Douglas A. Ducey, Governor Jami Snyder, Director

December 23, 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 2022 Appropriation Status Report for the Period Ended November 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 November 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 October 15, 2021, the Department of Health and Human Services extended the expiration date for the PHE to an assumed January 16, 2022. As a result, it is assumed that the temporary FMAP increase will continue until at least March 31, 2022, and the MOE will continue until at least January 31, 2022.

AHCCCS finalized its Fiscal Year 2023 budget request, including an update of Fiscal Year 2022 for submission to the Governor’s Office of Strategic Planning and Budgeting pursuant to A.R.S. § 35-113. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

FY22 Expenditure Authority Supplemental

ARPA - Section 9817 of ARPA provides qualifying states with a temporary 10 percentage point increase to the FMAP for certain Medicaid expenditures for home and community-based services
(HCBS). The savings from the additional federal funds must be utilized to supplement, not supplant,
existing state funds. These funds must be invested in activities to enhance, expand, or strengthen HCBS under the Medicaid program. The additional Federal Funds drawn from April 2021 to March 2022 will generate the state match to make approximately $1.5 billion in payments through March 2024 to support projects and initiatives that enhance and/or strengthen the HCBS delivery system, serving

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

The Honorable Karen Fann
The Honorable Russell “Rusty” Bowers
December 23, 2021
Page 2

seniors, individuals with disabilities, individuals living with a serious mental illness, and children with behavioral health needs. AHCCCS intends to meet with the Chairmen of the Appropriations and Health committees prior to start of the legislative session to review the proposed spending plan. To maximize this opportunity, which requires no general fund, AHCCCS will require an estimated $396.3 million expenditure authority supplemental in FY22.

FMAP – The AHCCCS FY22 Appropriation assumed the temporary 6.2 percentage point increase to the FMAP for only the first two quarters. The extension of the PHE and corresponding FMAP increase through March 31, 2022 will require additional federal expenditure authority and CHIP Fund.

CHIP Fund (Other Appropriated)	$19,870,300	
Federal Medicaid (FMAP - Expenditure Authority)	$208,598,000	
Federal Medicaid (ARPA – Expenditure Authority)	$396,300,000	
Total Supplemental	$624,768,300	

Note that if the PHE is extended again and the FMAP increase is continued through June 2022, AHCCCS will require additional expenditure authority and CHIP fund for the final quarter of FY2022.

Enrollment Update – November 2021 enrollment is 2,310,269 members, a 13,111 member increase over the prior month. Enrollment for December 2021 increased to 2,325,713 members, a 15,453 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 446,753 members or 23.8%.

Major December 2021 changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 6,392; Supplemental Security Income – increase of 831; Prop 204
Restoration - increase of 6,508; Adult Expansion – decrease of 639; Medicare Cost Sharing – increase of 291; KidsCare – increase of 1,403; and Federal Emergency Services – increase of 546.

Tobacco Funds Revenue Update - Tobacco tax collections through November 2021 are $4.1 million less than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2022 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

The Honorable Karen Fann
The Honorable Russell “Rusty” Bowers
December 23, 2021
Page 3

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 2022
Through November 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 2022…	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 2022 APPROPRIATION STATUS REPORT
For the Period Ending November 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	$	102,446,600	$	33,252,236	$	33,252,236	$		-	$	102,446,600	$	-	
AHCCCS Prop 204 Administration	19,906,200	8,404,358	8,404,358			-	19,906,200		-	
DES Eligibility	91,874,500	24,775,348	24,775,348			-	91,874,500		-	
DES Prop 204 Eligibility	44,358,700	10,021,623	10,021,623			-	44,358,700		-	
ADOA Data Center	19,325,800	2,029,591	2,029,591			-	19,325,800		-	
School District Suicide Prevention Coordinator	100,000	16,414	16,414			-	100,000		-	
TOTAL ADMINISTRATION	 	278,011,800  		 	78,499,570  		 	78,499,570  		 	-			 	278,011,800  		 	-			

