.00		13,621.59		
	4																
371J	ADULT <40% EXP M&F	1.00	2.00	3.00	0.00	4.00	0.00	0.00	36.28	17.35	0.00	0.00	0.00		63.63		
	6																
3726	ADULT <40% EXP MALE	8.00	11.22	10.68	12.00	12.00	15.00	14.64	15.00	19.51	17.90	0.00	0.00		135.95		
3727	ADULT <40% EXP FEMA	7.00	8.00	9.99	9.00	7.00	6.00	7.00	4.00	6.00	5.00	0.00	0.00		68.99		
	L																
3728	ADULT <40% EXP M&F	34.00	45.95	43.00	49.73	53.76	58.01	59.99	58.07	59.06	64.99	0.00	0.00		526.56		
	4																
3729	ADULT <40% EXP M&F	0.00	0.00	2.00	2.00	2.00	3.41	5.00	4.00	3.00	4.00	0.00	0.00		25.41		
	6																
372F	ADULT <40% EXP MALE	0.06	0.00	0.03	0.51	0.00	0.00	0.35	0.00	0.00	0.00	0.00	0.00		0.95		
372G	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.29	0.00	0.00	0.00		0.29		
	L																

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
372H	ADULT <40% EXP M&F 4	0.32	0.99	0.00	4.40	0.06	0.03	0.00	0.92	0.77	0.00	0.00	0.00		7.49		
372J	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	0.00	0.35	0.00	0.00	0.00	0.00	0.00	0.00		0.35		
SUBTOTAL:	337,007.15	340,209.02	346,246.67	350,796.19	353,100.17	361,905.50	365,149.49	368,451.13	373,535.19	378,593.27	0.00	0.00		3,574,993.78		

9935	BIRTH SUPP PAYMENT A	34.00	38.00	25.00	36.00	46.00	47.00	42.00	30.00	35.00	33.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	106.00	111.00	151.00	121.00	112.00	115.00	120.00	88.00	129.00	114.00	0.00	0.00	
SUBTOTAL:	140.00	149.00	176.00	157.00	158.00	162.00	162.00	118.00	164.00	147.00	0.00	0.00	

366.00	
1,167.00	
1,533.00	

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	3.00	3.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	44.12	55.77	58.00	71.00	92.00	101.28	108.00	88.35	92.74	97.72	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	27.54	33.64	38.82	54.00	63.89	64.00	69.34	63.88	70.56	73.30	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	667.68	818.49	919.22	1,076.97	1,177.19	1,292.40	1,392.46	1,287.40	1,357.92	1,415.83	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	416.57	489.92	615.59	712.70	853.17	987.35	1,125.31	960.16	1,061.60	1,144.92	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	2.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA L	1.45	0.00	0.90	0.00	0.00	0.00	0.00	0.00	1.29	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.57	1.57	0.00	11.23	0.03	0.00	0.35	15.67	37.41	0.86	0.00	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.83	12.61	0.93	0.00	3.60	15.64	0.00	0.83	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,343.06	4,693.16	4,912.59	5,363.27	5,634.51	6,001.40	6,315.06	6,556.79	6,787.21	6,721.02	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	4,680.17	5,098.94	5,243.82	5,690.96	5,965.12	6,356.53	6,692.49	7,006.91	7,262.57	7,119.50	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	21,942.82	23,709.36	24,635.82	26,538.89	28,013.81	29,718.60	31,140.07	32,492.56	33,768.27	34,084.55	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	30,421.79	32,719.36	34,193.85	36,849.49	39,250.97	41,664.50	44,085.97	45,531.98	47,295.40	48,069.08	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	30,261.50	31,823.14	32,676.26	34,354.05	35,792.16	37,322.69	38,737.27	39,930.45	41,189.17	41,454.69	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	32.00	42.00	47.99	59.00	63.00	73.99	87.00	89.32	94.00	102.00	0.00	0.00	
391D	NEWLY ELIGIBLE MALE	30.13	20.32	25.30	32.09	29.30	41.14	28.53	20.81	16.62	24.26	0.00	0.00	
391E	NEWLY ELIGIBLE FEMA L	38.63	25.82	41.44	52.52	30.42	42.79	39.33	38.52	33.56	27.19	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	308.08	288.17	291.62	390.67	335.44	425.52	350.46	256.61	353.57	208.84	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	384.30	361.56	371.61	509.50	338.84	515.80	445.16	304.86	370.18	252.26	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	398.00	367.30	378.20	515.08	367.62	735.96	528.63	406.00	473.79	318.82	0.00	0.00	
391J	NEWLY ELIGIBLE M&F 6	1.00	0.00	0.00	4.00	0.00	0.00	0.00	0.00	4.00	1.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	1.00	1.00	2.00	1.00	1.00	2.00	1.00	1.00	1.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	3.00	2.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	19.00	16.00	10.00	8.00	10.00	12.00	10.00	12.39	18.00	18.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	16.00	20.00	26.00	33.00	41.00	46.00	46.00	54.00	61.00	64.50	0.00	0.00	
392G	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.70	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.60	0.00	0.00	0.00	0.00	
392J	NEWLY ELIGIBLE M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	

3.00	
14.26	
808.98	
558.97	
11,405.56	
8,367.29	
2.22	
3.64	
67.69	
34.44	
57,328.07	
61,117.01	
286,044.75	
400,082.39	
363,541.38	
690.30	
268.50	
370.22	
3,208.98	
3,854.07	
4,489.40	
10.00	
11.00	
14.00	
133.39	
407.50	
0.70	
0.60	
1.00	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	94,039.60	100,589.52	104,492.12	112,344.03	118,063.40	125,406.95	131,211.03	135,136.90	140,352.86	141,202.90	0.00	0.00		1,202,839.31		

9939	BIRTH SUPP PAYMENT N	79.00	87.00	93.00	87.00	91.00	127.00	123.00	98.00	144.00	119.00	0.00	0.00		
SUBTOTAL:	79.00	87.00	93.00	87.00	91.00	127.00	123.00	98.00	144.00	119.00	0.00	0.00		

1,048.00

1,048.00

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	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	2.00	1.00	1.00	1.00	2.00	2.00	1.00	1.00	1.00	2.00	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	42,709.06	43,044.20	43,409.76	43,823.26	43,998.02	0.00	0.00	
4414	SOBRA 100-133% MALE	11,676.58	12,037.27	12,120.69	12,374.70	12,597.84	12,898.00	13,142.74	13,253.21	13,486.09	13,683.14	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	12,635.35	12,810.35	12,941.85	13,092.20	13,205.73	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	482.32	367.66	320.77	318.78	279.74	0.00	0.00	
441D	SOBRA 100-133% MALE	115.85	134.73	79.22	175.33	84.78	129.20	101.44	100.64	129.54	100.65	0.00	0.00	
441E	SOBRA 100-133% FEMA L	112.23	100.68	112.51	156.37	109.49	103.44	104.67	101.36	164.85	83.15	0.00	0.00	
4423	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	2.00	1.67	1.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	
SUBTOTAL:	63,325.74	64,946.16	65,156.10	66,877.07	67,472.29	68,961.37	69,575.06	70,132.59	71,019.72	71,355.43	0.00	0.00	

2.96	
2.32	
4.00	
14.00	
421,290.15	
127,270.26	
124,139.17	
1.00	
3,780.87	
1,151.38	
1,148.75	
2.00	
14.67	
678,821.53	

9944	BIRTH SUPP PAYMENT S	9.00	8.00	11.00	8.00	10.00	7.00	6.00	4.00	2.00	8.00	0.00	0.00	
SUBTOTAL:	9.00	8.00	11.00	8.00	10.00	7.00	6.00	4.00	2.00	8.00	0.00	0.00	

73.00

73.00

4517	BC PATIENT FEMALE 2 1	24.57	23.72	21.53	22.00	21.00	21.80	22.87	21.80	19.00	19.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	137.52	137.80	130.83	132.05	131.62	135.04	137.00	135.20	134.90	133.98	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	2.15	1.70	2.13	3.61	3.65	6.21	6.27	9.67	9.70	5.67	0.00	0.00	
451G	BC PATIENT FEMALE 2
1	0.41	1.25	1.46	0.00	0.00	2.19	0.12	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	11.70	4.93	1.44	5.04	1.98	0.00	0.00	
451J	BC PATIENT FEMALE 6
5	1.82	0.28	0.86	0.37	1.05	7.99	1.50	0.92	0.40	0.18	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	5.00	4.00	4.00	4.35	5.00	5.00	5.00	5.82	6.00	6.00	0.00	0.00	
4618	CC PATIENT FEMALE 4
5	9.00	8.80	8.00	7.00	7.00	6.00	6.00	5.00	5.00	5.46	0.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	2.64	0.00	0.00	0.00	1.17	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.53	0.00	0.00	
SUBTOTAL:	183.87	177.73	168.94	176.05	173.66	195.93	183.69	181.02	180.04	176.80	0.00	0.00	

217.29	
1,345.94	
50.76	
5.43	
37.17	
15.37	
50.17	
67.26	
3.81	
4.53	
1,797.73	

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
8700	SSI DISABLED FREEDO
M	2,191.36	2,199.68	2,207.03	2,212.61	2,218.74	2,235.24	2,237.40	2,214.76	2,227.74	2,237.60	0.00	0.00	

10.00	
6.00	
10.00	
22,182.16	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
870Z	SSI DISABLED FREEDO	62.50	51.80	54.03	57.66	15.22	29.86	23.69	44.08	68.75	23.79	0.00	0.00		431.38		
	M																
8710	SSI DISABLED FREEDO	325.68	326.15	323.89	323.25	323.81	325.50	327.00	332.47	336.15	341.35	0.00	0.00		3,285.25		
	M																
871Z	SSI DISABLED FREEDO	4.27	18.59	5.88	4.79	10.79	10.24	7.94	4.47	17.12	5.05	0.00	0.00		89.14		
	M																
8720	SSI DISABLED FREEDO	404.32	442.50	454.76	479.28	484.70	484.63	485.06	482.87	500.69	524.46	0.00	0.00		4,743.27		
	M																
872Z	SSI DISABLED FREEDO	1.67	8.60	2.75	7.54	0.06	4.24	2.92	5.67	5.82	3.66	0.00	0.00		42.93		
	M																
SUBTOTAL:	2,991.80	3,049.32	3,050.34	3,087.13	3,056.32	3,092.71	3,087.01	3,087.32	3,159.27	3,138.91	0.00	0.00		30,800.13		

TOTAL:	1,645,451.46	1,662,527.47	1,681,489.65	1,702,776.33	1,712,283.82	1,738,148.45	1,749,394.07	1,763,781.65	1,782,734.44	1,789,093.89	0.00	0.00		17,227,681.23		

ACUTE CAPITATION - AMERICAN INDIAN A - AMOUNTS
For The Period Ending April 30, 2021	
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	15.18	0.00	0.00	0.00	0.00	0.00	0.00		30.36		
1018	TANF 45-64 M & F NON	15.18	15.18	15.18	15.18	15.18	15.18	15.87	15.87	15.87	15.87	0.00	0.00		154.56		
2110	SSI AGED NON-MEDICA	0.00	15.18	15.18	15.18	15.18	15.18	15.87	15.87	15.87	15.87	0.00	0.00		139.38		
	R																
2120	SSI AGED WITH QMB	0.00	0.00	15.18	15.18	15.18	15.18	15.87	15.87	0.00	0.00	0.00	0.00		92.46		
2220	SSI DISABLED WITH Q	0.00	15.18	15.18	15.18	15.18	15.18	15.87	15.87	15.87	15.87	0.00	0.00		139.38		
	M																
4312	SOBRA CHILD 01-05 M	15.18	15.18	15.18	15.18	15.18	15.18	15.87	15.87	15.87	0.00	0.00	0.00		138.69		
4313	SOBRA CHILD 06-13 M	0.00	15.18	15.18	15.18	0.00	0.00	15.87	15.87	15.87	0.00	0.00	0.00		93.15		
SUBTOTAL:	30.36	75.90	91.08	91.08	91.08	91.08	95.22	95.22	79.35	47.61	0.00	0.00		787.98		

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	15.18	15.87	15.87	15.87	15.87	0.00	0.00	
2420	SSI AGED EXPANDED WI	15.18	30.36	30.36	30.36	30.36	30.36	31.74	31.74	31.74	47.61	0.00	0.00	
2610	SSI DISABLED EXPAND
E	0.00	15.18	15.18	15.18	15.18	15.18	15.87	15.87	15.87	0.00	0.00	0.00	
SUBTOTAL:	15.18	75.90	75.90	75.90	75.90	60.72	63.48	63.48	63.48	63.48	0.00	0.00	

60.72	
139.38	
309.81	
123.51	
633.42	

3516	ADULT 40-100% MALE 2	0.00	15.18	15.18	15.18	15.18	15.18	15.87	15.87	15.87	15.87	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	15.18	15.18	15.87	15.87	15.87	15.87	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	30.36	31.74	15.87	15.87	15.87	0.00	0.00	
SUBTOTAL:	0.00	30.36	45.54	45.54	60.72	60.72	63.48	47.61	47.61	47.61	0.00	0.00	

139.38	
93.84	
15.18	
200.79	
449.19	

3917	NEWLY ELIGIBLE FEMA L	0.00	15.18	15.18	15.18	15.18	15.18	15.87	15.87	15.87	15.87	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	15.18	15.18	15.18	15.18	15.18	15.87	15.87	15.87	15.87	0.00	0.00	
SUBTOTAL:	0.00	30.36	30.36	30.36	30.36	30.36	31.74	31.74	31.74	31.74	0.00	0.00	

139.38	
139.38	
278.76	

4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.87	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.87	0.00	0.00	

15.87

15.87

2,165.22

45.54	212.52	242.88	242.88	258.06	242.88	253.92	238.05	222.18	206.31	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN A - MEMBER MONTHS
For The Period Ending April 30, 2021	
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1018	TANF 45-64 M & F NON	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
2110	SSI AGED NON-MEDICA	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		9.00		
	R																
2120	SSI AGED WITH QMB	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00		6.00		
2220	SSI DISABLED WITH Q	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		9.00		
	M																
4312	SOBRA CHILD 01-05 M	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00		9.00		
4313	SOBRA CHILD 06-13 M	0.00	1.00	1.00	1.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00		6.00		
SUBTOTAL:	2.00	5.00	6.00	6.00	6.00	6.00	6.00	6.00	5.00	3.00	0.00	0.00		51.00		

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	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	1.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	0.00	0.00	
2610	SSI DISABLED EXPAND
E	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	
SUBTOTAL:	1.00	5.00	5.00	5.00	5.00	4.00	4.00	4.00	4.00	4.00	0.00	0.00	

4.00	
9.00	
20.00	
8.00	
41.00	

3516	ADULT 40-100% MALE 2	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	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	2.00	2.00	1.00	1.00	1.00	0.00	0.00	
SUBTOTAL:	0.00	2.00	3.00	3.00	4.00	4.00	4.00	3.00	3.00	3.00	0.00	0.00	

9.00	
6.00	
1.00	
13.00	
29.00	

3917	NEWLY ELIGIBLE FEMA L	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
SUBTOTAL:	0.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	

9.00	
9.00	
18.00	

4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	

1.00

1.00

TOTAL:	3.00	14.00	16.00	16.00	17.00	16.00	16.00	15.00	14.00	13.00	0.00	0.00		140.00		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.27	0.00	0.00	0.00	0.00		18.27		
1008	TANF 45-64 M & F WIT	34.92	34.92	34.92	17.46	34.92	17.46	36.54	54.81	54.81	36.54	0.00	0.00		357.30		
1009	TANF 65+ M & F WITH	69.84	87.30	87.30	69.84	52.38	69.84	73.08	91.35	54.81	54.81	0.00	0.00		710.55		
1011	TANF <1 M & F NON-ME	1,571.40	1,571.40	1,693.62	1,711.08	1,536.48	1,431.72	1,516.41	1,589.49	1,680.84	1,662.57	0.00	0.00		15,965.01		
1012	TANF 01-05 M & F NON	2,636.46	2,531.70	2,566.62	2,758.68	2,828.52	2,723.76	2,667.42	2,649.15	2,594.34	2,594.34	0.00	0.00		26,550.99		
1013	TANF 06-13 M & F NON	2,688.84	2,811.06	3,055.50	3,055.50	2,828.52	2,828.52	2,904.93	2,649.15	2,539.53	2,594.34	0.00	0.00		27,955.89		
1014	TANF 14-20 MALE NON-	506.34	628.56	698.40	733.32	750.78	838.08	895.23	876.96	1,004.85	968.31	0.00	0.00		7,900.83		
1015	TANF 14-20 FEMALE N	1,257.12	1,292.04	1,169.82	1,082.52	1,117.44	1,134.90	1,169.28	1,114.47	1,151.01	1,059.66	0.00	0.00		11,548.26		
	O																
1016	TANF 21-44 MALE NON-	3,265.02	3,299.94	3,422.16	3,369.78	3,282.48	3,195.18	3,306.87	3,398.22	3,580.92	3,580.92	0.00	0.00		33,701.49		
1017	TANF 21-44 FEMALE N	11,226.78	11,261.70	11,296.62	11,209.32	11,314.08	11,226.78	11,729.34	11,893.77	11,930.31	11,948.58	0.00	0.00		115,037.28		
	O																
1018	TANF 45-64 M & F NON	4,225.32	4,172.94	4,103.10	4,295.16	4,138.02	4,172.94	4,549.23	4,640.58	4,658.85	4,622.31	0.00	0.00		43,578.45		
1019	TANF 65+ M & F NON-M	34.92	34.92	34.92	34.92	34.92	17.46	18.27	18.27	18.27	18.27	0.00	0.00		265.14		
1028	TANF 45-64 M & F WIT	17.46	34.92	69.84	52.38	52.38	69.84	73.08	54.81	54.81	36.54	0.00	0.00		516.06		
1029	TANF 65+ M & F WITH	17.46	17.46	17.46	17.46	17.46	52.38	54.81	73.08	91.35	73.08	0.00	0.00		432.00		
2100	SSI AGED WITH MEDIC	122.22	122.22	139.68	139.68	139.68	157.14	219.24	219.24	219.24	219.24	0.00	0.00		1,697.58		
	A																
2110	SSI AGED NON-MEDICA	174.60	192.06	209.52	244.44	261.90	314.28	292.32	310.59	274.05	310.59	0.00	0.00		2,584.35		
	R																
2120	SSI AGED WITH QMB	1,693.62	1,676.16	1,658.70	1,641.24	1,658.70	1,693.62	1,845.27	1,863.54	1,900.08	1,900.08	0.00	0.00		17,531.01		
2200	SSI DISABLED WITH M	576.18	593.64	646.02	611.10	558.72	558.72	621.18	621.18	639.45	712.53	0.00	0.00		6,138.72		
	E																
2210	SSI DISABLED NON-ME	10,004.58	9,847.44	9,725.22	9,760.14	9,969.66	10,056.96	10,505.25	10,633.14	10,560.06	10,541.79	0.00	0.00		101,604.24		
	D																
2220	SSI DISABLED WITH Q	3,561.84	3,544.38	3,474.54	3,544.38	3,614.22	3,701.52	3,873.24	3,873.24	3,891.51	3,982.86	0.00	0.00		37,061.73		
	M																
2300	SSI BLIND WITH MEDIC	0.00	0.00	17.46	17.46	17.46	17.46	18.27	18.27	18.27	18.27	0.00	0.00		142.92		
2310	SSI BLIND NON-MEDIC	87.30	87.30	69.84	69.84	69.84	69.84	73.08	73.08	91.35	91.35	0.00	0.00		782.82		
	A																
2320	SSI BLIND WITH QMB	17.46	17.46	17.46	17.46	17.46	17.46	18.27	18.27	18.27	18.27	0.00	0.00		177.84		
4311	SOBRA CHILD <1 M & F	5,045.94	4,923.72	5,150.70	5,028.48	4,836.42	4,714.20	4,768.47	4,549.23	4,604.04	4,622.31	0.00	0.00		48,243.51		
4312	SOBRA CHILD 01-05 M	24,758.28	25,351.92	25,247.16	25,212.24	25,631.28	25,770.96	27,112.68	27,569.43	27,733.86	28,044.45	0.00	0.00		262,432.26		
4313	SOBRA CHILD 06-13 M	23,710.68	23,815.44	23,955.12	23,763.06	24,094.80	24,269.40	25,504.92	25,559.73	25,888.59	26,381.88	0.00	0.00		246,943.62		
4314	SOBRA CHILD 14-20 MA	5,674.50	5,709.42	5,884.02	6,006.24	6,058.62	6,198.30	6,558.93	6,796.44	6,796.44	6,960.87	0.00	0.00		62,643.78		
4315	SOBRA CHILD 14-20 FE	5,953.86	6,023.70	6,023.70	6,128.46	6,198.30	6,111.00	6,504.12	6,613.74	6,723.36	6,723.36	0.00	0.00		63,003.60		
5015	SOBRA PREG 14-20 FE	244.44	157.14	174.60	157.14	174.60	157.14	182.70	182.70	109.62	73.08	0.00	0.00		1,613.16		
	M																
5017	SOBRA PREG 21-44 FE	1,030.14	907.92	942.84	907.92	1,047.60	977.76	1,023.12	1,023.12	1,004.85	1,023.12	0.00	0.00		9,888.39		
	M																
SUBTOTAL:	110,207.52	110,748.78	111,586.86	111,656.70	112,337.64	112,564.62	118,115.55	119,047.32	119,887.74	120,874.32	0.00	0.00		1,147,027.05		

1107	TANF EXPANDED 21-44	17.46	17.46	17.46	17.46	17.46	17.46	18.27	18.27	18.27	18.27	0.00	0.00	
1108	TANF EXPANDED 45-64	174.60	122.22	139.68	139.68	139.68	157.14	146.16	91.35	91.35	73.08	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	209.52	174.60	174.60	226.98	226.98	192.06	182.70	146.16	146.16	164.43	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	18.27	18.27	0.00	0.00	

177.84	
1,274.94	
1,844.19	
141.30	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	69.84	69.84	87.30	122.22	104.76	104.76	109.62	109.62	91.35	146.16	0.00	0.00		1,015.47		
1116	TANF EXPANDED 21-44	1,868.22	1,780.92	1,728.54	1,728.54	1,798.38	1,920.60	2,064.51	2,064.51	2,009.70	2,027.97	0.00	0.00		18,991.89		
1117	TANF EXPANDED 21-44	5,639.58	5,622.12	5,709.42	5,849.10	5,622.12	5,831.64	6,303.15	6,193.53	6,193.53	6,376.23	0.00	0.00		59,340.42		
1118	TANF EXPANDED 45-64	2,898.36	2,950.74	2,985.66	2,811.06	2,880.90	2,845.98	2,923.20	2,886.66	2,850.12	2,831.85	0.00	0.00		28,864.53		
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	104.76	109.62	127.89	127.89	127.89	0.00	0.00		1,209.15		
1127	TANF EXPANDED 21-44	69.84	52.38	52.38	52.38	52.38	52.38	54.81	54.81	54.81	54.81	0.00	0.00		550.98		
1128	TANF EXPANDED 45-64	419.04	488.88	488.88	488.88	541.26	541.26	548.10	548.10	529.83	584.64	0.00	0.00		5,178.87		
1129	TANF EXPANDED 65+ M	331.74	331.74	331.74	366.66	349.20	331.74	365.40	420.21	456.75	475.02	0.00	0.00		3,760.20		
	&																
2400	SSI AGED EXPANDED	52.38	34.92	34.92	34.92	34.92	34.92	36.54	54.81	54.81	54.81	0.00	0.00		427.95		
	WI																
2410	SSI AGED EXPANDED N	17.46	17.46	17.46	17.46	17.46	17.46	18.27	18.27	36.54	18.27	0.00	0.00		196.11		
	O																
2420	SSI AGED EXPANDED	2,409.48	2,426.94	2,409.48	2,444.40	2,479.32	2,514.24	2,630.88	2,557.80	2,557.80	2,539.53	0.00	0.00		24,969.87		
	WI																
2600	SSI DISABLED EXPAND	34.92	17.46	17.46	52.38	34.92	34.92	18.27	18.27	18.27	18.27	0.00	0.00		265.14		
	E																
2610	SSI DISABLED EXPAND	261.90	244.44	226.98	174.60	157.14	157.14	182.70	255.78	237.51	237.51	0.00	0.00		2,135.70		
	E																
2620	SSI DISABLED EXPAND	1,012.68	1,082.52	1,134.90	1,117.44	1,134.90	1,134.90	1,205.82	1,224.09	1,315.44	1,297.17	0.00	0.00		11,659.86		
	E																
SUBTOTAL:	15,679.08	15,591.78	15,696.54	15,783.84	15,714.00	15,993.36	16,918.02	16,790.13	16,808.40	17,064.18	0.00	0.00		162,039.33		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	17.46	18.27	18.27	18.27	18.27	0.00	0.00	
3508	ADULT 40-100% M&F 45	34.92	34.92	34.92	34.92	52.38	34.92	36.54	91.35	54.81	36.54	0.00	0.00	
3509	ADULT 40-100% M&F 65	17.46	17.46	17.46	17.46	17.46	17.46	18.27	18.27	18.27	18.27	0.00	0.00	
3514	ADULT 40-100% MALE 1	244.44	244.44	226.98	244.44	244.44	226.98	310.59	310.59	292.32	328.86	0.00	0.00	
3515	ADULT 40-100% FEMAL E	314.28	296.82	296.82	384.12	366.66	314.28	420.21	438.48	438.48	383.67	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	1,379.34	1,443.33	1,516.41	1,534.68	1,626.03	0.00	0.00	
3517	ADULT 40-100% FEMAL E	1,047.60	995.22	995.22	960.30	995.22	995.22	1,041.39	1,004.85	950.04	1,023.12	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	3,474.54	3,562.65	3,398.22	3,507.84	3,453.03	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	18.27	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	18.27	18.27	18.27	18.27	0.00	0.00	
3708	ADULT <40% EXP M&F
4	0.00	0.00	0.00	17.46	17.46	17.46	36.54	36.54	36.54	36.54	0.00	0.00	
3714	ADULT <40% EXP MALE	785.70	785.70	873.00	890.46	942.84	1,012.68	1,096.20	1,023.12	1,077.93	1,023.12	0.00	0.00	
3715	ADULT <40% EXP FEMA L	750.78	803.16	820.62	890.46	960.30	1,030.14	950.04	931.77	913.50	1,041.39	0.00	0.00	
3716	ADULT <40% EXP MALE	9,306.18	9,183.96	9,568.08	9,742.68	9,760.14	9,899.82	10,578.33	10,706.22	11,053.35	11,637.99	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	5,604.66	5,937.75	6,010.83	6,303.15	6,339.69	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	12,099.78	12,569.76	12,514.95	12,642.84	12,989.97	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	17.46	17.46	17.46	18.27	18.27	18.27	18.27	0.00	0.00	
SUBTOTAL:	33,872.40	33,680.34	34,588.26	35,304.12	35,566.02	36,142.20	38,056.41	38,074.68	38,878.56	39,993.03	0.00	0.00	

90.54	
446.22	
177.84	
2,674.08	
3,653.82	
13,680.63	
10,008.18	
34,454.70	
34.92	
70.65	
73.08	
198.54	
9,510.75	
9,092.16	
101,436.75	
57,747.96	
120,679.74	
125.46	
364,156.02	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	17.46	17.46	17.46	18.27	0.00	0.00	0.00	0.00	0.00		70.65		
3908	NEWLY ELIGIBLE M&F	69.84	69.84	104.76	104.76	139.68	157.14	182.70	109.62	127.89	164.43	0.00	0.00		1,230.66		
	4																
3909	NEWLY ELIGIBLE M&F	34.92	34.92	34.92	34.92	34.92	34.92	73.08	91.35	91.35	91.35	0.00	0.00		556.65		
	6																
3914	NEWLY ELIGIBLE MALE	104.76	122.22	104.76	139.68	139.68	157.14	182.70	219.24	274.05	237.51	0.00	0.00		1,681.74		
3915	NEWLY ELIGIBLE FEMA	192.06	226.98	209.52	174.60	192.06	226.98	292.32	383.67	401.94	420.21	0.00	0.00		2,720.34		
	L																
3916	NEWLY ELIGIBLE MALE	1,204.74	1,309.50	1,309.50	1,414.26	1,466.64	1,571.40	1,772.19	1,772.19	1,845.27	1,936.62	0.00	0.00		15,602.31		
3917	NEWLY ELIGIBLE FEMA	1,606.32	1,798.38	1,798.38	1,972.98	2,217.42	2,514.24	2,722.23	2,886.66	3,142.44	3,160.71	0.00	0.00		23,819.76		
	L																
3918	NEWLY ELIGIBLE M&F	2,619.00	2,741.22	2,741.22	2,950.74	3,160.26	3,352.32	3,672.27	3,946.32	4,110.75	4,183.83	0.00	0.00		33,477.93		
	4																
3919	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	17.46	18.27	0.00	0.00	0.00	0.00	0.00		35.73		
	6																
SUBTOTAL:	5,831.64	6,303.06	6,303.06	6,809.40	7,368.12	8,049.06	8,934.03	9,409.05	9,993.69	10,194.66	0.00	0.00		79,195.77		

4413	SOBRA 100-133% M&F
6	2,444.40	2,252.34	2,304.72	2,234.88	2,199.96	2,357.10	2,521.26	2,502.99	2,411.64	2,429.91	0.00	0.00	
4414	SOBRA 100-133% MALE	698.40	680.94	680.94	698.40	820.62	785.70	822.15	840.42	858.69	858.69	0.00	0.00	
4415	SOBRA 100-133% FEMA L	506.34	558.72	593.64	646.02	646.02	715.86	730.80	785.61	822.15	931.77	0.00	0.00	
SUBTOTAL:	3,649.14	3,492.00	3,579.30	3,579.30	3,666.60	3,858.66	4,074.21	4,129.02	4,092.48	4,220.37	0.00	0.00	

23,659.20	
7,744.95	
6,936.93	
38,341.08	

4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	17.46	17.46	17.46	18.27	18.27	18.27	18.27	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	17.46	17.46	17.46	18.27	18.27	18.27	18.27	0.00	0.00	

125.46

125.46

8700	SSI DISABLED FREEDO M	87.30	87.30	87.30	87.30	87.30	87.30	91.35	91.35	91.35	91.35	0.00	0.00	
8710	SSI DISABLED FREEDO
M	17.46	17.46	17.46	17.46	17.46	17.46	18.27	36.54	36.54	36.54	0.00	0.00	
8720	SSI DISABLED FREEDO M	17.46	17.46	17.46	17.46	17.46	17.46	18.27	18.27	18.27	36.54	0.00	0.00	
SUBTOTAL:	122.22	122.22	122.22	122.22	122.22	122.22	127.89	146.16	146.16	164.43	0.00	0.00	

889.20	
232.65	
196.11	
1,317.96	

1,792,202.67

169,362.00	169,938.18	171,876.24	173,273.04	174,792.06	176,747.58	186,244.38	187,614.63	189,825.30	192,529.26	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00		1.00		
1008	TANF 45-64 M & F WIT	2.00	2.00	2.00	1.00	2.00	1.00	2.00	3.00	3.00	2.00	0.00	0.00		20.00		
1009	TANF 65+ M & F WITH	4.00	5.00	5.00	4.00	3.00	4.00	4.00	5.00	3.00	3.00	0.00	0.00		40.00		
1011	TANF <1 M & F NON-ME	90.00	90.00	97.00	98.00	88.00	82.00	83.00	87.00	92.00	91.00	0.00	0.00		898.00		
1012	TANF 01-05 M & F NON	151.00	145.00	147.00	158.00	162.00	156.00	146.00	145.00	142.00	142.00	0.00	0.00		1,494.00		
1013	TANF 06-13 M & F NON	154.00	161.00	175.00	175.00	162.00	162.00	159.00	145.00	139.00	142.00	0.00	0.00		1,574.00		
1014	TANF 14-20 MALE NON-	29.00	36.00	40.00	42.00	43.00	48.00	49.00	48.00	55.00	53.00	0.00	0.00		443.00		
1015	TANF 14-20 FEMALE N	72.00	74.00	67.00	62.00	64.00	65.00	64.00	61.00	63.00	58.00	0.00	0.00		650.00		
	O																
1016	TANF 21-44 MALE NON-	187.00	189.00	196.00	193.00	188.00	183.00	181.00	186.00	196.00	196.00	0.00	0.00		1,895.00		
1017	TANF 21-44 FEMALE N	643.00	645.00	647.00	642.00	648.00	643.00	642.00	651.00	653.00	654.00	0.00	0.00		6,468.00		
	O																
1018	TANF 45-64 M & F NON	242.00	239.00	235.00	246.00	237.00	239.00	249.00	254.00	255.00	253.00	0.00	0.00		2,449.00		
1019	TANF 65+ M & F NON-M	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		15.00		
1028	TANF 45-64 M & F WIT	1.00	2.00	4.00	3.00	3.00	4.00	4.00	3.00	3.00	2.00	0.00	0.00		29.00		
1029	TANF 65+ M & F WITH	1.00	1.00	1.00	1.00	1.00	3.00	3.00	4.00	5.00	4.00	0.00	0.00		24.00		
2100	SSI AGED WITH MEDIC	7.00	7.00	8.00	8.00	8.00	9.00	12.00	12.00	12.00	12.00	0.00	0.00		95.00		
	A																
2110	SSI AGED NON-MEDICA	10.00	11.00	12.00	14.00	15.00	18.00	16.00	17.00	15.00	17.00	0.00	0.00		145.00		
	R																
2120	SSI AGED WITH QMB	97.00	96.00	95.00	94.00	95.00	97.00	101.00	102.00	104.00	104.00	0.00	0.00		985.00		
2200	SSI DISABLED WITH M	33.00	34.00	37.00	35.00	32.00	32.00	34.00	34.00	35.00	39.00	0.00	0.00		345.00		
	E																
2210	SSI DISABLED NON-ME	573.00	564.00	557.00	559.00	571.00	576.00	575.00	582.00	578.00	577.00	0.00	0.00		5,712.00		
	D																
2220	SSI DISABLED WITH Q	204.00	203.00	199.00	203.00	207.00	212.00	212.00	212.00	213.00	218.00	0.00	0.00		2,083.00		
	M																
2300	SSI BLIND WITH MEDIC	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		8.00		
2310	SSI BLIND NON-MEDIC	5.00	5.00	4.00	4.00	4.00	4.00	4.00	4.00	5.00	5.00	0.00	0.00		44.00		
	A																
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
4311	SOBRA CHILD <1 M & F	289.00	282.00	295.00	288.00	277.00	270.00	261.00	249.00	252.00	253.00	0.00	0.00		2,716.00		
4312	SOBRA CHILD 01-05 M	1,418.00	1,452.00	1,446.00	1,444.00	1,468.00	1,476.00	1,484.00	1,509.00	1,518.00	1,535.00	0.00	0.00		14,750.00		
4313	SOBRA CHILD 06-13 M	1,358.00	1,364.00	1,372.00	1,361.00	1,380.00	1,390.00	1,396.00	1,399.00	1,417.00	1,444.00	0.00	0.00		13,881.00		
4314	SOBRA CHILD 14-20 MA	325.00	327.00	337.00	344.00	347.00	355.00	359.00	372.00	372.00	381.00	0.00	0.00		3,519.00		
4315	SOBRA CHILD 14-20 FE	341.00	345.00	345.00	351.00	355.00	350.00	356.00	362.00	368.00	368.00	0.00	0.00		3,541.00		
5015	SOBRA PREG 14-20 FE	14.00	9.00	10.00	9.00	10.00	9.00	10.00	10.00	6.00	4.00	0.00	0.00		91.00		
	M																
5017	SOBRA PREG 21-44 FE	59.00	52.00	54.00	52.00	60.00	56.00	56.00	56.00	55.00	56.00	0.00	0.00		556.00		
	M																
SUBTOTAL:	6,312.00	6,343.00	6,391.00	6,395.00	6,434.00	6,447.00	6,465.00	6,516.00	6,562.00	6,616.00	0.00	0.00		64,481.00		

1107	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
1108	TANF EXPANDED 45-64	10.00	7.00	8.00	8.00	8.00	9.00	8.00	5.00	5.00	4.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	12.00	10.00	10.00	13.00	13.00	11.00	10.00	8.00	8.00	9.00	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	1.00	1.00	0.00	0.00	

10.00	
72.00	
104.00	
8.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	4.00	4.00	5.00	7.00	6.00	6.00	6.00	6.00	5.00	8.00	0.00	0.00		57.00		
1116	TANF EXPANDED 21-44	107.00	102.00	99.00	99.00	103.00	110.00	113.00	113.00	110.00	111.00	0.00	0.00		1,067.00		
1117	TANF EXPANDED 21-44	323.00	322.00	327.00	335.00	322.00	334.00	345.00	339.00	339.00	349.00	0.00	0.00		3,335.00		
1118	TANF EXPANDED 45-64	166.00	169.00	171.00	161.00	165.00	163.00	160.00	158.00	156.00	155.00	0.00	0.00		1,624.00		
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	6.00	6.00	7.00	7.00	7.00	0.00	0.00		68.00		
1127	TANF EXPANDED 21-44	4.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	0.00	0.00		31.00		
1128	TANF EXPANDED 45-64	24.00	28.00	28.00	28.00	31.00	31.00	30.00	30.00	29.00	32.00	0.00	0.00		291.00		
1129	TANF EXPANDED 65+ M	19.00	19.00	19.00	21.00	20.00	19.00	20.00	23.00	25.00	26.00	0.00	0.00		211.00		
	&																
2400	SSI AGED EXPANDED	3.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	3.00	3.00	0.00	0.00		24.00		
	WI																
2410	SSI AGED EXPANDED N	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	1.00	0.00	0.00		11.00		
	O																
2420	SSI AGED EXPANDED	138.00	139.00	138.00	140.00	142.00	144.00	144.00	140.00	140.00	139.00	0.00	0.00		1,404.00		
	WI																
2600	SSI DISABLED EXPAND	2.00	1.00	1.00	3.00	2.00	2.00	1.00	1.00	1.00	1.00	0.00	0.00		15.00		
	E																
2610	SSI DISABLED EXPAND	15.00	14.00	13.00	10.00	9.00	9.00	10.00	14.00	13.00	13.00	0.00	0.00		120.00		
	E																
2620	SSI DISABLED EXPAND	58.00	62.00	65.00	64.00	65.00	65.00	66.00	67.00	72.00	71.00	0.00	0.00		655.00		
	E																
SUBTOTAL:	898.00	893.00	899.00	904.00	900.00	916.00	926.00	919.00	920.00	934.00	0.00	0.00		9,109.00		

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	2.00	2.00	2.00	2.00	3.00	2.00	2.00	5.00	3.00	2.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	14.00	14.00	13.00	14.00	14.00	13.00	17.00	17.00	16.00	18.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	18.00	17.00	17.00	22.00	21.00	18.00	23.00	24.00	24.00	21.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	67.00	67.00	73.00	73.00	74.00	79.00	79.00	83.00	84.00	89.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	60.00	57.00	57.00	55.00	57.00	57.00	57.00	55.00	52.00	56.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	198.00	196.00	196.00	195.00	192.00	199.00	195.00	186.00	192.00	189.00	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	1.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	0.00	0.00	0.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	0.00	0.00	
3714	ADULT <40% EXP MALE	45.00	45.00	50.00	51.00	54.00	58.00	60.00	56.00	59.00	56.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	43.00	46.00	47.00	51.00	55.00	59.00	52.00	51.00	50.00	57.00	0.00	0.00	
3716	ADULT <40% EXP MALE	533.00	526.00	548.00	558.00	559.00	567.00	579.00	586.00	605.00	637.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	312.00	312.00	317.00	319.00	318.00	321.00	325.00	329.00	345.00	347.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	645.00	644.00	659.00	679.00	687.00	693.00	688.00	685.00	692.00	711.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
SUBTOTAL:	1,940.00	1,929.00	1,981.00	2,022.00	2,037.00	2,070.00	2,083.00	2,084.00	2,128.00	2,189.00	0.00	0.00	

5.00	
25.00	
10.00	
150.00	
205.00	
768.00	
563.00	
1,938.00	
2.00	
4.00	
4.00	
11.00	
534.00	
511.00	
5,698.00	
3,245.00	
6,783.00	
7.00	
20,463.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		4.00		
3908	NEWLY ELIGIBLE M&F	4.00	4.00	6.00	6.00	8.00	9.00	10.00	6.00	7.00	9.00	0.00	0.00		69.00		
	4																
3909	NEWLY ELIGIBLE M&F	2.00	2.00	2.00	2.00	2.00	2.00	4.00	5.00	5.00	5.00	0.00	0.00		31.00		
	6																
3914	NEWLY ELIGIBLE MALE	6.00	7.00	6.00	8.00	8.00	9.00	10.00	12.00	15.00	13.00	0.00	0.00		94.00		
3915	NEWLY ELIGIBLE FEMA	11.00	13.00	12.00	10.00	11.00	13.00	16.00	21.00	22.00	23.00	0.00	0.00		152.00		
	L																
3916	NEWLY ELIGIBLE MALE	69.00	75.00	75.00	81.00	84.00	90.00	97.00	97.00	101.00	106.00	0.00	0.00		875.00		
3917	NEWLY ELIGIBLE FEMA	92.00	103.00	103.00	113.00	127.00	144.00	149.00	158.00	172.00	173.00	0.00	0.00		1,334.00		
	L																
3918	NEWLY ELIGIBLE M&F	150.00	157.00	157.00	169.00	181.00	192.00	201.00	216.00	225.00	229.00	0.00	0.00		1,877.00		
	4																
3919	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		2.00		
	6																
SUBTOTAL:	334.00	361.00	361.00	390.00	422.00	461.00	489.00	515.00	547.00	558.00	0.00	0.00		4,438.00		