Traditional Medicaid Services	6,758,335,700	2,799,930,775	2,799,930,775		6,758,335,700	-	
Proposition 204 Services	6,564,234,100	2,559,585,572	2,559,585,572		6,564,234,100	-	
ACA Adult Expansion	1,609,961,900	472,416,917	472,416,917		1,609,961,900	-	
KidsCare Services	141,691,200	64,228,851	64,228,851		141,691,200	-	
ALTCS Services	2,022,877,700	835,910,404	835,910,404		2,022,877,700	-	
Disproportionate Share Payments	5,087,100	-	-	5,087,100	-	
Rural Hospitals	28,612,400	-	-	28,612,400	-	
Voluntary Political Subdivision Programs	399,989,300		7,876,288		7,876,288		-		399,989,300		-	
DCS-CHP	227,089,300		95,781,101		95,781,101		-		227,089,300		-	
Behavioral Health Services - in Schools	18,003,300		4,310,651		4,310,651		-		18,003,300		-	
Targeted Investment Program	50,000,000		81,122		81,122		-		50,000,000		-	
Non Medicaid Seriously Mentally Ill Services	83,646,900		34,423,988		34,423,988		-		83,646,900		-	
Supported Housing	65,324,800		1,994,722		1,994,722		-		65,324,800		-	
Crisis Services	16,391,300		7,595,604		7,595,604		-		16,391,300		-	
TOTAL PROGRAMMATIC	 	17,991,245,000  		 	6,884,135,996  		 	6,884,135,996  		 	-			 	17,991,245,000  		 	-		

-
-
-
-
-
-
-

TOTAL EXPENDITURES

  $ 18,269,256,800  

  $	6,962,635,565  

  $	6,962,635,565  

  $	-	

  $   18,269,256,800	$	-

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2022 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2021 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

	(A)	(B)	(A) - (B)			
	EXPENDITURE			PROJECTED		
ANNUAL	PLAN	EXPENDITURES	VARIANCE	ANNUAL	ANNUALIZED	
APPROPRIATION	YTD	YTD	YTD	EXPENDITURES	VARIANCE	

STATE - GENERAL FUND

Administrative Expenditures

$	62,616,500	$

20,556,127	$

20,556,127

-	$	62,616,500	$	-

Proposition 204 - Administrative Expenditures	22,132,900	5,546,920	5,546,920	-	22,132,900	-

Programmatic Expenditures
Traditional Medicaid Services	1,148,967,200	492,702,143	492,702,143	-	1,148,967,200	-
Proposition 204 Services	188,667,600	91,095,787	91,095,787	-	188,667,600	-
ACA Adult Expansion	56,643,500	40,067,863	40,067,863	-	56,643,500	-
KidsCare Services	27,077,200	10,630,645	10,630,645	-	27,077,200	-
ALTCS Services	236,051,900	101,341,292	101,341,292	-	236,051,900	-
DSH and Rural Hospitals	8,846,200	-	-	-	8,846,200	-
DCS-CHP	58,514,400	22,485,535	22,485,535	-	58,514,400	-	
Behavior Health Services - in Schools	3,000,000	1,250,000	1,250,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	32,923,988	32,923,988	-	77,646,900	-	
Supported Housing	5,324,800	1,994,722	1,994,722	-	5,324,800	-	
Crisis Services	14,141,100	6,658,021	6,658,021	-	14,141,100	-	
Voluntary Political Subdivision Programs	 	6,000,000  	 	- 	 	- 	 	- 	 	6,000,000  	 	- 	
TOTAL GF EXPENDITURES	1,915,630,200	827,253,043	827,253,043	-	1,915,630,200	-	
	FEDERAL		
Administrative Expenditures	147,719,400	39,425,887	39,425,887	-	147,719,400	-	
Proposition 204 - Administrative Expenditures	37,994,900	11,860,010	11,860,010	-	37,994,900	-	
Programmatic Expenditures
Traditional Medicaid Services	
4,483,556,000	
1,748,942,796	
1,748,942,796	
-	
4,483,556,000	
-	
Proposition 204 Services	5,609,079,100	2,245,953,745	2,245,953,745	-	5,609,079,100	-	
ACA Adult Expansion	1,415,721,000	425,520,167	425,520,167	-	1,415,721,000	-	
KidsCare Services	99,767,100	53,343,734	53,343,734	-	99,767,100	-	
ALTCS Services and Nursing Facility Assessment	1,298,205,400	571,663,653	571,663,653	-	1,298,205,400	-	
DSH and Rural Hospitals	24,853,300	-	-	-	24,853,300	-	
DCS-CHP	165,974,200	72,964,680	72,964,680	-	165,974,200	-	
Behavior Health Services - in Schools	7,003,300	2,918,042	2,918,042	-	7,003,300	-	
Targeted Investment Program	34,504,800	40,561	40,561	-	34,504,800	-	
Supported Housing	60,000,000	-	-	-	60,000,000	-	
Voluntary Political Subdivision Programs	 	280,041,300  	 	5,283,410  	 	5,283,410  	 	- 	 	280,041,300  	 	- 	
TOTAL FEDERAL EXPENDITURES	13,664,419,800	5,177,916,685	5,177,916,685	-	13,664,419,800	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF	4,076,200	1,019,050	1,019,050	-	4,076,200	-	
Programmatic Expenditures
Traditional Medicaid Services Acute Care	
46,161,700	
19,014,167	
19,014,167	
-	
46,161,700	
-	
ALTCS Services	 	305,872,000  	 	91,935,424  	 	91,935,424  	 	- 	 	305,872,000  	 	- 	
TOTAL COUNTY EXPENDITURES	356,109,900	111,968,641	111,968,641
.	-	356,109,900	-	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2022 APPROPRIATION STATUS REPORT
For the Period Ending November 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	69,002,100	28,943,904	28,943,904	-	69,002,100	-	
Proposition 204 Services - Emergency Health Services	17,921,600	8,960,800	8,960,800	-	17,921,600	-	
Proposition 204 Services - Proposition 204 Protection	37,635,400	18,817,700	18,817,700	-	37,635,400	-	
Proposition 204 Services - ATLSF	 	102,000,000  	 	- 	 	- 	 	- 	 	102,000,000  	 	- 	
TOTAL TOBACCO EXPENDITURES	226,559,100	56,722,404	56,722,404	-	226,559,100	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program and SMI Housing Trust Fund	999,600	91,575	91,575	-	999,600	-	
Health Care Investment Fund	2,472,300	-	-	-	2,472,300	-	
Programmatic Expenditures							
Traditional Medicaid Services - IGA Fund	50,247,800	-	-	-	50,247,800	-	
Traditional Medicaid Services - Health Care Investment Fund	226,678,100	35,878,112	35,878,112	-	226,678,100	-	
Acute Care - Prescription Drug Rebate Program State Match	160,858,600	67,024,417	67,024,417	-	160,858,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	406,753,317	406,753,317	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	8,028,400	3,157,667	3,157,667	-	8,028,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	21,089,647	21,089,647	-	36,422,000	-	
Substance Abuse Disorder Services - Prescription Drug Rebate Program State Match	6,000,000	1,500,000	1,500,000	-	6,000,000	-	
Proposition 204 Services - Hospital Assessment	480,627,900	177,430,091	177,430,091	-	480,627,900	-	
Proposition 204 Services - IGA Fund	4,398,100	-	-	-	4,398,100	-	
Proposition 204 Services - Health Care Investment Fund	123,904,400	17,327,450	17,327,450	-	123,904,400	-	
ACA Adult Expansion - Hospital Assessment	128,069,000	4,982,630	4,982,630	-	128,069,000	-	
ACA Adult Expansion - IGA Fund	482,500	-	-	-	482,500	-	
ACA Adult Expansion - Health Care Investment Fund	9,045,900	1,846,258	1,846,258	-	9,045,900	-	
Traditional Medicaid Services - TPL	194,700	671,340	671,340	-	194,700	-	
ALTCS Services - TPL	-	965,125	965,125	-	-	-	
ALTCS Services - Nursing Facility Assessment	122,683,600	41,860,459	41,860,459	-	122,683,600	-	
ALTCS Services - Health Care Investment Fund	15,614,400	3,897,137	3,897,137	-	15,614,400	-	
DCS-CHP - Health Care Investment Fund	2,600,700	330,885	330,885	-	2,600,700	-	
Targeted Investment Program	15,495,200	40,561	40,561	-	15,495,200	-	
Children's Behavioral Health Services	8,000,000	142,610	142,610	-	8,000,000	-	
KidsCare Services - IGA Fund	462,900	-	-	-	462,900	-	
KidsCare Services -Health Care Investment Fund	2,232,700	254,171	254,171	-	2,232,700	-	
KidsCare Services Premiums	12,151,300	301	301	-	12,151,300	-	
Freedom to Work Premiums	31,200	580	580	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	937,583	937,583	-	2,250,200	-	
Voluntary Political Subdivision Programs	 	113,948,000  	 	2,592,878  	 	2,592,878  	 	- 	 	113,948,000  	 	- 	
TOTAL OTHER EXPENDITURES	2,106,537,800	788,774,793	788,774,793	-	2,106,537,800	-	
	TOTAL		
Administrative Expenditures	278,011,800	78,499,570	78,499,570	-	278,011,800	-	
Acute Care	15,968,367,300	6,048,225,592	6,048,225,592	-	15,968,367,300	-	
Long Term Care	 	2,022,877,700  	 	835,910,404  	 	835,910,404  	 	- 	 	2,022,877,700  	 	- 	
TOTAL EXPENDITURES	  $	18,269,256,800  	  $	6,962,635,565  	  $	6,962,635,565  	  $	- 	  $	18,269,256,800  	  $	- 	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2022 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending November 30, 2021