4413	SOBRA 100-133% M&F
6	140.00	129.00	132.00	128.00	126.00	135.00	138.00	137.00	132.00	133.00	0.00	0.00	
4414	SOBRA 100-133% MALE	40.00	39.00	39.00	40.00	47.00	45.00	45.00	46.00	47.00	47.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	29.00	32.00	34.00	37.00	37.00	41.00	40.00	43.00	45.00	51.00	0.00	0.00	
SUBTOTAL:	209.00	200.00	205.00	205.00	210.00	221.00	223.00	226.00	224.00	231.00	0.00	0.00	

1,330.00	
435.00	
389.00	
2,154.00	

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

7.00

7.00

8700	SSI DISABLED FREEDO M	5.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	0.00	0.00	
SUBTOTAL:	7.00	7.00	7.00	7.00	7.00	7.00	7.00	8.00	8.00	9.00	0.00	0.00	

50.00	
13.00	
11.00	
74.00	

TOTAL:	9,700.00	9,733.00	9,844.00	9,924.00	10,011.00	10,123.00	10,194.00	10,269.00	10,390.00	10,538.00	0.00	0.00		100,726.00		

ACUTE CAPITATION - AMERICAN INDIAN C - AMOUNTS
For The Period Ending April 30, 2021	
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	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		
	O																
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	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		
	O																
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	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		
	A																
2110	SSI AGED NON-MEDICA	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		
	R																
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	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		
	E																
2210	SSI DISABLED NON-ME	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		
	D																
2220	SSI DISABLED WITH Q	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		
	M																
2310	SSI BLIND NON-MEDIC	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		
	A																
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	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		
	M																
5015	SOBRA PREG 14-20 FE	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		
	M																
5017	SOBRA PREG 21-44 FE	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		
	M																
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 April 30, 2021	
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	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		
	WI																
2410	SSI AGED EXPANDED N	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		
	O																
2420	SSI AGED EXPANDED	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		
	WI																
2610	SSI DISABLED EXPAND	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		
	E																
2620	SSI DISABLED EXPAND	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		
	E																
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 April 30, 2021	
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 April 30, 2021	
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	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		
	O																
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	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		
	O																
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	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		
	A																
2110	SSI AGED NON-MEDICA	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		
	R																
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	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		
	E																
2210	SSI DISABLED NON-ME	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		
	D																
2220	SSI DISABLED WITH Q	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		
	M																
2310	SSI BLIND NON-MEDIC	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		
	A																
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	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		
	M																
5015	SOBRA PREG 14-20 FE	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		
	M																
5017	SOBRA PREG 21-44 FE	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		
	M																
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 April 30, 2021	
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	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		
	WI																
2410	SSI AGED EXPANDED N	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		
	O																
2420	SSI AGED EXPANDED	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		
	WI																
2610	SSI DISABLED EXPAND	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		
	E																
2620	SSI DISABLED EXPAND	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		
	E																
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 April 30, 2021	
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		

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

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	

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 April 30, 2021	
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	26.05	27.25	27.25	27.25	27.25	0.00	0.00		187.15		
1008	TANF 45-64 M & F WIT	52.10	26.05	52.10	52.10	52.10	52.10	54.50	81.75	81.75	81.75	0.00	0.00		586.30		
1009	TANF 65+ M & F WITH	78.15	78.15	78.15	52.10	26.05	52.10	81.75	109.00	81.75	81.75	0.00	0.00		718.95		
1011	TANF <1 M & F NON-ME	1,276.45	1,224.35	1,094.10	1,068.05	911.75	807.55	926.50	981.00	981.00	1,062.75	0.00	0.00		10,333.50		
1012	TANF 01-05 M & F NON	3,490.70	3,699.10	3,803.30	4,819.25	4,480.60	3,959.60	3,951.25	4,060.25	3,924.00	3,787.75	0.00	0.00		39,975.80		
1013	TANF 06-13 M & F NON	5,001.60	5,183.95	5,157.90	6,095.70	5,757.05	5,757.05	6,131.25	6,322.00	5,777.00	5,695.25	0.00	0.00		56,878.75		
1014	TANF 14-20 MALE NON-	1,302.50	1,354.60	1,458.80	1,693.25	1,589.05	1,563.00	1,798.50	1,744.00	1,716.75	1,853.00	0.00	0.00		16,073.45		
1015	TANF 14-20 FEMALE N	2,448.70	2,474.75	2,631.05	3,021.80	2,891.55	2,787.35	2,970.25	2,970.25	3,106.50	3,270.00	0.00	0.00		28,572.20		
	O																
1016	TANF 21-44 MALE NON-	8,935.15	9,325.90	9,664.55	10,550.25	10,420.00	10,341.85	10,682.00	10,872.75	11,172.50	11,363.25	0.00	0.00		103,328.20		
1017	TANF 21-44 FEMALE N	33,891.05	33,969.20	34,828.85	42,409.40	41,367.40	41,263.20	43,327.50	44,063.25	44,444.75	44,717.25	0.00	0.00		404,281.85		
	O																
1018	TANF 45-64 M & F NON	11,566.20	11,696.45	11,878.80	14,770.35	14,379.60	14,405.65	15,178.25	15,042.00	15,369.00	15,641.50	0.00	0.00		139,927.80		
1019	TANF 65+ M & F NON-M	26.05	52.10	52.10	52.10	52.10	52.10	54.50	54.50	54.50	81.75	0.00	0.00		531.80		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	26.05	26.05	26.05	27.25	27.25	27.25	27.25	0.00	0.00		187.15		
1029	TANF 65+ M & F WITH	26.05	26.05	26.05	52.10	52.10	26.05	27.25	27.25	27.25	0.00	0.00	0.00		290.15		
2100	SSI AGED WITH MEDIC	1,745.35	1,771.40	1,771.40	2,136.10	2,214.25	2,214.25	2,343.50	2,398.00	2,452.50	2,479.75	0.00	0.00		21,526.50		
	A																
2110	SSI AGED NON-MEDICA	703.35	755.45	755.45	963.85	937.80	989.90	1,008.25	1,062.75	1,090.00	1,171.75	0.00	0.00		9,438.55		
	R																
2120	SSI AGED WITH QMB	7,033.50	7,189.80	7,294.00	10,628.40	10,732.60	10,836.80	11,336.00	11,172.50	11,145.25	11,390.50	0.00	0.00		98,759.35		
2200	SSI DISABLED WITH M	4,662.95	4,689.00	4,871.35	5,783.10	5,835.20	5,835.20	6,131.25	6,131.25	6,076.75	6,158.50	0.00	0.00		56,174.55		
	E																
2210	SSI DISABLED NON-ME	24,200.45	24,330.70	24,408.85	30,712.95	30,791.10	30,739.00	32,291.25	32,127.75	32,046.00	31,773.50	0.00	0.00		293,421.55		
	D																
2220	SSI DISABLED WITH Q	10,810.75	10,758.65	10,836.80	14,952.70	14,978.75	14,900.60	15,532.50	15,505.25	15,505.25	15,587.00	0.00	0.00		139,368.25		
	M																
2300	SSI BLIND WITH MEDIC	26.05	26.05	26.05	26.05	26.05	26.05	27.25	27.25	27.25	27.25	0.00	0.00		265.30		
2310	SSI BLIND NON-MEDIC	442.85	416.80	416.80	547.05	547.05	547.05	545.00	545.00	599.50	599.50	0.00	0.00		5,206.60		
	A																
2320	SSI BLIND WITH QMB	182.35	182.35	182.35	286.55	286.55	260.50	272.50	272.50	272.50	272.50	0.00	0.00		2,470.65		
4311	SOBRA CHILD <1 M & F	3,829.35	3,464.65	2,969.70	2,865.50	2,500.80	2,031.90	2,043.75	1,662.25	1,389.75	1,553.25	0.00	0.00		24,310.90		
4312	SOBRA CHILD 01-05 M	41,237.15	41,185.05	41,393.45	49,599.20	49,573.15	50,042.05	52,238.25	51,529.75	51,148.25	50,766.75	0.00	0.00		478,713.05		
4313	SOBRA CHILD 06-13 M	58,820.90	59,211.65	59,862.90	69,032.50	69,631.65	69,423.25	72,566.75	72,621.25	73,438.75	74,147.25	0.00	0.00		678,756.85		
4314	SOBRA CHILD 14-20 MA	15,708.15	15,760.25	15,838.40	18,391.30	18,417.35	18,573.65	19,538.25	19,729.00	19,729.00	19,729.00	0.00	0.00		181,414.35		
4315	SOBRA CHILD 14-20 FE	16,385.45	16,619.90	16,984.60	19,954.30	19,902.20	19,902.20	20,710.00	20,764.50	20,764.50	20,737.25	0.00	0.00		192,724.90		
5013	SOBRA PREG 09-13 FE	26.05	26.05	26.05	52.10	26.05	26.05	27.25	27.25	27.25	27.25	0.00	0.00		291.35		
	M																
5015	SOBRA PREG 14-20 FE	182.35	182.35	234.45	312.60	338.65	364.70	381.50	408.75	327.00	299.75	0.00	0.00		3,032.10		
	M																
5017	SOBRA PREG 21-44 FE	2,344.50	2,474.75	2,631.05	4,037.75	4,141.95	3,933.55	4,033.00	4,196.50	4,223.75	4,223.75	0.00	0.00		36,240.55		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	26.05	26.05	26.05	0.00	27.25	27.25	0.00	0.00	0.00	0.00		132.65		
	M																
SUBTOTAL:	256,436.20	258,155.50	261,255.45	314,996.60	312,938.65	311,766.40	326,291.50	326,591.25	327,054.50	328,635.00	0.00	0.00		3,024,121.05		

530.60

1106	TANF EXPANDED 21-44	52.10	52.10	52.10	52.10	52.10	52.10	54.50	54.50	54.50	54.50	0.00	0.00	
1107	TANF EXPANDED 21-44	52.10	52.10	52.10	52.10	52.10	52.10	54.50	54.50	54.50	27.25	0.00	0.00	

503.35

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending April 30, 2021	
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	286.55	327.00	354.25	354.25	381.50	0.00	0.00		2,849.75		
1109	TANF EXPANDED 65+ M	260.50	286.55	286.55	286.55	286.55	260.50	272.50	299.75	299.75	327.00	0.00	0.00		2,866.20		
	&																
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	52.10	52.10	54.50	81.75	81.75	109.00	0.00	0.00		431.20		
1115	TANF EXPANDED 14-20	260.50	260.50	260.50	364.70	416.80	416.80	408.75	327.00	272.50	299.75	0.00	0.00		3,287.80		
1116	TANF EXPANDED 21-44	4,454.55	4,454.55	4,194.05	4,793.20	5,079.75	4,949.50	5,450.00	5,586.25	5,586.25	5,640.75	0.00	0.00		50,188.85		
1117	TANF EXPANDED 21-44	13,415.75	13,363.65	13,363.65	17,766.10	18,938.35	19,329.10	20,355.75	20,301.25	20,492.00	20,873.50	0.00	0.00		178,199.10		
1118	TANF EXPANDED 45-64	7,085.60	7,215.85	7,320.05	9,378.00	9,664.55	9,977.15	10,791.00	10,791.00	10,845.50	10,872.75	0.00	0.00		93,941.45		
1119	TANF EXPANDED 65+ M	26.05	26.05	26.05	26.05	26.05	26.05	54.50	54.50	54.50	54.50	0.00	0.00		374.30		
	&																
1126	TANF EXPANDED 21-44	208.40	208.40	234.45	260.50	234.45	208.40	245.25	245.25	245.25	245.25	0.00	0.00		2,335.60		
1127	TANF EXPANDED 21-44	286.55	286.55	286.55	312.60	312.60	312.60	327.00	327.00	327.00	327.00	0.00	0.00		3,105.45		
1128	TANF EXPANDED 45-64	807.55	833.60	859.65	1,068.05	963.85	963.85	1,062.75	1,035.50	1,062.75	1,062.75	0.00	0.00		9,720.30		
1129	TANF EXPANDED 65+ M	755.45	755.45	755.45	1,146.20	1,198.30	1,198.30	1,226.25	1,199.00	1,199.00	1,171.75	0.00	0.00		10,605.15		
	&																
2400	SSI AGED EXPANDED	26.05	26.05	26.05	182.35	234.45	234.45	190.75	218.00	190.75	190.75	0.00	0.00		1,519.65		
	WI																
2410	SSI AGED EXPANDED N	130.25	130.25	130.25	182.35	156.30	156.30	163.50	163.50	136.25	163.50	0.00	0.00		1,512.45		
	O																
2420	SSI AGED EXPANDED	4,220.10	4,141.95	4,141.95	6,720.90	6,746.95	6,877.20	7,330.25	7,493.75	7,466.50	7,466.50	0.00	0.00		62,606.05		
	WI																
2600	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	26.05	0.00	27.25	27.25	27.25	0.00	0.00		107.80		
	E																
2610	SSI DISABLED EXPAND	208.40	182.35	182.35	234.45	208.40	208.40	245.25	218.00	272.50	272.50	0.00	0.00		2,232.60		
	E																
2620	SSI DISABLED EXPAND	1,901.65	1,953.75	1,953.75	3,021.80	3,021.80	2,995.75	3,133.75	3,106.50	3,079.25	3,079.25	0.00	0.00		27,247.25		
	E																
SUBTOTAL:	34,359.95	34,412.05	34,333.90	46,134.55	47,905.95	48,583.25	51,747.75	51,938.50	52,102.00	52,647.00	0.00	0.00		454,164.90		

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	27.25	0.00	0.00	27.25	0.00	0.00	
3509	ADULT 40-100% M&F 65	26.05	26.05	26.05	52.10	52.10	52.10	54.50	54.50	109.00	109.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	885.70	885.70	911.75	1,094.10	1,015.95	1,068.05	1,035.50	1,062.75	1,062.75	1,171.75	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	1,354.60	1,444.25	1,444.25	1,498.75	1,526.00	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	3,256.25	3,624.25	3,678.75	3,678.75	3,951.25	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	3,178.10	3,161.00	3,242.75	3,297.25	3,433.50	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	7,450.30	7,848.00	8,147.75	8,175.00	7,984.25	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	26.05	26.05	26.05	27.25	27.25	27.25	27.25	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	26.05	27.25	27.25	27.25	27.25	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	52.10	78.15	156.30	156.30	182.35	272.50	218.00	218.00	190.75	0.00	0.00	
3714	ADULT <40% EXP MALE	3,647.00	3,568.85	3,699.10	4,011.70	4,168.00	4,194.05	4,360.00	4,387.25	4,578.00	4,387.25	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	4,871.35	5,232.00	5,368.25	5,177.50	5,341.00	0.00	0.00	
3716	ADULT <40% EXP MALE	28,811.30	29,280.20	29,697.00	33,344.00	33,969.20	33,865.00	36,106.25	36,188.00	36,406.00	37,196.25	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	18,208.95	19,238.50	19,483.75	19,810.75	19,974.25	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	38,632.15	40,520.75	40,793.25	40,984.00	41,828.75	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	

54.50	
561.45	
10,194.00	
13,259.35	
31,110.05	
28,035.10	
68,807.35	
187.15	
135.05	
1,524.45	
41,001.20	
47,793.95	
334,863.20	
176,220.80	
367,264.65	
26.05	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	90,445.60	91,722.05	93,727.90	113,604.05	115,844.35	116,365.35	122,979.25	124,123.75	125,050.25	127,175.75	0.00	0.00		1,121,038.30		

3908	NEWLY ELIGIBLE M&F	104.20	104.20	130.25	208.40	234.45	208.40	245.25	245.25	299.75	381.50	0.00	0.00		
	4														
3909	NEWLY ELIGIBLE M&F	26.05	26.05	26.05	208.40	260.50	286.55	327.00	272.50	272.50	327.00	0.00	0.00		
	6														
3914	NEWLY ELIGIBLE MALE	338.65	364.70	364.70	364.70	494.95	547.05	626.75	681.25	708.50	735.75	0.00	0.00		
3915	NEWLY ELIGIBLE FEMA	442.85	573.10	625.20	833.60	807.55	729.40	899.25	926.50	1,117.25	1,117.25	0.00	0.00		
	L														
3916	NEWLY ELIGIBLE MALE	2,162.15	2,396.60	2,657.10	3,282.30	3,412.55	3,568.85	3,896.75	4,223.75	4,496.25	4,687.00	0.00	0.00		
3917	NEWLY ELIGIBLE FEMA	3,308.35	3,751.20	3,985.65	6,069.65	6,486.45	6,877.20	7,657.25	7,711.75	8,229.50	8,556.50	0.00	0.00		
	L														
3918	NEWLY ELIGIBLE M&F	4,636.90	4,975.55	5,236.05	7,398.20	7,971.30	8,179.70	8,829.00	9,101.50	9,265.00	9,319.50	0.00	0.00		
	4														
3919	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	26.05	26.05	52.10	27.25	27.25	54.50	54.50	0.00	0.00		
	6														
SUBTOTAL:	11,019.15	12,191.40	13,025.00	18,391.30	19,693.80	20,449.25	22,508.50	23,189.75	24,443.25	25,179.00	0.00	0.00		

2,161.65	
2,032.60	
5,227.00	
8,071.95	
34,783.30	
62,633.50	
74,912.70	
267.70	
190,090.40	

4413	SOBRA 100-133% M&F
6	4,610.85	4,558.75	4,272.20	5,314.20	5,522.60	5,496.55	6,049.50	5,831.50	6,185.75	6,267.50	0.00	0.00	
4414	SOBRA 100-133% MALE	1,406.70	1,510.90	1,406.70	1,615.10	1,589.05	1,641.15	1,771.25	1,798.50	1,825.75	1,880.25	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	1,875.60	2,152.75	2,289.00	2,370.75	2,425.25	0.00	0.00	
SUBTOTAL:	7,372.15	7,476.35	7,033.50	8,622.55	8,935.15	9,013.30	9,973.50	9,919.00	10,382.25	10,573.00	0.00	0.00	

54,109.40	
16,445.35	
18,746.00	
89,300.75	

4518

BC PATIENT FEMALE 4 5

187.15

187.15

0.00	0.00	0.00	26.05	26.05	26.05	27.25	27.25	27.25	27.25	0.00	0.00	
0.00	0.00	0.00	26.05	26.05	26.05	27.25	27.25	27.25	27.25	0.00	0.00	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	26.05	26.05	26.05	104.20	104.20	104.20	109.00	109.00	109.00	109.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	52.10	52.10	52.10	78.15	78.15	78.15	81.75	109.00	81.75	109.00	0.00	0.00	
SUBTOTAL:	78.15	78.15	78.15	182.35	182.35	182.35	190.75	218.00	190.75	218.00	0.00	0.00	

826.75	
772.25	
1,599.00	

4,880,501.55

399,711.20	404,035.50	409,453.90	501,957.45	505,526.30	506,385.95	533,718.50	536,007.50	539,250.25	544,455.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending April 30, 2021	
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	1.00	1.00	1.00	1.00	1.00	0.00	0.00		7.00		
1008	TANF 45-64 M & F WIT	2.00	1.00	2.00	2.00	2.00	2.00	2.00	3.00	3.00	3.00	0.00	0.00		22.00		
1009	TANF 65+ M & F WITH	3.00	3.00	3.00	2.00	1.00	2.00	3.00	4.00	3.00	3.00	0.00	0.00		27.00		
1011	TANF <1 M & F NON-ME	49.00	47.00	42.00	41.00	35.00	31.00	34.00	36.00	36.00	39.00	0.00	0.00		390.00		
1012	TANF 01-05 M & F NON	134.00	142.00	146.00	185.00	172.00	152.00	145.00	149.00	144.00	139.00	0.00	0.00		1,508.00		
1013	TANF 06-13 M & F NON	192.00	199.00	198.00	234.00	221.00	221.00	225.00	232.00	212.00	209.00	0.00	0.00		2,143.00		
1014	TANF 14-20 MALE NON-	50.00	52.00	56.00	65.00	61.00	60.00	66.00	64.00	63.00	68.00	0.00	0.00		605.00		
1015	TANF 14-20 FEMALE N	94.00	95.00	101.00	116.00	111.00	107.00	109.00	109.00	114.00	120.00	0.00	0.00		1,076.00		
	O																
1016	TANF 21-44 MALE NON-	343.00	358.00	371.00	405.00	400.00	397.00	392.00	399.00	410.00	417.00	0.00	0.00		3,892.00		
1017	TANF 21-44 FEMALE N	1,301.00	1,304.00	1,337.00	1,628.00	1,588.00	1,584.00	1,590.00	1,617.00	1,631.00	1,641.00	0.00	0.00		15,221.00		
	O																
1018	TANF 45-64 M & F NON	444.00	449.00	456.00	567.00	552.00	553.00	557.00	552.00	564.00	574.00	0.00	0.00		5,268.00		
1019	TANF 65+ M & F NON-M	1.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	0.00	0.00		20.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		7.00		
1029	TANF 65+ M & F WITH	1.00	1.00	1.00	2.00	2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00		11.00		
2100	SSI AGED WITH MEDIC	67.00	68.00	68.00	82.00	85.00	85.00	86.00	88.00	90.00	91.00	0.00	0.00		810.00		
	A																
2110	SSI AGED NON-MEDICA	27.00	29.00	29.00	37.00	36.00	38.00	37.00	39.00	40.00	43.00	0.00	0.00		355.00		
	R																
2120	SSI AGED WITH QMB	270.00	276.00	280.00	408.00	412.00	416.00	416.00	410.00	409.00	418.00	0.00	0.00		3,715.00		
2200	SSI DISABLED WITH M	179.00	180.00	187.00	222.00	224.00	224.00	225.00	225.00	223.00	226.00	0.00	0.00		2,115.00		
	E																
2210	SSI DISABLED NON-ME	929.00	934.00	937.00	1,179.00	1,182.00	1,180.00	1,185.00	1,179.00	1,176.00	1,166.00	0.00	0.00		11,047.00		
	D																
2220	SSI DISABLED WITH Q	415.00	413.00	416.00	574.00	575.00	572.00	570.00	569.00	569.00	572.00	0.00	0.00		5,245.00		
	M																
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		10.00		
2310	SSI BLIND NON-MEDIC	17.00	16.00	16.00	21.00	21.00	21.00	20.00	20.00	22.00	22.00	0.00	0.00		196.00		
	A																
2320	SSI BLIND WITH QMB	7.00	7.00	7.00	11.00	11.00	10.00	10.00	10.00	10.00	10.00	0.00	0.00		93.00		
4311	SOBRA CHILD <1 M & F	147.00	133.00	114.00	110.00	96.00	78.00	75.00	61.00	51.00	57.00	0.00	0.00		922.00		
4312	SOBRA CHILD 01-05 M	1,583.00	1,581.00	1,589.00	1,904.00	1,903.00	1,921.00	1,917.00	1,891.00	1,877.00	1,863.00	0.00	0.00		18,029.00		
4313	SOBRA CHILD 06-13 M	2,258.00	2,273.00	2,298.00	2,650.00	2,673.00	2,665.00	2,663.00	2,665.00	2,695.00	2,721.00	0.00	0.00		25,561.00		
4314	SOBRA CHILD 14-20 MA	603.00	605.00	608.00	706.00	707.00	713.00	717.00	724.00	724.00	724.00	0.00	0.00		6,831.00		
4315	SOBRA CHILD 14-20 FE	629.00	638.00	652.00	766.00	764.00	764.00	760.00	762.00	762.00	761.00	0.00	0.00		7,258.00		
5013	SOBRA PREG 09-13 FE	1.00	1.00	1.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		11.00		
	M																
5015	SOBRA PREG 14-20 FE	7.00	7.00	9.00	12.00	13.00	14.00	14.00	15.00	12.00	11.00	0.00	0.00		114.00		
	M																
5017	SOBRA PREG 21-44 FE	90.00	95.00	101.00	155.00	159.00	151.00	148.00	154.00	155.00	155.00	0.00	0.00		1,363.00		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	1.00	1.00	1.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00		5.00		
	M																
SUBTOTAL:	9,844.00	9,910.00	10,029.00	12,092.00	12,013.00	11,968.00	11,974.00	11,985.00	12,002.00	12,060.00	0.00	0.00		113,877.00		

20.00

1106	TANF EXPANDED 21-44	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	0.00	0.00	
1107	TANF EXPANDED 21-44	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	0.00	0.00	

19.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending April 30, 2021	
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	11.00	12.00	13.00	13.00	14.00	0.00	0.00		107.00		
1109	TANF EXPANDED 65+ M	10.00	11.00	11.00	11.00	11.00	10.00	10.00	11.00	11.00	12.00	0.00	0.00		108.00		
	&																
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	2.00	2.00	2.00	3.00	3.00	4.00	0.00	0.00		16.00		
1115	TANF EXPANDED 14-20	10.00	10.00	10.00	14.00	16.00	16.00	15.00	12.00	10.00	11.00	0.00	0.00		124.00		
1116	TANF EXPANDED 21-44	171.00	171.00	161.00	184.00	195.00	190.00	200.00	205.00	205.00	207.00	0.00	0.00		1,889.00		
1117	TANF EXPANDED 21-44	515.00	513.00	513.00	682.00	727.00	742.00	747.00	745.00	752.00	766.00	0.00	0.00		6,702.00		
1118	TANF EXPANDED 45-64	272.00	277.00	281.00	360.00	371.00	383.00	396.00	396.00	398.00	399.00	0.00	0.00		3,533.00		
1119	TANF EXPANDED 65+ M	1.00	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	0.00	0.00		14.00		
	&																
1126	TANF EXPANDED 21-44	8.00	8.00	9.00	10.00	9.00	8.00	9.00	9.00	9.00	9.00	0.00	0.00		88.00		
1127	TANF EXPANDED 21-44	11.00	11.00	11.00	12.00	12.00	12.00	12.00	12.00	12.00	12.00	0.00	0.00		117.00		
1128	TANF EXPANDED 45-64	31.00	32.00	33.00	41.00	37.00	37.00	39.00	38.00	39.00	39.00	0.00	0.00		366.00		
1129	TANF EXPANDED 65+ M	29.00	29.00	29.00	44.00	46.00	46.00	45.00	44.00	44.00	43.00	0.00	0.00		399.00		
	&																
2400	SSI AGED EXPANDED	1.00	1.00	1.00	7.00	9.00	9.00	7.00	8.00	7.00	7.00	0.00	0.00		57.00		
	WI																
2410	SSI AGED EXPANDED N	5.00	5.00	5.00	7.00	6.00	6.00	6.00	6.00	5.00	6.00	0.00	0.00		57.00		
	O																
2420	SSI AGED EXPANDED	162.00	159.00	159.00	258.00	259.00	264.00	269.00	275.00	274.00	274.00	0.00	0.00		2,353.00		
	WI																
2600	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	1.00	0.00	1.00	1.00	1.00	0.00	0.00		4.00		
	E																
2610	SSI DISABLED EXPAND	8.00	7.00	7.00	9.00	8.00	8.00	9.00	8.00	10.00	10.00	0.00	0.00		84.00		
	E																
2620	SSI DISABLED EXPAND	73.00	75.00	75.00	116.00	116.00	115.00	115.00	114.00	113.00	113.00	0.00	0.00		1,025.00		
	E																
SUBTOTAL:	1,319.00	1,321.00	1,318.00	1,771.00	1,839.00	1,865.00	1,899.00	1,906.00	1,912.00	1,932.00	0.00	0.00		17,082.00		

3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	1.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	1.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	4.00	4.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	34.00	34.00	35.00	42.00	39.00	41.00	38.00	39.00	39.00	43.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	46.00	45.00	39.00	49.00	51.00	52.00	53.00	53.00	55.00	56.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	81.00	84.00	90.00	117.00	124.00	125.00	133.00	135.00	135.00	145.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	69.00	72.00	78.00	111.00	120.00	122.00	116.00	119.00	121.00	126.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	192.00	187.00	188.00	269.00	285.00	286.00	288.00	299.00	300.00	293.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	2.00	3.00	6.00	6.00	7.00	10.00	8.00	8.00	7.00	0.00	0.00	
3714	ADULT <40% EXP MALE	140.00	137.00	142.00	154.00	160.00	161.00	160.00	161.00	168.00	161.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	153.00	152.00	164.00	185.00	183.00	187.00	192.00	197.00	190.00	196.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1,106.00	1,124.00	1,140.00	1,280.00	1,304.00	1,300.00	1,325.00	1,328.00	1,336.00	1,365.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	542.00	566.00	573.00	678.00	693.00	699.00	706.00	715.00	727.00	733.00	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	1,483.00	1,487.00	1,497.00	1,504.00	1,535.00	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	

2.00	
21.00	
384.00	
499.00	
1,169.00	
1,054.00	
2,587.00	
7.00	
5.00	
57.00	
1,544.00	
1,799.00	
12,608.00	
6,632.00	
13,821.00	
1.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	3,472.00	3,521.00	3,598.00	4,361.00	4,447.00	4,467.00	4,513.00	4,555.00	4,589.00	4,667.00	0.00	0.00		42,190.00		

3908	NEWLY ELIGIBLE M&F	4.00	4.00	5.00	8.00	9.00	8.00	9.00	9.00	11.00	14.00	0.00	0.00		
	4														
3909	NEWLY ELIGIBLE M&F	1.00	1.00	1.00	8.00	10.00	11.00	12.00	10.00	10.00	12.00	0.00	0.00		
	6														
3914	NEWLY ELIGIBLE MALE	13.00	14.00	14.00	14.00	19.00	21.00	23.00	25.00	26.00	27.00	0.00	0.00		
3915	NEWLY ELIGIBLE FEMA	17.00	22.00	24.00	32.00	31.00	28.00	33.00	34.00	41.00	41.00	0.00	0.00		
	L														
3916	NEWLY ELIGIBLE MALE	83.00	92.00	102.00	126.00	131.00	137.00	143.00	155.00	165.00	172.00	0.00	0.00		
3917	NEWLY ELIGIBLE FEMA	127.00	144.00	153.00	233.00	249.00	264.00	281.00	283.00	302.00	314.00	0.00	0.00		
	L														
3918	NEWLY ELIGIBLE M&F	178.00	191.00	201.00	284.00	306.00	314.00	324.00	334.00	340.00	342.00	0.00	0.00		
	4														
3919	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	1.00	1.00	2.00	1.00	1.00	2.00	2.00	0.00	0.00		
	6														
SUBTOTAL:	423.00	468.00	500.00	706.00	756.00	785.00	826.00	851.00	897.00	924.00	0.00	0.00		

81.00	
76.00	
196.00	
303.00	
1,306.00	
2,350.00	
2,814.00	
10.00	
7,136.00	

4413	SOBRA 100-133% M&F
6	177.00	175.00	164.00	204.00	212.00	211.00	222.00	214.00	227.00	230.00	0.00	0.00	
4414	SOBRA 100-133% MALE	54.00	58.00	54.00	62.00	61.00	63.00	65.00	66.00	67.00	69.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	52.00	54.00	52.00	65.00	70.00	72.00	79.00	84.00	87.00	89.00	0.00	0.00	
SUBTOTAL:	283.00	287.00	270.00	331.00	343.00	346.00	366.00	364.00	381.00	388.00	0.00	0.00	

2,036.00	
619.00	
704.00	
3,359.00	

4518

BC PATIENT FEMALE 4 5

7.00

7.00

0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	
0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	1.00	1.00	1.00	4.00	4.00	4.00	4.00	4.00	4.00	4.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	2.00	2.00	2.00	3.00	3.00	3.00	3.00	4.00	3.00	4.00	0.00	0.00	
SUBTOTAL:	3.00	3.00	3.00	7.00	7.00	7.00	7.00	8.00	7.00	8.00	0.00	0.00	

31.00	
29.00	
60.00	

TOTAL:	15,344.00	15,510.00	15,718.00	19,269.00	19,406.00	19,439.00	19,586.00	19,670.00	19,789.00	19,980.00	0.00	0.00		183,711.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending April 30, 2021	
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	3,601.46	3,493.02	8,802.43	8,802.43	3,493.02	0.00	0.00		45,944.56		
1010	TANF NON-MEDICARE	3,291,897.58	3,285,053.48	3,288,548.72	3,306,465.97	3,375,616.84	4,183,310.77	3,574,026.74	3,603,855.81	3,569,106.11	3,593,780.60	0.00	0.00		35,071,662.62		
1020	TANF WITH QMB	9,680.62	4,840.31	4,840.31	4,840.31	5,398.51	6,110.81	5,263.81	5,309.41	5,309.41	5,309.41	0.00	0.00		56,902.91		
2100	SSI AGED WITH MEDIC	36,886,150.06	36,257,168.41	36,003,911.48	36,034,477.60	36,272,170.73	37,316,795.80	35,129,543.04	34,663,771.28	34,469,114.28	34,356,365.91	0.00	0.00		357,389,468.59		
	A																
210Z	SSI AGED WITH MEDIC	1,298,077.28	1,402,442.60	1,257,963.40	1,581,824.80	1,265,210.75	1,483,272.69	1,426,060.39	1,314,964.70	1,511,450.11	1,363,523.47	0.00	0.00		13,904,790.19		
	A																
2110	SSI AGED NON-MEDICA	3,936,251.45	3,919,215.33	3,905,281.54	3,844,314.05	3,846,434.80	4,741,285.99	3,948,263.96	4,028,650.04	3,940,469.49	3,937,675.57	0.00	0.00		40,047,842.22		
	R																
211Z	SSI AGED NON-MEDICA	58,332.16	48,168.31	33,594.18	79,175.95	120,089.00	54,436.21	24,869.34	62,586.72	44,466.89	56,874.03	0.00	0.00		582,592.79		
	R																
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	30,481,842.88	28,972,859.79	29,343,685.01	29,063,508.65	28,994,697.26	0.00	0.00		294,107,089.65		
212Z	SSI AGED WITH QMB P	52,730.40	29,814.20	66,471.69	48,436.02	47,234.04	34,941.73	53,592.62	37,694.52	37,590.01	49,152.57	0.00	0.00		457,657.80		
	P																
2200	SSI DISABLED WITH M	17,059,477.72	17,032,420.82	16,952,713.58	17,010,018.04	17,352,020.45	20,062,642.56	17,941,385.04	17,454,892.67	17,351,123.66	17,480,510.88	0.00	0.00		175,697,205.42		
	E																
220Z	SSI DISABLED WITH M	98,578.03	155,770.48	142,184.45	146,143.08	109,406.57	137,305.83	144,818.07	103,990.51	173,868.11	127,354.55	0.00	0.00		1,339,419.68		
	E																
2210	SSI DISABLED NON-ME	162,684,114.64	163,041,594.79	163,677,617.83	164,231,246.48	169,081,414.23	207,037,631.34	178,719,496.74	180,269,523.92	181,026,342.90	181,563,085.02	0.00	0.00		1,751,332,067.89		
	D																
221Z	SSI DISABLED NON-ME	35,551.37	116,027.59	170,841.19	178,006.17	232,484.37	173,213.57	162,692.05	128,448.00	182,097.31	105,425.39	0.00	0.00		1,484,787.01		
	D																
2220	SSI DISABLED WITH Q	34,878,015.83	34,889,678.58	35,047,772.64	34,970,006.24	35,712,723.67	41,701,981.61	37,032,263.13	37,258,967.01	37,336,499.70	37,307,507.75	0.00	0.00		366,135,416.16		
	M																
222Z	SSI DISABLED WITH Q	6,530.37	27,041.24	249.93	368.96	6,478.11	3,442.84	10,494.00	2,517.78	19,899.70	33,297.15	0.00	0.00		110,320.08		
	M																
2300	SSI BLIND WITH MEDIC	13,493.19	13,493.19	18,333.50	18,333.50	23,173.81	27,970.07	37,242.30	5,309.41	5,309.41	5,309.41	0.00	0.00		167,967.79		
2310	SSI BLIND NON-MEDIC	87,574.55	94,928.07	94,586.84	105,994.80	128,773.95	154,495.01	145,160.94	50,344.52	77,196.65	66,272.75	0.00	0.00		1,005,328.08		
	A																
2320	SSI BLIND WITH QMB	13,529.94	13,596.77	14,463.63	17,446.82	17,562.00	26,182.78	20,003.28	18,240.66	19,083.94	29,702.76	0.00	0.00		189,812.58		
SUBTOTAL:	290,273,602.06	289,931,962.65	289,934,161.67	290,674,902.76	297,047,524.01	347,630,463.95	307,351,528.26	308,361,554.40	308,841,238.76	309,079,337.50	0.00	0.00		3,039,126,276.02		

8700	SSI DISABLED FREEDO M	259,279.78	247,188.10	270,149.86	246,516.30	253,566.44	304,847.07	246,614.18	256,319.52	247,769.55	293,205.82	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	264,671.23	265,551.59	264,399.91	265,969.54	263,464.57	312,730.39	281,012.41	277,812.60	294,733.56	289,622.79	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	5,473.25	0.00	21,775.91	0.00	0.00	15,738.48	0.00	0.00	29,718.48	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	146,790.24	110,880.83	111,906.00	114,475.07	121,639.92	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	4,231.89	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	780,106.18	642,739.31	646,038.12	686,696.66	704,468.53	0.00	0.00	

2,625,456.62	
0.00	
2,779,968.59	
72,706.12	
1,227,487.67	
4,231.89	
6,709,850.89	

3,045,836,126.91

290,925,964.90	290,572,481.23	290,613,425.93	291,310,327.18	297,689,756.00	348,410,570.13	307,994,267.57	309,007,592.52	309,527,935.42	309,783,806.03	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending April 30, 2021	
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	1.00	1.00	2.00	2.00	1.00	0.00	0.00		12.00		
1010	TANF NON-MEDICARE	674.29	672.89	673.13	677.17	676.16	679.36	672.89	672.90	666.34	671.01	0.00	0.00		6,736.14		
1020	TANF WITH QMB	2.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00		11.00		
2100	SSI AGED WITH MEDIC	11,098.06	10,918.90	10,833.93	10,836.05	10,806.73	10,585.08	10,325.12	10,189.81	10,118.90	10,089.79	0.00	0.00		105,802.37		
	A																
210Z	SSI AGED WITH MEDIC	373.44	404.87	364.02	461.37	361.20	414.27	407.49	374.45	429.19	385.59	0.00	0.00		3,975.89		
	A																
2110	SSI AGED NON-MEDICA	554.21	552.90	548.01	540.06	529.65	541.02	515.64	527.00	515.68	511.60	0.00	0.00		5,335.77		
	R																
211Z	SSI AGED NON-MEDICA	8.27	6.41	4.89	10.89	15.38	6.71	3.31	8.06	5.81	7.54	0.00	0.00		77.27		
	R																
2120	SSI AGED WITH QMB	9,354.00	9,262.01	9,160.70	9,097.54	9,115.79	8,969.47	8,827.31	8,933.47	8,850.57	8,819.63	0.00	0.00		90,390.49		
212Z	SSI AGED WITH QMB P	14.65	8.61	18.56	13.25	13.94	9.54	14.42	10.31	10.12	13.79	0.00	0.00		127.19		
	P																
2200	SSI DISABLED WITH M	4,238.21	4,227.15	4,206.93	4,222.19	4,217.22	4,255.50	4,185.82	4,030.14	4,013.96	4,043.18	0.00	0.00		41,640.30		
	E																
220Z	SSI DISABLED WITH M	28.56	44.79	40.99	42.67	31.20	38.22	40.99	29.29	50.61	35.32	0.00	0.00		382.64		
	E																
2210	SSI DISABLED NON-ME	31,815.64	31,895.15	32,020.73	32,121.78	32,152.70	32,247.40	32,214.63	32,276.55	32,434.50	32,526.30	0.00	0.00		321,705.38		
	D																
221Z	SSI DISABLED NON-ME	4.68	15.55	23.26	24.58	29.25	19.43	20.57	15.63	22.39	13.31	0.00	0.00		188.65		
	D																
2220	SSI DISABLED WITH Q	8,199.32	8,200.99	8,238.64	8,213.75	8,223.88	8,146.28	8,145.66	8,086.84	8,098.47	8,099.83	0.00	0.00		81,653.66		
	M																
222Z	SSI DISABLED WITH Q	1.67	8.46	0.06	0.09	1.72	0.89	2.75	0.79	5.39	9.27	0.00	0.00		31.09		
	M																
2300	SSI BLIND WITH MEDIC	3.00	3.00	4.00	4.00	5.00	5.00	8.00	1.00	1.00	1.00	0.00	0.00		35.00		
2310	SSI BLIND NON-MEDIC	15.95	17.58	18.00	20.00	23.86	24.00	26.00	9.00	13.48	12.00	0.00	0.00		179.87		
	A																
2320	SSI BLIND WITH QMB	3.35	4.00	5.09	6.00	6.00	7.28	6.00	5.57	4.00	6.00	0.00	0.00		53.29		
SUBTOTAL:	66,390.30	66,245.26	66,162.94	66,293.39	66,211.68	65,951.45	65,418.60	65,173.81	65,243.41	65,247.16	0.00	0.00		658,338.00		

8700	SSI DISABLED FREEDO M	62.00	59.00	61.99	58.73	60.00	60.97	57.00	58.39	55.08	65.75	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	39.16	39.41	38.96	39.00	37.99	37.99	38.00	37.99	40.25	39.03	0.00	0.00	
871Z	SSI DISABLED FREEDO
M	0.83	0.00	3.03	0.00	0.00	2.00	0.00	0.00	3.63	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	28.00	29.00	28.00	28.00	28.00	25.99	24.88	23.99	24.48	25.83	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	1.09	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	129.99	127.41	131.98	125.73	125.99	126.95	120.97	120.37	123.44	130.61	0.00	0.00	

598.91	
0.00	
387.78	
9.49	
266.17	
1.09	
1,263.44	

TOTAL:	66,520.29	66,372.67	66,294.92	66,419.12	66,337.67	66,078.40	65,539.57	65,294.18	65,366.85	65,377.77	0.00	0.00		659,601.44		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending April 30, 2021	
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		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-41.43	0.00	0.00	0.00	0.00		-41.43		
1015	TANF 14-20 FEMALE N	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		
	O																
2210	SSI DISABLED NON-ME	1,006.49	202.98	0.00	0.00	0.00	752.82	0.00	0.00	0.00	0.00	0.00	0.00		1,962.29		
	D																
4311	SOBRA CHILD <1 M & F	482.75	-28.45	0.00	-140.72	-164.97	0.00	-113.80	-0.50	0.00	0.00	0.00	0.00		34.31		
4312	SOBRA CHILD 01-05 M	1,089.51	-183.46	0.00	0.00	0.00	0.00	-203.77	-13.90	752.82	0.00	0.00	0.00		1,441.20		
4313	SOBRA CHILD 06-13 M	-301.38	0.00	-641.66	1,286.76	0.00	0.00	-28.45	0.00	0.00	0.00	0.00	0.00		315.27		
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		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	-1,153.09	0.00	0.00	0.00	0.00	0.00		-1,153.09		
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	752.82	-1,499.11	-55.83	752.82	0.00	0.00	0.00		2,678.64		

473.62

473.62

3,152.26

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	

-718.99	425.96	-228.91	752.82	-1,499.11	-55.83	752.82	0.00	0.00	0.00	

TOTAL:

2,277.37

1,446.13

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE 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		
	O																
2210	SSI DISABLED 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		
	D																
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		
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	

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

Current and prior month data is

under revision.