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,286,073,400	$	554,576,133	$	514,508,270	
Proposition 204 Services & Administrative	210,800,500	96,642,707	113,970,158	
KidsCare Services	27,077,200.00	10,630,644.91	10,630,645	
ALTCS Services	236,051,900	101,341,292	101,341,292	
Behavioral Health Traditional Medicaid Services	 	155,627,200  	 	64,062,266  	 	64,062,266  	
TOTAL	1,915,630,200	827,253,043	804,512,631	

FEDERAL:
Acute & Administrative	12,100,473,100	4,479,944,618	4,485,222,439	
KidsCare Services	99,767,100	53,343,734	58,277,635	
ALTCS Services	1,298,205,400	571,663,653	617,496,880	
Behavioral Health Traditional Medicaid Services	 	165,974,200  	 	72,964,680  	 	75,312,131  	
TOTAL	13,664,419,800	5,177,916,685	5,236,309,086	

COUNTY:				
Acute & Administrative	50,237,900		20,033,217		21,136,021	
ALTCS Services	 	305,872,000  		 	91,935,424  		 	117,997,500  	
TOTAL	356,109,900		111,968,641		139,133,521	

TOBACCO FUNDS:						
Traditional Medicaid Services	69,002,100		28,943,904		28,943,904	
Proposition 204 Services	 	157,557,000  		 	27,778,500  		 	27,778,500  	
TOTAL	226,559,100		56,722,404		56,722,404	

OTHER:

Administrative	3,471,900	91,575	91,575	
Traditional Medicaid Services - IGA Fund	50,247,800	-	-	
Acute Care - Prescription Drug Rebate Program	733,496,900	473,777,733	473,777,733	
Long Term Care - Prescription Drug Rebate Program	44,450,400	24,247,314	24,247,314	
Hospital Assessment	613,577,500	182,412,720	266,290,790	
Health Care Investment Fund	362,229,100	55,382,706	-	
Substance Abuse Disorder Services	6,000,000	1,500,000	1,500,000	
ALTCS	138,298,000	45,757,596	140,721	
Acute TPL - Note 1	194,700	671,340	671,340	
LTC TPL - Note 1	-	965,125	965,125	
KidsCare Services	2,695,600	254,171	-	
KidsCare TPL - Note 1	-	-	816.00	
Member Premiums - CHIP	12,151,300	301	301	
Member Premiums - Freedom to Work	31,200	580	580	
Targeted Investment Program	15,495,200	40,561	4,646,519	
Children's Behavioral Health Services	8,000,000	142,610	-	
Behavioral Health Traditional Medicaid Services	2,250,200	937,583	636,767	
Voluntary Political Subdivision - State Match	 	113,948,000  	 	2,592,878  	 	5,509,220  	
TOTAL	2,106,537,800	788,774,793	778,478,801	

TOTAL REVENUE

$	18,269,256,800

$	6,962,635,565

$	7,015,156,442

BUDGET

BUDGET YTD

RECEIPTS YTD

Appropriation Status Report
Footnotes

.-;))\HCCCS
Ari:i:ona Health Care Cost Containment System

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2022 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2021

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

$	1,358,441	$

1,225,030	$

7,978,219	$

6,027,230

LTC	785,005	1,078,452	5,490,008	4,188,930
KidsCare	206	505	8,140	2,200

Total TPL Collections

  $	2,143,652  

  $	2,303,987  

  $	13,476,367  

  $	10,218,360  

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	104,729	$	112,341	$	671,340	$	599,943	
LTC		135,516	200,246		965,125	774,152	
KidsCare		27	5		816	(25)	
Total Expenditure Offsets	  $	240,272  		  $	312,592  		  $	1,637,281  		  $	1,374,070  	

November 2021

November 2020

July 1, 2021	July 1, 2020
November 30, 2021	November 30, 2020

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

`

FY 22 Total

1,163.2
1,030.8

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2022 APPROPRIATION STATUS REPORT
For the Period Ending November 30, 2021

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2021	$    4,150,697	
	Revenues	3,867,022	
	Transfers-In	 	166,967  	
	Total Revenues	 	4,033,989  	
	Expenditures	3,349,556	
	Transfers-out	 	700,000  	
	Total Expenditures	 	4,049,556  	
	Ending Balance November 30, 2021	  $    4,135,130  	

Of the $4,135,130 ending balance, $3,144,161 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through December 2021.

Summary of Voluntary Political Subdivision Contribution Expenditures:

Note 4:

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

DSH Voluntary

$	48,666,500

$	2,592,878	$

5,283,410	$

7,876,288

GME Voluntary	351,322,800	-	-	-

Total Voluntary Political Subdivision Program Expenditures

$	399,989,300

$	2,592,878	$

5,283,410	$

7,876,288

Appropriation Status Report
Caseload and Expenditures by Rate Code

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

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

TITLE XIX TRADITIONAL
CAPITATION - ACC	399,729,224	400,663,939	400,303,014	418,888,745	422,479,616	0	0	0	0	0	0	0	2,042,064,539	
CAPITATION - AIMHS	499,959	508,769	516,921	523,415	528,615	0	0	0	0	0	0	0	2,577,679	
CAPITATION - LTC	311,534,987	312,797,811	312,922,147	328,780,162	329,411,512	0	0	0	0	0	0	0	1,595,446,619	
MENTAL HEALTH - CHILD	0	-4,177	-795	-819	410	0	0	0	0	0	0	0	-5,381	
MENTAL HEALTH - ADULT	358,926	335,026	334,344	372,475	397,312	0	0	0	0	0	0	0	1,798,083	
MENTAL HEALTH - GENERAL	-1,461	1,869	-3,606	-745	2,068	0	0	0	0	0	0	0	-1,875	
MENTAL HEALTH - DCS-CHP	3,105	-4,462	373	9,818	0	0	0	0	0	0	0	0	8,834	
MENTAL HEALTH - DD	1,741	0	-1,743	0	0	0	0	0	0	0	0	0	-3	
MENTAL HEALTH - RBHA CRISIS	6,436,264	6,466,842	6,508,793	8,405,546	8,472,895	0	0	0	0	0	0	0	36,290,340	
FEE FOR SERVICE - ACUTE	51,503,190	64,714,701	72,123,684	46,005,167	59,475,217	0	0	0	0	0	0	0	293,821,958	
FFS - PRIOR QUARTER COVERAGE	191,354	190,653	188,192	148,225	203,121	0	0	0	0	0	0	0	921,545	
EMERGENCY SERVICES - FEDERAL	3,795,664	2,999,894	3,845,463	3,282,560	3,155,336	0	0	0	0	0	0	0	17,078,916	
FFS MEDICAID IN PUBLIC SCHOOLS	994,537	559,921	590,617	1,102,922	1,441,406	0	0	0	0	0	0	0	4,689,402	
QMB - FEE FOR SERVICE	435,180	487,099	843,662	376,845	859,000	0	0	0	0	0	0	0	3,001,787	
STATE ONLY TRBHA FFS	126,690	136,684	170,831	251,538	197,157	0	0	0	0	0	0	0	882,900	
INPATIENT INMATES FFS	398,924	299,175	306,578	272,297	306,207	0	0	0	0	0	0	0	1,583,182	
FFS TRBHA FEE FOR SERVICE	11,550,985	10,288,216	13,849,019	10,648,441	12,654,931	0	0	0	0	0	0	0	58,991,592	
COCONINO COUNTY INMATES FFS	0	0	0	0	5,884	0	0	0	0	0	0	0	5,884	
YAVAPAI COUNTY INMATES FFS	0	3,010	0	0	0	0	0	0	0	0	0	0	3,010	
PINAL COUNTY INMATES FFS	0	1,846	25,877	313	117	0	0	0	0	0	0	0	28,152	
PIMA COUNTY INMATES FFS	1,350	36,189	20,025	1,797	21,141	0	0	0	0	0	0	0	80,502	
MARICOPA CTY INMATES FFS	44,024	47,762	24,962	5,377	23,744	0	0	0	0	0	0	0	145,869	
FEE FOR SERVICE - LTC	11,939,262	13,188,397	14,071,541	10,960,743	11,493,550	0	0	0	0	0	0	0	61,653,493	
LFFS - PRIOR QUARTER COVERAGE	127	3,518	777	0	68	0	0	0	0	0	0	0	4,491	
INPATIENT INMATES LTC FFS	0	0	0	18	0	0	0	0	0	0	0	0	18	
PINAL COUNTY INMATES LTC FEE F	289	11,451	29,922	1,170	1,395	0	0	0	0	0	0	0	44,227	
PIMA COUNTY INMATES LTC FEE FO	0	161	0	0	14	0	0	0	0	0	0	0	176	
MARICOPA CTY INMATES LTC FFS	0	0	0	9,992	0	0	0	0	0	0	0	0	9,992	
LFFS MEDICAID IN PUBLIC SCHOOLS	998,152	680,777	746,634	1,338,274	1,810,614	0	0	0	0	0	0	0	5,574,452	
REINSURANCE - ACC	17,723,732	17,310,667	14,746,668	19,274,278	14,666,729	0	0	0	0	0	0	0	83,722,073	
REINSURANCE - LTC	6,522,995	6,319,518	4,868,013	8,085,292	10,843,927	0	0	0	0	0	0	0	36,639,746	
SMIB - ACC	19,104,213	19,481,020	19,359,169	19,547,997	19,511,572	0	0	0	0	0	0	0	97,003,972	
HIB - ACC	1,093,988	1,149,262	1,174,776	1,173,378	1,139,436	0	0	0	0	0	0	0	5,730,839	
Q1	3,186,885	3,196,654	3,204,188	3,218,204	3,205,932	0	0	0	0	0	0	0	16,011,863	
SMIB - LTC	4,084,446	4,088,119	4,077,453	4,097,245	4,080,967	0	0	0	0	0	0	0	20,428,230	
HIB - LTC	372,541	368,920	376,844	366,793	369,878	0	0	0	0	0	0	0	1,854,976	
SUBTOTAL	852,631,275	866,329,231	875,224,345	887,147,463	906,759,770	0	0	0	0	0	0	0	4,388,092,083	