0.00

0.00

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2021	
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	44,089.96	44,124.79	45,765.86	45,765.86	52,521.93	0.00	0.00		435,299.08		
1014	TANF 14-20 MALE NON-	0.00	166.11	0.00	166.11	343.31	3.47	0.00	351.66	0.00	0.00	0.00	0.00		1,030.66		
1015	TANF 14-20 FEMALE N	0.00	249.17	219.91	0.00	0.00	0.00	0.00	58.61	0.00	1,976.30	0.00	0.00		2,503.99		
	O																
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	505.74	-16.42	0.00	0.00	0.00	0.00	0.00	0.00		489.32		
1017	TANF 21-44 FEMALE N	37,014.36	1,152.57	6,630.70	-529.82	6,675.96	1,786.43	0.00	0.00	2,508.71	3,212.48	0.00	0.00		58,451.39		
	O																
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	1,325.23	506.26	0.00	0.00	0.00	0.00	0.00	0.00		1,831.49		
2100	SSI AGED WITH MEDIC	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		
	A																
210Z	SSI AGED 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		
	A																
2120	SSI AGED WITH QMB	1,493.14	4,206.47	1,649.28	3,768.58	4,030.94	5,145.58	3,247.31	3,247.31	5,839.64	4,371.68	0.00	0.00		36,999.93		
2200	SSI DISABLED WITH M	12,359.84	10,710.56	13,285.32	10,710.56	11,599.08	11,547.29	10,989.47	10,989.47	11,714.87	12,595.71	0.00	0.00		116,502.17		
	E																
220Z	SSI DISABLED WITH M	0.00	2,574.76	0.00	5,816.28	0.00	2,571.04	0.00	2,245.84	0.00	0.00	0.00	0.00		13,207.92		
	E																
2210	SSI DISABLED NON-ME	193,855.87	191,768.29	188,680.16	193,415.19	226,777.05	197,166.93	193,658.93	192,569.37	193,757.09	196,378.49	0.00	0.00		1,968,027.37		
	D																
221Z	SSI DISABLED NON-ME	2,237.23	2,574.76	398.17	2,823.93	5,378.82	19.28	919.86	0.00	0.00	0.00	0.00	0.00		14,352.05		
	D																
2220	SSI DISABLED WITH Q	91,009.08	94,482.21	78,859.66	75,456.21	88,696.59	83,028.65	76,150.41	83,216.11	75,692.37	75,069.29	0.00	0.00		821,660.58		
	M																
222Z	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	1,138.92	0.00	0.00	0.00	0.00	0.00	0.00		1,138.92		
	M																
2310	SSI BLIND NON-MEDIC	1,649.28	1,649.28	1,649.28	1,649.28	2,155.02	1,624.65	1,641.07	1,641.07	1,641.07	1,641.07	0.00	0.00		16,941.07		
	A																
4310	SOBRA CHILD NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,641.07	0.00	0.00	0.00		1,641.07		
	DI																
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	1,054.90	17.04	1,923.33	92.58	0.00	0.00	0.00	0.00		3,087.85		
4315	SOBRA CHILD 14-20 FE	0.00	1,411.97	96.33	0.00	109.95	154.89	0.00	1,382.58	0.00	1,382.58	0.00	0.00		4,538.30		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	3,679.44	0.00	0.00	0.00	0.00	0.00		3,679.44		
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	0.00	0.00	1,649.28	1,649.28	1,649.28	1,641.07	1,641.07	1,641.07	1,641.07	1,641.07	0.00	0.00		13,153.19		
	MAN																
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	-16.42	0.00	0.00	0.00	0.00	0.00	0.00		-16.42		
	M																
5010	SOBRA PREGNANT WO	4,224.04	4,224.04	2,574.76	4,224.04	5,873.32	3,282.14	1,641.07	0.00	0.00	0.00	0.00	0.00		26,043.41		
	MAN																
5015	SOBRA PREG 14-20 FE	0.00	0.00	1,201.55	0.00	0.00	35.14	0.00	0.00	0.00	0.00	0.00	0.00		1,236.69		
	M																
5017	SOBRA PREG 21-44 FE	0.00	0.00	5,149.52	0.00	0.00	-16.42	0.00	0.00	0.00	0.00	0.00	0.00		5,133.10		
	M																
501G	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	473.12	0.00	0.00	516.29	0.00	0.00	0.00	0.00		989.41		
	M																
SUBTOTAL:	380,720.68	355,991.96	348,738.40	342,000.04	398,446.05	353,709.48	339,616.75	343,717.82	340,201.75	350,790.60	0.00	0.00		3,553,933.53		

1100	TANF EXPANDED FPR FI	5,873.32	4,224.04	2,574.76	2,574.76	2,574.76	2,592.33	2,592.33	2,592.33	2,592.33	2,592.33	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	35.14	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	109.46	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	16,829.11	18,435.35	21,027.68	20,041.59	18,435.35	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	482.23	0.00	0.00	0.00	754.06	0.00	0.00	

30,783.29	
505.74	
540.88	
1,554.43	
167,854.66	
444.26	
8,102.48	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	2,847.37	261.32	0.00	344.19	0.00	2,466.90	0.00	0.00		5,919.78		
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		319.22		
1120	TANF EXPANDED FOR	1,493.14	4,791.70	4,791.70	4,791.70	7,366.46	7,480.71	7,480.71	7,480.71	7,480.71	7,480.71	0.00	0.00		60,638.25		
	FI																
1127	TANF EXPANDED 21-44	1,276.86	0.00	0.00	0.00	0.00	-16.42	0.00	0.00	0.00	0.00	0.00	0.00		1,260.44		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	444.26	209.78	0.00	0.00	0.00	0.00	0.00	0.00		654.04		
240Z	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	829.03	0.00	0.00	0.00		829.03		
	WI																
2420	SSI AGED EXPANDED	6,642.66	6,642.66	6,642.66	6,642.66	7,531.18	7,087.38	6,790.90	6,790.90	6,790.90	6,790.90	0.00	0.00		68,352.80		
	WI																
2600	SSI DISABLED EXPAND	-962.49	0.00	0.00	0.00	0.00	1.14	0.00	0.00	644.71	2,592.33	0.00	0.00		2,275.69		
	E																
260Z	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	198.73	0.00	0.00	2,351.99	1,247.23	83.62	0.00	0.00		3,881.57		
	E																
2610	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,666.50	2,592.33	0.00	0.00	0.00		4,258.83		
	E																
2620	SSI DISABLED EXPAND	25,031.96	28,174.38	28,631.08	25,031.96	36,892.82	25,972.58	25,330.74	25,330.74	28,477.75	23,689.67	0.00	0.00		272,563.68		
	E																
262Z	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	505.74	585.36	0.00	0.00	0.00	0.00	0.00	0.00		1,091.10		
	E																
SUBTOTAL:	54,303.49	59,335.04	55,354.89	55,062.83	82,346.28	61,630.12	60,630.03	67,585.04	70,696.58	64,885.87	0.00	0.00		631,830.17		

3510	ADULT 40-100% FOR FI	39,398.90	45,272.22	42,697.46	41,048.18	41,048.18	39,933.46	43,180.77	41,574.53	39,933.46	40,884.72	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	18.72	0.00	0.00	0.00	2,478.05	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	3,286.68	0.00	7,261.32	560.12	5,270.63	-2,541.01	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	600.93	2,896.14	0.00	-3,302.78	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	
351E	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	172.82	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	3,271.85	0.00	537.58	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	334.49	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	92.58	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	1,029.90	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	207,342.51	212,196.06	215,774.48	211,934.61	225,586.07	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	52.94	0.00	8,777.49	4,348.42	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	0.00	0.00	0.00	429.16	0.00	-1.58	0.00	1,606.24	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	5,900.92	-2,121.28	3,031.35	1,087.11	5,917.78	0.00	0.00	
3717	ADULT <40% EXP FEMA L	1,340.71	12,707.58	1,012.66	415.28	13,303.84	31,176.19	-1,058.75	-580.93	5,281.82	-1,468.20	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	-2,238.59	944.08	2,132.36	3,595.81	8,883.61	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	5,413.37	5,448.63	722.75	1,337.97	0.00	0.00	0.00	

414,971.88	
444.26	
10,041.31	
13,837.74	
5,609.84	
581.40	
172.82	
8,336.04	
334.49	
92.58	
1,029.90	
85.83	
1,495.02	
1,998,020.97	
13,178.85	
2,033.82	
86,920.60	
62,130.20	
81,692.35	
83.06	
1,968.46	
19,788.48	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
371G	ADULT <40% EXP FEMA L	3,146.98	0.00	4,205.44	0.00	1,029.90	589.35	0.00	1,942.22	0.00	-1,641.07	0.00	0.00		9,272.82		
371H	ADULT <40% EXP M&F
4	561.88	638.43	8,153.41	0.00	-4,479.42	24,509.18	1,975.57	0.00	83.62	979.67	0.00	0.0		32,422.34		
SUBTOTAL:	263,141.57	258,628.19	284,724.45	243,560.25	308,101.86	317,302.19	270,096.24	273,069.64	264,300.04	281,620.63	0.00	0.00		2,764,545.06		

3900	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	2,592.33	2,592.33	2,592.33	2,592.33	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	49.77	3.77	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	19,421.44	15,188.04	16,174.13	16,174.13	21,358.79	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	35.14	0.00	0.00	0.00	2,073.86	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	1,802.33	2,574.76	-686.60	0.00	161.39	720.55	-1,243.54	0.00	1,254.35	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	298.78	0.00	4,324.53	0.00	-777.70	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	1,396.81	0.00	0.00	0.00	0.00	919.86	0.00	2,407.16	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	69.32	0.00	1,087.11	0.00	0.00	0.00	0.00	
SUBTOTAL:	19,939.16	20,807.92	20,121.32	23,216.21	21,019.08	21,468.86	16,536.83	26,585.26	20,020.81	25,247.28	0.00	0.00	

10,369.32	
53.54	
185,713.47	
2,109.00	
4,583.24	
3,845.61	
4,723.83	
3,564.72	
214,962.73	

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	83.06	0.00	0.56	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	
SUBTOTAL:	85.83	0.00	0.00	83.06	0.00	0.56	0.00	0.00	0.00	0.00	0.00	0.00	

83.62	
85.83	
169.45	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	2,574.76	0.00	0.00	0.00	-2,574.76	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	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,592.33	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	2,574.76	505.74	0.00	0.00	-2,574.76	0.00	2,592.33	0.00	0.00	

0.00	
505.74	
2,592.33	
3,098.07	

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	-332.23	0.00	582.32	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	-332.23	0.00	582.32	0.00	0.00	0.00	0.00	0.00	

250.09

250.09

7,168,789.10

718,190.73	694,763.11	708,939.06	666,497.15	810,086.78	754,111.21	687,462.17	708,383.00	695,219.18	725,136.71	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 April 30, 2021

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
210Z	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
222Z	SSI DISABLED WITH Q
M

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

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

n. 0.00	0.00

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

2310

4310

4314

4315

431D

431E

5000

5007

5010

5015

5017

501G

SSI BLIND NON-MEDIC A
SOBRA CHILD NON-ME
DI
SOBRA CHILD 14-20 MA

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

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		0.00		
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1120	TANF EXPANDED FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	FI																
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
240Z	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	WI																
2420	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	WI																
2600	SSI DISABLED EXPAND	0.00	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																
260Z	SSI DISABLED EXPAND	0.00	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																
2610	SSI DISABLED EXPAND	0.00	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																
2620	SSI DISABLED EXPAND	0.00	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																
262Z	SSI DISABLED EXPAND	0.00	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:	0.00	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	
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	
3707	ADULT <40% EXP FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 MEMBER MONTHS - ADULT
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3900	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	
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	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
0.00	
0.00	
0.00	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	

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

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

Current and prior month data is under revision.

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

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1015	TANF 14-20 FEMALE N	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		
	O																
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	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		
	O																
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	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		
	O																
2100	SSI AGED WITH MEDIC	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		
	A																
210Z	SSI AGED WITH MEDIC	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		
	A																
2110	SSI AGED NON-MEDICA	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		
	R																
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	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		
	E																
2210	SSI DISABLED NON-ME	3,736.31	3,460.72	1,131.86	-0.67	1,460.62	-1,362.04	-211.66	0.00	0.00	0.00	0.00	0.00		8,215.14		
	D																
221Z	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	-12.67	0.00	0.00	0.00	0.00	0.00		-12.67		
	D																
2220	SSI DISABLED WITH Q	916.89	0.00	334.20	0.00	282.12	-282.12	0.00	0.00	0.00	0.00	0.00	0.00		1,251.09		
	M																
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	0.00	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																
501E	SOBRA PREG 14-20 FE	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		
	M																
SUBTOTAL:	13,949.99	10,451.00	3,405.87	835.75	966.91	-1,644.16	-224.33	0.00	0.00	0.00	0.00	0.00		27,741.03		

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	-0.45	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	1,460.62	1,221.19	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	1,460.62	1,220.74	0.00	0.00	

1,271.64	
2,394.50	
845.91	
70.53	
3,926.77	
282.12	
8,791.47	

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	-493.71	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	-11.13	-839.51	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	-2,590.78	0.00	-593.82	0.00	-71.07	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	1,460.62	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	-2,227.96	0.00	0.00	0.00	-75.14	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	

0.00	
1,309.51	
113.17	
594.26	
1,693.00	
6,349.39	
4,330.65	
2,311.17	
-23.14	
40.94	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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	-15.94	0.00	0.00		-15.94		
SUBTOTAL:	14,078.62	9,741.71	0.00	-1,658.64	-0.24	-4,818.74	0.00	866.80	-11.13	-1,495.37	0.00	0.00		16,703.01		

3916	NEWLY ELIGIBLE MALE	846.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-141.06	0.00	0.00	0.00	
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	-295.45	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,243.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-141.06	-295.45	0.00	0.00	

705.30	
1,102.10	
0.00	
1,807.40	

4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-13.60	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-13.60	0.00	0.00	

-13.60

-13.60

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	0.00	0.00	-17.04	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	-17.04	0.00	0.00	0.00	0.00	0.00	

-17.04

-17.04

55,012.27

34,141.06	21,955.96	3,884.19	-822.89	966.67	-6,462.90	-241.37	866.80	1,308.43	-583.68	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending April 30, 2021

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

221Z

2220

4312

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

4314

SOBRA CHILD 14-20 MA

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

5017

501E

SOBRA PREG 21-44 FE M
SOBRA PREG 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

M
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	

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	

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 April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
371H	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	

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

0.00

0.00

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

0.00

0.00

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending April 30, 2021	
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	524,465.96	510,071.64	514,418.31	457,104.42	0.00	0.00	0.00		4,484,741.91		
1011	TANF <1 M & F NON-ME	18,250.52	22,539.27	32,615.10	15,545.58	52,944.65	102,842.03	23,016.35	14,026.74	18,544.73	-1,355.01	0.00	0.00		298,969.96		
1012	TANF 01-05 M & F NON	1,830.78	-799.39	7,686.18	-16,879.18	25,702.98	30,686.95	603.85	-6,677.07	-4,902.37	0.00	0.00	0.00		37,252.73		
1013	TANF 06-13 M & F NON	2,624.03	9,884.36	17,196.09	7,358.19	12,112.27	24,898.27	3,155.75	-1,087.27	5,756.28	0.00	0.00	0.00		81,897.97		
1014	TANF 14-20 MALE NON-	1,158.73	2,879.58	5,007.88	-647.35	4,536.14	6,096.48	1,082.86	193.88	3,926.06	0.00	0.00	0.00		24,234.26		
1015	TANF 14-20 FEMALE N	3,215.93	3,304.16	4,542.04	3,111.21	7,728.19	8,982.56	1,579.89	-1,227.64	3,704.94	0.00	0.00	0.00		34,941.28		
	O																
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	938.24	0.00	-629.56	0.00	0.00	0.00	0.00		308.68		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	175.33	28.43	0.00	0.00	0.00	0.00	0.00		203.76		
101B	TANF 01-05 M & F NON	0.00	-1,017.84	441.06	27.27	1,376.86	0.00	726.98	0.00	0.00	0.00	0.00	0.00		1,554.33		
101C	TANF 06-13 M & F NON	9,263.82	0.00	33.93	0.00	1,654.93	50.72	0.00	0.00	0.00	0.00	0.00	0.00		11,003.40		
101D	TANF 14-20 MALE NON-	101.78	0.00	0.00	0.00	312.12	315.84	0.00	0.00	0.00	0.00	0.00	0.00		729.74		
101E	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	27.27	2.11	0.00	0.00	0.00	0.00	0.00	0.00		29.38		
	O																
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	824.52	0.00	0.00	0.00	0.00	0.00	0.00		824.52		
2210	SSI DISABLED NON-ME	408,654.27	424,352.66	423,589.32	410,028.60	437,491.67	533,482.95	437,104.37	423,759.78	434,901.17	-1,137.26	0.00	0.00		3,932,227.53		
	D																
221Z	SSI DISABLED NON-ME	-2,347.06	-560.34	-667.67	-2,849.73	3,772.53	-2,097.01	0.00	0.00	314.78	56.86	0.00	0.00		-4,377.64		
	D																
2220	SSI DISABLED WITH Q	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		
	M																
2310	SSI BLIND NON-MEDIC	817.98	817.98	1,417.83	1,635.96	1,635.96	2,016.36	1,762.76	1,762.76	1,762.76	0.00	0.00	0.00		13,630.35		
	A																
4310	SOBRA CHILD NON-ME	11,486,063.32	11,314,030.73	11,474,882.63	11,389,831.57	11,530,567.10	12,969,821.07	13,051,750.83	12,895,946.96	12,797,770.38	0.00	0.00	0.00		108,910,664.59		
	DI																
4311	SOBRA CHILD <1 M & F	39,388.90	49,308.13	69,495.86	47,599.12	172,293.18	297,280.24	38,319.63	18,258.08	50,252.23	7,308.81	0.00	0.00		789,504.18		
4312	SOBRA CHILD 01-05 M	-77,519.72	24,412.60	-11,511.06	-28,260.56	560,837.74	947,724.25	-49,708.45	-52,936.31	9,961.07	-2,075.51	0.00	0.00		1,320,924.05		
4313	SOBRA CHILD 06-13 M	-99,853.49	28,110.86	-44,630.93	-28,342.05	570,798.15	940,978.86	-32,926.87	-39,541.45	43,967.56	0.00	0.00	0.00		1,338,560.64		
4314	SOBRA CHILD 14-20 MA	-29,493.13	2,805.33	-32,320.28	-1,909.91	130,680.50	237,018.48	-29,776.59	-11,515.93	-219.02	908.04	0.00	0.00		266,177.49		
4315	SOBRA CHILD 14-20 FE	-18,582.82	5,555.02	-24,766.46	-6,396.00	157,086.46	237,511.28	-22,027.99	-15,044.86	18,250.64	2,086.56	0.00	0.00		333,671.83		
431A	SOBRA CHILD < 1 M &	4,160.74	7,257.75	1,436.41	5,948.23	3,869.87	7,356.09	6,842.74	3,934.67	4,355.54	1,108.83	0.00	0.00		46,270.87		
431B	SOBRA CHILD 01-05 M	16,416.41	14,807.75	2,042.33	17,443.93	13,306.99	14,924.63	16,982.85	12,400.31	30,264.90	-3,301.12	0.00	0.00		135,288.98		
431C	SOBRA CHILD 6-13 M&F	16,098.60	30,558.45	10,758.92	12,166.77	26,075.98	14,322.68	5,148.26	9,270.06	8,617.06	767.65	0.00	0.00		133,784.43		
431D	SOBRA CHILD 14-20 MA	1,389.83	2,961.87	3,442.84	7,121.24	11,555.07	5,987.94	5,695.68	17,579.94	4,624.91	1,718.87	0.00	0.00		62,078.19		
431E	SOBRA CHILD 14-20 FE	5,207.63	3,738.27	4,760.32	3,944.09	25,023.89	4,464.20	1,857.74	4,428.04	6,933.78	1,514.31	0.00	0.00		61,872.27		
5010	SOBRA PREGNANT WO	5,714.89	6,932.59	9,586.39	10,404.37	11,840.47	14,112.05	12,349.29	13,573.17	12,349.29	0.00	0.00	0.00		96,862.51		
	MAN																
5015	SOBRA PREG 14-20 FE	0.00	-168.22	0.00	0.00	2,730.62	2,669.93	0.00	-830.49	-796.09	0.00	0.00	0.00		3,605.75		
	M																
501E	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	364.55	398.04	0.00	0.00	0.00	0.00	0.00	0.00		762.59		
	M																
SUBTOTAL:	12,247,672.27	12,427,829.73	12,449,744.41	12,371,139.66	14,298,123.42	16,928,251.05	13,983,640.00	13,800,062.12	13,907,445.02	7,601.03	0.00	0.00		122,421,508.71		

51.03

21,211.08

3710	AHC CARE EXPANDED FO	1,635.96	2,653.80	2,653.80	2,653.80	2,653.80	2,986.64	2,986.64	2,986.64	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	361.17	0.00	0.00	0.00	0.00	665.68	0.00	-975.82	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	

527.73

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	2,524.86	2,653.80	2,653.80	2,653.80	2,653.80	3,652.32	2,986.64	2,010.82	0.00	0.00	0.00	0.00		21,789.84		

3910	NEWLY ELIGIBLE FOR F	817.98	817.98	817.98	817.98	817.98	881.38	881.38	881.38	881.38	0.00	0.00	0.00		
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	126.80	0.00	0.00	0.00	0.00	0.00	0.00		
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-796.09	0.00	0.00	0.00		
SUBTOTAL:	817.98	817.98	817.98	817.98	817.98	1,008.18	881.38	881.38	85.29	0.00	0.00	0.00		

7,615.42	
126.80	
-796.09	
6,946.13	

4410	SOBRA 100-133% FOR F	22,851.99	22,237.27	20,201.59	18,365.77	16,529.95	19,888.95	19,546.45	20,488.06	14,590.70	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	1,710.46	6,970.68	8,115.40	2,686.51	8,482.83	9,755.98	3,054.55	-351.31	3,714.82	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,248.94	330.73	163.60	2,577.05	1,350.56	3,007.19	952.73	0.00	1,434.56	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2,101.36	395.80	3,223.33	1,894.72	3,130.64	2,648.11	777.08	1,311.30	1,478.45	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	79.05	0.00	3.80	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28,912.75	29,934.48	31,703.92	25,603.10	29,493.98	35,304.03	24,330.81	21,448.05	21,218.53	0.00	0.00	0.00	

174,700.73	
44,139.92	
12,065.36	
16,960.79	
82.85	
247,949.65	

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	63.40	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	63.40	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	126.80	0.00	0.00	0.00	0.00	0.00	0.00	

63.40	
63.40	
126.80	

122,698,321.13

12,279,927.86	12,461,235.99	12,484,920.11	12,400,214.54	14,331,089.18	16,968,342.38	14,011,838.83	13,824,402.37	13,928,748.84	7,601.03	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending April 30, 2021

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1015	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1016	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	
101A	TANF < 1 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	TANF 14-20 FEMALE 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	

101F	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	
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

221Z

SSI DISABLED NON-ME D

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

2310

4310	SSI BLIND NON-MEDIC A
SOBRA CHILD 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

0.00	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	DI
SOBRA CHILD <1 M & F	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00		
0.00	
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5010

5015	SOBRA PREGNANT WO MAN
SOBRA PREG 14-20 FE	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	

501E	M
SOBRA PREG 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	
	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	
																
3710	AHC CARE EXPANDED FO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
371D	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

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

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending April 30, 2021	
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		

3910	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

6012	KIDS 1-5 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	
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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

TOTAL:	0.00	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 April 30, 2021	
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	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		
	A																
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	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		
	E																
2210	SSI DISABLED NON-ME	12,535.37	11,751.46	-1,110.26	0.00	0.00	-12,214.33	0.00	0.00	0.00	0.00	0.00	0.00		10,962.24		
	D																
2220	SSI DISABLED WITH Q	14,885.23	4,308.04	-1,064.70	0.00	0.00	0.00	-5,587.04	0.00	0.00	0.00	0.00	0.00		12,541.53		
	M																
SUBTOTAL:	32,246.24	18,225.59	-2,174.96	0.00	0.00	-12,214.33	-5,587.04	0.00	0.00	0.00	0.00	0.00		30,495.50		

30,495.50

32,246.24	18,225.59	-2,174.96	0.00	0.00	-12,214.33	-5,587.04	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending April 30, 2021	
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	0.00	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	0.00	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	0.00	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	0.00	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 April 30, 2021	
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	11.59	11.59	25.19	25.19	11.59	0.00	0.00		143.07		
1004	TANF 14-20 MALE WITH	2.74	2.74	2.74	4.18	4.18	4.18	11.59	11.59	23.18	0.00	0.00	0.00		67.12		
1005	TANF 14-20 FEMALE WI	8.79	8.79	8.79	13.60	0.00	0.00	0.00	0.00	5.68	5.68	0.00	0.00		51.33		
1006	TANF 21-44 MALE WITH	757.08	843.75	873.72	1,395.68	1,417.43	1,508.84	1,464.02	1,388.45	1,351.44	1,295.15	0.00	0.00		12,295.56		
1007	TANF 21-44 FEMALE WI	1,148.91	1,198.02	1,236.36	1,940.40	1,892.38	1,915.56	2,050.98	1,824.38	1,867.42	1,628.77	0.00	0.00		16,703.18		
1008	TANF 45-64 M & F WIT	2,224.32	2,273.07	2,170.83	3,354.27	3,433.87	3,768.34	3,857.51	3,694.08	3,581.03	3,408.60	0.00	0.00		31,765.92		
1009	TANF 65+ M & F WITH	1,453.62	1,368.54	1,396.89	1,761.23	1,910.36	1,906.23	2,041.88	1,927.41	1,927.99	1,829.35	0.00	0.00		17,523.50		
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	1,686.55	1,541.93	1,448.67	1,366.61	1,347.65	0.00	0.00		15,342.68		
1011	TANF <1 M & F NON-ME	17,524.33	17,720.42	17,977.97	18,748.57	19,216.69	19,436.71	19,585.97	19,940.05	20,053.45	20,464.20	0.00	0.00		190,668.36		
1012	TANF 01-05 M & F NON	41,559.69	43,158.68	44,336.78	44,787.11	44,237.37	41,923.29	41,559.85	41,317.68	40,492.82	39,558.58	0.00	0.00		422,931.85		
1013	TANF 06-13 M & F NON	74,475.95	76,508.88	77,270.23	78,027.08	77,859.96	77,365.96	78,088.99	78,000.84	77,162.10	76,481.91	0.00	0.00		771,241.90		
1014	TANF 14-20 MALE NON-	46,352.86	48,408.65	49,479.57	63,037.32	64,017.06	64,575.94	65,473.62	66,560.89	67,462.98	68,238.30	0.00	0.00		603,607.19		
1015	TANF 14-20 FEMALE N	70,065.73	72,493.21	73,478.73	93,801.79	95,609.44	95,951.91	97,332.77	99,097.76	99,567.02	99,881.04	0.00	0.00		897,279.40		
	O																
1016	TANF 21-44 MALE NON-	286,728.72	289,965.21	290,793.96	381,398.57	377,375.31	379,024.23	381,418.72	386,514.98	387,575.71	391,225.28	0.00	0.00		3,552,020.69		
1017	TANF 21-44 FEMALE N	943,158.63	957,428.07	962,937.12	1,280,678.05	1,263,182.70	1,265,568.05	1,271,534.27	1,288,070.17	1,299,560.37	1,310,696.29	0.00	0.00		11,842,813.72		
	O																
1018	TANF 45-64 M & F NON	237,180.33	240,443.73	241,435.89	320,683.79	317,563.20	319,757.53	322,215.07	327,666.95	331,342.27	334,460.36	0.00	0.00		2,992,749.12		
1019	TANF 65+ M & F NON-M	1,090.95	1,132.92	1,164.09	1,609.02	1,612.92	1,541.60	1,552.96	1,719.82	1,731.41	1,752.47	0.00	0.00		14,908.16		
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	13.60	0.00	0.00	0.00	0.00	0.00	0.00		30.64		
101E	TANF 14-20 FEMALE N	0.00	0.00	0.00	25.79	30.87	13.60	0.00	0.00	0.00	0.00	0.00	0.00		70.26		
	O																
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	182.52	283.05	96.86	0.00	0.00	0.00	0.00	0.00	0.00		562.43		
101G	TANF 21-44 FEMALE N	0.00	0.00	0.00	295.22	278.11	60.08	0.00	0.00	0.00	0.00	0.00	0.00		633.41		
	O																
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	104.43	54.05	38.79	0.00	0.00	0.00	0.00	0.00	0.00		197.27		
1020	TANF WITH QMB	20.37	11.58	11.58	11.59	11.59	11.59	11.59	11.59	11.59	11.59	0.00	0.00		124.66		
1023	TANF 06-13 M & F WIT	2.74	2.74	2.74	4.18	4.18	4.18	4.18	4.18	4.18	4.18	0.00	0.00		37.48		
1024	TANF 14-20 MALE WITH	21.73	21.73	21.73	26.02	26.02	26.02	66.82	66.82	41.63	14.43	0.00	0.00		332.95		
1025	TANF 14-20 FEMALE WI	17.58	8.79	8.79	13.60	13.60	13.60	13.60	13.60	13.60	13.60	0.00	0.00		130.36		
1026	TANF 21-44 MALE WITH	631.98	645.60	602.85	940.47	1,000.32	1,000.32	1,084.16	961.88	998.78	973.47	0.00	0.00		8,839.83		
1027	TANF 21-44 FEMALE WI	1,027.86	1,126.14	971.16	1,606.63	1,698.16	1,604.97	1,585.23	1,697.00	1,792.31	1,761.21	0.00	0.00		14,870.67		
1028	TANF 45-64 M & F WIT	1,226.46	1,331.52	1,349.07	1,792.97	2,025.59	1,957.94	2,014.35	2,010.21	2,052.79	2,173.41	0.00	0.00		17,934.31		
1029	TANF 65+ M & F WITH	616.38	634.38	648.75	843.49	944.25	1,071.98	1,110.42	1,123.55	1,190.97	1,193.21	0.00	0.00		9,377.38		
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	139,858.53	137,184.75	135,820.08	174,153.40	177,373.80	180,105.20	179,833.47	176,727.03	175,126.84	175,593.27	0.00	0.00		1,651,776.37		
	A																

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
210Z	SSI AGED WITH MEDIC	0.00	0.00	0.00	1,316.42	671.75	125.72	0.00	0.00	0.00	0.00	0.00	0.00		2,113.89		
	A																
2110	SSI AGED NON-MEDICA	74,282.82	75,580.74	76,795.26	104,227.52	105,621.86	107,133.52	108,202.85	109,652.77	111,264.96	112,786.42	0.00	0.00		985,548.72		
	R																
2120	SSI AGED WITH QMB	416,017.41	417,094.59	418,032.84	531,062.49	537,484.36	544,163.44	546,059.45	547,936.34	551,624.15	553,051.70	0.00	0.00		5,062,526.77		
212Z	SSI AGED WITH QMB P	0.00	0.00	0.00	496.85	358.23	141.56	0.00	0.00	0.00	0.00	0.00	0.00		996.64		
	P																
2200	SSI DISABLED WITH M	71,832.38	71,039.81	71,388.26	101,638.41	102,480.35	104,692.91	106,551.83	104,513.10	103,712.57	103,671.10	0.00	0.00		941,520.72		
	E																
220Z	SSI DISABLED WITH M	0.00	0.00	0.00	453.31	284.55	129.97	0.00	0.00	0.00	0.00	0.00	0.00		867.83		
	E																
2210	SSI DISABLED NON-ME	497,259.09	498,233.77	498,770.01	756,361.99	761,835.25	765,902.85	766,931.14	768,836.62	769,710.64	770,148.49	0.00	0.00		6,853,989.85		
	D																
221Z	SSI DISABLED NON-ME	0.00	0.00	0.00	348.14	389.54	168.69	0.00	0.00	0.00	0.00	0.00	0.00		906.37		
	D																
2220	SSI DISABLED WITH Q	283,547.52	283,698.51	284,153.29	435,345.08	437,311.49	437,272.75	436,316.84	435,924.03	436,018.80	435,807.67	0.00	0.00		3,905,395.98		
	M																
222Z	SSI DISABLED WITH Q	0.00	0.00	0.00	351.51	266.24	166.52	0.00	0.00	0.00	0.00	0.00	0.00		784.27		
	M																
2300	SSI BLIND WITH MEDIC	317.64	326.43	351.60	487.51	495.43	495.43	559.18	495.20	470.01	460.31	0.00	0.00		4,458.74		
2310	SSI BLIND NON-MEDIC	4,496.64	4,503.52	4,523.15	6,167.70	6,214.50	6,253.45	6,284.32	6,170.53	6,235.34	6,221.58	0.00	0.00		57,070.73		
	A																
231Z	SSI BLIND NON-MEDIC	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		
	A																
2320	SSI BLIND WITH QMB	2,450.94	2,435.37	2,451.75	3,187.52	3,205.02	3,224.07	3,193.20	3,131.23	3,104.15	3,139.04	0.00	0.00		29,522.29		
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	5.84	5.01	5.01	9.19	0.00	0.00	0.00		74.12		
4303	SOBRA CHILD 06-13 M	10.96	17.80	21.90	12.54	12.54	12.54	8.36	12.54	12.54	9.19	0.00	0.00		130.91		
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	56,250.24	55,622.88	54,630.25	53,565.28	52,701.63	0.00	0.00		562,257.61		
4312	SOBRA CHILD 01-05 M	307,647.78	309,622.43	311,363.75	314,613.62	316,789.46	320,875.62	323,045.86	325,161.94	327,917.07	329,466.56	0.00	0.00		3,186,504.09		
4313	SOBRA CHILD 06-13 M	405,453.91	406,204.52	409,021.56	408,771.56	410,246.50	411,590.27	413,259.55	414,831.92	417,000.08	418,413.56	0.00	0.00		4,114,793.43		
4314	SOBRA CHILD 14-20 MA	207,687.12	208,776.60	211,648.39	252,887.94	254,602.57	256,859.10	258,428.32	259,859.37	261,182.75	263,663.40	0.00	0.00		2,435,595.56		
4315	SOBRA CHILD 14-20 FE	211,543.83	211,668.46	213,887.32	255,979.41	256,333.27	256,440.95	257,950.25	259,201.50	262,078.31	263,606.80	0.00	0.00		2,448,690.10		
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	5.84	0.00	0.00	0.00	0.00	0.00	0.00		15.00		
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	26.71	20.84	14.20	0.00	0.00	0.00	0.00	0.00	0.00		61.75		
431D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	121.49	88.34	53.19	0.00	0.00	0.00	0.00	0.00	0.00		263.02		
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	0.83	0.83	0.83	0.83	0.83	0.00	0.00		9.89		
4323	SOBRA CHILD 06-13 M	2.72	5.46	1.36	0.00	0.83	0.83	0.83	0.83	0.83	0.83	0.00	0.00		14.52		
4324	SOBRA CHILD 14-20 MA	0.00	0.00	2.74	0.00	0.71	0.00	0.00	0.83	0.83	0.83	0.00	0.00		5.94		
4325	SOBRA CHILD 14-20 FE	25.85	27.32	27.37	28.07	28.07	28.07	33.04	33.04	33.04	33.04	0.00	0.00		296.91		
5005	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	25.19	25.19	0.00	0.00	0.00	0.00	0.00	0.00		50.38		
	M																
5007	SOBRA PREG 21-44 FE	258.87	206.55	285.24	272.73	265.04	278.64	270.72	245.76	224.59	214.66	0.00	0.00		2,522.80		
	M																
500G	SOBRA PREG 21-44 FE	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		
	M																

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 FE	4.19	4.30	7.13	3.79	3.08	2.37	10.73	6.55	7.38	11.44	0.00	0.00		60.96		
	M																
5015	SOBRA PREG 14-20 FE	21,816.24	21,187.06	20,711.01	25,710.00	25,229.18	24,362.07	23,775.98	23,587.80	23,350.18	23,555.01	0.00	0.00		233,284.53		
	M																
5017	SOBRA PREG 21-44 FE	146,781.51	144,124.83	144,011.01	189,108.61	188,191.29	183,386.68	179,834.07	178,426.69	175,404.36	173,334.25	0.00	0.00		1,702,603.30		
	M																
5018	SOBRA PREG 45-64 FE	448.26	457.05	462.63	594.53	555.74	563.89	602.45	642.90	621.73	645.26	0.00	0.00		5,594.44		
	M																
501E	SOBRA PREG 14-20 FE	0.00	0.00	0.00	38.79	25.90	11.59	0.00	0.00	0.00	0.00	0.00	0.00		76.28		
	M																
501G	SOBRA PREG 21-44 FE	0.00	0.00	0.00	63.75	58.07	50.38	0.00	0.00	0.00	0.00	0.00	0.00		172.20		
	M																
5025	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	11.59	0.00	0.00	0.00	0.00	0.00		11.59		
	M																
5027	SOBRA PREG 21-44 FE	256.44	270.03	286.83	383.77	368.51	378.09	364.72	401.62	399.26	368.39	0.00	0.00		3,477.66		
	M																
5028	SOBRA PREG 45-64 FE	17.58	17.58	17.58	46.48	46.48	60.08	46.48	46.48	46.48	46.48	0.00	0.00		391.70		
	M																
502G	SOBRA PREG 21-44 FE	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		
	M																
SUBTOTAL:	4,579,833.46	4,609,412.17	4,631,258.29	5,920,849.65	5,921,433.13	5,943,092.62	5,962,836.02	5,995,580.45	6,020,324.71	6,045,382.06	0.00	0.00		55,630,002.56		

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

54.16

54.16

1106	TANF EXPANDED 21-44	1,918.77	1,901.97	1,925.55	2,823.15	2,929.47	2,942.72	2,975.95	2,964.01	3,018.64	3,069.14	0.00	0.00	
1107	TANF EXPANDED 21-44	3,377.31	3,350.52	3,346.14	5,159.34	5,355.42	5,297.35	5,250.29	5,199.45	5,150.85	5,263.31	0.00	0.00	
1108	TANF EXPANDED 45-64	11,446.20	11,088.69	11,155.77	16,201.76	16,457.80	16,785.16	16,800.41	16,548.63	16,699.67	16,972.86	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	7,541.79	7,727.49	7,848.15	9,923.38	10,141.48	10,381.44	10,653.94	10,222.61	10,273.22	10,481.27	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	36.78	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	38.79	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	11.56	18.97	6.55	5.72	5.72	0.00	0.00	
1114	TANF EXPANDED 14-20	2,137.89	2,183.40	2,235.41	2,827.86	2,904.86	2,790.97	2,663.24	2,732.90	2,801.86	2,842.20	0.00	0.00	
1115	TANF EXPANDED 14-20	12,100.24	12,246.55	12,634.78	17,051.57	17,132.72	17,511.47	17,218.03	16,725.02	16,948.50	16,658.85	0.00	0.00	
1116	TANF EXPANDED 21-44	238,739.25	239,841.90	245,166.93	324,012.20	332,026.34	334,575.82	336,703.49	336,805.91	339,445.16	338,690.71	0.00	0.00	
1117	TANF EXPANDED 21-44	652,361.52	654,421.89	666,647.64	902,331.72	928,880.45	937,420.72	945,367.81	950,784.78	955,933.07	955,290.60	0.00	0.00	
1118	TANF EXPANDED 45-64	233,628.21	234,349.74	240,186.39	317,094.08	321,240.45	321,165.20	324,290.66	326,296.12	327,893.67	328,335.53	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	980.31	989.88	1,027.02	1,354.52	1,462.97	1,449.37	1,555.81	1,495.50	1,592.71	1,602.29	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	42.46	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	38.79	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	
1125	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.59	11.59	11.59	0.00	0.00	

26,469.37	
46,749.98	
150,156.95	
95,194.77	
13.60	
81.60	
120.04	
114.13	
2.19	
95.68	
26,120.59	
156,227.73	
3,066,007.71	
8,549,440.20	
2,974,480.05	
13,510.38	
38.56	
422.14	
520.89	
116.37	
13.60	
34.77	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1126	TANF EXPANDED 21-44	5,821.38	5,882.04	5,927.94	8,514.05	8,680.22	8,694.28	8,804.74	8,981.92	9,005.45	8,969.71	0.00	0.00		79,281.73		
1127	TANF EXPANDED 21-44	12,463.98	12,562.26	12,708.45	19,888.76	19,782.09	20,007.37	20,037.39	20,156.01	20,146.08	20,138.28	0.00	0.00		177,890.67		
1128	TANF EXPANDED 45-64	23,018.61	23,289.18	23,649.48	34,074.12	34,088.57	34,304.63	34,424.67	34,493.88	35,126.61	35,166.37	0.00	0.00		311,636.12		
1129	TANF EXPANDED 65+ M	17,478.51	17,974.95	18,052.89	22,905.63	23,319.33	23,280.08	23,530.79	23,905.79	24,154.53	24,409.26	0.00	0.00		219,011.76		
	&																
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	25.19	0.00	0.00	0.00	0.00	0.00	0.00		113.78		
112J	TANF EXPANDED 65+ M	0.00	0.00	0.00	63.98	23.18	11.59	0.00	0.00	0.00	0.00	0.00	0.00		98.75		
	&																
2400	SSI AGED EXPANDED	2,198.04	2,297.10	2,639.49	4,168.98	4,391.33	4,527.09	4,551.82	4,465.85	4,338.93	4,458.97	0.00	0.00		38,037.60		
	WI																
240Z	SSI AGED EXPANDED	0.00	0.00	0.00	145.23	164.51	50.38	0.00	0.00	0.00	0.00	0.00	0.00		360.12		
	WI																
2410	SSI AGED EXPANDED N	1,276.38	1,223.25	1,200.45	1,622.77	1,717.73	1,733.46	1,702.36	1,851.49	1,830.32	1,886.73	0.00	0.00		16,044.94		
	O																
2420	SSI AGED EXPANDED	256,763.58	259,681.14	261,436.05	344,322.99	349,311.72	355,036.79	358,708.18	361,369.20	364,925.64	368,193.05	0.00	0.00		3,279,748.34		
	WI																
242Z	SSI AGED EXPANDED	0.00	0.00	0.00	396.44	373.14	164.39	0.00	0.00	0.00	0.00	0.00	0.00		933.97		
	WI																
2520	SSI BLIND EXPANDED	17.58	17.58	17.58	27.20	27.20	27.20	27.20	13.60	13.60	13.60	0.00	0.00		202.34		
	W																
2600	SSI DISABLED EXPAND	2,905.74	2,871.84	2,794.77	4,695.85	4,641.21	5,003.69	5,250.53	4,890.86	4,759.46	5,340.59	0.00	0.00		43,154.54		
	E																
260Z	SSI DISABLED EXPAND	0.00	0.00	0.00	274.97	166.52	96.86	0.00	0.00	0.00	0.00	0.00	0.00		538.35		
	E																
2610	SSI DISABLED EXPAND	13,819.14	13,651.29	13,377.27	17,933.85	18,215.56	18,111.74	18,081.33	18,301.89	17,998.68	18,580.76	0.00	0.00		168,071.51		
	E																
261Z	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	11.59	0.00	0.00	0.00	0.00	0.00	0.00		11.59		
	E																
2620	SSI DISABLED EXPAND	117,410.01	118,277.28	118,655.28	202,018.14	202,902.19	204,950.71	205,775.15	207,273.80	208,057.78	206,624.93	0.00	0.00		1,791,945.27		
	E																
262Z	SSI DISABLED EXPAND	0.00	0.00	0.00	193.37	136.62	77.58	0.00	0.00	0.00	0.00	0.00	0.00		407.57		
	E																
SUBTOTAL:	1,617,412.73	1,625,838.23	1,652,643.08	2,260,835.20	2,307,181.66	2,326,603.22	2,344,392.76	2,355,497.36	2,370,131.74	2,373,006.32	0.00	0.00		21,233,542.30		

3506	ADULT 40-100% MALE 2	128.22	156.18	179.76	321.56	294.71	307.96	321.56	360.35	366.03	348.53	0.00	0.00	
3507	ADULT 40-100% FEMAL E	97.86	115.44	118.23	170.19	189.47	185.80	251.79	267.05	288.57	313.76	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	2,524.57	3,932.67	3,481.84	2,748.58	3,375.40	0.00	0.00	
3509	ADULT 40-100% M&F 65	817.35	817.77	988.38	1,451.78	1,616.52	1,825.38	1,928.50	1,947.43	2,194.62	2,411.06	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	75,766.28	75,590.97	76,042.91	76,228.86	77,853.84	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	81,603.08	82,031.39	81,775.93	82,213.38	83,955.48	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	312,218.53	323,098.21	329,335.77	334,625.20	339,068.81	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	259,377.16	265,130.39	270,620.70	273,199.53	275,947.56	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	505,132.40	514,867.19	520,340.98	523,016.16	525,457.38	0.00	0.00	
3519	ADULT 40-100% M&F 65	54.33	71.91	59.13	88.94	98.52	75.34	63.75	69.66	73.33	112.12	0.00	0.00	
351D	ADULT 40-100% MALE 1	0.00	0.00	0.00	61.74	34.54	27.20	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	274.97	0.00	0.00	0.00	0.00	0.00	0.00	

2,784.86	
1,998.16	
27,615.81	
15,998.79	
19.28	
696,631.31	
746,121.10	
2,814,221.65	
2,336,216.68	
4,626,726.66	
767.03	
123.48	
36.55	
2,181.91	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351G	ADULT 40-100% FEMAL	0.00	0.00	0.00	453.66	253.22	124.06	0.00	0.00	0.00	0.00	0.00	0.00		830.94		
	E																
351H	ADULT 40-100% M&F 45	0.00	0.00	0.00	443.85	342.62	149.13	0.00	0.00	0.00	0.00	0.00	0.00		935.60		
3524	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	13.60	13.60	13.60	13.60	13.60	0.00	0.00		68.00		
3526	ADULT 40-100% MALE 2	31.95	20.37	20.37	38.79	61.97	50.38	50.38	25.19	38.79	38.79	0.00	0.00		376.98		
3527	ADULT 40-100% FEMAL	4.80	4.80	0.00	13.60	25.19	38.79	38.79	27.20	27.20	13.60	0.00	0.00		193.97		
	E																
3528	ADULT 40-100% M&F 45	88.29	94.29	121.44	243.87	269.29	365.80	315.77	302.17	366.15	377.74	0.00	0.00		2,544.81		
3529	ADULT 40-100% M&F 65	22.38	38.76	42.75	60.08	88.94	92.96	110.23	185.45	185.80	185.80	0.00	0.00		1,013.15		
352G	ADULT 40-100% FEMAL	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		
	E																
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	897.51	891.83	928.61	878.23	930.39	0.00	0.00		7,834.51		
3707	ADULT <40% EXP FEMA	141.84	170.19	158.61	366.04	463.13	509.84	564.24	544.96	599.36	631.66	0.00	0.00		4,149.87		
	L																
3708	ADULT <40% EXP M&F	2,051.13	2,017.17	2,270.01	4,031.38	4,244.49	4,313.07	5,029.65	4,982.35	4,986.99	5,609.12	0.00	0.00		39,535.36		
	4																
3709	ADULT <40% EXP M&F	298.02	381.51	410.67	594.18	650.47	648.23	644.56	713.99	671.53	810.50	0.00	0.00		5,823.66		
	6																
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	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		
	4																
3714	ADULT <40% EXP MALE	108,326.43	110,706.57	112,937.91	149,401.97	152,045.44	154,032.59	156,959.54	159,823.42	161,730.18	165,183.28	0.00	0.00		1,431,147.33		
3715	ADULT <40% EXP FEMA	99,812.34	101,749.14	105,598.59	140,735.20	142,422.53	143,758.44	145,412.61	147,653.60	149,033.50	152,697.23	0.00	0.00		1,328,873.18		
	L																
3716	ADULT <40% EXP MALE	766,708.20	780,770.91	794,516.55	1,094,785.41	1,105,414.67	1,115,953.73	1,137,986.61	1,159,352.92	1,173,562.46	1,201,804.70	0.00	0.00		10,330,856.16		
3717	ADULT <40% EXP FEMA	440,857.62	449,652.90	458,141.52	638,474.33	642,157.28	646,596.67	658,106.09	668,265.97	675,335.49	690,474.95	0.00	0.00		5,968,062.82		
	L																
3718	ADULT <40% EXP M&F	832,800.54	843,593.64	853,079.10	1,162,060.67	1,168,879.77	1,174,652.74	1,191,675.52	1,206,427.92	1,215,771.31	1,236,576.27	0.00	0.00		10,885,517.48		
	4																
3719	ADULT <40% EXP M&F	52.74	55.53	35.16	73.68	54.40	54.40	58.07	75.34	96.86	125.72	0.00	0.00		681.90		
	6																
371D	ADULT <40% EXP MALE	0.00	0.00	0.00	214.89	195.73	63.75	0.00	0.00	0.00	0.00	0.00	0.00		474.37		
371E	ADULT <40% EXP FEMA	0.00	0.00	0.00	65.99	50.38	36.78	0.00	0.00	0.00	0.00	0.00	0.00		153.15		
	L																
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	2,612.12	2,613.81	1,108.73	0.00	0.00	0.00	0.00	0.00	0.00		6,334.66		
371G	ADULT <40% EXP FEMA	0.00	0.00	0.00	1,103.33	1,058.79	371.83	0.00	0.00	0.00	0.00	0.00	0.00		2,533.95		
	L																
371H	ADULT <40% EXP M&F	0.00	0.00	0.00	1,459.06	1,353.25	501.45	0.00	0.00	0.00	0.00	0.00	0.00		3,313.76		
	4																
3726	ADULT <40% EXP MALE	49.53	83.49	83.49	151.26	147.24	188.04	166.52	180.12	261.72	254.03	0.00	0.00		1,565.44		
3727	ADULT <40% EXP FEMA	42.75	51.54	63.12	98.52	81.25	69.66	83.26	44.47	63.75	50.15	0.00	0.00		648.47		
	L																
3728	ADULT <40% EXP M&F	266.07	384.72	335.19	601.87	684.90	706.42	725.70	673.66	780.10	789.45	0.00	0.00		5,948.08		
	4																
3729	ADULT <40% EXP M&F	0.00	0.00	25.17	30.87	30.87	38.79	61.97	42.46	36.78	48.37	0.00	0.00		315.28		
	6																
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	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		
	4																
SUBTOTAL:	3,067,661.76	3,117,048.27	3,182,208.15	4,367,087.95	4,437,166.94	4,484,656.06	4,566,111.36	4,634,506.02	4,679,394.06	4,765,459.29	0.00	0.00		41,301,299.86		

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

26.37

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3905	NEWLY ELIGIBLE FEMA	0.00	11.58	11.58	27.20	27.20	40.80	40.80	0.00	0.00	0.00	0.00	0.00		159.16		
	L																
3906	NEWLY ELIGIBLE MALE	308.43	407.49	404.28	895.15	1,117.15	1,240.75	1,308.52	1,052.83	1,151.70	1,173.22	0.00	0.00		9,059.52		
3907	NEWLY ELIGIBLE FEMA	217.29	258.84	306.39	634.63	750.77	746.87	834.15	741.31	840.41	875.18	0.00	0.00		6,205.84		
	L																
3908	NEWLY ELIGIBLE M&F	6,100.62	7,320.66	8,082.60	12,967.30	14,144.57	15,680.88	16,820.41	15,681.59	16,460.02	17,258.68	0.00	0.00		130,517.33		
	4																
3909	NEWLY ELIGIBLE M&F	3,880.74	4,533.12	5,770.68	8,561.31	10,218.86	11,887.08	13,513.52	11,560.41	12,816.58	13,707.36	0.00	0.00		96,449.66		
	6																
390H	NEWLY ELIGIBLE M&F	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		
	4																
3914	NEWLY ELIGIBLE MALE	41,282.46	44,627.58	46,656.78	67,833.98	71,410.86	75,811.06	79,966.18	82,945.28	86,195.58	85,163.09	0.00	0.00		681,892.85		
3915	NEWLY ELIGIBLE FEMA	44,199.27	48,238.71	49,500.84	72,022.58	75,448.88	80,355.82	84,785.22	88,689.11	91,906.48	90,215.72	0.00	0.00		725,362.63		
	L																
3916	NEWLY ELIGIBLE MALE	205,392.54	222,209.34	230,776.62	331,475.21	351,343.98	370,896.26	390,728.69	407,319.81	424,066.83	427,835.94	0.00	0.00		3,362,045.22		
3917	NEWLY ELIGIBLE FEMA	285,434.55	307,647.78	321,376.26	462,680.43	494,429.75	523,937.52	555,626.34	574,456.27	596,530.52	607,177.83	0.00	0.00		4,729,297.25		
	L																
3918	NEWLY ELIGIBLE M&F	280,711.11	296,004.21	303,941.64	420,095.77	438,924.09	455,813.65	475,338.08	490,644.51	505,546.24	507,967.96	0.00	0.00		4,174,987.26		
	4																
3919	NEWLY ELIGIBLE M&F	288.48	369.18	439.08	729.95	773.72	914.82	1,071.41	1,168.27	1,185.54	1,274.71	0.00	0.00		8,215.16		
	6																
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	0.00	0.00	0.00	5.68	5.68	11.59	0.00	0.00	0.00	0.00	0.00	0.00		22.95		
	L																
391F	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	283.16	194.34	77.58	0.00	0.00	0.00	0.00	0.00	0.00		555.08		
391G	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	119.35	109.65	44.47	0.00	0.00	0.00	0.00	0.00	0.00		273.47		
	L																
391H	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	138.51	115.33	61.97	0.00	0.00	0.00	0.00	0.00	0.00		315.81		
	4																
3926	NEWLY ELIGIBLE MALE	0.00	8.79	8.79	25.19	13.60	13.60	25.19	11.59	11.59	25.19	0.00	0.00		143.53		
3927	NEWLY ELIGIBLE FEMA	11.58	11.58	11.58	11.59	11.59	11.59	11.59	25.19	38.79	25.19	0.00	0.00		170.27		
	L																
3928	NEWLY ELIGIBLE M&F	171.78	152.22	97.08	110.46	121.82	164.63	127.27	154.47	218.22	194.69	0.00	0.00		1,512.64		
	4																
3929	NEWLY ELIGIBLE M&F	160.17	202.92	258.06	392.77	487.97	533.87	539.78	636.64	725.58	764.02	0.00	0.00		4,701.78		
	6																
SUBTOTAL:	868,176.60	932,012.79	967,642.26	1,379,029.50	1,459,649.81	1,538,244.81	1,620,737.15	1,675,087.28	1,737,694.08	1,753,658.78	0.00	0.00		13,931,933.06		

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	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	0.00	0.00	0.00	0.83	0.83	0.83	0.83	0.00	0.00	
4412	SOBRA 100-133% M&F
1	4.10	2.74	2.74	4.18	5.01	5.01	4.18	4.18	4.18	5.01	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	75,327.09	75,963.38	76,443.87	77,402.79	77,721.59	0.00	0.00	
4414	SOBRA 100-133% MALE	39,394.30	40,697.82	40,945.35	50,269.37	51,430.63	52,160.95	53,498.52	53,811.06	54,985.05	56,168.95	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	51,047.72	51,651.85	52,235.01	52,670.71	54,066.42	0.00	0.00	
441C	SOBRA 100-133% M&F
6	0.00	0.00	0.00	1.66	5.84	4.18	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	
4423	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.83	0.83	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	2.83	1.54	0.83	1.54	1.54	1.54	1.54	1.54	0.00	0.00	
SUBTOTAL:	148,768.42	153,231.03	154,165.37	172,918.03	176,282.12	178,546.49	181,120.30	182,497.32	185,065.93	187,964.34	0.00	0.00	

9.58	
2.94	
3.32	
41.33	
747,194.11	
493,362.00	
479,912.33	
11.68	
3.32	
4.18	
1.66	
12.90	
1,720,559.35	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4517	BC PATIENT FEMALE 2	201.75	187.38	178.59	249.55	237.96	237.96	251.56	265.16	216.79	238.31	0.00	0.00		2,265.01		
	1																
4518	BC PATIENT FEMALE 4	1,239.21	1,274.37	1,203.27	1,544.23	1,557.83	1,577.11	1,547.67	1,562.93	1,524.14	1,506.29	0.00	0.00		14,537.05		
	5																
4519	BC PATIENT FEMALE 6	0.00	8.79	8.79	13.60	13.60	13.60	13.60	13.60	27.20	38.79	0.00	0.00		151.57		
	5																
451H	BC PATIENT FEMALE 4	0.00	0.00	0.00	38.79	38.79	27.20	0.00	0.00	0.00	0.00	0.00	0.00		104.78		
	5																
451J	BC PATIENT FEMALE 6	0.00	0.00	0.00	24.96	48.14	59.73	0.00	0.00	0.00	0.00	0.00	0.00		132.83		
	5																
4617	CC PATIENT FEMALE 2	31.17	26.37	26.37	54.40	65.99	65.99	65.99	65.99	71.67	71.67	0.00	0.00		545.61		
	1																
4618	CC PATIENT FEMALE 4	90.27	90.27	78.69	91.18	91.18	77.58	77.58	65.99	65.99	65.99	0.00	0.00		794.72		
	5																
SUBTOTAL:	1,562.40	1,587.18	1,495.71	2,016.71	2,053.49	2,059.17	1,956.40	1,973.67	1,905.79	1,921.05	0.00	0.00		18,531.57		

8600	SSI BLIND FREEDOM/W O	8.79	8.79	8.79	13.60	13.60	13.60	13.60	13.60	13.60	13.60	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	13.60	13.60	13.60	13.60	13.60	13.60	0.00	0.00	
8620	SSI BLIND FREEDOM/W O	11.58	11.58	11.58	11.59	11.59	11.59	11.59	11.59	11.59	11.59	0.00	0.00	
8700	SSI DISABLED FREEDO
M	15,056.52	15,234.33	15,259.50	28,097.70	28,228.75	28,375.29	28,482.08	28,126.59	28,277.84	28,423.07	0.00	0.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	85.27	69.66	13.60	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	4,507.62	4,525.24	4,616.42	4,633.81	4,757.64	0.00	0.00	
8720	SSI DISABLED FREEDO M	2,895.96	3,145.26	3,171.21	6,119.61	6,203.22	6,180.04	6,174.82	6,244.82	6,398.20	6,753.34	0.00	0.00	
872Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	13.60	0.00	5.68	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	39,121.02	39,220.93	39,026.62	39,348.64	39,972.84	0.00	0.00	

121.57	
81.60	
115.87	
243,561.67	
168.53	
41,055.39	
53,286.48	
19.28	
338,410.39	

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.71	0.00	0.00	0.00	0.00	
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.13	0.00	0.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	11.59	11.59	11.59	11.59	25.19	25.19	25.19	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	13.60	13.60	13.60	27.20	27.20	27.20	13.60	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	25.19	25.19	25.19	38.79	55.23	52.39	38.79	0.00	0.00	

0.71	
2.13	
121.93	
136.00	
260.77	

134,174,594.02

10,304,406.49	10,460,508.78	10,610,859.44	14,141,628.82	14,342,855.04	14,512,354.26	14,716,419.39	14,884,229.63	15,033,923.02	15,167,409.15	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending April 30, 2021

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 April 30, 2021

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 April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5013	SOBRA PREG 09-13 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																
5015	SOBRA PREG 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		
	M																
5017	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																
5018	SOBRA PREG 45-64 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																
501E	SOBRA PREG 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		
	M																
501G	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																
5025	SOBRA PREG 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		
	M																
5027	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																
5028	SOBRA PREG 45-64 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																
502G	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																
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

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	

1125	&
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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

1107

TANF EXPANDED 21-44

TANF EXPANDED 21-44

Current and

0.00

0.00

0.00

0.00

0.00

prior m

0.00

0.00

0.00

0.00

onth

0.00

0.00

data is

0.00

0.00

0.00

0.00

under re

0.00

0.00

0.00

0.00

visio

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

n.

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 April 30, 2021

RATE CODE	DESCRIPTION 1126	TANF EXPANDED 21-44
1127	TANF EXPANDED 21-44

1128	TANF EXPANDED 45-64

1129	TANF EXPANDED 65+ M
&
112F	TANF EXPANDED 21-44

112G	TANF EXPANDED 21-44

112H	TANF EXPANDED 45-64

112J	TANF EXPANDED 65+ M
&
2400	SSI AGED EXPANDED
WI
240Z	SSI AGED EXPANDED
WI
2410	SSI AGED EXPANDED N
O
2420	SSI AGED EXPANDED
WI
242Z	SSI AGED EXPANDED
WI
2520	SSI BLIND EXPANDED
W
2600	SSI DISABLED EXPAND
E

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

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

n. 0.00	0.00

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

2610

261Z

2620

262Z

SSI DISABLED EXPAND E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
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:

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	

0.00	
0.00	
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 April 30, 2021

RATE CODE	DESCRIPTION 351G	ADULT 40-100% FEMAL
E
351H	ADULT 40-100% M&F 45

3524	ADULT 40-100% MALE 1

3526	ADULT 40-100% MALE 2

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

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

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

370F	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

370H

3714

3715

3716

3717

3718

3719

371D

371E

371F

371G

371H

3726

3727

3728

3729

372F

372H

ADULT <40% EXP M&F 4
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 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

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 April 30, 2021

RATE CODE	DESCRIPTION 3905	NEWLY ELIGIBLE FEMA
L
3906	NEWLY ELIGIBLE MALE

3907	NEWLY ELIGIBLE FEMA
L
3908	NEWLY ELIGIBLE M&F
4
3909	NEWLY ELIGIBLE M&F
6
390H	NEWLY ELIGIBLE M&F
4
3914	NEWLY ELIGIBLE MALE

3915	NEWLY ELIGIBLE FEMA
L
3916	NEWLY ELIGIBLE MALE

3917	NEWLY ELIGIBLE FEMA
L
3918	NEWLY ELIGIBLE M&F
4
3919	NEWLY ELIGIBLE M&F
6
391D	NEWLY ELIGIBLE MALE

391E	NEWLY ELIGIBLE FEMA
L

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

391F	NEWLY ELIGIBLE MALE

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

391G

391H

3926

3927

3928

3929

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

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE M&F
4
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

0.00

SUBTOTAL:

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	
4411	SOBRA 100-133% 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	
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	
4423	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	
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	
0.00	
0.00	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4517	BC PATIENT FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	1																
4518	BC PATIENT FEMALE 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		
	5																
4519	BC PATIENT FEMALE 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		
	5																
451H	BC PATIENT FEMALE 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		
	5																
451J	BC PATIENT FEMALE 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		
	5																
4617	CC PATIENT FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	1																
4618	CC PATIENT FEMALE 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		
	5																
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	

Current and prior month data is under revision.

6012	KIDS 1-5 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	
6013	KIDS 6-13 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	
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	

0.00	
0.00	
0.00	
0.00	
0.00	

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

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	5,139.24	25.08	2,280.53	7,271.27	5,114.85	0.00	0.00		45,342.77		
1007	TANF 21-44 FEMALE WI	2,399.61	2,476.68	1,470.45	963.42	926.19	1,240.67	3,202.07	4,214.92	5,426.60	2,491.84	0.00	0.00		24,812.45		
1008	TANF 45-64 M & F WIT	16,050.19	2,693.87	9,242.22	6,204.84	6,251.59	26,974.95	9,564.18	16,283.21	21,121.20	1,936.08	0.00	0.00		116,322.33		
1009	TANF 65+ M & F WITH	3,934.85	3,443.16	8,365.71	8,977.18	703.15	2,959.33	4,514.39	11,939.33	14,419.43	3,536.71	0.00	0.00		62,793.24		
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	888,414.66	820,496.01	916,769.85	1,310,707.19	958,559.08	0.00	0.00		10,151,490.27		
1012	TANF 01-05 M & F NON	302,488.54	183,924.52	319,614.33	276,361.86	211,619.30	106,290.99	104,016.65	183,108.56	391,002.31	213,232.65	0.00	0.00		2,291,659.71		
1013	TANF 06-13 M & F NON	442,447.04	357,697.74	470,463.34	388,182.19	350,844.29	209,619.27	187,355.77	319,399.34	743,937.31	376,864.28	0.00	0.00		3,846,810.57		
1014	TANF 14-20 MALE NON-	179,326.07	115,950.93	147,569.55	177,009.38	140,974.44	134,866.24	100,669.05	163,669.46	287,128.70	209,099.65	0.00	0.00		1,656,263.47		
1015	TANF 14-20 FEMALE N	403,238.79	280,105.48	400,421.58	369,405.06	424,042.24	370,706.23	205,193.79	321,388.13	643,569.38	423,487.20	0.00	0.00		3,841,557.88		
	O																
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	2,169,796.22	1,675,986.27	2,631,276.17	4,026,392.03	2,898,661.29	0.00	0.00		24,669,202.97		
1017	TANF 21-44 FEMALE N	8,152,997.95	6,589,523.27	7,909,860.92	6,956,770.12	6,614,624.36	5,931,845.11	4,791,264.81	8,299,460.92	14,360,533.80	8,232,046.65	0.00	0.00		77,838,927.91		
	O																
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	2,373,897.28	2,031,740.46	3,633,068.30	6,899,827.40	3,897,121.22	0.00	0.00		35,725,523.87		
1019	TANF 65+ M & F NON-M	17,787.96	12,713.74	17,492.62	26,877.72	23,881.53	24,530.81	19,291.97	14,775.19	34,382.55	16,082.68	0.00	0.00		207,816.77		
1026	TANF 21-44 MALE WITH	958.00	0.00	8,171.26	8,540.70	0.00	24.63	0.00	998.00	1,104.60	0.00	0.00	0.00		19,797.19		
1027	TANF 21-44 FEMALE WI	3.40	0.00	0.00	0.00	147.37	816.51	24.00	2,299.41	6,005.80	1,422.26	0.00	0.00		10,718.75		
1028	TANF 45-64 M & F WIT	16,080.90	3,050.13	15,165.34	9,217.35	6,136.86	7,386.95	1,435.57	6,913.49	22,309.74	10,927.72	0.00	0.00		98,624.05		
1029	TANF 65+ M & F WITH	3,044.78	2,956.97	2,415.26	7,334.78	5,687.96	3,296.14	6,759.53	8,902.01	9,662.01	3,500.53	0.00	0.00		53,559.97		
2100	SSI AGED WITH MEDIC	194,486.50	175,951.46	235,250.41	146,935.14	151,740.99	147,519.73	80,963.24	214,109.30	312,950.91	188,375.05	0.00	0.00		1,848,282.73		
	A																
2110	SSI AGED NON-MEDICA	391,217.59	195,742.50	293,734.14	194,552.87	317,396.37	169,183.82	202,887.61	694,927.99	723,088.01	505,142.82	0.00	0.00		3,687,873.72		
	R																
2120	SSI AGED WITH QMB	766,999.79	502,596.08	788,594.23	648,763.75	704,020.99	608,714.29	367,078.80	811,495.51	1,527,672.40	691,651.53	0.00	0.00		7,417,587.37		
2200	SSI DISABLED WITH M	607,153.39	552,267.62	628,213.48	501,317.00	479,718.70	553,869.13	418,295.30	610,721.62	1,111,518.09	484,996.81	0.00	0.00		5,948,071.14		
	E																
2210	SSI DISABLED NON-ME	12,335,676.27	9,169,869.59	11,995,340.00	10,537,334.58	9,042,453.48	8,305,525.03	5,375,811.50	10,089,561.79	18,261,792.39	10,683,205.56	0.00	0.00		105,796,570.19		
	D																
2220	SSI DISABLED WITH Q	1,793,601.32	1,226,778.38	1,898,431.16	1,578,101.37	1,438,425.90	1,526,555.48	1,037,911.37	1,655,300.71	3,083,235.05	1,528,508.70	0.00	0.00		16,766,849.44		
	M																
2300	SSI BLIND WITH MEDIC	1,608.24	673.68	2,512.83	3,636.12	1,795.27	-1,189.01	12,217.27	5,649.92	7,425.46	1,233.84	0.00	0.00		35,563.62		
2310	SSI BLIND NON-MEDIC	152,422.10	93,321.49	149,231.08	113,600.43	132,231.51	98,675.01	61,911.29	103,110.86	270,959.60	137,453.23	0.00	0.00		1,312,916.60		
	A																
2320	SSI BLIND WITH QMB	25,634.25	24,559.95	37,139.99	23,276.74	13,811.64	23,971.71	14,124.75	20,893.84	40,807.62	18,878.00	0.00	0.00		243,098.49		
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	2,131,120.56	1,229,050.02	1,466,970.73	2,801,861.85	1,772,825.29	0.00	0.00		20,822,986.28		
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	1,165,875.18	1,030,396.32	2,087,948.08	5,304,458.63	3,368,860.52	0.00	0.00		27,737,677.86		
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	2,827,113.43	2,059,107.70	3,973,291.08	7,866,739.12	5,048,929.06	0.00	0.00		43,372,636.25		
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	2,110,956.94	1,035,973.58	764,176.01	2,835,015.43	1,963,524.45	0.00	0.00		17,023,940.83		
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	1,614,852.44	1,443,861.45	2,123,566.92	3,971,581.38	2,482,330.90	0.00	0.00		21,212,345.43		
5007	SOBRA PREG 21-44 FE	0.00	-869.63	1,227.93	3,933.81	3,507.87	7,419.84	8,389.12	196.21	749.20	22,720.81	0.00	0.00		47,275.16		
	M																
5013	SOBRA PREG 09-13 FE	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		
	M																
5015	SOBRA PREG 14-20 FE	280,143.25	255,035.69	321,386.91	275,451.33	215,187.55	251,699.34	207,942.11	186,998.85	273,753.19	190,418.04	0.00	0.00		2,458,016.26		
	M																
5017	SOBRA PREG 21-44 FE	2,120,937.76	1,696,357.50	2,481,926.63	1,794,581.26	1,573,705.52	1,409,645.51	1,090,240.66	1,704,224.43	2,474,387.01	1,590,767.05	0.00	0.00		17,936,773.33		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	131.02	2,231.25	998.67	-613.62	-225.57	2,048.17	7,343.33	10,889.52	0.00	0.00		22,802.77		
	M																

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	21.44	0.00	0.00	0.00		254.13		
SUBTOTAL:	49,466,816.16	37,873,233.05	50,470,064.01	43,108,358.25	41,932,639.00	35,208,700.04	25,637,476.12	43,051,938.84	79,660,161.43	47,944,795.87	0.00	0.00		454,354,182.77		

1106	TANF EXPANDED 21-44	10,719.07	2,754.62	10,524.51	4,113.87	2,913.63	2,584.39	142.15	5,148.75	11,551.16	1,514.69	0.00	0.00	
1107	TANF EXPANDED 21-44	12,744.48	5,787.56	7,452.91	4,698.46	4,399.14	8,155.69	9,163.23	6,210.93	11,244.33	8,824.81	0.00	0.00	
1108	TANF EXPANDED 45-64	49,184.51	37,567.63	57,495.92	44,944.46	38,201.61	67,471.07	18,225.73	87,989.21	109,694.08	42,811.90	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	38,767.41	35,261.90	71,251.48	32,620.04	36,396.95	29,177.95	20,791.47	48,791.79	101,386.78	52,851.20	0.00	0.00	
1113	TANF EXPANDED 06-13	479.00	0.00	0.00	479.00	0.00	479.00	958.00	519.00	2,060.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	19,707.00	9,009.57	2,634.78	900.23	958.00	-201.46	-1,293.00	6,959.01	20,425.39	9,188.24	0.00	0.00	
1115	TANF EXPANDED 14-20	40,100.87	45,046.73	70,200.68	76,246.39	68,058.34	36,234.74	20,877.62	39,454.58	86,545.45	64,720.78	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	849,794.65	601,633.27	1,153,244.47	2,005,918.44	1,235,059.96	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	2,794,236.44	1,886,673.15	3,808,985.25	6,728,305.68	3,604,575.48	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	1,676,353.98	1,103,383.64	2,310,710.71	4,626,610.15	2,250,227.38	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	17,517.32	15,998.57	7,155.65	3,786.00	3,674.97	3,106.79	7,114.66	12,694.37	40,321.07	13,808.49	0.00	0.00	
1126	TANF EXPANDED 21-44	13,901.46	16,461.71	14,904.40	14,105.59	15,832.91	18,992.60	14,806.56	24,518.27	31,174.60	11,500.89	0.00	0.00	
1127	TANF EXPANDED 21-44	65,453.82	39,775.55	141,091.85	66,421.55	61,981.26	59,035.74	59,510.31	60,000.65	98,324.66	51,297.07	0.00	0.00	
1128	TANF EXPANDED 45-64	132,467.26	83,131.59	137,301.27	106,263.54	106,646.11	136,591.47	65,568.12	147,297.02	252,019.28	113,948.39	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	87,910.22	56,540.60	100,676.03	82,007.61	96,822.45	95,757.88	52,354.10	121,728.09	222,306.69	96,660.88	0.00	0.00	
2400	SSI AGED EXPANDED WI	20,666.39	20,877.98	22,604.08	27,197.38	22,731.64	10,994.73	11,619.09	21,801.45	27,386.68	11,109.45	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	6,038.01	10,782.48	24,732.73	54,374.35	32,892.19	0.00	0.00	
2420	SSI AGED EXPANDED WI	728,155.76	456,967.26	757,729.97	574,278.79	491,847.75	464,541.91	283,107.28	676,911.22	1,350,516.71	553,322.22	0.00	0.00	
2600	SSI DISABLED EXPAND
E	11,068.56	11,417.78	17,322.50	7,391.71	26,602.77	75,092.25	24,898.86	15,294.78	25,931.09	9,937.40	0.00	0.00	
2610	SSI DISABLED EXPAND E	325,985.77	103,184.75	130,458.74	236,797.14	90,254.57	24,601.18	145,655.16	200,595.42	311,700.12	101,636.70	0.00	0.00	
2620	SSI DISABLED EXPAND
E	453,609.45	306,446.97	571,061.51	490,368.08	395,860.73	457,988.09	258,073.44	495,856.09	884,354.29	485,746.71	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	6,817,027.10	4,594,045.32	9,269,443.79	17,002,151.00	8,751,634.83	0.00	0.00	

51,966.84	
78,681.54	
553,586.12	
467,296.97	
4,974.00	
68,287.76	
547,486.18	
10,933,818.21	
34,745,874.04	
22,598,368.94	
125,177.89	
176,198.99	
702,892.46	
1,281,234.05	
1,012,764.55	
196,988.87	
263,780.03	
6,337,378.87	
224,957.70	
1,670,869.55	
4,799,365.36	
86,841,948.92	

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	3,786.80	1,390.10	771.55	4,559.36	6,197.30	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	15,778.91	4,967.37	14,190.51	24,031.59	2,877.55	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	5,125.14	783.87	9,262.49	9,644.09	3,045.08	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	120,989.90	75,524.31	95,414.44	309,903.00	93,737.95	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	93,251.52	126,434.22	110,563.48	235,418.55	125,988.71	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	1,295,781.18	1,132,051.70	1,683,808.80	2,661,272.28	1,893,016.42	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	813,878.89	673,593.25	916,954.22	1,718,738.23	1,054,373.76	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	2,038,715.51	1,452,684.25	3,509,024.26	5,971,938.11	3,094,959.21	0.00	0.00	

17,561.87	
125,687.34	
50,007.68	
1,081,674.70	
1,301,460.17	
15,300,068.42	
9,884,594.17	
31,378,696.25	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	-1,922.04	-874.62	2,980.84	6,028.00	4,959.96	0.00	0.00		19,619.46		
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	6,311.32	8,008.81	4,195.61	1,144.41	100.56	0.00	0.00		54,063.67		
3706	ADULT <40% EXP MALE	862.07	537.53	4,219.43	2,641.24	5,047.04	843.15	-390.93	5,282.67	4,683.81	202.11	0.00	0.00		23,928.12		
3707	ADULT <40% EXP FEMA	5,201.56	3,370.01	606.76	0.00	0.00	-455.00	-409.86	1,176.51	1,790.57	2,080.25	0.00	0.00		13,360.80		
	L																
3708	ADULT <40% EXP M&F	7,945.68	7,604.64	52,277.89	20,799.69	32,882.50	4,577.73	1,443.98	60,550.30	50,681.10	11,730.41	0.00	0.00		250,493.92		
	4																
3709	ADULT <40% EXP M&F	697.97	500.67	84.98	169.42	479.00	25.10	-910.00	1,543.83	795.67	680.60	0.00	0.00		4,067.24		
	6																
3714	ADULT <40% EXP MALE	549,983.14	425,687.45	439,852.57	575,005.01	388,057.89	550,063.85	382,940.53	564,206.11	1,068,362.74	584,909.09	0.00	0.00		5,529,068.38		
3715	ADULT <40% EXP FEMA	476,422.20	362,759.11	530,706.67	563,869.62	525,585.88	457,547.30	392,331.63	604,632.79	1,066,281.77	708,225.55	0.00	0.00		5,688,362.52		
	L																
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	12,413,253.05	9,408,963.02	14,231,347.77	21,154,478.23	16,221,450.94	0.00	0.00		137,756,380.28		
3717	ADULT <40% EXP FEMA	6,400,827.19	5,817,880.47	7,144,686.24	6,548,974.08	5,707,235.04	5,404,310.89	4,266,551.89	6,169,426.02	10,462,095.48	7,820,122.74	0.00	0.00		65,742,110.04		
	L																
3718	ADULT <40% EXP M&F	16,215,570.02	12,524,194.77	18,122,144.94	13,020,323.85	12,771,869.49	12,388,581.53	9,108,021.10	17,192,136.22	28,269,425.81	17,869,637.76	0.00	0.00		157,481,905.49		
	4																
3719	ADULT <40% EXP M&F	3,519.78	106,471.32	2,050.43	645.01	1,059.46	2,227.52	631.77	3,223.30	12,712.66	4,315.74	0.00	0.00		136,856.99		
	6																
3726	ADULT <40% EXP MALE	455.00	479.00	958.00	0.00	0.00	0.00	479.00	0.00	0.00	1,252.20	0.00	0.00		3,623.20		
3727	ADULT <40% EXP FEMA	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		
	L																
3728	ADULT <40% EXP M&F	552.34	8,792.98	26,960.97	19,860.83	15,851.29	5,025.67	-78.66	1,417.82	7,095.39	8,307.43	0.00	0.00		93,786.06		
	4																
SUBTOTAL:	43,359,796.06	34,997,222.01	48,570,760.65	38,894,030.07	35,729,313.50	35,617,697.92	27,034,136.73	45,182,109.54	73,041,080.85	49,512,171.32	0.00	0.00		431,938,318.65		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	315.07	1,218.50	1,863.09	101.80	4,435.17	2,620.41	178.34	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	86.42	412.68	1,415.55	734.09	568.83	2,484.83	1,516.61	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	28,171.18	45,872.60	45,191.03	60,290.86	28,227.84	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	17,318.27	9,925.12	26,893.30	36,500.60	38,480.17	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	54,617.76	57,176.78	62,252.00	49,496.21	48,590.06	49,299.26	45,386.24	65,373.03	104,231.73	49,314.04	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	58,564.32	46,277.33	135,450.54	64,522.02	79,450.98	65,229.64	63,238.82	123,490.66	203,644.40	117,822.12	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	995,607.08	676,745.41	807,264.33	923,623.17	939,115.93	1,038,197.97	1,138,330.79	1,057,075.27	1,870,458.80	1,170,111.06	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	948,571.70	705,932.26	1,534,556.09	2,697,682.04	1,359,524.83	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	1,829,577.52	1,304,744.74	3,296,838.80	5,415,602.22	2,720,594.76	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	479.00	1,090.56	4,214.46	4,214.46	7,313.70	10,003.92	2,117.05	10,290.24	16,520.62	1,038.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	546.44	1,074.65	1,291.37	57.18	651.12	2,787.03	693.17	1,820.25	6,078.85	1,502.25	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	239.25	0.00	479.00	0.00	660.22	0.00	0.00	479.00	1,038.00	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	3,992,435.13	3,317,076.68	6,167,011.67	10,417,153.36	5,488,310.02	0.00	0.00	