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

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

TITLE XIX PROP 204
CAPITATION - ACC	371,575,704	375,838,177	380,752,717	391,880,046	393,528,561	0	0	0	0	0	0	0	1,913,575,205	
CAPITATION - AIMHS	266,281	272,611	279,187	282,398	284,518	0	0	0	0	0	0	0	1,384,994	
MENTAL HEALTH - ADULT	324,272	340,920	374,489	460,431	523,899	0	0	0	0	0	0	0	2,024,012	
MENTAL HEALTH - GENERAL	-739	142	379	-2,221	1,303	0	0	0	0	0	0	0	-1,136	
MENTAL HEALTH - RBHA CRISIS	7,386,408	7,474,384	7,555,611	4,334,461	4,343,964	0	0	0	0	0	0	0	31,094,828	
FEE FOR SERVICE - ACUTE	60,749,420	71,123,262	79,520,969	51,916,426	64,523,923	0	0	0	0	0	0	0	327,834,000	
FFS - PRIOR QUARTER COVERAGE	-113	-309	-7,209	1,845	0	0	0	0	0	0	0	0	-5,787	
EMERGENCY SERVICES - FEDERAL	3,942,636	3,125,660	4,376,209	3,269,109	3,488,602	0	0	0	0	0	0	0	18,202,216	
FFS MEDICAID IN PUBLIC SCHOOLS	1,535	1,162	972	809	1,025	0	0	0	0	0	0	0	5,503	
FFS TRBHA FEE FOR SERVICE	10,710,586	10,187,265	13,791,530	11,707,851	12,547,356	0	0	0	0	0	0	0	58,944,588	
INPATIENT INMATES FFS	810,012	856,799	1,147,633	568,639	494,621	0	0	0	0	0	0	0	3,877,703	
STATE ONLY TRBHA FFS	487,687	411,171	701,277	524,457	668,807	0	0	0	0	0	0	0	2,793,399	
YAVAPAI COUNTY INMATES FFS	30,896	5,315	0	0	0	0	0	0	0	0	0	0	36,211	
MARICOPA CTY INMATES FFS	50,607	118,615	141,733	120,681	116,912	0	0	0	0	0	0	0	548,549	
COCONINO COUNTY INMATES FFS	0	467	0	1,575	5,136	0	0	0	0	0	0	0	7,177	
YUMA COUNTY INMATES FFS	0	0	0	-170	0	0	0	0	0	0	0	0	-170	
PIMA COUNTY INMATES FFS	65,555	57,923	36,817	21,456	50,547	0	0	0	0	0	0	0	232,297	
PINAL COUNTY INMATES FFS	19,831	1,120	5,559	11,511	3,758	0	0	0	0	0	0	0	41,779	
MOHAVE COUNTY INMATES FFS	6,474	9,365	638	12,904	0	0	0	0	0	0	0	0	29,381	
REINSURANCE - ACC	7,247,946	11,078,691	6,909,613	10,643,746	8,260,899	0	0	0	0	0	0	0	44,140,894	
SMIB - ACC	8,735,642	8,826,554	8,791,193	8,847,034	8,892,559	0	0	0	0	0	0	0	44,092,982	
HIB - ACC	5,440	5,440	5,487	4,498	5,440	0	0	0	0	0	0	0	26,305	
SUBTOTAL	472,416,078	489,734,734	504,384,804	484,607,483	497,741,830	0	0	0	0	0	0	0	2,448,884,929	