10,732.38	
7,219.01	
301,822.37	
174,883.72	
585,737.11	
957,690.83	
10,616,529.81	
13,015,678.24	
25,409,128.15	
57,282.01	
16,502.31	
2,895.47	
51,156,101.41	

4413	SOBRA 100-133% M&F
6	350,048.99	246,594.45	388,953.30	358,715.26	389,766.96	263,709.24	117,242.23	412,752.55	685,235.81	425,117.05	0.00	0.00	
4414	SOBRA 100-133% MALE	141,121.62	102,127.86	115,367.94	131,387.01	133,833.98	174,348.12	91,803.90	160,723.96	253,226.85	183,449.65	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	327,872.71	-34,856.44	426,457.69	500,656.84	355,992.69	0.00	0.00	
SUBTOTAL:	634,066.95	484,472.35	664,288.15	683,995.12	701,860.12	765,930.07	174,189.69	999,934.20	1,439,119.50	964,559.39	0.00	0.00	

3,638,135.84	
1,487,390.89	
2,386,888.81	
7,512,415.54	

4517

BC PATIENT FEMALE 2 1

479.00

0.00

0.00

0.00

479.00

-455.00

-910.00	479.00

1,996.00

2,399.38

0.00

0.00

4,467.38

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	13,546.77	2,791.74	13,061.33	10,149.28	23,402.87	0.00	0.00		121,292.18		
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	-455.00	0.00	0.00	0.00	0.00	0.00	0.00		-455.00		
SUBTOTAL:	10,518.34	2,607.82	19,699.11	15,646.80	10,826.12	12,636.77	1,881.74	13,540.33	12,145.28	25,802.25	0.00	0.00		125,304.56		

8700	SSI DISABLED FREEDO M	26,937.59	15,130.22	30,464.05	12,339.35	34,548.98	21,305.90	8,484.33	23,017.68	39,022.77	25,146.06	0.00	0.00	
8710	SSI DISABLED FREEDO
M	31,044.49	14,723.13	13,850.82	40,287.34	29,099.04	34,783.77	29,408.95	21,790.53	82,045.72	45,404.97	0.00	0.00	
8720	SSI DISABLED FREEDO M	26,216.72	21,512.86	21,777.97	-1,518.26	4,414.48	10,093.68	3,271.23	1,986.47	6,015.26	4,441.93	0.00	0.00	
SUBTOTAL:	84,198.80	51,366.21	66,092.84	51,108.43	68,062.50	66,183.35	41,164.51	46,794.68	127,083.75	74,992.96	0.00	0.00	

236,396.93	
342,438.76	
98,212.34	
677,048.03	

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

0.00

0.00

1,032,605,319.58

107,411,105.06	83,457,939.86	113,673,538.97	95,204,141.84	90,392,395.12	82,480,610.38	60,793,653.49	104,730,773.05	181,698,895.17	112,762,266.64	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2021	
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	4,878.16	67.93	147.33	2,191.43	68.37	0.00	0.00		13,127.24		
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	616.63	0.00	0.00		1,843.73		
1013	TANF 06-13 M & F NON	1,255.10	0.00	9,406.29	240.35	224.44	0.00	0.00	897.22	400.30	456.95	0.00	0.00		12,880.65		
1014	TANF 14-20 MALE NON-	553.23	273.18	3,498.78	0.00	0.00	0.00	0.00	2,029.34	8,888.59	165.43	0.00	0.00		15,408.55		
1015	TANF 14-20 FEMALE N	2,538.69	2,147.84	4,602.24	950.19	965.19	11,540.81	0.00	3,112.35	1,767.90	0.00	0.00	0.00		27,625.21		
	O																
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	31,834.14	12,820.33	6,592.11	7,094.24	32,763.74	13,905.62	39,531.22	26,181.54	26,312.46	20,750.93	0.00	0.00		217,786.33		
	O																
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	-92.78	0.00	0.00	0.00	0.00	0.00		-92.78		
2100	SSI AGED WITH MEDIC	0.00	0.00	-62.02	0.00	0.00	0.00	-1,350.36	0.00	0.00	0.00	0.00	0.00		-1,412.38		
	A																
2200	SSI DISABLED WITH M	-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		
	E																
2210	SSI DISABLED NON-ME	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		
	D																
4311	SOBRA CHILD <1 M & F	60,059.97	30,560.13	36,385.04	81,057.95	40,352.68	13,234.47	30,089.69	23,882.73	12,637.83	24,375.58	0.00	0.00		352,636.07		
4312	SOBRA CHILD 01-05 M	96,645.58	29,504.41	14,980.14	15,786.95	9,360.79	20,010.36	13,134.34	33,519.65	5,503.83	11,522.38	0.00	0.00		249,968.43		
4313	SOBRA CHILD 06-13 M	28,540.89	41,368.11	21,037.74	9,508.29	9,250.91	7,548.73	18,472.27	11,156.96	14,075.06	7,262.78	0.00	0.00		168,221.74		
4314	SOBRA CHILD 14-20 MA	15,316.91	13,767.28	31,611.58	5,386.94	11,173.10	10,085.74	22,293.68	22,074.11	23,393.81	7,425.24	0.00	0.00		162,528.39		
4315	SOBRA CHILD 14-20 FE	35,626.01	10,194.98	22,640.89	15,683.31	6,051.69	6,891.27	5,735.39	39,838.08	12,137.66	9,436.89	0.00	0.00		164,236.17		
5007	SOBRA PREG 21-44 FE	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		
	M																
5015	SOBRA PREG 14-20 FE	20,756.69	11,700.05	20,494.48	12,164.49	17,204.99	21,037.08	13,917.07	22,810.38	16,682.70	9,838.71	0.00	0.00		166,606.64		
	M																
5017	SOBRA PREG 21-44 FE	118,243.42	110,937.05	85,990.10	71,271.89	87,059.37	84,622.54	50,141.23	64,361.28	95,862.64	54,074.27	0.00	0.00		822,563.79		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	874.93	0.00	0.00	0.00	0.00	0.00	193.14	0.00	0.00	0.00		1,068.07		
	M																
SUBTOTAL:	413,729.80	263,535.53	260,845.80	222,366.75	215,385.34	193,754.78	191,939.68	250,010.97	220,047.35	145,994.16	0.00	0.00		2,377,610.16		

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	
2420	SSI AGED EXPANDED
WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-53.23	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	-53.23	0.00	0.00	0.00	0.00	

33.48	
-136.78	
-427.00	
-112.02	
-53.23	
-173.96	
-869.51	

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	-640.60	-161.93	970.52	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	-61.56	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	-92.85	0.00	0.00	0.00	0.00	0.00	

-670.80	
-660.75	
-982.72	
-718.45	
5,655.56	
-3,555.76	
-3,596.60	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	6,319.15	-925.19	-4,174.02	-5,763.04	0.00	0.00	-795.01	-161.93	970.52	0.00	0.00	0.00		-4,529.52		

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		
3917	NEWLY ELIGIBLE FEMA L	-7.47	0.00	0.00	0.00	0.00	76.03	0.00	0.00	0.00	0.00	0.00	0.00		
3918	NEWLY ELIGIBLE M&F
4	236.25	-302.72	-429.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
SUBTOTAL:	228.78	-302.72	-429.02	-100.00	0.00	76.03	0.00	0.00	0.00	0.00	0.00	0.00		

-100.00	
68.56	
-495.49	
-526.93	

4413	SOBRA 100-133% M&F
6	3,690.96	1,766.09	4,790.07	1,024.30	3,142.56	2,109.11	1,515.92	1,313.61	5,968.19	33,479.86	0.00	0.00	
4414	SOBRA 100-133% MALE	103,321.39	13,115.92	6,531.34	780.45	6,459.47	2,983.11	4,119.07	72,928.83	12,794.02	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	5,061.43	1,478.57	480.90	513.00	807.22	1,420.38	24,604.09	1,195.79	2,129.13	9,066.94	0.00	0.00	
SUBTOTAL:	112,073.78	16,360.58	11,802.31	2,317.75	10,409.25	6,512.60	30,239.08	75,438.23	20,891.34	42,546.80	0.00	0.00	

58,800.67	
223,033.60	
46,757.45	
328,591.72	

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	52.15	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	52.15	0.00	0.00	0.00	0.00	0.00	

52.15

52.15

TOTAL:	532,251.37	278,668.20	268,045.07	218,532.32	225,367.59	200,343.41	221,435.90	325,234.04	241,909.21	188,540.96	0.00	0.00		2,700,328.07		

FEDERAL EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	-2,744.05	56,683.84	8.25	727.55	-15.45	0.00	0.00		63,142.76		
1012	TANF 01-05 M & F NON	29,766.61	5,058.03	27,650.24	11,021.48	9,272.33	64,070.39	10,847.79	12,553.72	4,868.03	10,047.83	0.00	0.00		185,156.45		
1013	TANF 06-13 M & F NON	48,909.26	269,034.29	84,803.20	98,338.33	62,944.65	11,222.28	57,128.08	37,938.44	152,843.66	49,519.36	0.00	0.00		872,681.55		
1014	TANF 14-20 MALE NON-	142,120.31	36,400.94	76,985.27	225,065.73	75,386.98	57,081.26	40,889.15	44,092.65	20,572.50	24,090.22	0.00	0.00		742,685.01		
1015	TANF 14-20 FEMALE N	193,775.73	243,632.31	169,948.20	224,563.08	239,176.64	212,403.66	109,490.24	177,989.30	200,619.01	160,375.61	0.00	0.00		1,931,973.78		
	O																
1016	TANF 21-44 MALE NON-	398.83	20.28	0.00	209.94	419.88	4,237.46	134.27	-10.60	546.04	0.00	0.00	0.00		5,956.10		
1017	TANF 21-44 FEMALE N	1,503,087.87	1,418,081.95	1,807,767.82	1,641,076.56	1,758,788.67	1,692,920.06	1,271,748.88	1,534,786.33	1,662,306.22	1,096,956.56	0.00	0.00		15,387,520.92		
	O																
1018	TANF 45-64 M & F NON	14,122.04	726.72	4,499.74	8,809.39	4,651.57	0.00	1,554.04	13,094.33	9,883.77	9,366.47	0.00	0.00		66,708.07		
2100	SSI AGED WITH MEDIC	27,107.23	11,301.18	14,673.08	9,365.03	57,953.86	20,615.68	10,836.74	17,209.86	26,234.24	15,401.81	0.00	0.00		210,698.71		
	A																
2110	SSI AGED NON-MEDICA	1,748,492.75	1,469,447.90	1,954,407.98	2,156,559.09	1,681,396.58	1,802,319.31	2,464,373.13	1,812,228.36	2,676,442.67	1,433,716.23	0.00	0.00		19,199,384.00		
	R																
2200	SSI DISABLED WITH M	7,695.04	2,242.16	2,186.04	1,055.36	1,510.22	2,132.80	2,454.33	2,200.78	463.04	759.63	0.00	0.00		22,699.40		
	E																
2210	SSI DISABLED NON-ME	43,003.05	25,262.16	37,324.27	26,198.68	22,405.37	33,787.80	164,986.14	45,885.55	24,226.69	12,073.02	0.00	0.00		435,152.73		
	D																
2220	SSI DISABLED WITH Q	0.00	872.61	829.45	1,030.81	153.89	1,629.38	81.87	1.70	2,281.84	2.27	0.00	0.00		6,883.82		
	M																
SUBTOTAL:	3,758,804.16	3,482,080.53	4,181,075.29	4,408,706.61	3,916,804.69	3,899,676.03	4,191,208.50	3,697,978.67	4,782,015.26	2,812,293.56	0.00	0.00		39,130,643.30		

1107	TANF EXPANDED 21-44	4,466.01	104.64	3,762.29	4,739.12	4,817.71	411.20	2,522.65	5,197.36	8,404.52	3,008.85	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	297.14	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	45.44	0.00	24.00	0.00	0.00	142.51	0.00	0.00	983.00	34.30	0.00	0.00	
1114	TANF EXPANDED 14-20	1,467.16	57.65	2,619.15	159.61	0.00	0.00	29,923.66	0.00	456.70	141.25	0.00	0.00	
1115	TANF EXPANDED 14-20	16,920.86	8,954.44	9,776.25	21,267.81	28,364.80	15,545.57	16,501.85	16,834.46	18,314.88	27,975.12	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	704,095.58	585,376.13	1,079,795.80	964,984.18	548,302.54	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	1,787,777.71	1,331,997.58	1,885,829.76	1,667,787.18	1,264,406.44	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	1,571,607.53	1,291,636.87	1,733,798.49	1,527,324.12	1,267,810.62	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	17,553.31	27,593.94	23,073.73	25,812.60	4,455.76	29,750.87	102,272.87	17,900.66	4,751.19	31,595.15	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	78.04	71.28	14.10	8.52	0.00	21.56	26.55	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	790.13	0.00	326.95	2,407.29	65.55	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	2,530.63	2,761.76	2,708.06	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,553.46	624.96	2,507.20	2,574.32	4,755.26	2,493.37	1,986.22	5,821.48	11,311.67	4,704.87	0.00	0.00	
2600	SSI DISABLED EXPAND
E	3.37	481.07	116.07	0.00	0.00	191.72	1,869.33	275.96	65.51	1,624.53	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	4,112,806.19	3,364,108.72	4,748,338.10	4,209,552.00	3,152,674.42	0.00	0.00	

37,434.35	
4,934.99	
1,229.25	
34,825.18	
180,456.04	
8,083,121.52	
16,580,690.91	
14,632,825.25	
284,760.08	
220.05	
11,023.55	
29,233.19	
39,332.81	
4,627.56	
39,924,714.73	

3906	NEWLY ELIGIBLE MALE	27.16	0.00	0.00	210.25	106.48	4,216.54	978.85	1,674.46	70.99	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	9,298.97	9,664.47	13,878.81	11,300.87	14,207.43	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	48,771.41	26,843.13	38,162.53	81,367.29	21,903.46	174,114.39	27,268.53	20,286.76	59,904.91	40,982.67	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	30,491.91	32,512.18	81,659.01	41,078.30	38,429.84	48,992.49	34,823.52	91,626.82	45,912.32	24,568.58	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	1,348,988.17	1,009,656.42	1,315,625.71	1,311,739.86	1,252,005.57	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	582,367.45	380,259.32	676,716.49	607,775.50	719,647.01	673,695.51	613,410.03	878,788.38	240,896.91	579,408.02	0.00	0.00	

7,284.73	
92,535.21	
539,605.08	
470,094.97	
13,893,837.81	
5,952,964.62	

FEDERAL EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	4,658,469.80	4,812,691.33	5,064,903.64	4,681,151.68	3,798,711.48	0.00	0.00		45,791,923.12		
3919	NEWLY ELIGIBLE M&F
6	6,763.68	14,681.00	18,917.68	9,507.32	-1,577.11	3,131.00	300.49	9,133.39	27,482.60	3,288.56	0.00	0.00		91,628.61		
SUBTOTAL:	5,996,983.35	5,467,004.70	8,309,800.13	6,955,425.57	7,193,409.47	6,920,906.87	6,508,793.64	7,395,917.97	6,378,460.14	5,713,172.31	0.00	0.00		66,839,874.15		

145,895,232.18

13,695,898.84	12,178,848.34	17,061,458.15	15,652,129.65	15,418,994.82	14,933,389.09	14,064,110.86	15,842,234.74	15,370,027.40	11,678,140.29	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE
For The Period Ending April 30, 2021	
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	584,556.73	367,344.13	505,470.51	582,062.94	373,850.26	0.00	0.00		4,756,542.70		
8040	SLMB	859.02	384.95	416.46	223.84	0.00	18.40	1.97	923.65	20,055.64	21,294.86	0.00	0.00		44,178.79		
8050	QI1	223.92	1.85	76.32	1.50	31.93	0.00	0.00	149.15	979.99	394.90	0.00	0.00		1,859.56		
SUBTOTAL:	560,175.21	366,856.62	563,569.70	394,825.92	460,050.47	584,575.13	367,346.10	506,543.31	603,098.57	395,540.02	0.00	0.00		4,802,581.05		

TOTAL:	560,175.21	366,856.62	563,569.70	394,825.92	460,050.47	584,575.13	367,346.10	506,543.31	603,098.57	395,540.02	0.00	0.00		4,802,581.05		

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2021	
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		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.38	0.00	0.00	0.00	0.00		4.38		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.99	427.00	0.00	0.00	0.00		441.99		
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	245.64	1,806.46	2,076.00	263.19	1,474.83	0.00	0.00		13,319.56		
1012	TANF 01-05 M & F NON	6,130.49	6,317.48	6,021.42	8,420.77	5,043.61	6,045.31	3,321.96	9,436.77	7,667.52	3,348.86	0.00	0.00		61,754.19		
1013	TANF 06-13 M & F NON	185,370.72	142,831.84	95,609.79	111,919.80	86,340.81	70,303.94	118,103.59	70,645.72	155,598.05	37,951.10	0.00	0.00		1,074,675.36		
1014	TANF 14-20 MALE NON-	61,620.57	53,913.40	60,192.12	53,420.91	26,399.63	42,535.04	36,194.89	71,373.19	62,556.88	66,218.83	0.00	0.00		534,425.46		
1015	TANF 14-20 FEMALE N	117,992.97	113,226.00	123,239.60	81,482.04	291,370.40	55,488.73	53,877.63	46,582.95	65,516.14	70,642.47	0.00	0.00		1,019,418.93		
	O																
1016	TANF 21-44 MALE NON-	620,695.88	661,887.71	508,772.72	544,819.32	554,579.21	633,477.27	596,169.59	651,186.63	815,967.23	753,188.67	0.00	0.00		6,340,744.23		
1017	TANF 21-44 FEMALE N	1,377,131.11	1,347,188.67	2,150,745.77	1,860,697.10	1,618,408.52	1,944,142.87	1,964,290.86	1,769,824.51	2,960,042.77	1,973,418.12	0.00	0.00		18,965,890.30		
	O																
1018	TANF 45-64 M & F NON	215,528.64	200,049.81	187,946.09	205,377.01	318,056.06	491,862.50	388,099.78	449,707.05	513,729.71	406,174.78	0.00	0.00		3,376,531.43		
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		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	221.18	0.00	0.00	0.00		221.18		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	1,193.52	0.00	0.00	1,429.04	357.26	0.00	0.00		2,979.82		
2100	SSI AGED WITH MEDIC	7,356.70	7,970.44	32,587.83	18,666.50	6,326.10	10,311.13	4,261.88	7,897.79	16,897.12	11,630.98	0.00	0.00		123,906.47		
	A																
2110	SSI AGED NON-MEDICA	3,465.84	2,684.56	4,610.40	3,382.34	2,526.28	6,761.99	5,346.06	3,471.94	3,426.22	353.07	0.00	0.00		36,028.70		
	R																
2120	SSI AGED WITH QMB	32,438.17	3,015.69	22,662.12	36,255.22	13,600.28	100,629.03	35,629.95	52,475.27	88,403.35	80,143.14	0.00	0.00		465,252.22		
2200	SSI DISABLED WITH M	30,039.85	40,301.42	111,308.73	65,026.37	47,099.49	66,082.93	69,312.17	45,792.69	78,730.00	49,301.94	0.00	0.00		602,995.59		
	E																
2210	SSI DISABLED NON-ME	1,255,916.44	1,615,532.63	1,623,080.23	1,668,643.25	1,710,373.89	1,784,678.01	1,385,173.63	1,903,968.32	2,100,523.27	1,597,822.75	0.00	0.00		16,645,712.42		
	D																
2220	SSI DISABLED WITH Q	272,422.20	182,362.18	293,693.70	298,895.88	324,477.49	334,593.22	335,212.20	285,894.37	350,383.12	419,713.02	0.00	0.00		3,097,647.38		
	M																
2310	SSI BLIND NON-MEDIC	12,525.00	6,005.79	13,810.86	10,763.03	4,693.09	8,460.00	10,130.53	6,648.56	58,426.23	35,052.76	0.00	0.00		166,515.85		
	A																
2320	SSI BLIND WITH QMB	335.08	6,421.99	8,018.43	5,962.24	3,829.35	7,692.99	3,321.00	10,905.28	4,236.26	2,237.68	0.00	0.00		52,960.30		
4311	SOBRA CHILD <1 M & F	697.99	3,413.73	4,065.67	6,904.39	3,975.73	4,189.99	5,694.15	2,036.00	5,629.00	3,643.03	0.00	0.00		40,249.68		
4312	SOBRA CHILD 01-05 M	84,847.46	78,017.20	132,552.69	102,131.77	87,345.27	90,791.77	75,981.03	50,695.55	182,536.46	390,674.12	0.00	0.00		1,275,573.32		
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	2,079,008.55	1,725,160.44	1,506,415.76	2,607,089.07	2,596,198.60	0.00	0.00		19,799,470.42		
4314	SOBRA CHILD 14-20 MA	627,970.65	708,102.87	883,452.56	554,719.48	786,315.32	656,126.71	766,473.47	655,169.96	1,028,489.89	718,931.32	0.00	0.00		7,385,752.23		
4315	SOBRA CHILD 14-20 FE	998,234.53	914,646.46	1,087,806.06	751,126.20	734,615.63	820,971.86	1,090,240.70	729,672.81	1,205,904.40	894,033.16	0.00	0.00		9,227,251.81		
5015	SOBRA PREG 14-20 FE	3,278.24	2,027.10	7,703.37	4,535.80	13,940.45	11,429.69	8,523.07	5,736.11	6,441.34	1,711.14	0.00	0.00		65,326.31		
	M																
5017	SOBRA PREG 21-44 FE	123,360.35	133,963.53	111,567.28	53,007.63	63,736.11	60,789.41	109,370.28	83,167.97	223,438.90	152,589.13	0.00	0.00		1,114,990.59		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	0.00	108.88	450.07	62.93	496.02	0.00	0.00	0.00		1,117.90		
	M																
SUBTOTAL:	7,986,374.23	7,942,316.90	9,613,019.40	8,068,960.97	8,568,626.71	9,287,920.98	8,792,145.39	8,420,863.50	12,544,469.36	10,266,810.76	0.00	0.00		91,491,508.20		

14.00

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	14.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	37.22	0.00	26.79	33.49	18.41	0.00	0.00	0.00	217.03	0.00	0.00	

332.94

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	95.24	2,825.54	636.74	606.96	78.54	-645.87	0.00	84.95	45.61	0.00	0.00	0.00		3,727.71		
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		34.76		
	&																
1115	TANF EXPANDED 14-20	4,291.30	3,116.32	11,400.90	912.66	0.00	0.00	1,125.54	519.00	2,321.38	686.54	0.00	0.00		24,373.64		
1116	TANF EXPANDED 21-44	150,464.88	172,162.28	236,032.28	223,385.34	160,482.48	242,263.85	245,068.43	220,059.12	435,733.69	163,041.91	0.00	0.00		2,248,694.26		
1117	TANF EXPANDED 21-44	290,841.09	309,930.99	535,130.11	498,290.49	278,238.77	532,765.72	618,317.12	557,343.03	881,087.73	545,736.08	0.00	0.00		5,047,681.13		
1118	TANF EXPANDED 45-64	156,393.42	107,630.94	162,823.58	114,741.68	95,514.96	225,179.83	196,581.10	223,769.27	411,975.28	230,191.04	0.00	0.00		1,924,801.10		
1126	TANF EXPANDED 21-44	8,290.05	10,593.08	12,340.88	5,518.00	-5,426.78	516.09	45.61	67.15	180.88	1,170.98	0.00	0.00		33,295.94		
1127	TANF EXPANDED 21-44	40,868.90	21,762.10	8,958.51	5,716.20	-46,919.05	0.00	11,818.43	975.62	160.27	0.00	0.00	0.00		43,340.98		
1128	TANF EXPANDED 45-64	12,122.71	8,778.37	12,439.16	5,011.05	4,664.20	5,705.39	2,846.17	5,242.82	11,499.79	5,324.71	0.00	0.00		73,634.37		
1129	TANF EXPANDED 65+ M	644.34	2,501.67	1,255.54	2,503.31	6,614.13	5,821.74	3,424.54	2,389.03	2,953.40	444.02	0.00	0.00		28,551.72		
	&																
2400	SSI AGED EXPANDED	442.80	442.80	680.80	0.00	0.00	0.00	1,071.69	0.00	125.40	0.00	0.00	0.00		2,763.49		
	WI																
2420	SSI AGED EXPANDED	30,641.77	21,083.87	28,740.99	12,662.60	20,609.41	49,885.09	14,834.62	76,294.80	72,254.58	60,823.27	0.00	0.00		387,831.00		
	WI																
2600	SSI DISABLED EXPAND	0.00	72.26	0.00	0.00	0.00	0.00	299.21	363.91	767.68	1,024.21	0.00	0.00		2,527.27		
	E																
2610	SSI DISABLED EXPAND	3,274.87	1,138.41	3,688.60	1,228.51	878.99	1,824.48	3,476.73	5,338.85	1,741.67	938.62	0.00	0.00		23,529.73		
	E																
2620	SSI DISABLED EXPAND	46,298.74	30,206.09	48,063.47	25,851.79	70,098.46	42,590.79	28,788.71	37,015.18	56,350.01	28,011.65	0.00	0.00		413,274.89		
	E																
SUBTOTAL:	744,670.11	692,281.94	1,062,196.72	896,479.82	584,872.76	1,105,925.52	1,127,711.90	1,129,462.73	1,877,197.37	1,037,610.06	0.00	0.00		10,258,408.93		

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	200.16	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	176.72	0.00	0.00	
3514	ADULT 40-100% MALE 1	10,038.11	6,591.57	4,422.92	2,290.33	2,528.07	7,264.33	31,011.18	24,533.06	27,364.81	21,493.35	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	47,899.77	4,575.06	9,167.40	7,982.00	3,961.72	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	219,526.05	190,405.77	199,044.11	291,512.48	255,367.18	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	70,360.71	79,730.93	81,899.34	191,811.69	109,717.74	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	99,828.24	90,241.96	122,654.03	144,636.19	149,691.82	0.00	0.00	
3706	ADULT <40% EXP MALE	502.62	1,172.78	1,507.86	0.00	2,752.16	7,572.33	25.79	434.11	14,630.40	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	479.00	141.70	0.00	0.00	0.00	1,496.32	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	45.61	0.00	1,292.10	283.54	0.00	0.00	
3714	ADULT <40% EXP MALE	182,327.26	275,741.34	189,987.08	192,777.65	195,859.86	211,270.58	143,495.83	118,729.45	147,742.35	81,795.81	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	145,568.70	115,457.25	172,192.86	149,394.35	149,435.09	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	3,518,720.36	3,095,530.29	3,288,124.42	4,521,706.57	3,548,792.66	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	1,733,716.28	1,480,771.29	1,512,038.10	2,453,759.29	1,805,092.00	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	1,659,664.87	1,230,285.15	1,504,790.37	2,276,861.77	1,822,047.85	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	7,722,888.54	6,461,576.11	7,033,607.25	10,228,694.00	7,948,055.64	0.00	0.00	

200.16	
176.72	
137,537.73	
143,908.07	
1,883,680.37	
1,009,092.44	
1,123,099.50	
28,598.05	
2,117.02	
1,621.25	
1,739,727.21	
1,348,527.76	
34,523,231.50	
17,808,466.16	
16,714,920.91	
320.13	
76,465,224.98	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	273.66	273.66	3,304.59	273.66	10,977.02	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	659.34	136.83	670.09	1,410.10	2,418.04	1,235.04	846.98	815.73	796.27	726.84	0.00	0.00	

9,715.26

15,102.59

FFS TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3909	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	243.80	0.00	0.00	167.54	0.00	0.00		411.34		
	6																
3914	NEWLY ELIGIBLE MALE	-399.88	11,204.19	1,404.51	1,437.00	958.00	1,916.00	1,316.53	4,571.28	8,104.56	6,830.62	0.00	0.00		37,342.81		
3915	NEWLY ELIGIBLE FEMA	3,139.31	6,363.67	17,446.59	11,764.36	12,189.94	15,970.73	11,035.50	11,411.92	15,933.48	11,463.89	0.00	0.00		116,719.39		
	L																
3916	NEWLY ELIGIBLE MALE	105,054.12	122,406.42	121,054.76	119,805.83	104,417.20	158,579.82	153,696.50	80,867.56	139,801.10	123,913.77	0.00	0.00		1,229,597.08		
3917	NEWLY ELIGIBLE FEMA	37,204.00	38,075.01	39,222.52	50,246.64	73,368.40	80,384.87	117,422.57	64,823.93	92,751.66	101,509.62	0.00	0.00		695,009.22		
	L																
3918	NEWLY ELIGIBLE M&F	37,918.72	28,319.56	78,701.86	45,037.65	57,502.82	56,621.59	131,873.20	127,686.16	125,736.36	69,164.33	0.00	0.00		758,562.25		
	4																
3928	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	67.15	0.00	0.00	0.00	0.00	0.00		67.15		
	4																
3929	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	43.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.38		
	6																
SUBTOTAL:	183,575.61	206,505.68	258,500.33	229,701.58	250,897.78	314,981.71	416,775.89	293,481.17	383,397.09	324,753.63	0.00	0.00		2,862,570.47		

4413	SOBRA 100-133% M&F
6	74,321.05	52,735.46	98,524.58	71,072.61	90,508.89	119,026.82	69,184.26	80,075.47	116,237.96	212,453.43	0.00	0.00	
4414	SOBRA 100-133% MALE	12,411.47	19,114.63	238,232.13	16,466.58	28,092.40	35,592.18	31,354.46	32,927.52	42,848.35	39,351.66	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	33,008.61	52,775.40	24,838.17	52,376.27	20,653.80	0.00	0.00	
SUBTOTAL:	134,040.20	93,427.89	363,510.54	109,315.11	147,503.71	187,627.61	153,314.12	137,841.16	211,462.58	272,458.89	0.00	0.00	

984,140.53	
496,391.38	
329,969.90	
1,810,501.81	

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	7,915.80	704.33	581.74	759.67	519.00	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	7,915.80	704.33	581.74	759.67	519.00	0.00	0.00	

1.85	
14,649.11	
479.00	
15,129.96	

182,903,344.35

16,472,295.13	15,672,313.59	19,933,396.22	17,202,178.70	15,931,647.21	18,627,260.16	16,952,227.74	17,015,837.55	25,245,980.07	19,850,207.98	0.00	0.00	

TOTAL:

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending April 30, 2021	
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	23,042.90	0.00	5,971.91	73,776.26	29,655.74	0.00	0.00		212,115.84		
1017	TANF 21-44 FEMALE N	19,969.29	32,704.70	57,587.38	37,280.52	26,460.90	29,920.61	24,441.09	48,797.63	55,513.76	59,749.98	0.00	0.00		392,425.86		
	O																
1018	TANF 45-64 M & F NON	5,094.30	9,249.68	17,529.99	3,363.52	6,825.04	0.00	6,825.04	2,559.39	20,528.55	0.00	0.00	0.00		71,975.51		
2200	SSI DISABLED WITH M	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		
	E																
2210	SSI DISABLED NON-ME	91,974.79	90,886.53	231,219.63	64,967.52	35,206.84	70,372.93	89,962.46	55,166.79	82,879.58	64,557.66	0.00	0.00		877,194.73		
	D																
2220	SSI DISABLED WITH Q	2,816.00	1,408.00	0.00	1,408.00	0.00	4,271.75	5,829.04	10,090.62	0.00	12,786.04	0.00	0.00		38,609.45		
	M																
2310	SSI BLIND NON-MEDIC	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		
	A																
5017	SOBRA PREG 21-44 FE	2,959.48	0.00	5,943.35	0.00	0.00	0.00	3,408.44	2,559.39	5,971.91	0.00	0.00	0.00		20,842.57		
	M																
SUBTOTAL:	128,659.23	157,306.95	364,070.04	114,279.38	73,009.63	127,608.19	130,466.07	125,145.73	238,670.06	166,749.42	0.00	0.00		1,625,964.70		

1116	TANF EXPANDED 21-44	4,245.25	5,012.64	10,923.34	2,522.64	13,454.16	8,441.48	0.00	4,265.65	8,531.30	19,621.99	0.00	0.00	
1117	TANF EXPANDED 21-44	8,408.85	4,528.02	6,792.40	11,234.18	16,932.01	10,760.96	3,412.52	25,565.34	11,090.69	8,575.64	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	3,330.88	0.00	0.00	0.00	1,698.10	0.00	3,412.52	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	19,202.44	5,110.62	29,830.99	23,034.51	28,197.63	0.00	0.00	

77,018.45	
107,300.61	
8,441.50	
1,408.00	
5,632.00	
199,800.56	

3516	ADULT 40-100% MALE 2	8,301.74	21,895.67	23,332.49	6,369.94	21,838.65	3,077.84	3,832.51	29,227.74	3,092.64	14,716.58	0.00	0.00	
3517	ADULT 40-100% FEMAL E	16,825.85	9,061.94	6,661.76	5,886.16	0.00	9,249.68	0.00	0.00	7,678.17	5,094.70	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	3,865.80	4,439.22	12,796.95	1,546.32	0.00	0.00	
3716	ADULT <40% EXP MALE	182,372.02	306,323.87	381,788.94	206,633.92	223,016.99	199,193.95	195,331.59	417,232.68	367,190.37	276,263.40	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	76,338.41	57,661.17	32,203.98	111,635.92	71,936.71	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	63,138.19	27,273.62	64,767.56	144,912.32	74,690.58	0.00	0.00	
SUBTOTAL:	471,910.36	544,545.49	625,777.83	369,747.21	356,975.77	350,998.07	287,964.69	547,871.18	647,306.37	444,248.29	0.00	0.00	

135,685.80	
60,458.26	
27,842.18	
2,755,347.73	
913,733.53	
754,277.76	
4,647,345.26	

3916	NEWLY ELIGIBLE MALE	24,443.39	35,034.19	27,447.29	24,675.52	26,025.15	16,883.02	19,995.30	32,139.47	0.00	31,693.33	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	7,625.11	11,472.38	16,210.58	10,977.43	8,291.39	2,522.64	6,792.40	17,386.92	10,237.56	9,241.56	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	5,620.87	7,119.57	10,689.36	0.00	5,943.35	4,758.08	0.00	24,724.45	0.00	7,976.18	0.00	0.00	
SUBTOTAL:	37,689.37	53,626.14	54,347.23	35,652.95	40,259.89	24,163.74	26,787.70	74,250.84	10,237.56	48,911.07	0.00	0.00	

238,336.66	
100,757.97	
66,831.86	
405,926.49	

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,971.91	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,971.91	0.00	0.00	0.00	

5,971.91

5,971.91

TOTAL:	652,321.06	765,019.24	1,066,649.72	534,844.36	503,447.46	521,972.44	450,329.08	777,098.74	925,220.41	688,106.41	0.00	0.00		6,885,008.92		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,895.45	29,775.77	0.00	0.00		32,671.22		
1017	TANF 21-44 FEMALE N	57.36	0.00	0.00	0.00	0.00	0.00	0.00	159.31	0.00	0.00	0.00	0.00		216.67		
	O																
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	162,739.34	14,576.78	123,537.18	152,337.26	170,994.25	60,833.56	100,995.33	60,077.75	95,794.68	120,059.84	0.00	0.00		1,061,945.97		
	A																
2110	SSI AGED NON-MEDICA	128,802.10	132,314.60	259,968.44	159,816.72	249,391.00	64,037.17	147,487.15	154,292.42	291,676.62	324,452.62	0.00	0.00		1,912,238.84		
	R																
2120	SSI AGED WITH QMB	8.25	0.00	9.71	0.00	26.16	1,740.12	6,674.47	-262.40	158.68	535.36	0.00	0.00		8,890.35		
2200	SSI DISABLED WITH M	33,272.30	45,153.97	25,391.06	59,972.74	59,597.26	70,468.82	9,354.40	25,941.98	136,676.65	37,310.02	0.00	0.00		503,139.20		
	E																
2210	SSI DISABLED NON-ME	298.48	27,666.88	32,456.73	634.16	749.01	586.05	5,161.08	0.00	0.00	50,718.58	0.00	0.00		118,270.97		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	1,811.44	1,393.92	359.93	12,642.45	2,103.74	0.00	0.00		18,311.48		
	M																
5017	SOBRA PREG 21-44 FE	3,450.13	10,314.26	4,557.85	12,034.92	1,452.88	42.06	7,338.01	546.04	0.00	6,619.98	0.00	0.00		46,356.13		
	M																
SUBTOTAL:	328,698.04	230,026.49	445,920.97	384,795.80	482,210.56	199,519.22	278,404.36	241,115.03	539,844.53	571,575.91	0.00	0.00		3,702,110.91		

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.90	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	133.07	8,024.52	6,783.96	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	133.07	8,024.52	6,848.86	0.00	0.00	

64.90	
14,941.55	
15,006.45	

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	-5,043.62	1,628.45	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	1,393.92	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	15,327.56	0.00	0.00	9,106.92	0.00	0.00	
3716	ADULT <40% EXP MALE	268,736.40	447,744.68	385,725.54	262,081.54	457,684.63	297,726.04	149,638.43	166,118.34	682,707.20	259,110.97	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	5,566.04	8,207.36	42,026.57	32,560.02	22,596.43	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	153,976.35	369,074.26	416,904.57	572,841.07	264,804.96	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,882.86	4,146.01	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	1,393.92	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	457,268.43	543,641.53	621,399.78	1,305,619.60	559,765.29	0.00	0.00	

57.36	
5,472.42	
15,358.78	
48,212.97	
3,377,273.77	
188,220.49	
4,117,185.96	
20,028.87	
1,393.92	
7,773,204.54	

3908	NEWLY ELIGIBLE M&F 4	0.00	11,510.95	57.36	600.35	107.63	0.00	0.00	139.87	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	8,836.04	29,210.66	11,783.38	57,927.26	7,237.26	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	4,588.77	0.00	-28.54	86.89	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	8,593.12	2,549.40	29,008.33	31,673.41	4,156.30	0.00	0.00	
SUBTOTAL:	30,171.90	37,484.14	124,660.27	55,689.14	68,900.42	17,400.62	31,846.95	40,931.58	89,600.67	11,393.56	0.00	0.00	

12,416.16	
244,022.04	
4,647.12	
246,993.93	
508,079.25	

11,998,401.15

993,749.44	1,217,068.14	1,554,106.85	1,144,132.27	1,565,010.94	674,188.27	853,892.84	903,579.46	1,943,089.32	1,149,583.62	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2021	
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	1,174.43	15,727.71	0.00	4,575.52	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	1,174.43	15,727.71	0.00	4,575.52	0.00	0.00	

28,271.81	
13,373.23	
41,645.04	

TOTAL:	6,732.51	0.00	10,866.52	405.93	3,701.50	0.00	1,174.43	15,727.71	0.00	4,575.52	0.00	0.00		43,184.12		

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2021	
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	11,535.93	9,361.97	475.66	3,928.71	0.00	0.00	0.00		77,837.88		
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	6,390.58	0.00	4,221.39	0.00	350.37	243.65	0.00	0.00		11,205.99		
	O																
2210	SSI DISABLED NON-ME	6,614.01	2,282.64	2,170.99	486.47	1,660.54	5,326.11	6,245.58	1,846.15	15,584.08	1,224.37	0.00	0.00		43,440.94		
	D																
4314	SOBRA CHILD 14-20 MA	7,370.21	5,177.15	0.00	0.00	607.40	6,869.52	0.00	0.00	33,746.39	0.00	0.00	0.00		53,770.67		
5017	SOBRA PREG 21-44 FE	3,299.45	4,460.34	0.00	0.00	0.00	3,833.46	0.00	0.00	9,645.94	0.00	0.00	0.00		21,239.19		
	M																
SUBTOTAL:	17,312.21	13,478.42	6,405.97	50,009.91	13,219.56	27,565.02	19,828.94	2,321.81	63,255.49	1,468.02	0.00	0.00		214,865.35		

1116	TANF EXPANDED 21-44	1,392.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,813.88	0.00	0.00	
1117	TANF EXPANDED 21-44	9,614.96	0.00	0.00	570.81	6,128.49	0.00	195.86	0.00	9,991.55	292.07	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	195.86	0.00	9,991.55	4,105.95	0.00	0.00	

5,206.19	
26,793.74	
359.78	
32,359.71	

3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,350.19	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	3,453.35	6,582.06	39,818.48	10,821.50	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	809.64	0.00	0.00	0.00	0.00	0.00	0.00	14,097.94	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	5,305.97	9.73	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	2,514.26	1,112.18	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	64,028.51	45,446.48	33,529.50	91,363.90	40,999.12	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	8,647.24	2,686.58	3,714.98	2,125.78	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	10,911.76	52,538.44	898.96	71,313.03	35,870.24	0.00	0.00	
SUBTOTAL:	79,227.09	55,286.17	48,379.25	234,982.11	139,411.87	74,940.27	112,599.77	44,809.28	230,964.49	89,826.37	0.00	0.00	

5,350.19	
60,675.39	
14,907.58	
5,838.14	
3,626.44	
690,122.46	
93,401.24	
236,505.23	
1,110,426.67	

3916	NEWLY ELIGIBLE MALE	6,096.69	363.74	27,112.74	0.00	921.78	0.00	10,038.12	0.00	6,414.33	6,200.37	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	882.53	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,096.69	363.74	27,112.74	15,499.33	921.78	0.00	10,038.12	882.53	6,414.33	6,200.37	0.00	0.00	

57,147.77	
16,381.86	
73,529.63	

301,062.16

310,625.86

0.00

0.00

TOTAL:

113,643.26

69,462.74

81,923.33

159,681.70

102,505.29

142,662.69

48,013.62

101,600.71

1,431,181.36

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2021	
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	5,321.16	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	5,778.75	7,090.01	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	51.70	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	75.48	16,851.05	14,420.58	0.00	220.32	0.00	0.00	
SUBTOTAL:	9,592.71	279.80	17,881.92	7,260.33	92.91	5,396.64	16,851.05	14,420.58	5,830.45	7,310.33	0.00	0.00	

5,391.24	
16,377.81	
6,305.94	
56,841.73	
84,916.72	

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	5,396.64	16,851.05	14,420.58	5,830.45	7,310.33	0.00	0.00		98,224.08		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	9,397.80	0.00	258.35	222.87	0.00	0.00		9,879.02		
1017	TANF 21-44 FEMALE N	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		
	O																
2110	SSI AGED NON-MEDICA	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		
	R																
2210	SSI DISABLED NON-ME	80.07	8,270.74	18.40	13,837.24	5,115.81	7,469.50	1,286.27	0.00	8,805.24	0.00	0.00	0.00		44,883.27		
	D																
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.32	4,551.09	0.00	0.00	0.00		4,574.41		
	M																
SUBTOTAL:	88.32	8,270.74	6,438.25	13,837.24	5,115.81	7,469.50	10,684.07	23.32	13,614.68	222.87	0.00	0.00		65,764.80		

2610

SSI DISABLED EXPAND E

554.15

554.15

0.00	0.00	0.00	0.00	0.00	0.00	0.00	342.02	212.13	0.00	0.00	0.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	342.02	212.13	0.00	0.00	0.00	

SUBTOTAL:

3516	ADULT 40-100% MALE 2	0.00	1,019.08	0.00	0.00	6,512.73	207.09	257.01	0.00	81.18	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	5,324.59	0.00	64.90	117.11	0.00	0.00	
3716	ADULT <40% EXP MALE	4,774.28	38,972.56	357.17	7,208.49	4,090.03	7,763.03	6,441.17	18,416.12	1,169.66	5,341.83	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	6,772.26	0.00	5,179.37	78.94	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	3,828.18	3,377.83	12,020.67	71,917.57	0.00	0.00	
SUBTOTAL:	12,600.28	43,980.23	17,411.00	16,589.34	18,826.45	7,970.12	22,623.21	21,793.95	18,515.78	77,455.45	0.00	0.00	

8,077.09	
5,506.60	
94,534.34	
42,409.36	
107,238.42	
257,765.81	

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,238.93	0.00	0.00	0.00	0.00	
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	3,238.93	0.00	0.00	0.00	0.00	

3,238.93	
11,905.50	
15,144.43	

339,229.19

12,688.60	58,028.82	29,637.84	30,517.45	24,190.45	15,439.62	33,307.28	25,398.22	32,342.59	77,678.32	0.00	0.00	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2021	
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	3,049.44	0.00	387.45	6,177.87	0.00	0.00	0.00		9,855.86		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	235.22	0.00	0.00	0.00	0.00	0.00	0.00		235.22		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	2,964.76	0.00	0.00	449.68	0.00	0.00	0.00		3,414.44		
SUBTOTAL:	0.00	0.00	0.00	0.00	241.10	6,249.42	0.00	387.45	6,627.55	0.00	0.00	0.00		13,505.52		

2420

SSI AGED EXPANDED WI

2,665.90

2,665.90

163.89	2,230.55	0.00	231.50	0.00	39.96	0.00	0.00	0.00	0.00	0.00	0.00	
163.89	2,230.55	0.00	231.50	0.00	39.96	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,433.30	782.04	0.00	0.00	
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	414.62	559.60	0.00	10,632.97	1,528.95	0.00	0.00	
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	6,280.55	0.00	308.83	6,078.75	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	934.34	223.84	207.40	6,609.12	9,851.92	723.45	6,638.35	0.00	12,066.27	2,310.99	0.00	0.00	

2,215.34	
1,148.62	
23,533.59	
12,668.13	
39,565.68	

TOTAL:	1,098.23	2,454.39	207.40	6,840.62	10,093.02	7,012.83	6,638.35	387.45	18,693.82	2,310.99	0.00	0.00		55,737.10		

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending April 30, 2021	
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		

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	218.35	185.17	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	274.03	803.48	13,427.87	145.56	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	349.14	5,163.34	4,996.21	0.00	4,782.79	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	6,187.57	1,131.22	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	274.03	1,370.97	18,776.38	11,329.34	1,131.22	4,782.79	0.00	0.00	

403.52	
14,650.94	
15,291.48	
7,318.79	
37,664.73	

49,221.33

11,214.23	0.00	342.37	0.00	274.03	1,370.97	18,776.38	11,329.34	1,131.22	4,782.79	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending April 30, 2021	
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	1,581.00	0.00	0.00	0.00		5,413.00		
2100	SSI AGED WITH MEDIC	3,330,616.47	2,456,192.60	3,516,340.54	2,423,276.39	2,320,640.96	2,888,239.32	2,790,108.86	2,736,052.18	3,223,990.40	2,417,213.46	0.00	0.00		28,102,671.18		
	A																
2110	SSI AGED NON-MEDICA	187,328.99	149,799.02	235,218.18	120,294.47	154,163.67	159,519.55	186,460.70	261,044.03	255,068.37	185,402.94	0.00	0.00		1,894,299.92		
	R																
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	4,523,177.83	3,938,360.10	4,231,027.55	5,454,349.97	3,888,703.66	0.00	0.00		43,541,232.52		
2200	SSI DISABLED WITH M	555,517.35	422,232.69	592,574.28	442,575.93	485,649.40	573,592.22	507,919.75	640,446.16	535,963.67	411,722.45	0.00	0.00		5,168,193.90		
	E																
2210	SSI DISABLED NON-ME	3,676,881.67	2,853,162.88	3,642,622.41	3,148,700.46	2,918,107.57	3,103,562.30	2,796,599.98	3,531,047.50	4,844,155.07	3,328,430.59	0.00	0.00		33,843,270.43		
	D																
2220	SSI DISABLED WITH Q	1,181,251.47	893,296.91	1,183,450.91	939,777.85	1,039,867.17	1,114,224.83	974,252.02	1,109,822.82	1,321,746.70	974,721.03	0.00	0.00		10,732,411.71		
	M																
2310	SSI BLIND NON-MEDIC	479.00	492.39	1,044.80	479.00	958.00	-803.97	-852.27	1,461.00	998.00	0.00	0.00	0.00		4,255.95		
	A																
2320	SSI BLIND WITH QMB	0.00	17.38	2,606.91	2,415.70	2,389.06	17,090.03	753.73	469.81	58.95	0.00	0.00	0.00		25,801.57		
SUBTOTAL:	14,017,309.23	10,334,273.37	14,423,604.48	11,079,760.74	10,534,920.07	12,378,602.11	11,193,602.87	12,511,371.05	15,637,912.13	11,206,194.13	0.00	0.00		123,317,550.18		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.09	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	4,401.60	3,521.28	4,408.89	3,509.76	3,481.04	4,418.15	3,514.32	3,521.28	4,456.40	2,640.96	0.00	0.00	
SUBTOTAL:	4,401.60	3,521.28	4,408.89	3,509.76	3,481.04	4,418.15	3,514.32	3,521.28	4,474.49	2,640.96	0.00	0.00	

37,891.77

37,873.68

18.09

TOTAL:	14,021,710.83	10,337,794.65	14,428,013.37	11,083,270.50	10,538,401.11	12,383,020.26	11,197,117.19	12,514,892.33	15,642,386.62	11,208,835.09	0.00	0.00		123,355,441.95		

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending April 30, 2021	
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		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-90.84	0.00	0.00	0.00	0.00		-90.84		
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	176.75	238.77	0.00	120.47	1,493.49	0.00	0.00		3,092.75		
SUBTOTAL:	-2,222.33	-5,828.56	269.45	455.11	0.00	176.75	238.77	-90.84	120.47	1,493.49	0.00	0.00		-5,387.69		

-5,387.69

-2,222.33	-5,828.56	269.45	455.11	0.00	176.75	238.77	-90.84	120.47	1,493.49	0.00	0.00	

TOTAL:

YAVAPAI COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending April 30, 2021	
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	7.61	224.64	0.00	0.00	0.00	0.00	0.00		407.47		
SUBTOTAL:	0.00	0.00	0.00	0.00	175.22	7.61	224.64	0.00	0.00	0.00	0.00	0.00		407.47		

TOTAL:	0.00	0.00	0.00	0.00	175.22	7.61	224.64	0.00	0.00	0.00	0.00	0.00		407.47		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending April 30, 2021	
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	49,569.30	32,734.40	20,351.95	65,955.17	33,872.14	0.00	0.00		304,749.45		
1013	TANF 06-13 M & F NON	45,652.16	16,990.31	15,315.71	57,451.65	87,519.88	107,308.76	87,765.07	53,860.74	177,739.34	71,078.92	0.00	0.00		720,682.54		
1014	TANF 14-20 MALE NON-	4,083.21	1,462.24	1,486.56	4,428.17	6,494.95	9,814.48	6,074.26	4,161.88	13,748.26	5,790.26	0.00	0.00		57,544.27		
1015	TANF 14-20 FEMALE N	3,673.46	1,597.88	1,159.70	3,922.03	6,560.32	7,746.57	3,899.82	2,828.70	6,774.27	4,356.22	0.00	0.00		42,518.97		
	O																
2200	SSI DISABLED WITH M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	67.60	0.00	0.00		67.60		
	E																
2210	SSI DISABLED NON-ME	123,882.31	60,436.07	35,826.98	106,378.59	184,120.82	211,390.17	168,698.09	100,167.36	310,698.22	153,881.87	0.00	0.00		1,455,480.48		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	8.30	0.00	26.72	26.69	0.00	0.00	0.00		61.71		
	M																
2310	SSI BLIND NON-MEDIC	2,716.64	0.00	0.00	1,974.96	1,711.60	2,669.39	1,638.51	1,709.08	5,052.35	2,245.12	0.00	0.00		19,717.65		
	A																
4312	SOBRA CHILD 01-05 M	101,401.93	44,462.78	26,948.19	96,081.99	162,611.90	208,812.05	156,790.45	92,509.37	284,238.82	146,454.78	0.00	0.00		1,320,312.26		
4313	SOBRA CHILD 06-13 M	149,379.80	64,797.33	55,814.71	202,394.94	347,789.79	395,559.50	307,360.14	185,788.50	678,344.87	266,775.59	0.00	0.00		2,654,005.17		
4314	SOBRA CHILD 14-20 MA	15,372.03	5,852.75	3,740.63	12,944.99	25,606.49	31,527.16	23,121.31	9,680.24	45,621.03	23,003.74	0.00	0.00		196,470.37		
4315	SOBRA CHILD 14-20 FE	6,104.83	2,259.18	2,434.07	5,356.84	12,784.63	16,753.93	9,025.24	5,307.99	21,777.82	13,047.79	0.00	0.00		94,852.32		
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	30.55	0.00	0.00		30.55		
SUBTOTAL:	473,716.20	209,551.95	148,999.17	515,935.79	873,049.38	1,041,159.61	797,107.29	476,392.53	1,609,976.84	720,604.58	0.00	0.00		6,866,493.34		

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	10.00	88.75	78.75	0.00	46.36	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	27.18	33.33	0.00	136.95	60.00	153.32	0.00	38.23	161.05	134.41	0.00	0.00	
3714	ADULT <40% EXP MALE	337.33	0.00	78.76	118.75	646.93	450.24	48.07	218.17	706.92	493.80	0.00	0.00	
3715	ADULT <40% EXP FEMA L	157.49	147.28	0.00	29.46	20.00	175.75	66.54	56.32	322.10	310.35	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	868.06	193.36	312.72	1,236.43	938.56	0.00	0.00	

223.86	
744.47	
3,098.97	
1,285.29	
10.00	
157.51	
5,520.10	

3914	NEWLY ELIGIBLE MALE	53.27	14.57	0.00	32.49	16.00	244.95	86.66	0.00	237.51	46.36	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	244.95	86.66	0.00	237.51	46.36	0.00	0.00	

854.87

123.06

731.81

4413	SOBRA 100-133% M&F
6	35,057.25	14,906.93	12,516.25	48,450.64	77,223.02	85,606.81	72,239.20	37,087.98	146,575.28	59,612.19	0.00	0.00	
4414	SOBRA 100-133% MALE	2,658.53	1,194.12	775.03	2,336.31	5,254.71	5,625.71	4,046.72	1,881.26	8,915.45	4,447.60	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,298.91	375.48	427.60	1,324.38	2,116.86	1,336.34	1,285.43	227.93	2,690.28	1,578.32	0.00	0.00	
SUBTOTAL:	39,014.69	16,476.53	13,718.88	52,111.33	84,594.59	92,568.86	77,571.35	39,197.17	158,181.01	65,638.11	0.00	0.00	

589,275.55	
37,135.44	
12,661.53	
639,072.52	

7,511,940.83

513,473.46	226,233.66	162,796.81	568,364.77	958,510.17	1,134,841.48	874,958.66	515,902.42	1,769,631.79	787,227.61	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending April 30, 2021	
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	29,188.18	23,720.48	15,493.88	44,678.54	16,386.32	0.00	0.00		195,632.42		
2200	SSI DISABLED WITH M	774.73	316.00	263.12	558.66	3,031.07	2,215.23	3,560.70	1,835.62	3,938.99	1,853.19	0.00	0.00		18,347.31		
	E																
2210	SSI DISABLED NON-ME	587,639.52	246,975.00	184,726.70	540,569.92	935,503.94	1,123,212.14	849,238.20	580,081.20	1,563,104.39	777,292.94	0.00	0.00		7,388,343.95		
	D																
2220	SSI DISABLED WITH Q	1,089.49	424.23	0.00	409.41	1,271.35	969.41	348.34	395.41	3,172.70	1,679.48	0.00	0.00		9,759.82		
	M																
2310	SSI BLIND NON-MEDIC	335.75	55.50	0.00	102.26	111.00	1,126.63	493.30	493.95	382.22	733.47	0.00	0.00		3,834.08		
	A																
SUBTOTAL:	607,580.28	255,440.94	189,102.40	555,825.44	962,373.61	1,156,711.59	877,361.02	598,300.06	1,615,276.84	797,945.40	0.00	0.00		7,615,917.58		

TOTAL:	607,580.28	255,440.94	189,102.40	555,825.44	962,373.61	1,156,711.59	877,361.02	598,300.06	1,615,276.84	797,945.40	0.00	0.00		7,615,917.58		

ACC REINSURANCE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	142,326.30	0.00	0.00	0.00	0.00		142,326.30		
1005	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14,281.41	0.00	0.00	0.00		14,281.41		
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	785,686.88	486,000.31	545,139.37	186,681.44	855,595.18	0.00	0.00		7,633,259.24		
1012	TANF 01-05 M & F NON	37,196.19	202,649.53	96,281.70	57,600.45	93,430.01	-31,621.85	116,225.83	127,993.14	1,212,345.54	109,603.90	0.00	0.00		2,021,704.44		
1013	TANF 06-13 M & F NON	241,018.88	227,000.67	175,147.65	135,216.71	272,433.89	133,789.06	218,472.52	162,250.55	260,707.32	233,499.41	0.00	0.00		2,059,536.66		
1014	TANF 14-20 MALE NON-	185,768.53	101,928.26	117,286.61	132,042.93	223,418.15	147,407.56	155,973.96	79,696.09	381,104.33	616,783.67	0.00	0.00		2,141,410.09		
1015	TANF 14-20 FEMALE N	67,973.73	116,298.84	58,224.98	33,714.58	62,429.34	112,140.76	64,226.61	72,816.75	109,569.71	56,856.53	0.00	0.00		754,251.83		
	O																
1016	TANF 21-44 MALE NON-	172,317.95	239,808.12	303,605.09	2,001.56	287,108.22	49,272.67	130,813.22	191,081.92	409,810.21	98,575.34	0.00	0.00		1,884,394.30		
1017	TANF 21-44 FEMALE N	403,162.64	313,990.42	496,728.85	515,075.80	542,798.01	671,670.50	250,120.35	430,323.62	278,219.08	264,069.00	0.00	0.00		4,166,158.27		
	O																
1018	TANF 45-64 M & F NON	403,812.03	193,025.91	212,646.30	133,716.49	303,317.46	420,369.32	618,750.28	533,656.13	314,742.17	368,048.82	0.00	0.00		3,502,084.91		
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	-1,749.83	39,482.84	51,580.53	108,557.87	23,760.43	72,906.27	144,644.69	45,657.37	40,170.92	13,279.47	0.00	0.00		538,290.56		
	A																
2110	SSI AGED NON-MEDICA	24,771.85	240,105.43	67,897.62	317,685.62	191,608.14	144,083.16	224,843.77	91,119.28	60,390.82	105,766.65	0.00	0.00		1,468,272.34		
	R																
2200	SSI DISABLED WITH M	53,684.93	538,549.83	19,150.52	1,401,916.46	49,178.76	275,783.86	108,435.96	39,160.79	-35,942.68	89,619.94	0.00	0.00		2,539,538.37		
	E																
2210	SSI DISABLED NON-ME	5,330,188.46	6,117,760.41	5,324,232.76	3,977,811.96	7,992,327.32	4,903,914.73	5,577,505.71	5,877,675.09	6,350,568.04	6,594,648.23	0.00	0.00		58,046,632.71		
	D																
2310	SSI BLIND NON-MEDIC	12,975.28	34,269.50	26,913.55	18,991.17	177,029.37	10,008.83	31,833.12	0.00	0.00	-383.42	0.00	0.00		311,637.40		
	A																
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	2,276,490.39	1,615,197.99	934,752.72	1,485,572.29	2,405,294.89	0.00	0.00		21,108,140.16		
4312	SOBRA CHILD 01-05 M	1,603,767.69	471,995.20	700,534.12	665,075.87	672,817.22	3,621,155.22	718,794.20	531,099.92	1,219,042.16	493,177.66	0.00	0.00		10,697,459.26		
4313	SOBRA CHILD 06-13 M	393,530.06	1,103,420.81	1,375,296.20	1,014,224.32	903,029.66	1,261,629.23	926,746.95	690,410.53	1,581,995.46	1,238,377.35	0.00	0.00		10,488,660.57		
4314	SOBRA CHILD 14-20 MA	866,162.72	613,892.46	732,587.61	514,047.49	762,706.38	710,006.56	313,857.54	1,257,335.26	628,636.13	402,011.37	0.00	0.00		6,801,243.52		
4315	SOBRA CHILD 14-20 FE	41,106.92	116,339.99	360,104.67	524,801.78	236,905.19	703,057.75	390,721.12	407,616.78	202,491.49	132,363.28	0.00	0.00		3,115,508.97		
5015	SOBRA PREG 14-20 FE	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		
	M																
5017	SOBRA PREG 21-44 FE	49,769.88	12,363.53	10,220.12	18,346.43	89,537.67	-3,415.41	15,252.44	16,967.51	17,978.12	38,584.21	0.00	0.00		265,604.50		
	M																
SUBTOTAL:	12,864,243.64	15,638,547.70	12,782,089.51	12,459,477.19	16,624,205.08	16,264,335.49	12,108,416.57	12,177,079.12	14,718,363.96	14,115,771.48	0.00	0.00		139,752,529.74		

3100

TRANSPLANT OPTION 1

141,647.98

141,647.98

134.39	-16.22	0.00	0.00	1,453.86	-5.97	238.22	113,593.15	0.00	26,250.55	0.00	0.00	
134.39	-16.22	0.00	0.00	1,453.86	-5.97	238.22	113,593.15	0.00	26,250.55	0.00	0.00	

SUBTOTAL:

1106	TANF EXPANDED 21-44	0.76	0.00	0.00	0.00	0.00	10.57	0.00	234.28	0.00	1.60	0.00	0.00	
1107	TANF EXPANDED 21-44	3.08	31.67	0.00	0.00	1,174.10	0.00	4,703.38	-1,269.50	1,301.42	31,375.09	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	226.26	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	6.83	95.63	11.42	0.00	0.00	1,924.38	16.61	665.55	0.00	753.67	0.00	0.00	
1116	TANF EXPANDED 21-44	192,649.96	315,409.98	173,146.22	286,855.23	266,833.29	278,497.51	147,857.88	254,932.83	303,566.11	190,073.50	0.00	0.00	
1117	TANF EXPANDED 21-44	407,414.66	317,876.10	350,750.10	259,221.48	343,239.00	1,290,253.86	273,656.73	201,058.62	596,990.47	374,734.52	0.00	0.00	
1118	TANF EXPANDED 45-64	-8,008.80	128,198.41	178,292.82	218,582.20	503,388.33	184,505.41	583,459.43	222,251.49	469,677.70	595,050.68	0.00	0.00	

247.21	
37,319.24	
226.26	
3,474.09	
2,409,822.51	
4,415,195.54	
3,075,397.67	

ACC REINSURANCE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		19,705.90		
	&																
2400	SSI AGED EXPANDED	12,604.44	8,481.20	6,982.23	6,979.39	17,336.29	8,671.70	83,861.92	26.75	58.23	146,006.50	0.00	0.00		291,008.65		
	WI																
2410	SSI AGED EXPANDED N	0.00	1,937.58	0.00	0.00	8,757.95	13,412.04	0.00	0.00	0.00	9,969.58	0.00	0.00		34,077.15		
	O																
2600	SSI DISABLED EXPAND	2,701.12	-71,013.92	9,869.12	309.19	6,736.62	53,885.89	44,036.28	-17,423.46	18,519.18	-2,253.33	0.00	0.00		45,366.69		
	E																
2610	SSI DISABLED EXPAND	91,569.18	26,200.30	107,032.85	75,814.89	69,987.22	126,842.18	45,344.67	99,383.44	69,754.31	191,220.93	0.00	0.00		903,149.97		
	E																
SUBTOTAL:	698,941.23	727,216.95	826,084.76	867,468.28	1,217,452.80	1,958,003.54	1,182,936.90	759,860.00	1,460,093.68	1,536,932.74	0.00	0.00		11,234,990.88		

3508	ADULT 40-100% M&F 45	199.90	8,524.08	0.00	0.00	-8,524.08	12,065.16	0.00	821.00	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	8,982.07	20,406.89	80,618.81	57,354.21	161,631.64	0.00	0.00	
3515	ADULT 40-100% FEMAL E	-3,007.18	54,380.63	0.00	32,525.76	1,139.36	2,440.30	16,793.91	0.00	0.00	9,950.01	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	346,217.13	692,165.73	-123,424.49	709,054.26	469,647.33	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	134,215.65	74,882.95	252,666.75	41,881.78	49,988.40	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	344,639.51	710,708.31	669,806.16	887,697.90	831,575.15	0.00	0.00	
3705	ADULT <40% EXP FEMA L	0.00	0.00	34,949.77	0.00	0.00	0.00	454.98	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	1,073.96	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	-2,777.28	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	-3,005.22	1,702.54	-966.32	2,188.06	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	106,237.31	273,272.87	139,148.01	153,257.67	159,663.08	0.00	0.00	
3715	ADULT <40% EXP FEMA L	184.66	103,301.82	-1,282.40	41,044.21	-28,386.07	84,905.94	225,163.48	59,875.92	41,442.30	21,818.41	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	1,463,160.28	1,733,495.33	1,697,539.20	2,186,550.07	1,509,087.29	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	476,949.55	1,342,124.85	408,269.10	657,372.04	537,011.53	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	2,231,337.52	2,754,618.63	1,644,456.92	2,661,428.57	2,026,511.70	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	127.95	139.85	392.34	0.00	745.43	0.00	0.00	932.69	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	5,208,890.63	7,843,013.19	4,828,811.06	7,400,233.51	5,776,884.54	0.00	0.00	

13,086.06	
605,379.70	
114,222.79	
3,423,375.57	
1,485,713.37	
7,316,435.92	
35,404.75	
2,154.47	
14,401.06	
107,285.29	
1,925,686.47	
548,068.27	
20,235,217.78	
6,267,504.38	
25,605,563.53	
2,338.26	
67,701,837.67	

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	7,717.17	-7,499.50	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	-1,566.61	1,786.73	0.00	0.00	79.76	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	644.15	0.00	12,398.47	0.00	47,552.37	1,889.87	329.81	340.01	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	485.89	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	42,188.29	1,203.60	39,418.08	1,163.20	47,460.40	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	925.66	41,535.06	20,767.53	31,316.39	20,767.53	20,767.53	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	247,454.55	522,183.94	728,791.43	385,752.60	751,038.77	371,681.40	441,334.78	358,530.01	514,353.28	379,053.86	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	30,506.87	357,384.91	305,336.74	101,290.66	7,736.46	105,886.79	87,747.81	232,125.78	397,904.23	235,409.15	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	249,396.24	555,753.15	566,520.70	430,738.47	755,979.51	0.00	0.00	
SUBTOTAL:	746,102.23	1,535,864.31	1,471,109.81	1,139,420.73	1,741,339.36	802,107.56	1,156,145.97	1,229,800.83	1,365,256.52	1,439,090.22	0.00	0.00	

217.67	
6,152.90	
63,154.68	
485.89	
325,320.99	
136,079.70	
4,700,174.62	
1,861,329.40	
5,533,321.69	
12,626,237.54	

3,267,394.48

4413	SOBRA 100-133% M&F
6	294,812.82	246,412.43	216,055.33	305,884.98	363,191.92	452,334.10	221,044.35	559,873.03	320,414.58	287,370.94	0.00	0.00	
4414	SOBRA 100-133% MALE	102,547.39	274,951.01	298,082.53	236,398.62	168,885.43	475,763.31	193,415.08	144,583.96	246,146.43	181,389.93	0.00	0.00	

2,322,163.69

ACC REINSURANCE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	10,385.08	726.93	36,590.94	12,443.17	7,259.91	31,602.49	9,510.25	5,704.68	18,302.70	24,692.00	0.00	0.00		157,218.15		
SUBTOTAL:	407,745.29	522,090.37	550,728.80	554,726.77	539,337.26	959,699.90	423,969.68	710,161.67	584,863.71	493,452.87	0.00	0.00		5,746,776.32		

4518	BC PATIENT FEMALE 4 5	0.00	0.00	1,584.30	0.00	0.00	11,328.33	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	1,584.30	0.00	0.00	11,328.33	0.00	0.00	0.00	0.00	0.00	0.00	

12,912.63

12,912.63

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	12,436.24	12,518.33	12,483.15	-12,415.31	133.76	46.62	0.00	0.00	
8710	SSI DISABLED FREEDO
M	318,524.01	68,836.44	4,993.81	0.00	42,017.12	22,618.29	9,740.00	18,714.96	0.00	655,090.88	0.00	0.00	
SUBTOTAL:	318,524.01	68,836.44	4,993.81	0.00	54,453.36	35,136.62	22,223.15	6,299.65	133.76	655,137.50	0.00	0.00	

25,202.79	
1,140,535.51	
1,165,738.30	

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

238,382,671.06

20,318,436.12	25,568,339.31	23,880,977.68	22,914,480.62	28,325,927.03	25,239,496.10	22,736,943.68	19,825,605.48	25,528,945.14	24,043,519.90	0.00	0.00	

TOTAL:

LONG TERM CARE REINSURANCE
For The Period Ending April 30, 2021	
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	7,093.50	0.00	0.00	0.00	0.00		15,731.02		
1010	TANF NON-MEDICARE	69,901.43	86,772.10	131,865.39	193,696.46	125,063.49	112,406.33	137,740.17	283,257.45	29,142.62	94,584.01	0.00	0.00		1,264,429.45		
2100	SSI AGED WITH MEDIC	60,397.22	169,241.05	240,471.75	231,709.44	240,620.97	318,395.24	357,856.32	188,348.83	221,953.39	187,678.21	0.00	0.00		2,216,672.42		
	A																
2110	SSI AGED NON-MEDICA	11,714.39	67,113.76	57,237.79	60,757.45	48,712.62	103,868.11	57,902.25	18,342.65	3,878.97	24,326.92	0.00	0.00		453,854.91		
	R																
2200	SSI DISABLED WITH M	275,434.62	431,387.49	427,970.76	416,500.37	497,429.27	408,398.77	482,750.42	275,905.10	401,463.28	331,362.61	0.00	0.00		3,948,602.69		
	E																
2210	SSI DISABLED NON-ME	2,845,203.33	7,270,389.52	5,088,943.39	9,241,961.50	4,431,222.60	6,055,123.52	5,877,157.04	3,225,040.54	3,548,288.87	6,222,709.69	0.00	0.00		53,806,040.00		
	D																
2300	SSI BLIND WITH MEDIC	0.00	-4,174.91	0.00	0.00	0.00	-168.37	0.00	0.00	0.00	-168.37	0.00	0.00		-4,511.65		
2310	SSI BLIND NON-MEDIC	0.00	0.00	6,927.33	0.00	0.00	0.00	3,074.02	0.00	10,522.01	0.00	0.00	0.00		20,523.36		
	A																
SUBTOTAL:	3,262,650.99	8,020,729.01	5,953,416.41	10,153,262.74	5,343,048.95	6,998,023.60	6,916,480.22	3,997,988.07	4,215,249.14	6,860,493.07	0.00	0.00		61,721,342.20		

8710	SSI DISABLED FREEDO M	128,929.98	0.00	0.00	116,115.14	116,115.14	0.00	0.00	137,042.44	127,089.85	41,854.60	0.00	0.00	
SUBTOTAL:	128,929.98	0.00	0.00	116,115.14	116,115.14	0.00	0.00	137,042.44	127,089.85	41,854.60	0.00	0.00	

667,147.15

667,147.15

TOTAL:	3,391,580.97	8,020,729.01	5,953,416.41	10,269,377.88	5,459,164.09	6,998,023.60	6,916,480.22	4,135,030.51	4,342,338.99	6,902,347.67	0.00	0.00		62,388,489.35		

ACC SMIB
For The Period Ending April 30, 2021	
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	70,998.30	71,581.00	72,015.30	61,906.20	48,164.10	0.00	0.00		652,616.80		
1010	TANF NON-MEDICARE	723.00	867.60	578.40	578.40	578.40	578.40	594.00	594.00	445.50	445.50	0.00	0.00		5,983.20		
1020	TANF WITH QMB	41,334.30	44,476.10	48,151.80	46,127.40	46,127.40	48,296.40	53,819.40	51,074.80	52,471.00	48,833.10	0.00	0.00		480,711.70		
2100	SSI AGED WITH MEDIC	52,524.10	61,427.70	56,665.00	59,124.30	55,976.20	71,559.90	67,470.10	65,281.70	60,605.30	68,517.20	0.00	0.00		619,151.50		
	A																
2110	SSI AGED NON-MEDICA	584,914.80	589,054.90	584,770.50	585,051.60	582,125.40	587,427.90	603,647.90	601,959.80	585,916.60	604,769.30	0.00	0.00		5,909,638.70		
	R																
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	5,220,684.80	5,423,849.70	5,397,923.10	5,463,283.60	5,509,777.60	0.00	0.00		52,659,366.90		
2200	SSI DISABLED WITH M	113,156.40	98,272.00	93,790.10	90,638.30	96,275.60	94,510.20	104,666.20	98,214.70	97,077.20	104,558.30	0.00	0.00		991,159.00		
	E																
2210	SSI DISABLED NON-ME	488,752.00	495,625.10	497,089.30	502,260.70	501,612.00	494,658.40	515,358.00	518,823.90	516,588.60	500,408.60	0.00	0.00		5,031,176.60		
	D																
2220	SSI DISABLED WITH Q	4,085,066.00	4,232,863.20	4,229,921.70	4,231,086.40	4,215,256.30	4,220,812.50	4,308,659.30	4,314,926.00	4,317,074.70	4,302,885.50	0.00	0.00		42,458,551.60		
	M																
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	4,338.00	4,338.00	4,627.20	4,916.40	4,338.00	4,338.00	4,455.00	4,752.00	4,455.00	4,455.00	0.00	0.00		45,012.60		
	A																
2320	SSI BLIND WITH QMB	39,729.50	40,488.00	40,488.00	40,921.80	40,632.60	41,789.40	42,017.70	40,989.90	41,134.50	40,540.50	0.00	0.00		408,731.90		
4320	SOBRA CHILD WITH Q	1,012.20	1,301.40	1,012.20	723.00	723.00	723.00	1,180.20	1,039.50	1,039.50	1,039.50	0.00	0.00		9,793.50		
	MB																
5020	SOBRA PREGNANT WO	4,627.20	4,048.80	4,048.80	6,507.00	3,036.60	4,048.80	4,869.30	2,376.00	4,001.70	3,712.50	0.00	0.00		41,276.70		
	MAN																
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	973,861.70	1,030,658.70	1,048,138.20	1,064,867.10	1,058,240.90	0.00	0.00		9,898,055.70		
8040	SLMB	5,934,242.50	6,014,077.30	6,023,078.00	6,037,424.30	5,985,247.70	6,046,179.00	6,384,782.00	6,316,087.60	6,347,685.40	6,461,192.10	0.00	0.00		61,549,995.90		
8888	SMIB ONLY NOT ELIGIB	-25,842.80	-13,500.40	-27,654.60	-24,276.80	-16,165.30	-10,712.40	-20,019.60	-16,943.70	-21,532.50	-43,321.90	0.00	0.00		-219,970.00		
9999	SMIB ONLY NOT ELIGIB	152,609.30	62,699.50	57,203.90	97,707.80	93,547.60	262,965.90	34,361.10	157,855.70	97,044.90	74,268.50	0.00	0.00		1,090,264.20		
SUBTOTAL:	17,458,267.60	17,781,045.10	17,759,177.80	17,875,472.30	17,834,953.40	18,132,720.20	18,631,950.00	18,675,108.50	18,694,064.30	18,788,486.30	0.00	0.00		181,631,245.50		

1100	TANF EXPANDED FPR FI	245,986.80	252,086.80	233,269.00	238,028.50	245,831.70	248,583.60	267,602.20	264,184.80	256,305.90	255,655.50	0.00	0.00	
1110	TANF EXPANDED FOR
FI	289.20	289.20	289.20	289.20	289.20	433.80	445.50	742.50	445.50	445.50	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	1,035,997.70	1,062,398.20	1,063,856.50	1,069,853.10	1,085,117.20	0.00	0.00	
2400	SSI AGED EXPANDED
WI	21,556.00	22,548.50	25,686.10	26,264.50	26,119.90	27,999.70	28,190.00	30,355.00	28,266.60	29,813.40	0.00	0.00	
2410	SSI AGED EXPANDED N O	1,012.20	1,012.20	1,003.10	867.60	723.00	723.00	594.00	594.00	594.00	594.00	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	4,342,573.60	4,517,462.20	4,523,071.10	4,545,609.90	4,613,455.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	144.60	144.60	144.60	144.60	144.60	144.60	148.50	148.50	148.50	148.50	0.00	0.00	
2600	SSI DISABLED EXPAND
E	35,293.00	39,602.20	23,416.10	27,329.40	35,716.20	32,535.00	39,298.20	39,366.60	36,159.00	34,041.00	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	2,458,698.00	2,530,989.00	2,520,959.70	2,564,061.20	2,557,784.30	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	8,147,689.00	8,447,127.80	8,443,278.70	8,501,443.70	8,577,054.40	0.00	0.00	

2,507,534.80	
3,958.80	
10,398,413.00	
266,799.70	
7,717.10	
43,650,617.50	
1,461.60	
342,756.70	
24,799,487.60	
81,978,746.80	

3500	ADULT 40-100% FOR FI	0.00	0.00	0.00	144.60	144.60	433.80	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	3,904.20	4,584.00	4,158.00	5,791.50	7,866.60	0.00	0.00	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	0.00	0.00	723.00	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	9,977.40	8,171.40	10,836.60	9,652.50	15,115.80	0.00	0.00	
SUBTOTAL:	6,073.20	6,073.20	9,543.60	10,122.00	11,134.20	15,038.40	12,755.40	14,994.60	15,444.00	22,982.40	0.00	0.00	

723.00	
38,739.90	
723.00	
83,975.10	
124,161.00	

ACC SMIB
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3900	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	723.00	433.80	867.60	0.00	0.00	0.00	0.00	0.00	0.00		2,024.40		
3920	NEWLY ELIGIBLE FOR
F	2,313.60	235.60	6,507.00	4,338.00	6,362.40	6,362.40	7,401.60	8,561.30	9,941.70	12,614.70	0.00	0.00		64,638.30		
SUBTOTAL:	2,313.60	235.60	6,507.00	5,061.00	6,796.20	7,230.00	7,401.60	8,561.30	9,941.70	12,614.70	0.00	0.00		66,662.70		

8620	SSI BLIND FREEDOM/W O	144.60	144.60	144.60	144.60	144.60	144.60	148.50	148.50	148.50	148.50	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	67,972.60	68,078.70	68,082.60	67,641.00	72,975.30	0.00	0.00	
SUBTOTAL:	54,658.80	61,156.70	64,198.60	65,785.00	69,400.00	68,117.20	68,227.20	68,231.10	67,789.50	73,123.80	0.00	0.00	

1,461.60	
289.20	
658,937.10	
660,687.90	

264,461,503.90

25,328,141.20	25,806,825.80	25,806,865.20	26,010,001.30	25,998,294.60	26,370,794.80	27,167,462.00	27,210,174.20	27,288,683.20	27,474,261.60	0.00	0.00	

TOTAL:

ACC HIB
For The Period Ending April 30, 2021	
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	-1,182.00	0.00	0.00		-724.00		
1020	TANF WITH QMB	458.00	458.00	0.00	458.00	1,374.00	1,419.80	1,460.10	1,460.10	1,460.10	1,460.10	0.00	0.00		10,008.20		
2100	SSI AGED WITH MEDIC	1,328.00	1,832.00	1,374.00	1,374.00	9,160.00	10,076.00	2,826.00	-942.00	3,297.00	147.00	0.00	0.00		30,472.00		
	A																
2110	SSI AGED NON-MEDICA	0.00	1,374.00	0.00	1,374.00	0.00	0.00	1,387.00	6,170.00	0.00	0.00	0.00	0.00		10,305.00		
	R																
2120	SSI AGED WITH QMB	638,046.60	712,477.40	698,452.00	726,674.00	696,932.20	723,512.20	737,927.00	725,141.20	731,045.20	726,256.10	0.00	0.00		7,116,463.90		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	0.00	458.00	0.00	0.00	0.00	0.00	471.00	0.00	0.00		929.00		
	E																
2210	SSI DISABLED NON-ME	1,374.00	1,374.00	0.00	1,374.00	0.00	0.00	0.00	7,842.00	0.00	0.00	0.00	0.00		11,964.00		
	D																
2220	SSI DISABLED WITH Q	292,661.40	301,870.60	317,862.20	323,094.60	322,969.60	320,611.00	345,029.00	332,472.00	336,224.90	330,791.70	0.00	0.00		3,223,587.00		
	M																
2310	SSI BLIND NON-MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	471.00	0.00	0.00	0.00	0.00		471.00		
	A																
2320	SSI BLIND WITH QMB	3,000.00	2,084.00	3,458.00	2,542.00	2,542.00	2,542.00	3,543.00	2,614.00	3,085.00	3,085.00	0.00	0.00		28,495.00		
8020	QMB ONLY	6,847.80	7,007.80	6,091.80	7,649.00	6,137.60	6,137.60	6,596.10	6,596.10	6,596.10	6,596.10	0.00	0.00		66,256.00		
9999	SMIB ONLY NOT ELIGIB	-4,692.20	-14,104.00	-9,020.40	-13,028.00	-6,116.80	-4,554.60	-2,456.10	-7,795.90	-6,468.40	-32,144.00	0.00	0.00		-100,380.40		
SUBTOTAL:	939,023.60	1,014,831.80	1,018,217.60	1,051,511.60	1,033,456.60	1,059,744.00	1,096,312.10	1,074,028.50	1,075,239.90	1,035,481.00	0.00	0.00		10,397,846.70		

1100	TANF EXPANDED FPR FI	0.00	0.00	0.00	1,374.00	4,580.00	458.00	471.00	-471.00	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	1,413.00	471.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	4,580.00	5,496.00	5,038.00	5,038.00	4,580.00	916.00	5,181.00	4,451.00	4,239.00	4,239.00	0.00	0.00	
SUBTOTAL:	5,038.00	5,496.00	5,038.00	6,412.00	9,618.00	1,374.00	5,652.00	3,980.00	5,652.00	4,710.00	0.00	0.00	

6,412.00	
2,800.00	
43,758.00	
52,970.00	

TOTAL:	944,061.60	1,020,327.80	1,023,255.60	1,057,923.60	1,043,074.60	1,061,118.00	1,101,964.10	1,078,008.50	1,080,891.90	1,040,191.00	0.00	0.00		10,450,816.70		

Q1
For The Period Ending April 30, 2021	
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	3,114,706.10	2,897,725.30	2,977,720.90	3,097,171.80	3,079,684.90	0.00	0.00		30,754,113.30		
9999	SMIB ONLY NOT ELIGIB	5,176.20	12,716.80	4,713.80	8,912.60	12,217.10	2,594.80	158,533.50	90,735.80	71,988.10	86,243.30	0.00	0.00		453,832.00		
SUBTOTAL:	3,107,017.00	3,143,329.80	3,119,658.10	3,147,956.70	3,112,879.20	3,117,300.90	3,056,258.80	3,068,456.70	3,169,159.90	3,165,928.20	0.00	0.00		31,207,945.30		

31,207,945.30

3,107,017.00	3,143,329.80	3,119,658.10	3,147,956.70	3,112,879.20	3,117,300.90	3,056,258.80	3,068,456.70	3,169,159.90	3,165,928.20	0.00	0.00	

TOTAL:

LTC SMIB
For The Period Ending April 30, 2021	
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	289.20	297.00	148.50	445.50	297.00	0.00	0.00		2,344.80		
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	144.60	148.50	148.50	148.50	148.50	0.00	0.00		1,606.20		
2100	SSI AGED WITH MEDIC	1,126,718.00	1,111,814.50	1,067,152.00	1,061,789.40	1,059,040.40	1,053,962.40	1,088,569.70	1,046,819.70	1,001,153.30	1,010,241.70	0.00	0.00		10,627,261.10		
	A																
2110	SSI AGED NON-MEDICA	246,457.10	249,967.40	235,625.20	235,517.00	231,070.80	228,912.40	234,739.50	229,299.60	238,013.90	231,216.10	0.00	0.00		2,360,819.00		
	R																
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	1,301,303.90	1,329,385.70	1,314,419.60	1,320,412.40	1,302,025.90	0.00	0.00		13,211,969.60		
2200	SSI DISABLED WITH M	396,138.30	394,263.10	387,700.90	384,275.90	382,674.10	385,573.40	406,427.20	396,721.20	372,733.80	368,241.70	0.00	0.00		3,874,749.60		
	E																
2210	SSI DISABLED NON-ME	10,411.20	10,555.80	10,845.00	11,857.20	13,592.40	15,038.40	13,798.80	13,216.50	3,861.00	4,752.00	0.00	0.00		107,928.30		
	D																
2220	SSI DISABLED WITH Q	1,167,867.40	1,176,443.50	1,169,313.90	1,168,028.20	1,176,378.70	1,181,364.60	1,187,892.00	1,194,613.60	1,191,768.40	1,187,072.40	0.00	0.00		11,800,742.70		
	M																
2300	SSI BLIND WITH MEDIC	433.80	289.20	433.80	433.80	578.40	578.40	742.50	742.50	148.50	148.50	0.00	0.00		4,529.40		
2310	SSI BLIND NON-MEDIC	144.60	144.60	144.60	144.60	144.60	144.60	445.50	594.00	148.50	0.00	0.00	0.00		2,055.60		
	A																
2320	SSI BLIND WITH QMB	433.80	433.80	433.80	723.00	723.00	867.60	1,039.50	891.00	891.00	742.50	0.00	0.00		7,179.00		
SUBTOTAL:	4,300,703.40	4,300,461.80	4,198,635.60	4,172,583.50	4,165,343.60	4,168,179.50	4,263,485.90	4,197,614.70	4,129,724.80	4,104,886.30	0.00	0.00		42,001,619.10		

28,047.90

8720	SSI DISABLED FREEDO M	3,181.20	3,181.20	3,036.60	2,747.40	2,602.80	2,458.20	2,376.00	2,821.50	2,821.50	2,821.50	0.00	0.00	
SUBTOTAL:	3,181.20	3,181.20	3,036.60	2,747.40	2,602.80	2,458.20	2,376.00	2,821.50	2,821.50	2,821.50	0.00	0.00	

28,047.90

TOTAL:	4,303,884.60	4,303,643.00	4,201,672.20	4,175,330.90	4,167,946.40	4,170,637.70	4,265,861.90	4,200,436.20	4,132,546.30	4,107,707.80	0.00	0.00		42,029,667.00		

LTC HIB
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC	252.00	0.00	0.00	0.00	0.00	0.00	471.00	-471.00	0.00	0.00	0.00	0.00		252.00		
	A																
2110	SSI AGED NON-MEDICA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,201.00	0.00	0.00	0.00	0.00		1,201.00		
	R																
2120	SSI AGED WITH QMB	387,600.40	394,738.80	385,097.80	378,053.40	376,695.40	382,649.40	386,821.70	382,283.70	369,934.60	366,926.20	0.00	0.00		3,810,801.40		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	252.00	0.00	458.00	-458.00	0.00	471.00	730.00	0.00	0.00		1,453.00		
	E																
2220	SSI DISABLED WITH Q	-1,704.00	10,626.00	8,084.00	10,122.00	10,328.00	10,420.00	10,197.00	12,280.00	3,556.00	2,826.00	0.00	0.00		76,735.00		
	M																
SUBTOTAL:	386,148.40	405,364.80	393,181.80	388,427.40	387,023.40	393,527.40	397,031.70	395,293.70	373,961.60	370,482.20	0.00	0.00		3,890,442.40		

3,890,442.40

393,181.80	388,427.40	387,023.40	393,527.40	397,031.70	395,293.70	373,961.60	370,482.20	0.00	0.00	

TOTAL:

386,148.40

405,364.80

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	-5,005.00	-464.16	-455.00	3,060.22	15.20	0.00	0.00		555.69		
1007	TANF 21-44 FEMALE WI	479.00	1,103.94	1,157.60	172.76	926.19	479.00	21.49	3,339.46	3,374.29	1,379.82	0.00	0.00		12,433.55		
1008	TANF 45-64 M & F WIT	8,767.23	-910.29	5,272.07	6,144.46	5,040.47	5,272.96	-585.70	7,781.69	18,207.61	1,177.50	0.00	0.00		56,168.00		
1009	TANF 65+ M & F WITH	986.51	3,063.18	3,790.49	3,572.44	-310.19	389.86	958.13	6,305.29	10,267.30	3,124.35	0.00	0.00		32,147.36		
1011	TANF <1 M & F NON-ME	461,027.80	365,528.50	585,976.36	388,106.47	345,703.40	299,206.57	275,489.57	443,467.57	848,982.20	549,831.89	0.00	0.00		4,563,320.33		
1012	TANF 01-05 M & F NON	184,699.98	125,380.18	209,789.47	202,225.60	147,986.22	49,373.97	54,416.11	123,842.06	301,341.58	154,051.85	0.00	0.00		1,553,107.02		
1013	TANF 06-13 M & F NON	280,888.33	237,331.61	258,132.90	255,486.61	247,492.83	122,251.83	106,940.01	241,443.54	500,316.87	247,892.55	0.00	0.00		2,498,177.08		
1014	TANF 14-20 MALE NON-	95,294.65	80,813.56	107,335.51	102,835.97	93,386.49	71,372.37	64,313.67	116,640.71	205,222.01	119,220.52	0.00	0.00		1,056,435.46		
1015	TANF 14-20 FEMALE N	213,030.75	145,779.58	176,320.19	169,924.94	193,520.45	111,261.06	75,895.18	165,875.97	420,198.22	207,355.09	0.00	0.00		1,879,161.43		
	O																
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	693,015.45	492,844.59	1,232,848.63	2,352,830.86	1,214,032.46	0.00	0.00		11,622,062.41		
1017	TANF 21-44 FEMALE N	4,972,790.03	3,889,893.65	4,776,934.09	3,835,954.02	3,670,193.90	2,556,568.60	1,747,839.15	4,718,698.13	9,946,933.74	4,548,234.19	0.00	0.00		44,664,039.50		
	O																
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	1,085,376.07	815,520.16	2,277,744.06	4,877,352.18	2,093,738.64	0.00	0.00		20,871,984.61		
1019	TANF 65+ M & F NON-M	15,796.27	10,852.49	15,650.88	24,856.64	20,583.53	16,659.07	17,900.35	12,908.72	28,824.40	9,365.35	0.00	0.00		173,397.70		
1026	TANF 21-44 MALE WITH	958.00	0.00	0.00	0.00	0.00	0.00	0.00	519.00	519.00	0.00	0.00	0.00		1,996.00		
1027	TANF 21-44 FEMALE WI	3.40	0.00	0.00	0.00	0.00	0.00	24.00	154.50	2,885.23	1,422.26	0.00	0.00		4,489.39		
1028	TANF 45-64 M & F WIT	3,521.84	1,872.66	3,233.35	4,381.92	2,927.29	1,566.59	1,755.56	3,117.38	9,933.65	8,198.05	0.00	0.00		40,508.29		
1029	TANF 65+ M & F WITH	292.98	1,924.55	1,814.10	3,656.83	2,583.93	1,280.30	1,409.94	3,980.47	6,093.27	2,537.84	0.00	0.00		25,574.21		
2100	SSI AGED WITH MEDIC	64,634.29	62,083.72	80,244.64	50,806.57	42,479.32	24,142.23	-5,179.52	83,558.98	202,767.78	52,946.07	0.00	0.00		658,484.08		
	A																
2110	SSI AGED NON-MEDICA	173,482.40	97,035.25	135,410.01	128,622.04	103,594.26	59,802.89	38,132.46	310,732.70	413,784.96	123,697.57	0.00	0.00		1,584,294.54		
	R																
2120	SSI AGED WITH QMB	342,909.69	213,466.09	401,178.02	334,494.11	295,693.94	95,264.34	-14,305.49	401,747.80	1,005,550.18	287,571.27	0.00	0.00		3,363,569.95		
2200	SSI DISABLED WITH M	238,117.73	322,298.77	284,942.31	213,312.02	159,020.75	88,995.23	23,729.97	276,410.41	567,927.93	188,010.29	0.00	0.00		2,362,765.41		
	E																
2210	SSI DISABLED NON-ME	5,265,752.86	3,391,013.01	5,234,629.96	4,031,910.63	3,551,491.53	1,897,319.36	884,170.32	4,341,887.82	10,707,867.79	4,328,176.19	0.00	0.00		43,634,219.47		
	D																
2220	SSI DISABLED WITH Q	511,611.84	318,762.10	584,682.65	474,952.83	421,893.82	123,265.41	26,577.97	509,381.02	1,450,757.76	409,434.72	0.00	0.00		4,831,320.12		
	M																
2300	SSI BLIND WITH MEDIC	1,532.50	506.14	2,480.40	3,264.32	1,472.43	-1,574.79	-1,250.04	3,116.92	6,259.43	137.84	0.00	0.00		15,945.15		
2310	SSI BLIND NON-MEDIC	69,578.89	33,696.39	68,573.05	65,030.17	59,992.48	31,781.63	14,579.67	70,617.89	198,808.70	77,601.53	0.00	0.00		690,260.40		
	A																
2320	SSI BLIND WITH QMB	10,798.66	4,826.98	7,965.99	11,309.28	5,219.78	2,750.88	-442.25	5,745.23	17,568.05	7,770.84	0.00	0.00		73,513.44		
4311	SOBRA CHILD <1 M & F	1,382,791.01	1,137,325.32	1,342,518.25	998,706.89	870,760.17	955,940.08	519,364.30	933,397.59	1,708,759.77	1,064,272.83	0.00	0.00		10,913,836.21		
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	485,512.36	481,652.77	1,406,399.52	4,124,802.73	2,192,987.45	0.00	0.00		17,511,931.06		
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	1,078,969.55	829,093.16	2,356,747.12	5,555,288.87	2,589,174.78	0.00	0.00		26,045,241.91		
4314	SOBRA CHILD 14-20 MA	826,137.69	690,281.33	845,508.96	744,062.61	987,252.37	566,060.25	391,935.81	850,975.53	1,734,564.80	1,020,232.13	0.00	0.00		8,657,011.48		
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	753,053.25	648,196.36	1,180,307.78	2,629,480.63	1,451,099.22	0.00	0.00		12,224,280.36		
5007	SOBRA PREG 21-44 FE	0.00	0.00	1,148.13	951.17	109.35	-455.00	0.00	0.00	109.72	0.00	0.00	0.00		1,863.37		
	M																
5013	SOBRA PREG 09-13 FE	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		
	M																
5015	SOBRA PREG 14-20 FE	149,844.64	168,483.13	235,339.53	192,153.92	122,055.54	114,037.69	99,853.25	106,764.64	151,117.78	103,750.96	0.00	0.00		1,443,401.08		
	M																
5017	SOBRA PREG 21-44 FE	1,254,267.06	1,120,613.96	1,358,338.46	1,056,066.84	820,333.28	676,862.43	462,148.42	1,028,524.15	1,621,138.97	811,276.19	0.00	0.00		10,209,569.76		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	0.00	1,437.00	479.00	-853.20	-391.00	1,621.00	7,298.00	10,889.52	0.00	0.00		20,480.32		
	M																

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	11,959,943.29	8,052,144.21	23,226,148.28	51,640,196.48	23,880,606.96	0.00	0.00		233,299,073.70		

1106	TANF EXPANDED 21-44	3,449.22	2,456.28	5,305.62	2,879.12	724.85	-2,669.54	-642.85	2,835.78	7,344.40	1,217.89	0.00	0.00	
1107	TANF EXPANDED 21-44	1,495.62	2,650.65	1,179.37	2,183.78	1,035.22	2,512.40	839.62	2,818.71	5,371.79	2,768.66	0.00	0.00	
1108	TANF EXPANDED 45-64	22,534.78	14,660.12	18,395.58	20,478.08	11,971.17	10,317.77	-475.60	24,016.34	55,824.37	16,005.82	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	24,627.45	14,126.14	26,378.54	21,167.86	23,291.61	7,492.58	3,859.46	28,439.28	64,878.93	23,346.42	0.00	0.00	
1113	TANF EXPANDED 06-13	479.00	0.00	0.00	479.00	0.00	479.00	958.00	519.00	2,060.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	19,340.12	7,687.57	2,085.44	479.00	958.00	253.54	-1,293.00	2,875.67	7,868.59	1,619.74	0.00	0.00	
1115	TANF EXPANDED 14-20	20,932.02	36,988.35	47,861.85	34,191.93	21,802.53	12,828.81	8,899.77	22,895.37	37,191.87	58,679.11	0.00	0.00	
1116	TANF EXPANDED 21-44	666,818.56	414,380.34	680,595.60	479,046.55	498,578.64	356,867.61	300,570.24	797,112.07	1,412,490.71	745,499.01	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	1,483,546.83	918,711.38	2,480,792.90	4,952,111.00	2,278,424.29	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	743,153.41	495,424.89	1,664,206.33	3,592,329.15	1,362,538.62	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	11,587.12	13,358.17	5,471.83	3,353.00	3,297.05	2,439.33	663.00	12,615.00	37,675.00	12,864.91	0.00	0.00	
1126	TANF EXPANDED 21-44	4,910.70	5,871.25	6,081.22	7,253.80	5,113.82	2,692.46	3,689.31	6,997.50	21,683.56	6,040.05	0.00	0.00	
1127	TANF EXPANDED 21-44	11,844.40	10,977.19	14,175.84	10,330.94	9,628.43	6,670.51	3,168.60	15,905.33	36,335.69	7,388.05	0.00	0.00	
1128	TANF EXPANDED 45-64	48,690.03	35,791.38	56,299.47	51,960.38	41,962.28	22,731.81	2,912.68	60,257.94	140,885.30	46,876.32	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	44,086.51	30,330.82	61,293.03	45,982.14	46,929.38	15,631.51	7,970.07	59,815.98	136,860.44	42,401.76	0.00	0.00	
2400	SSI AGED EXPANDED WI	13,125.49	6,724.46	11,450.45	9,578.83	7,515.97	3,637.00	4,500.12	9,256.11	19,348.81	3,934.09	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	1,412.02	1,196.67	22,865.96	52,664.33	17,399.57	0.00	0.00	
2420	SSI AGED EXPANDED WI	286,357.53	181,598.46	335,861.63	297,425.59	233,880.27	91,717.27	-10,254.96	333,292.59	893,666.29	270,548.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	5,240.90	6,423.21	7,096.28	4,843.36	4,391.04	6,221.12	7,882.32	11,417.92	15,744.60	6,152.89	0.00	0.00	
2610	SSI DISABLED EXPAND E	79,539.43	37,645.54	75,232.24	71,096.00	38,633.10	-6,523.80	81,808.29	62,059.50	182,967.75	56,729.36	0.00	0.00	
2620	SSI DISABLED EXPAND
E	157,341.19	106,840.18	191,309.60	146,677.46	125,575.11	59,370.44	12,447.29	168,247.72	450,533.05	118,733.08	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	2,820,782.08	1,842,835.30	5,789,243.00	12,125,835.63	5,079,167.64	0.00	0.00	

22,900.77	
22,855.82	
193,728.43	
237,608.27	
4,974.00	
41,874.67	
302,271.61	
6,351,959.33	
22,401,096.99	
14,732,014.84	
103,324.41	
70,333.67	
126,424.98	
508,367.59	
491,301.64	
89,071.33	
183,776.89	
2,914,092.67	
75,413.64	
679,187.41	
1,537,075.12	
51,089,654.08	

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	254.06	461.61	312.18	85.40	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	1,566.99	-627.42	6,182.80	11,397.39	2,117.70	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	4,875.40	783.87	3,980.79	6,132.23	1,685.78	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	53,881.93	45,766.18	61,263.56	143,038.95	58,564.91	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	33,096.01	34,713.53	83,312.73	181,137.00	93,636.89	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	380,818.65	335,358.27	696,890.94	1,315,009.01	739,485.70	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	296,610.15	251,527.55	528,456.85	1,134,118.47	549,123.02	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	914,372.41	330,430.55	2,309,562.08	4,361,152.28	1,835,238.73	0.00	0.00	

1,592.25	
40,461.33	
39,243.05	
641,247.25	
757,373.27	
6,089,780.36	
5,277,979.74	
17,872,199.63	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	-2,251.00	-1,365.00	1,629.00	6,028.00	4,631.00	0.00	0.00		13,462.00		
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	1,058.54	165.08	100.54	958.00	0.00	0.00	0.00		4,425.67		
3706	ADULT <40% EXP MALE	804.69	451.18	2,510.50	1,599.36	574.66	599.11	-390.93	2,894.52	2,583.71	151.88	0.00	0.00		11,778.68		
3707	ADULT <40% EXP FEMA	0.00	2,685.20	479.00	0.00	0.00	-455.00	-455.00	1,176.51	1,661.43	1,596.42	0.00	0.00		6,688.56		
	L																
3708	ADULT <40% EXP M&F	5,758.15	2,913.43	3,250.81	7,741.77	5,017.67	1,891.62	-2,043.87	18,974.10	40,658.10	5,944.79	0.00	0.00		90,106.57		
	4																
3709	ADULT <40% EXP M&F	92.75	455.00	84.98	169.42	479.00	10.26	-910.00	906.00	731.72	582.20	0.00	0.00		2,601.33		
	6																
3714	ADULT <40% EXP MALE	196,306.17	183,586.66	188,675.61	201,294.46	188,343.13	122,560.38	108,588.57	214,723.68	495,429.48	251,964.90	0.00	0.00		2,151,473.04		
3715	ADULT <40% EXP FEMA	311,743.87	248,388.04	288,045.49	273,441.97	286,117.53	203,034.78	156,681.61	349,543.43	713,834.14	388,098.08	0.00	0.00		3,218,928.94		
	L																
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	3,096,960.77	2,293,497.98	4,611,335.65	9,397,143.68	5,084,312.62	0.00	0.00		45,957,628.46		
3717	ADULT <40% EXP FEMA	2,830,538.66	2,155,568.38	2,672,114.61	2,508,099.05	2,334,511.12	1,493,794.41	1,189,331.67	2,594,811.35	5,487,375.85	2,768,559.51	0.00	0.00		26,034,704.61		
	L																
3718	ADULT <40% EXP M&F	7,151,333.82	5,480,862.38	7,158,543.80	5,805,766.95	5,347,048.36	3,081,283.23	2,093,358.49	8,148,106.98	16,133,074.03	7,185,998.46	0.00	0.00		67,585,376.50		
	4																
3719	ADULT <40% EXP M&F	2,451.46	24.00	63.50	479.00	479.00	48.00	-415.00	2,475.00	11,902.05	519.00	0.00	0.00		18,026.01		
	6																
3726	ADULT <40% EXP MALE	455.00	479.00	958.00	0.00	0.00	0.00	479.00	0.00	0.00	0.00	0.00	0.00		2,371.00		
3727	ADULT <40% EXP FEMA	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		
	L																
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	479.00	479.00	824.00	-266.54	998.00	3,292.13	1,557.00	0.00	0.00		7,362.59		
	4																
SUBTOTAL:	18,575,171.89	13,762,600.13	18,916,203.03	15,637,373.80	14,356,750.64	9,684,580.64	6,834,462.65	19,637,786.12	39,446,969.83	18,973,853.99	0.00	0.00		175,825,752.72		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	257.69	981.33	1,805.71	86.88	4,269.92	2,249.72	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	600.34	479.00	2,395.00	519.00	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	12,428.67	1,957.64	17,146.98	35,045.95	13,537.71	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	8,982.47	2,539.16	13,173.16	25,023.76	18,565.15	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	28,552.16	34,187.66	17,902.90	24,247.07	23,279.03	29,279.48	23,342.43	40,820.14	67,699.13	39,850.35	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	42,858.76	38,635.33	58,592.99	50,209.04	51,152.85	38,728.44	37,486.79	94,514.47	140,065.83	99,839.07	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	435,087.68	344,992.87	435,758.45	449,378.63	401,130.42	502,532.57	389,867.08	623,438.67	1,217,582.48	633,864.75	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	778,864.23	651,565.50	737,757.48	691,072.76	652,933.26	600,157.98	411,928.31	1,082,457.86	2,050,110.85	899,500.14	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	1,020,592.89	517,976.21	1,866,195.72	3,878,164.11	1,567,057.91	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	479.00	958.00	3,353.00	3,353.00	5,269.00	3,842.03	1,437.00	7,609.32	13,684.27	519.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	489.26	479.00	566.53	0.00	0.00	958.00	18.41	0.00	2,595.00	15.27	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	239.25	0.00	479.00	0.00	660.22	0.00	0.00	479.00	1,038.00	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	2,219,308.24	1,387,240.25	3,750,584.24	7,435,654.10	3,273,268.35	0.00	0.00	

9,651.25	
3,993.34	
118,473.48	
88,034.79	
329,160.35	
652,083.57	
5,433,633.60	
8,556,348.37	
15,042,265.77	
40,503.62	
5,121.47	
2,895.47	
30,282,165.08	

4413	SOBRA 100-133% M&F
6	268,764.47	149,124.80	243,206.55	252,433.32	314,497.28	140,969.20	70,195.66	283,646.67	492,943.64	250,202.59	0.00	0.00	
4414	SOBRA 100-133% MALE	77,334.28	65,345.20	64,800.01	92,558.03	89,554.16	64,637.88	53,413.98	109,498.21	196,217.33	132,406.26	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	72,696.56	59,233.66	141,015.27	310,613.52	143,915.52	0.00	0.00	
SUBTOTAL:	452,831.14	305,390.58	412,072.51	443,988.92	496,342.00	278,303.64	182,843.30	534,160.15	999,774.49	526,524.37	0.00	0.00	

2,465,984.18	
945,765.34	
1,220,481.58	
4,632,231.10	

4517

BC PATIENT FEMALE 2 1

479.00

0.00

0.00

0.00

479.00

-455.00

-910.00	479.00

1,996.00

1,557.00

0.00

0.00

3,625.00

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	2,576.30	-2,794.43	6,659.00	6,577.71	5,669.00	0.00	0.00		34,076.01		
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	-455.00	0.00	0.00	0.00	0.00	0.00	0.00		-455.00		
SUBTOTAL:	3,776.43	958.00	3,353.00	5,748.00	2,511.00	1,666.30	-3,704.43	7,138.00	8,573.71	7,226.00	0.00	0.00		37,246.01		

8700	SSI DISABLED FREEDO M	7,365.17	3,199.17	11,015.35	5,903.62	7,578.25	3,230.22	2,170.18	11,408.18	20,649.63	7,051.25	0.00	0.00	
8710	SSI DISABLED FREEDO
M	13,811.11	6,905.41	10,003.43	10,017.05	22,789.45	28,368.97	4,556.52	4,655.00	33,816.88	7,841.47	0.00	0.00	
8720	SSI DISABLED FREEDO M	3,819.95	597.17	2,231.90	2,110.53	743.92	1,094.40	28.40	1,629.95	1,993.91	28.41	0.00	0.00	
SUBTOTAL:	24,996.23	10,701.75	23,250.68	18,031.20	31,111.62	32,693.59	6,755.10	17,693.13	56,460.42	14,921.13	0.00	0.00	

79,571.02	
142,765.29	
14,278.54	
236,614.85	

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:	52,666,977.10	39,258,032.93	53,950,300.43	45,587,825.73	42,207,961.17	26,997,277.78	18,302,576.38	52,962,752.92	111,713,464.66	51,755,568.44	0.00	0.00		495,402,737.54		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	30,734.20	24,039.78	36,151.58	40,638.56	33,080.34	0.00	0.00		335,567.85		
8040	SLMB	8.80	15.80	148.42	0.00	0.00	0.00	0.00	0.00	5,164.95	4,365.16	0.00	0.00		9,703.13		
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	30,734.20	24,039.78	36,151.58	45,803.51	37,445.50	0.00	0.00		345,270.98		

29,711.98

45,803.51

0.00

0.00

TOTAL:

30,474.84

32,548.39

46,501.05

31,860.15

30,734.20

24,039.78

36,151.58

37,445.50

345,270.98

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	4,888.61	9,176.18	23,730.79	2,769.19	12,546.15	0.00	0.00		147,814.62		
1012	TANF 01-05 M & F NON	178.37	0.00	-43.85	0.00	95.96	0.00	488.00	0.00	36.66	151.65	0.00	0.00		906.79		
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	86.96	0.00	0.00		86.96		
1014	TANF 14-20 MALE NON-	70.93	92.86	0.00	0.00	0.00	54.05	0.00	415.39	0.00	0.00	0.00	0.00		633.23		
1015	TANF 14-20 FEMALE N	320.79	0.00	0.00	0.00	0.00	100.00	0.00	0.00	0.00	1,403.14	0.00	0.00		1,823.93		
	O																
1016	TANF 21-44 MALE NON-	2,461.05	5,953.60	3,099.07	8,551.42	1,150.19	1,253.25	3,042.95	9,904.13	3,839.67	15,612.82	0.00	0.00		54,868.15		
1017	TANF 21-44 FEMALE N	10,550.22	4,750.51	23,956.39	203,788.44	878.49	2,478.08	5,738.42	992.15	7,707.87	5,807.04	0.00	0.00		266,647.61		
	O																
1018	TANF 45-64 M & F NON	3,043.28	23,696.09	0.00	275.90	60.30	9,517.23	29,431.75	5,462.53	19,372.00	875.21	0.00	0.00		91,734.29		
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	1,934.75	901.85	382.17	70.83	2,545.62	63.31	9,105.72	1,294.19	4,291.63	4,937.87	0.00	0.00		25,527.94		
	A																
2110	SSI AGED NON-MEDICA	135,338.97	11,318.42	46,363.24	5,707.11	23,015.34	217.68	889.52	6,729.67	29,284.08	31,287.25	0.00	0.00		290,151.28		
	R																
2120	SSI AGED WITH QMB	554.79	1,883.86	84.85	133.17	32.62	3,256.86	3,698.18	0.00	3,805.04	90.15	0.00	0.00		13,539.52		
2200	SSI DISABLED WITH M	1,221.33	2,336.37	1,746.49	1,970.76	254.62	3,299.91	3,658.98	1,635.45	3,466.68	10,015.70	0.00	0.00		29,606.29		
	E																
2210	SSI DISABLED NON-ME	401,433.67	623,439.40	19,509.76	306,904.50	202,617.77	124,607.64	153,312.10	152,568.73	14,566.39	31,125.79	0.00	0.00		2,030,085.75		
	D																
2220	SSI DISABLED WITH Q	1,482.16	1,102.71	1,030.41	-614.25	595.37	1,517.10	1,271.82	4,310.50	61.69	510.48	0.00	0.00		11,267.99		
	M																
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	A																
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	36,242.05	11,719.91	6,983.29	9,198.51	3,011.98	0.00	0.00		1,410,674.20		
4312	SOBRA CHILD 01-05 M	3,632.61	1,568.94	12,843.72	166,524.97	172,903.79	2,662.63	1,721.68	2,138.53	1,609.22	958.47	0.00	0.00		366,564.56		
4313	SOBRA CHILD 06-13 M	3,206.57	510.76	4,684.35	19,833.69	11,886.91	1,925.91	4,686.93	10,594.84	11,631.27	5,114.56	0.00	0.00		74,075.79		
4314	SOBRA CHILD 14-20 MA	1,438.36	4,864.53	6,125.57	17,653.91	17,033.77	9,219.73	948.29	1,674.56	1,262.29	755.00	0.00	0.00		60,976.01		
4315	SOBRA CHILD 14-20 FE	1,022.13	919.34	8,921.65	114.72	11,833.94	700.86	5,180.22	18,906.19	209,245.80	1,113.80	0.00	0.00		257,958.65		
5007	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																
5013	SOBRA PREG 09-13 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																
5015	SOBRA PREG 14-20 FE	9,538.67	2,430.46	-701.00	3,967.13	6,489.30	361.21	2,123.00	818.20	5,539.97	3,577.77	0.00	0.00		34,144.71		
	M																
5017	SOBRA PREG 21-44 FE	16,547.82	23,491.79	11,070.21	15,334.15	19,899.25	11,502.88	20,300.01	19,720.30	21,617.86	8,427.36	0.00	0.00		167,911.63		
	M																
5018	SOBRA PREG 45-64 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																

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	213,868.99	266,493.66	267,879.44	349,305.82	137,409.15	0.00	0.00		5,337,030.18		

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	133.63	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	7,426.08	870.19	2,009.53	4,643.62	53,502.74	0.00	0.00	
1117	TANF EXPANDED 21-44	2,926.00	2,023.77	11,445.24	5,923.35	8,087.62	1,501.82	12,502.04	3,712.52	5,173.87	988.89	0.00	0.00	
1118	TANF EXPANDED 45-64	743.54	2,547.77	36,753.27	1,421.03	1,862.86	4,105.05	6,321.37	30,044.23	1,607.56	199.89	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	67.84	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	2,023.88	2,061.08	1,651.90	568.38	110.42	0.00	0.00	
2410	SSI AGED EXPANDED N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	478.58	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	216.54	21.31	6.66	47.65	126.61	176.78	0.00	0.00	2,673.22	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	0.00	39.34	119.11	53.18	178.20	5,346.32	0.00	174.06	695.90	242.69	0.00	0.00	
2610	SSI DISABLED EXPAND E	133,775.92	0.00	76.32	92,651.00	0.00	66.85	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	120.77	250.46	278.68	0.00	0.00	
SUBTOTAL:	151,042.99	16,535.78	53,654.68	101,227.63	13,349.81	20,646.78	21,754.68	38,191.59	15,680.85	55,456.94	0.00	0.00	

0.00	
0.00	
960.93	
0.00	
0.00	
0.00	
0.00	
97,139.09	
54,285.12	
85,606.57	
0.00	
0.00	
0.00	
290.71	
0.00	
11,156.21	
478.58	
3,268.77	
6,848.80	
226,570.09	
936.86	
487,541.73	

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	100.00	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	100.00	0.00	206.00	0.00	234.38	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	17,903.45	4,629.62	19,668.29	9,659.56	-11,418.35	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	48,781.31	2,189.62	4,948.51	6,241.60	18,754.92	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	13,121.19	1,893.63	5,115.45	22,847.32	9,165.62	0.00	0.00	

0.00	
0.00	
0.00	
100.00	
9,065.10	
256,149.00	
106,996.92	
172,206.82	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	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		
	L																
3708	ADULT <40% EXP M&F	0.00	0.00	41.68	62.36	36.34	125.32	88.97	266.61	1,111.27	43.77	0.00	0.00		1,776.32		
	4																
3709	ADULT <40% EXP 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		
	6																
3714	ADULT <40% EXP MALE	0.00	1,476.69	4,393.92	0.00	0.00	10,195.44	2,076.53	24,415.16	19,282.48	937.38	0.00	0.00		62,777.60		
3715	ADULT <40% EXP FEMA	2,166.89	361.54	1,379.91	54,494.24	955.89	1,967.01	278.40	0.00	1,070.28	1,708.87	0.00	0.00		64,383.03		
	L																
3716	ADULT <40% EXP MALE	226,474.25	117,784.32	153,008.13	150,508.65	117,090.07	105,672.45	102,267.06	115,996.78	187,002.01	221,254.44	0.00	0.00		1,497,058.16		
3717	ADULT <40% EXP FEMA	36,163.97	65,186.57	26,135.15	19,805.42	51,793.92	29,228.29	21,902.26	26,828.43	22,178.71	37,028.98	0.00	0.00		336,251.70		
	L																
3718	ADULT <40% EXP M&F	131,866.31	54,563.94	131,702.15	41,024.07	31,357.80	252,515.90	61,060.57	127,005.84	109,053.31	362,776.03	0.00	0.00		1,302,925.92		
	4																
3719	ADULT <40% EXP 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		
	6																
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	L																
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	90.62	0.00	0.00	0.00	0.00		90.62		
	4																
SUBTOTAL:	522,335.34	272,554.35	377,855.85	295,354.90	327,311.02	479,610.36	196,386.66	324,641.69	378,446.54	640,486.04	0.00	0.00		3,814,982.75		

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	31,428.71	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	183.10	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	22.28	0.00	18,781.79	0.00	0.00	0.00	152.51	1,057.11	829.76	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	1,816.88	44,050.95	4,465.72	15,700.00	14,604.36	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	3,199.26	1,188.81	2,125.73	17,289.64	1,242.65	2,414.01	892.88	10,032.77	571.22	7,315.96	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	25,561.36	20,022.30	14,060.14	136,163.03	15,230.56	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	29,792.25	96,547.35	29,615.74	153,264.01	37,333.98	0.00	0.00	

0.00	
0.00	
31,428.71	
0.00	
965.16	
20,843.45	
147,965.82	
46,272.93	
521,662.79	
0.00	
0.00	
0.00	
769,138.86	

4413	SOBRA 100-133% M&F
6	1,723.43	235.48	2,162.37	1,724.15	631.21	3,195.77	291.68	857.22	373.05	58.73	0.00	0.00	
4414	SOBRA 100-133% MALE	321.12	360.49	735.38	492.80	162.89	960.20	100.00	138.94	393.21	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,104.51	3,007.59	260.66	417.68	839.77	1,000.61	210.01	0.00	22,840.71	103,985.84	0.00	0.00	
SUBTOTAL:	3,149.06	3,603.56	3,158.41	2,634.63	1,633.87	5,156.58	601.69	996.16	23,606.97	104,044.57	0.00	0.00	

11,253.09	
3,665.03	
133,667.38	
148,585.50	

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 April 30, 2021	
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	104.33	0.00	0.00	222.03	0.00	0.00	0.00		3,375.59		
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	239.31	2,502.30	307.62	104.33	0.00	0.00	222.03	0.00	0.00	0.00		3,375.59		

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	

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

0.00

0.00

TOTAL:	2,448,509.36	1,039,642.17	637,237.68	1,677,068.05	877,340.07	749,179.29	575,466.74	661,324.62	920,526.22	974,730.68	0.00	0.00		10,561,024.88		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	553,822.53	343,304.35	469,310.32	538,990.62	337,144.31	0.00	0.00		4,414,825.69		
8040	SLMB	81.79	311.97	259.45	223.84	0.00	0.00	0.00	209.55	12,332.10	12,305.09	0.00	0.00		25,723.79		
8050	QI1	175.98	1.85	76.32	1.50	31.93	0.00	0.00	149.15	181.74	394.90	0.00	0.00		1,013.37		
SUBTOTAL:	528,802.82	334,251.05	517,060.06	365,113.94	428,190.32	553,822.53	343,304.35	469,669.02	551,504.46	349,844.30	0.00	0.00		4,441,562.85		

365,113.94

551,504.46

0.00

0.00

TOTAL:

528,802.82

334,251.05

517,060.06

428,190.32

553,822.53

343,304.35

469,669.02

349,844.30

4,441,562.85

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2021	
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	1,581.00	0.00	0.00	0.00		5,413.00		
2100	SSI AGED WITH MEDIC	266,079.56	234,408.52	196,721.73	144,847.62	122,644.71	94,528.38	60,296.68	192,236.91	638,175.50	377,831.79	0.00	0.00		2,327,771.40		
	A																
2110	SSI AGED NON-MEDICA	28,192.26	13,746.42	25,768.01	15,172.67	19,328.07	9,051.39	51,792.42	39,560.16	68,984.75	31,726.76	0.00	0.00		303,322.91		
	R																
2120	SSI AGED WITH QMB	250,820.13	171,461.90	292,915.59	221,877.83	197,346.76	44,705.50	-35,883.35	265,382.57	1,093,940.82	515,905.99	0.00	0.00		3,018,473.74		
2200	SSI DISABLED WITH M	33,409.98	20,684.24	36,391.21	35,796.06	24,400.79	23,051.65	343.01	40,349.58	162,050.31	104,064.70	0.00	0.00		480,541.53		
	E																
2210	SSI DISABLED NON-ME	801,056.57	582,866.97	787,325.61	793,819.43	660,360.27	255,100.38	495,657.18	868,014.06	1,741,816.52	814,139.76	0.00	0.00		7,800,156.75		
	D																
2220	SSI DISABLED WITH Q	115,571.37	75,938.00	124,823.54	92,502.68	84,465.58	36,871.32	11,726.41	96,488.31	280,937.83	107,436.12	0.00	0.00		1,026,761.16		
	M																
2310	SSI BLIND NON-MEDIC	479.00	492.39	958.00	479.00	958.00	-803.97	-852.27	1,461.00	998.00	0.00	0.00	0.00		4,169.15		
	A																
2320	SSI BLIND WITH QMB	0.00	17.38	21.56	0.00	0.00	95.73	149.63	189.19	26.14	0.00	0.00	0.00		499.63		
SUBTOTAL:	1,495,608.87	1,100,094.82	1,466,841.25	1,305,932.29	1,109,504.18	462,600.38	583,229.71	1,503,681.78	3,988,510.87	1,951,105.12	0.00	0.00		14,967,109.27		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00

0.00

0.00

TOTAL:	1,495,608.87	1,100,094.82	1,466,841.25	1,305,932.29	1,109,504.18	462,600.38	583,229.71	1,503,681.78	3,988,510.87	1,951,105.12	0.00	0.00		14,967,109.27		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending April 30, 2021	
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	41,898.28	24,031.58	1,334.40	-17,318.68	16,523.63	4,648.04	8,183.24	2,976.11	20,193.67	4,459.55	0.00	0.00		106,929.82		
	A																
2110	SSI AGED NON-MEDICA	441.64	634.60	20.36	0.00	14,873.95	764.77	-14,133.47	0.00	2,130.97	0.00	0.00	0.00		4,732.82		
	R																
2120	SSI AGED WITH QMB	62.97	19.40	88.39	68.64	4,726.15	8,917.80	4,358.45	867.00	3,737.46	57.98	0.00	0.00		22,904.24		
2200	SSI DISABLED WITH M	4,906.83	16,206.71	237.30	0.00	25.78	384.93	14.47	0.00	0.00	0.00	0.00	0.00		21,776.02		
	E																
2210	SSI DISABLED NON-ME	44,870.39	36,856.53	39,258.86	79,291.71	22,673.52	7,632.40	9,844.81	19,979.26	93,232.23	68,230.96	0.00	0.00		421,870.67		
	D																
2220	SSI DISABLED WITH Q	3,634.92	1,629.28	2,794.35	972.51	1,506.65	954.77	2,417.16	1,947.46	3,807.24	4,148.99	0.00	0.00		23,813.33		
	M																
2310	SSI BLIND NON-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		
	A																
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	23,302.71	10,684.66	25,769.83	123,101.57	76,897.48	0.00	0.00		602,026.90		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.09	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18.09	0.00	0.00	0.00	

18.09

0.00

18.09

602,044.99

95,815.03	79,378.10	43,733.66	63,014.18	60,329.68	23,302.71	10,684.66	25,769.83	123,119.66	76,897.48	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2021	
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	10,144.24	489.24	2,735.53	4,211.05	5,099.65	0.00	0.00		44,787.08		
1007	TANF 21-44 FEMALE WI	1,920.61	1,372.74	291.54	790.66	0.00	761.67	3,180.58	875.46	2,052.31	1,112.02	0.00	0.00		12,357.59		
1008	TANF 45-64 M & F WIT	7,282.96	3,604.16	3,970.15	60.38	1,211.12	21,701.99	10,149.88	8,501.52	2,913.59	758.58	0.00	0.00		60,154.33		
1009	TANF 65+ M & F WITH	2,939.37	379.98	4,575.22	5,404.74	1,013.34	2,569.47	3,556.26	5,634.04	4,152.13	412.36	0.00	0.00		30,636.91		
1011	TANF <1 M & F NON-ME	634,706.45	295,612.73	796,508.26	644,978.35	643,691.46	584,319.48	535,830.26	449,571.49	458,955.80	396,181.04	0.00	0.00		5,440,355.32		
1012	TANF 01-05 M & F NON	117,610.19	58,544.34	109,868.71	74,136.26	63,537.12	56,917.02	49,112.54	59,266.50	89,624.07	59,029.15	0.00	0.00		737,645.90		
1013	TANF 06-13 M & F NON	161,558.71	120,366.13	212,330.44	132,695.58	103,351.46	87,367.44	80,415.76	77,955.80	243,620.44	128,884.77	0.00	0.00		1,348,546.53		
1014	TANF 14-20 MALE NON-	83,960.49	35,044.51	40,234.04	74,173.41	47,587.95	63,439.82	36,355.38	46,613.36	81,906.69	89,879.13	0.00	0.00		599,194.78		
1015	TANF 14-20 FEMALE N	189,887.25	134,325.90	224,101.39	199,480.12	230,521.79	259,345.17	129,298.61	155,512.16	223,371.16	214,728.97	0.00	0.00		1,960,572.52		
	O																
1016	TANF 21-44 MALE NON-	963,942.03	1,024,074.63	1,286,021.02	1,373,759.50	961,588.06	1,475,527.52	1,180,098.73	1,388,523.41	1,669,721.50	1,669,016.01	0.00	0.00		12,992,272.41		
1017	TANF 21-44 FEMALE N	3,169,657.70	2,694,879.11	3,108,970.44	2,917,027.66	2,943,551.97	3,372,798.43	3,037,687.24	3,579,770.64	4,405,892.19	3,678,005.42	0.00	0.00		32,908,240.80		
	O																
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	1,279,003.98	1,186,788.55	1,349,861.71	2,003,103.22	1,802,507.37	0.00	0.00		14,761,804.97		
1019	TANF 65+ M & F NON-M	1,991.69	1,861.25	1,841.74	2,021.08	3,298.00	7,871.74	1,391.62	1,866.47	5,558.15	6,717.33	0.00	0.00		34,419.07		
1026	TANF 21-44 MALE WITH	0.00	0.00	8,171.26	8,540.70	0.00	24.63	0.00	479.00	585.60	0.00	0.00	0.00		17,801.19		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	147.37	816.51	0.00	2,144.91	3,120.57	0.00	0.00	0.00		6,229.36		
1028	TANF 45-64 M & F WIT	12,559.06	1,177.47	11,931.99	4,835.43	3,209.57	5,820.36	-319.99	3,796.11	12,376.09	2,729.67	0.00	0.00		58,115.76		
1029	TANF 65+ M & F WITH	2,751.80	1,032.42	601.16	3,677.95	3,104.03	2,015.84	5,349.59	4,921.54	3,568.74	962.69	0.00	0.00		27,985.76		
2100	SSI AGED WITH MEDIC	127,917.46	112,965.89	154,623.60	96,057.74	106,716.05	123,314.19	77,037.04	129,256.13	105,891.50	130,491.11	0.00	0.00		1,164,270.71		
	A																
2110	SSI AGED NON-MEDICA	82,396.22	87,388.83	111,960.89	60,223.72	190,786.77	109,163.25	163,865.63	377,465.62	280,018.97	350,158.00	0.00	0.00		1,813,427.90		
	R																
2120	SSI AGED WITH QMB	423,535.31	287,246.13	387,331.36	314,136.47	408,294.43	510,193.09	377,686.11	409,747.71	518,317.18	403,990.11	0.00	0.00		4,040,477.90		
2200	SSI DISABLED WITH M	367,814.33	227,632.48	341,524.68	286,034.22	320,443.33	461,573.99	390,906.35	332,675.76	540,123.48	286,970.82	0.00	0.00		3,555,699.44		
	E																
2210	SSI DISABLED NON-ME	6,668,489.74	5,155,417.18	6,741,200.28	6,198,519.45	5,288,344.18	6,283,598.03	4,338,329.08	5,595,105.24	7,539,358.21	6,323,903.58	0.00	0.00		60,132,264.97		
	D																
2220	SSI DISABLED WITH Q	1,280,507.32	906,913.57	1,312,718.10	1,103,762.79	1,015,936.71	1,401,772.97	1,010,061.58	1,141,609.19	1,632,415.60	1,118,563.50	0.00	0.00		11,924,261.33		
	M																
2300	SSI BLIND WITH MEDIC	75.74	167.54	32.43	371.80	322.84	385.78	13,467.31	2,533.00	1,166.03	1,096.00	0.00	0.00		19,618.47		
2310	SSI BLIND NON-MEDIC	82,843.21	59,625.10	80,658.03	48,570.26	72,239.03	66,893.38	47,331.62	32,492.97	72,150.90	59,851.70	0.00	0.00		622,656.20		
	A																
2320	SSI BLIND WITH QMB	14,835.59	19,732.97	29,174.00	11,967.46	8,591.86	21,220.83	14,567.00	15,148.61	23,239.57	11,107.16	0.00	0.00		169,585.05		
4311	SOBRA CHILD <1 M & F	814,131.23	1,007,677.65	740,565.25	692,925.67	1,090,237.93	1,138,938.43	697,965.81	526,589.85	1,083,903.57	705,540.48	0.00	0.00		8,498,475.87		
4312	SOBRA CHILD 01-05 M	1,005,758.92	1,055,286.32	958,237.67	645,433.10	1,937,372.86	677,700.19	547,021.87	679,410.03	1,178,046.68	1,174,914.60	0.00	0.00		9,859,182.24		
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	1,746,217.97	1,225,327.61	1,605,949.12	2,299,818.98	2,454,639.72	0.00	0.00		17,253,318.55		
4314	SOBRA CHILD 14-20 MA	871,236.80	482,124.72	1,586,773.58	614,045.59	619,754.63	1,535,676.96	643,089.48	-88,474.08	1,099,188.34	942,537.32	0.00	0.00		8,305,953.34		
4315	SOBRA CHILD 14-20 FE	842,681.59	721,641.34	792,887.23	757,468.21	876,519.07	861,098.33	790,484.87	924,352.95	1,132,854.95	1,030,117.88	0.00	0.00		8,730,106.42		
5007	SOBRA PREG 21-44 FE	0.00	-869.63	79.80	2,982.64	3,398.52	7,874.84	8,389.12	196.21	639.48	22,720.81	0.00	0.00		45,411.79		
	M																
5013	SOBRA PREG 09-13 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																
5015	SOBRA PREG 14-20 FE	120,759.94	84,122.10	86,748.38	79,330.28	86,642.71	137,300.44	105,965.86	79,416.01	117,095.44	83,089.31	0.00	0.00		980,470.47		
	M																
5017	SOBRA PREG 21-44 FE	850,122.88	552,251.75	1,112,517.96	723,180.27	733,472.99	721,280.20	607,792.23	655,979.98	831,630.18	771,063.50	0.00	0.00		7,559,291.94		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	131.02	794.25	519.67	239.58	165.43	427.17	45.33	0.00	0.00	0.00		2,322.45		
	M																

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2021	
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	21.44	0.00	0.00	0.00		163.57		
SUBTOTAL:	22,085,348.65	17,857,456.76	23,687,339.95	19,857,083.61	20,721,773.90	23,034,887.76	17,318,838.25	19,557,911.12	27,670,659.13	23,926,779.76	0.00	0.00		215,718,078.89		

1106	TANF EXPANDED 21-44	7,269.85	298.34	5,218.89	1,234.75	2,188.78	5,253.93	785.00	2,312.97	4,206.76	296.80	0.00	0.00	
1107	TANF EXPANDED 21-44	11,248.86	3,136.91	6,273.54	2,514.68	3,363.92	5,643.29	8,323.61	3,392.22	5,872.54	6,056.15	0.00	0.00	
1108	TANF EXPANDED 45-64	26,649.73	22,080.21	39,100.34	24,466.38	26,230.44	57,153.30	18,701.33	63,972.87	53,869.71	26,672.45	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	14,139.96	21,135.76	44,872.94	11,452.18	13,105.34	21,685.37	16,932.01	20,352.51	36,507.85	29,504.78	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	-455.00	0.00	4,083.34	12,556.80	7,568.50	0.00	0.00	
1115	TANF EXPANDED 14-20	19,168.85	8,058.38	22,338.83	42,054.46	46,255.81	23,405.93	11,977.85	16,559.21	49,353.58	6,041.67	0.00	0.00	
1116	TANF EXPANDED 21-44	662,679.18	445,720.42	482,022.37	397,787.19	331,851.64	485,500.96	300,192.84	354,122.87	588,784.11	436,058.21	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	1,309,187.79	955,459.73	1,324,479.83	1,771,020.81	1,325,162.30	0.00	0.00	
1118	TANF EXPANDED 45-64	935,668.87	655,642.66	711,948.32	766,059.08	644,073.24	929,095.52	601,637.38	616,460.15	1,032,673.44	887,488.87	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	5,930.20	2,640.40	1,683.82	433.00	377.92	667.46	6,451.66	79.37	2,646.07	943.58	0.00	0.00	
1126	TANF EXPANDED 21-44	8,990.76	10,590.46	8,823.18	6,851.79	10,719.09	16,300.14	11,117.25	17,520.77	9,491.04	5,460.84	0.00	0.00	
1127	TANF EXPANDED 21-44	53,609.42	28,798.36	126,916.01	56,090.61	52,352.83	52,365.23	56,341.71	44,095.32	61,988.97	43,909.02	0.00	0.00	
1128	TANF EXPANDED 45-64	83,777.23	47,340.21	80,778.93	54,303.16	64,683.83	113,859.66	62,655.44	87,039.08	111,066.14	67,072.07	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	43,823.71	26,209.78	39,383.00	36,025.47	49,893.07	80,126.37	44,384.03	61,912.11	85,446.25	54,259.12	0.00	0.00	
2400	SSI AGED EXPANDED WI	7,302.67	11,896.35	9,991.15	16,747.73	15,003.82	5,333.85	5,057.89	10,893.44	7,469.49	7,064.94	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	4,625.99	9,585.81	1,388.19	1,710.02	15,492.62	0.00	0.00	
2420	SSI AGED EXPANDED WI	441,581.69	275,347.49	421,861.68	276,805.55	257,840.87	372,647.86	293,362.24	343,618.63	454,177.20	282,774.22	0.00	0.00	
2600	SSI DISABLED EXPAND
E	5,827.66	4,955.23	10,107.11	2,495.17	22,033.53	63,524.81	17,016.54	3,702.80	9,490.59	3,541.82	0.00	0.00	
2610	SSI DISABLED EXPAND E	112,670.42	65,539.21	55,150.18	73,050.14	51,621.47	31,058.13	63,846.87	138,535.92	128,732.37	44,907.34	0.00	0.00	
2620	SSI DISABLED EXPAND
E	296,268.26	199,455.26	379,638.05	343,669.06	270,285.62	398,617.65	245,626.15	327,487.60	433,570.78	366,734.95	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	3,975,598.24	2,729,455.34	3,442,009.20	4,860,634.52	3,617,010.25	0.00	0.00	

29,066.07	
55,825.72	
358,896.76	
229,688.70	
0.00	
26,413.09	
245,214.57	
4,484,719.79	
12,290,491.93	
7,780,747.53	
21,853.48	
105,865.32	
576,467.48	
772,575.75	
521,462.91	
96,761.33	
79,524.56	
3,420,017.43	
142,695.26	
765,112.05	
3,261,353.38	
35,264,753.11	

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	3,786.80	1,136.04	309.94	4,247.18	6,111.90	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	14,211.92	5,594.79	8,007.71	12,634.20	759.85	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	48.11	313.92	0.00	249.74	0.00	5,281.70	3,511.86	1,359.30	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	67,107.97	29,758.13	34,050.88	166,864.05	35,173.04	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	60,055.51	91,720.69	27,044.75	54,281.55	32,117.44	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	897,059.08	792,063.81	967,249.57	1,336,603.71	1,164,949.07	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	468,487.43	419,876.08	383,548.86	578,378.16	486,495.82	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	1,111,221.91	1,120,360.07	1,194,346.73	1,587,938.51	1,250,554.86	0.00	0.00	

15,969.62	
85,226.01	
10,764.63	
440,327.45	
535,021.80	
8,954,139.06	
4,499,617.51	
13,334,289.80	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2021	
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	328.96	490.38	1,351.84	0.00	328.96	0.00	0.00		6,157.46		
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	5,252.78	7,843.73	4,095.07	186.41	100.56	0.00	0.00		49,638.00		
3706	ADULT <40% EXP MALE	57.38	86.35	1,708.93	1,041.88	4,472.38	244.04	0.00	2,388.15	2,100.10	50.23	0.00	0.00		12,149.44		
3707	ADULT <40% EXP FEMA	0.00	684.81	127.76	0.00	0.00	0.00	45.14	0.00	129.14	483.83	0.00	0.00		1,470.68		
	L																
3708	ADULT <40% EXP M&F	2,187.53	4,691.21	48,985.40	12,995.56	27,828.49	2,560.79	3,398.88	41,309.59	8,911.73	5,741.85	0.00	0.00		158,611.03		
	4																
3709	ADULT <40% EXP M&F	605.22	45.67	0.00	0.00	0.00	14.84	0.00	637.83	63.95	98.40	0.00	0.00		1,465.91		
	6																
3714	ADULT <40% EXP MALE	353,676.97	240,624.10	246,783.04	373,710.55	199,714.76	417,308.03	272,275.43	325,067.27	553,650.78	332,006.81	0.00	0.00		3,314,817.74		
3715	ADULT <40% EXP FEMA	162,511.44	114,009.53	241,281.27	235,933.41	238,512.46	252,545.51	235,371.62	255,089.36	351,377.35	318,418.60	0.00	0.00		2,405,050.55		
	L																
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	9,210,619.83	7,013,197.98	9,504,015.34	11,570,332.54	10,915,883.88	0.00	0.00		90,301,693.66		
3717	ADULT <40% EXP FEMA	3,534,124.56	3,597,125.52	4,446,436.48	4,021,069.61	3,320,930.00	3,881,288.19	3,055,317.96	3,547,786.24	4,952,540.92	5,014,534.25	0.00	0.00		39,371,153.73		
	L																
3718	ADULT <40% EXP M&F	8,932,369.89	6,988,768.45	10,831,898.99	7,173,532.83	7,393,463.33	9,054,782.40	6,953,602.04	8,917,023.40	12,027,298.47	10,320,863.27	0.00	0.00		88,593,603.07		
	4																
3719	ADULT <40% EXP M&F	1,068.32	106,447.32	1,986.93	166.01	580.46	2,179.52	1,046.77	748.30	810.61	3,796.74	0.00	0.00		118,830.98		
	6																
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,252.20	0.00	0.00		1,252.20		
3727	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	L																
3728	ADULT <40% EXP M&F	552.34	8,792.98	26,960.97	19,381.83	15,372.29	4,201.67	187.88	329.20	3,803.26	6,750.43	0.00	0.00		86,332.85		
	4																
SUBTOTAL:	24,262,288.83	20,962,067.53	29,276,701.77	22,961,301.37	21,045,251.84	25,453,506.92	20,003,287.42	25,219,681.73	33,215,664.48	29,897,831.29	0.00	0.00		252,297,583.18		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	57.38	237.17	57.38	14.92	165.25	370.69	178.34	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	86.42	412.68	1,415.55	133.75	89.83	89.83	997.61	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	15,742.51	12,486.25	28,044.05	25,244.91	14,690.13	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	8,335.80	7,385.96	13,720.14	11,476.84	19,915.02	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	26,065.60	22,466.51	44,089.65	25,249.14	25,311.03	20,019.78	22,043.81	24,552.89	36,532.60	9,280.59	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	15,683.28	7,642.00	58,075.76	14,312.98	28,298.13	26,501.20	25,599.52	27,919.08	62,748.81	17,983.05	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	533,216.42	328,287.76	361,705.82	452,282.75	533,187.21	533,848.52	704,412.76	429,170.88	637,176.32	521,641.95	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	404,707.40	216,150.60	319,306.14	444,759.88	847,247.98	345,999.71	293,111.07	442,065.46	646,999.97	452,708.73	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	783,423.27	766,746.23	1,416,582.94	1,401,275.08	1,138,306.29	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	132.56	861.46	861.46	2,044.70	6,161.89	680.05	2,680.92	2,836.35	519.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	57.18	595.65	724.84	57.18	651.12	1,829.03	674.76	1,820.25	3,483.85	1,486.98	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	1,743,334.64	1,833,289.08	2,386,811.69	2,828,235.25	2,177,707.69	0.00	0.00	

1,081.13	
3,225.67	
151,920.18	
86,848.93	
255,611.60	
284,763.81	
5,034,930.39	
4,413,056.94	
9,845,199.59	
16,778.39	
11,380.84	
0.00	
20,104,797.47	

4413	SOBRA 100-133% M&F
6	79,561.09	97,234.17	143,584.38	104,557.79	74,638.47	119,544.27	46,754.89	128,248.66	191,919.12	174,855.73	0.00	0.00	
4414	SOBRA 100-133% MALE	63,466.22	36,422.17	49,832.55	38,336.18	44,116.93	108,750.04	38,289.92	51,086.81	56,616.31	51,043.39	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	254,175.54	-94,300.11	285,442.42	167,202.61	108,091.33	0.00	0.00	
SUBTOTAL:	178,086.75	175,478.21	249,057.23	237,371.57	203,884.25	482,469.85	-9,255.30	464,777.89	415,738.04	333,990.45	0.00	0.00	

1,160,898.57	
537,960.52	
1,032,739.85	
2,731,598.94	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

842.38

0.00

0.00

842.38

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2021	
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	10,866.14	5,586.17	6,402.33	3,349.54	17,733.87	0.00	0.00		83,840.58		
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:	6,741.91	1,649.82	16,106.80	7,396.50	8,007.50	10,866.14	5,586.17	6,402.33	3,349.54	18,576.25	0.00	0.00		84,682.96		

8700	SSI DISABLED FREEDO M	19,266.93	11,931.03	19,448.70	6,435.73	26,970.73	18,075.68	6,314.15	11,609.50	18,373.14	18,094.81	0.00	0.00	
8710	SSI DISABLED FREEDO
M	17,233.38	7,817.72	3,782.63	30,270.29	6,309.59	6,414.80	24,852.43	17,135.53	48,228.84	37,563.50	0.00	0.00	
8720	SSI DISABLED FREEDO M	22,396.77	20,915.69	19,546.07	-3,628.79	3,670.56	8,999.28	3,242.83	356.52	4,021.35	4,413.52	0.00	0.00	
SUBTOTAL:	58,897.08	40,664.44	42,777.40	33,077.23	36,950.88	33,489.76	34,409.41	29,101.55	70,623.33	60,071.83	0.00	0.00	

156,520.40	
199,608.71	
83,933.80	
440,062.91	

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

TOTAL:	52,295,618.60	43,160,264.76	59,086,000.86	47,939,248.06	47,307,093.88	54,734,153.31	41,915,610.37	51,106,695.51	69,064,904.29	60,031,967.52	0.00	0.00		526,641,557.16		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2021	
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	3,022,638.63	2,197,752.50	3,318,284.41	2,295,747.45	2,181,472.62	2,789,062.90	2,721,628.94	2,540,839.16	2,565,621.23	2,034,922.12	0.00	0.00		25,667,969.96		
	A																
2110	SSI AGED NON-MEDICA	158,695.09	135,418.00	209,429.81	105,121.80	119,961.65	149,703.39	148,801.75	221,483.87	183,952.65	153,676.18	0.00	0.00		1,586,244.19		
	R																
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	4,469,554.53	3,969,885.00	3,964,777.98	4,356,671.69	3,372,739.69	0.00	0.00		40,499,854.54		
2200	SSI DISABLED WITH M	517,200.54	385,341.74	555,945.77	406,779.87	461,222.83	550,155.64	507,562.27	600,096.58	373,913.36	307,657.75	0.00	0.00		4,665,876.35		
	E																
2210	SSI DISABLED NON-ME	2,830,954.71	2,233,439.38	2,816,037.94	2,275,589.32	2,235,073.78	2,840,829.52	2,291,097.99	2,643,054.18	3,009,106.32	2,446,059.87	0.00	0.00		25,621,243.01		
	D																
2220	SSI DISABLED WITH Q	1,062,045.18	815,729.63	1,055,833.02	846,302.66	953,894.94	1,076,398.74	960,108.45	1,011,387.05	1,037,001.63	863,135.92	0.00	0.00		9,681,837.22		
	M																
2310	SSI BLIND NON-MEDIC	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		
	A																
2320	SSI BLIND WITH QMB	0.00	0.00	2,585.35	2,415.70	2,389.06	16,994.30	604.10	280.62	32.81	0.00	0.00	0.00		25,301.94		
SUBTOTAL:	12,425,885.33	9,154,800.45	12,913,029.57	9,710,814.27	9,365,086.21	11,892,699.02	10,599,688.50	10,981,919.44	11,526,299.69	9,178,191.53	0.00	0.00		107,748,414.01		

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	4,401.60	3,521.28	4,408.89	3,509.76	3,481.04	4,418.15	3,514.32	3,521.28	4,456.40	2,640.96	0.00	0.00	
SUBTOTAL:	4,401.60	3,521.28	4,408.89	3,509.76	3,481.04	4,418.15	3,514.32	3,521.28	4,456.40	2,640.96	0.00	0.00	

37,873.68

37,873.68

0.00

107,786,287.69

12,430,286.93	9,158,321.73	12,917,438.46	9,714,324.03	9,368,567.25	11,897,117.17	10,603,202.82	10,985,440.72	11,530,756.09	9,180,832.49	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending April 30, 2021	
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	8.61	2,433.76	3,625.61	0.00	0.00		6,093.51		
8040	SLMB	768.43	57.18	8.59	0.00	0.00	18.40	1.97	714.10	2,558.59	4,624.61	0.00	0.00		8,751.87		
8050	QI1	47.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	798.25	0.00	0.00	0.00		846.19		
SUBTOTAL:	841.90	57.18	8.59	0.00	0.00	18.40	1.97	722.71	5,790.60	8,250.22	0.00	0.00		15,691.57		

TOTAL:	841.90	57.18	8.59	0.00	0.00	18.40	1.97	722.71	5,790.60	8,250.22	0.00	0.00		15,691.57		

KidsCare - CAPITATION AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	174,491.07	172,577.29	175,116.99	181,138.61	210,661.14	197,625.40	190,255.11	197,185.85	213,137.15	202,428.68	0.00	0.00		1,914,617.29		
	C																
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	2,504,053.05	2,295,215.28	2,333,988.60	2,385,228.22	2,434,965.67	0.00	0.00		21,640,798.66		
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	4,944,093.98	4,485,613.07	4,587,829.91	4,672,672.25	4,777,598.75	0.00	0.00		42,435,555.10		
6014	KIDS 14-19 MALE NON-	935,140.73	970,724.10	997,580.62	1,035,181.24	1,224,752.36	1,370,245.62	1,257,368.05	1,305,788.91	1,328,090.51	1,371,576.24	0.00	0.00		11,796,448.38		
6015	KIDS 14-19 FEMALE NO	940,472.58	978,761.40	1,004,941.00	1,036,585.75	1,232,555.27	1,365,185.51	1,245,114.36	1,294,429.59	1,320,315.86	1,364,134.31	0.00	0.00		11,782,495.63		
9960	KIDSCARE KICK PAYME	18,508.35	18,450.92	0.00	12,292.30	24,512.75	20,720.13	6,398.60	6,755.61	32,057.87	19,116.61	0.00	0.00		158,813.14		
	N																
SUBTOTAL:	7,336,022.91	7,539,106.23	7,723,213.98	7,942,713.85	9,458,482.48	10,401,923.69	9,479,964.47	9,725,978.47	9,951,501.86	10,169,820.26	0.00	0.00		89,728,728.20		

89,728,728.20

7,336,022.91	7,539,106.23	7,723,213.98	7,942,713.85	9,458,482.48	10,401,923.69	9,479,964.47	9,725,978.47	9,951,501.86	10,169,820.26	0.00	0.00	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	295.03	291.32	294.78	306.33	302.62	291.42	307.59	318.98	345.12	328.05	0.00	0.00		3,081.24		
	C																
6012	KIDS 1-5 M & F NON-M	9,545.70	9,706.14	9,896.73	10,069.56	10,442.41	10,930.63	11,321.13	11,510.18	11,763.48	12,007.36	0.00	0.00		107,193.32		
6013	KIDS 6-13 M & F NON-	18,395.31	18,912.65	19,476.39	20,009.53	20,741.37	21,502.11	22,104.15	22,608.11	23,026.65	23,532.09	0.00	0.00		210,308.36		
6014	KIDS 14-19 MALE NON-	4,949.42	5,141.98	5,271.77	5,471.18	5,702.02	5,962.15	6,184.31	6,411.59	6,523.36	6,728.47	0.00	0.00		58,346.25		
6015	KIDS 14-19 FEMALE NO	4,967.01	5,155.01	5,290.42	5,477.04	5,721.82	5,917.52	6,122.17	6,360.99	6,488.79	6,698.95	0.00	0.00		58,199.72		
9960	KIDSCARE KICK PAYME	3.00	3.00	0.00	2.00	4.00	3.00	1.00	1.00	5.00	3.00	0.00	0.00		25.00		
	N																
SUBTOTAL:	38,155.47	39,210.10	40,230.09	41,335.64	42,914.24	44,606.83	46,040.35	47,210.85	48,152.40	49,297.92	0.00	0.00		437,153.89		

TOTAL:	38,155.47	39,210.10	40,230.09	41,335.64	42,914.24	44,606.83	46,040.35	47,210.85	48,152.40	49,297.92	0.00	0.00		437,153.89		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	523.48	519.05	545.17	551.07	548.70	488.05	536.73	548.98	576.45	549.23	0.00	0.00		5,386.91		
	C																
6012	KIDS 1-5 M & F NON-M	18,360.10	18,658.73	18,175.10	17,610.60	17,534.47	18,302.40	19,734.86	20,068.18	19,673.25	20,175.72	0.00	0.00		188,293.41		
6013	KIDS 6-13 M & F NON-	36,515.44	36,931.37	38,384.30	37,928.95	39,221.06	40,588.54	41,124.71	42,219.67	41,826.26	40,358.75	0.00	0.00		395,099.05		
6014	KIDS 14-19 MALE NON-	16,095.74	17,066.38	17,392.64	21,055.70	21,135.84	22,511.13	24,119.47	25,344.43	25,758.62	25,792.37	0.00	0.00		216,272.32		
6015	KIDS 14-19 FEMALE NO	17,125.52	18,323.05	18,377.60	22,240.63	24,612.18	24,439.68	28,040.47	26,143.98	25,502.93	26,266.65	0.00	0.00		231,072.69		
SUBTOTAL:	88,620.28	91,498.58	92,874.81	99,386.95	103,052.25	106,329.80	113,556.24	114,325.24	113,337.51	113,142.72	0.00	0.00		1,036,124.38		

1,036,124.38

92,874.81	99,386.95	103,052.25	106,329.80	113,556.24	114,325.24	113,337.51	113,142.72	0.00	0.00	

TOTAL:

88,620.28

91,498.58

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	302.00	300.00	316.00	318.00	315.00	298.00	316.00	326.00	348.00	340.00	0.00	0.00		3,179.00		
	C																
6012	KIDS 1-5 M & F NON-M	9,877.76	10,041.06	10,220.03	10,395.03	10,775.00	11,283.00	11,680.03	11,856.03	12,144.00	12,386.00	0.00	0.00		110,657.94		
6013	KIDS 6-13 M & F NON-	19,182.12	19,701.53	20,303.13	20,834.12	21,612.09	22,382.09	22,978.09	23,489.91	23,892.06	24,417.00	0.00	0.00		218,792.14		
6014	KIDS 14-19 MALE NON-	5,207.03	5,397.03	5,548.03	5,752.03	5,989.00	6,254.00	6,477.03	6,711.03	6,812.03	7,020.00	0.00	0.00		61,167.21		
6015	KIDS 14-19 FEMALE NO	5,227.03	5,431.03	5,579.03	5,785.03	6,026.16	6,241.03	6,449.06	6,705.03	6,820.00	7,052.00	0.00	0.00		61,315.40		
SUBTOTAL:	39,795.94	40,870.65	41,966.22	43,084.21	44,717.25	46,458.12	47,900.21	49,088.00	50,016.09	51,215.00	0.00	0.00		455,111.69		

TOTAL:	39,795.94	40,870.65	41,966.22	43,084.21	44,717.25	46,458.12	47,900.21	49,088.00	50,016.09	51,215.00	0.00	0.00		455,111.69		

KidsCare - FEE FOR SERVICE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	12,185.87	25.59	1,926.12	500.01	1,522.92	725.73	62.76	-310.32	8,474.12	320.37	0.00	0.00		25,433.17		
	C																
6012	KIDS 1-5 M & F NON-M	38,128.70	11,226.18	35,357.21	11,548.78	15,116.25	7,609.63	11,054.58	11,035.42	29,604.11	17,687.49	0.00	0.00		188,368.35		
6013	KIDS 6-13 M & F NON-	41,178.75	41,588.86	72,955.66	65,638.47	71,046.15	55,665.82	44,627.90	64,628.73	152,720.17	64,457.82	0.00	0.00		674,508.33		
6014	KIDS 14-19 MALE NON-	20,137.82	10,886.64	27,745.48	29,751.16	24,120.16	46,285.14	21,031.21	27,193.04	41,767.24	38,830.10	0.00	0.00		287,747.99		
6015	KIDS 14-19 FEMALE NO	79,656.09	37,344.80	63,073.99	65,343.28	34,653.28	29,820.79	75,727.50	49,746.25	53,814.93	53,081.39	0.00	0.00		542,262.30		
SUBTOTAL:	191,287.23	101,072.07	201,058.46	172,781.70	146,458.76	140,107.11	152,503.95	152,293.12	286,380.57	174,377.17	0.00	0.00		1,718,320.14		

1,718,320.14

201,058.46	172,781.70	146,458.76	140,107.11	152,503.95	152,293.12	286,380.57	174,377.17	0.00	0.00	

TOTAL:

191,287.23

101,072.07

KidsCare - REINSURANCE
For The Period Ending April 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	0.00	0.00	0.00	0.00	33,763.91	0.00	10,914.57	-44,678.47	39,065.20	0.00	0.00	0.00		39,065.21		
	C																
6012	KIDS 1-5 M & F NON-M	32,192.38	15,576.63	23,224.89	15,553.91	23,540.42	4,746.52	33.39	63,770.93	64,572.43	38,853.79	0.00	0.00		282,065.29		
6013	KIDS 6-13 M & F NON-	64,628.70	108,533.95	62,469.56	224,072.07	113,035.42	173,802.41	6,080.22	276,225.20	110,143.46	107,455.14	0.00	0.00		1,246,446.13		
6014	KIDS 14-19 MALE NON-	-0.01	178,495.68	70,224.52	225,495.71	117,693.19	159,023.64	80,711.05	119,564.07	77,019.69	56,664.82	0.00	0.00		1,084,892.36		
6015	KIDS 14-19 FEMALE NO	135,893.44	0.00	11,530.86	31,118.94	1,797.99	4,637.59	20,154.83	20,880.34	26,276.91	36,542.12	0.00	0.00		288,833.02		
SUBTOTAL:	232,714.51	302,606.26	167,449.83	496,240.63	289,830.93	342,210.16	117,894.06	435,762.07	317,077.69	239,515.87	0.00	0.00		2,941,302.01		

TOTAL:	232,714.51	302,606.26	167,449.83	496,240.63	289,830.93	342,210.16	117,894.06	435,762.07	317,077.69	239,515.87	0.00	0.00		2,941,302.01		

KidsCare - TRANSPLANT REINSURANCE
For The Period Ending April 30, 2021	
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	280,496.89	0.00	0.00		296,830.64		
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	8,176.41	0.00	0.00	65,305.50	0.00	0.00		73,481.91		
SUBTOTAL:	4,465.07	11,868.68	0.00	23,264.66	0.00	0.00	8,176.41	0.00	0.00	345,802.39	0.00	0.00		393,577.21		

23,264.66

0.00

0.00

0.00

TOTAL:

4,465.07

11,868.68

0.00

0.00

0.00

8,176.41

0.00

345,802.39

393,577.21

00110007 DES-DD - CAP MEMBER MONTHS		
For The Period Ending April 30, 2021		
RJAuTEnCeO3DE0, 202DE0SCRIPTION	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	1.00	1.00	0.00	0.00	0.00		2.00		
1010	TANF NON-MEDICARE	663.29	661.89	661.10	666.17	664.16		667.36	660.89	660.90	654.34	659.02	0.00	0.00		6,619.12		
1020	TANF WITH QMB	2.00	1.00	1.00	1.00	1.00		1.00	1.00	1.00	1.00	1.00	0.00	0.00		11.00		
2100	SSI AGED WITH MEDICA	277.71	272.54	275.25	277.55	272.96		281.92	281.45	282.33	285.92	290.60	0.00	0.00		2,798.23		
2110	SSI AGED NON-MEDICAR	10.00	10.00	11.00	11.00	11.00		12.99	12.00	11.00	12.00	12.00	0.00	0.00		112.99		
2120	SSI AGED WITH QMB	442.10	445.44	444.28	448.54	450.50		449.04	452.01	460.87	463.28	456.03	0.00	0.00		4,512.09		
2200	SSI DISABLED WITH ME	1,899.08	1,908.78	1,906.12	1,919.56	1,936.87		1,968.49	1,972.29	1,918.82	1,903.34	1,921.97	0.00	0.00		19,255.32		
2210	SSI DISABLED NON-MED	27,309.05	27,444.84	27,549.29	27,631.79	27,650.45		27,770.03	27,772.09	27,850.40	28,025.14	28,094.53	0.00	0.00		277,097.61		
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		5,156.27	5,160.60	5,226.72	5,240.85	5,235.81	0.00	0.00		51,817.12		
2300	SSI BLIND WITH MEDIC	2.00	2.00	3.00	3.00	4.00		4.00	5.00	1.00	1.00	1.00	0.00	0.00		26.00		
2310	SSI BLIND NON-MEDICA	12.00	13.58	15.00	16.00	20.00		21.00	23.00	8.00	11.48	11.00	0.00	0.00		151.06		
2320	SSI BLIND WITH QMB	2.00	2.00	2.00	2.00	2.00		2.99	1.00	1.00	3.00	5.00	0.00	0.00		22.99		
8700	SSI DISABLED FREEDOM	32.00	31.00	42.99	31.73	30.00		33.85	26.12	28.00	30.22	34.00	0.00	0.00		319.91		
8710	SSI DISABLED FREEDOM	11.00	11.00	10.00	10.00	10.00		10.99	9.00	10.00	10.00	8.53	0.00	0.00		100.52		
871Z	SSI DISABLED FREEDOM	0.00	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 FREEDOM	21.00	22.00	21.00	21.00	21.00		20.93	17.05	16.99	17.48	18.83	0.00	0.00		197.28		
SUBTOTAL:	35,820.81	35,972.55	36,117.76	36,208.89	36,241.4	7	36,400.86	36,393.50	36,478.03	36,660.05	36,749.32	0.00	0.0		363,043.24		
TOTAL:	35,820.81	35,972.55	36,117.76	36,208.	36,241.4	7	36,400.8	36,393.50	36,478.03	36,660.05	36,749.3	0.00	0.00		363,043.24		

89

6

2

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending April 30, 2021

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	404,742.26	393,479.09	388,410.94	384,876.36	384,175.72	0.00	0.00	4,038,508.11	
EPD	117,131,570.69	116,026,496.12	115,369,118.41	115,627,611.21	117,001,923.31	125,747,616.33	116,016,893.89	114,938,917.88	114,499,323.64	114,278,674.74	0.00	0.00	1,166,638,146.22	
TOTAL AHCCCS LTC	117,538,951.69	116,450,256.22	115,789,040.72	116,044,000.42	117,417,294.43	126,152,358.59	116,410,372.98	115,327,328.82	114,884,200.00	114,662,850.46	0.00	0.00	1,170,676,654.33	
DES/DD	173,387,013.21	174,122,225.01	174,824,385.21	175,266,326.76	180,272,461.57	222,258,211.54	191,583,894.59	193,680,263.70	194,643,735.42	195,120,955.57	0.00	0.00	1,875,159,472.58	
TOTAL DES LTC	173,387,013.21	174,122,225.01	174,824,385.21	175,266,326.76	180,272,461.57	222,258,211.54	191,583,894.59	193,680,263.70	194,643,735.42	195,120,955.57	0.00	0.00	1,875,159,472.58	
TOTAL LTC - CAP	290,925,964.90	290,572,481.23	290,613,425.93	291,310,327.18	297,689,756.00	348,410,570.13	307,994,267.57	309,007,592.52	309,527,935.42	309,783,806.03	0.00	0.00	3,045,836,126.91	

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	12,383,020.26	11,197,117.19	12,514,892.33	15,642,386.62	11,208,835.09	0.00	0.00	123,355,441.95	
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	12,383,020.26	11,197,117.19	12,514,892.33	15,642,386.62	11,208,835.09	0.00	0.00	123,355,441.95	

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	3,880,347.92	4,759,694.47	2,522,595.57	2,972,173.10	3,243,374.43	0.00	0.00	34,101,766.75	
DES/DD	1,680,993.32	5,370,676.23	2,819,557.30	4,346,653.22	2,152,807.03	3,117,675.68	2,156,785.75	1,612,434.94	1,370,165.89	3,658,973.24	0.00	0.00	28,286,722.60	
TOTAL DES LTC	1,680,993.32	5,370,676.23	2,819,557.30	4,346,653.22	2,152,807.03	3,117,675.68	2,156,785.75	1,612,434.94	1,370,165.89	3,658,973.24	0.00	0.00	28,286,722.60	
TOTAL LTC - REIN	3,391,580.97	8,020,729.01	5,953,416.41	10,269,377.88	5,459,164.09	6,998,023.60	6,916,480.22	4,135,030.51	4,342,338.99	6,902,347.67	0.00	0.00	62,388,489.35	

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	4,564,165.10	4,662,893.60	4,595,729.90	4,506,507.90	4,478,190.00	0.00	0.00	45,920,109.40	

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.

146

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending April 30, 2021

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	-59.49	0.00	-2,184.14	0.00	0.00	0.00	0.00	-3,077.88	
Subtotal	-834.25	0.00	0.00	0.00	0.00	-59.49	0.00	-2,184.14	0.00	0.00	0.00	0.00	-3,077.88	

-834.25	0.00	0.00	0.00	0.00	-59.49	0.00	-2,184.14	0.00	0.00	0.00	0.00	-3,077.88	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending April 30, 2021

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 April 30, 2021

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	8,752,924.16	8,891,956.40	9,007,338.31	9,107,520.98	9,199,356.50	0.00	0.00	78,600,201.67	

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	4,739,073.48	4,793,631.03	4,836,903.91	4,878,265.96	4,914,317.51	0.00	0.00	45,742,389.74	

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	1,020,356.62	1,030,831.96	1,039,987.41	1,048,136.08	1,053,735.14	0.00	0.00	9,832,002.61	

00010705	HEALTH CHOICE RBHA - CAP AMOUNTS	717.13	-141.92	702.46	-1,460.63	0.00	0.00	-224.33	-41.43	-11.13	0.00	0.00	0.00	-459.85	

00010730	CENPATICO RBHA - CAP AMOUNTS	37,232.19	1,693.00	478.32	2,305.86	-512.65	0.00	-1,001.63	0.00	0.00	-1,214.68	0.00	0.00	38,980.41	

00010789	MERCY MARICOPA RBHA - CAP AMOUNTS	74,475.62	32,139.90	1,984.42	-1,241.49	1,250.65	-13,418.79	-3,759.88	866.80	2,072.38	7,412.91	0.00	0.00	101,782.52	
			
Subtotal		
	10,416,831.43	10,494,199.76	10,614,024.64	14,141,232.56	14,343,593.04	14,498,935.47	14,711,433.55	14,885,055.00	15,035,984.27	15,173,607.38	0.00	0.00	134,314,897.10	

10,416,831.43	10,494,199.76	10,614,024.64	14,141,232.56	14,343,593.04	14,498,935.47	14,711,433.55	14,885,055.00	15,035,984.27	15,173,607.38	0.00	0.00	134,314,897.10	

GRAND TOTAL

BEHAVIORAL HEALTH EXPENDITURES BY RBHA - MEMBER MONTHS
For the Period Ending April 30, 2021

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	1,087,122.00	1,099,606.00	1,110,228.00	1,119,631.00	1,127,270.00	0.00	0.00	10,710,872.00	
			
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	540,939.00	546,285.00	550,525.00	554,572.00	557,852.00	0.00	0.00	5,330,166.00	
			
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	260,604.00	262,793.00	264,649.00	266,340.00	267,366.00	0.00	0.00	2,570,463.00	
			
00010705	HEALTH CHOICE RBHA - CAP MEMBER MONTHS	7.67	-2.00	9.68	-23.31	0.00	0.00	-3.15	-1.00	-0.20	0.00	0.00	0.00	-12.31	
			
00010730	CENPATICO RBHA - CAP MEMBER MONTHS	218.57	24.00	6.00	41.54	-9.31	0.00	-17.70	0.00	0.00	-18.00	0.00	0.00	245.10	
			
00010789	MERCY MARICOPA RBHA - CAP MEMBER MONTHS	380.01	368.10	17.23	-40.31	25.38	-116.78	-41.30	15.59	46.00	22.15	0.00	0.00	676.07	
			
Subtotal	1,735,906.25	1,758,316.10	1,779,029.91	1,851,679.92	1,871,810.07	1,888,548.22	1,908,621.85	1,925,416.59	1,940,588.80	1,952,492.15	0.00	0.00	18,612,409.86	

1,735,906.25	1,758,316.10	1,779,029.91	1,851,679.92	1,871,810.07	1,888,548.22	1,908,621.85	1,925,416.59	1,940,588.80	1,952,492.15	0.00	0.00	18,612,409.86	

GRAND TOTAL