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

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

TITLE XIX ACA ADULT EXPANSION

CAPITATION - ACC	73,125,256	73,453,635	73,911,077	76,878,675	76,416,237	0	0	0	0	0	0	0	373,784,880	
CAPITATION - AIMHS	39,668	41,162	42,190	42,481	42,599	0	0	0	0	0	0	0	208,100	
MENTAL HEALTH - ADULT	34,568	41,196	33,334	33,503	33,474	0	0	0	0	0	0	0	176,075	
MENTAL HEALTH - RBHA CRISIS	1,783,151	1,790,056	1,805,041	1,020,760	1,014,382	0	0	0	0	0	0	0	7,413,390	
FEE FOR SERVICE - ACUTE	5,825,473	7,828,428	7,645,678	4,831,001	6,553,673	0	0	0	0	0	0	0	32,684,253	
FFS - PRIOR QUARTER COVERAGE	0	0	-667	0	0	0	0	0	0	0	0	0	-667	
EMERGENCY SERVICES - FEDERAL	6,513,412	5,298,522	7,706,741	5,483,395	4,574,803	0	0	0	0	0	0	0	29,576,874	
FFS MEDICAID IN PUBLIC SCHOOLS	76	0	11	23	106	0	0	0	0	0	0	0	216	
INPATIENT INMATES FFS	28,391	46,767	36,606	18,325	26,399	0	0	0	0	0	0	0	156,489	
FFS TRBHA FEE FOR SERVICE	386,803	472,001	754,790	490,575	689,884	0	0	0	0	0	0	0	2,794,053	
STATE ONLY TRBHA FFS	83,084	61,258	70,300	46,282	62,605	0	0	0	0	0	0	0	323,530	
YAVAPAI COUNTY INMATES FFS	0	0	496	9	1,657	0	0	0	0	0	0	0	2,162	
PIMA COUNTY INMATES FFS	13,885	2,236	468	13,737	0	0	0	0	0	0	0	0	30,326	
MOHAVE COUNTY INMATES FFS	0	124	0	0	0	0	0	0	0	0	0	0	124	
MARICOPA CTY INMATES FFS	6,340	16,110	39,601	63	662	0	0	0	0	0	0	0	62,775	
REINSURANCE - ACC	402,888	1,794,647	1,513,941	1,393,893	769,651	0	0	0	0	0	0	0	5,875,021	
SMIB - ACC	14,108	14,702	15,147	15,741	19,379	0	0	0	0	0	0	0	79,076	
	88,257,103	90,860,844	93,574,755	90,268,464	90,205,510	0	0	0	0	0	0	0	453,166,676	
	1,413,304,456	1,446,924,808	1,473,183,904	1,462,023,410	1,494,707,110	0	0	0	0	0	0	0	7,290,143,688	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - RBHA CRISIS	52	52	81	50	50	0	0	0	0	0	0	0	286	
KidsCare - CAPITATION	11,005,329	11,301,371	13,129,471	12,114,310	12,394,535	0	0	0	0	0	0	0	59,945,017	
KidsCare - FEE FOR SERVICE	202,286	268,870	303,460	177,992	262,007	0	0	0	0	0	0	0	1,214,615	
KidsCare - MENTAL HEALTH	123,237	124,202	126,787	399,446	409,199	0	0	0	0	0	0	0	1,182,870	
KidsCare - REINSURANCE	344,676	1,469,000	-200,584	497,697	359,046	0	0	0	0	0	0	0	2,469,834	
KidsCare - TRANSPLANT REIN	43,580	0	973,348	142,540	147,957	0	0	0	0	0	0	0	1,307,425	

11,719,160	13,163,495	14,332,563	13,332,034	13,572,794	0	0	0	0	0	0	0	66,120,047	

TOTAL TITLE XXI

1,425,023,617	1,460,088,303	1,487,516,466	1,475,355,444	1,508,279,904	0	0	0	0	0	0	0	7,356,263,735	

GRAND TOTAL

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1005	TANF 14-20 FEMALE WI	117.20	117.20	117.20	132.81	132.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		617.22		
1006	TANF 21-44 MALE WITH	29,444.45	26,953.29	31,212.32	37,591.15	35,359.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160,560.63		
1007	TANF 21-44 FEMALE WI	40,581.51	35,879.34	30,736.33	39,424.42	46,366.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192,988.00		
1008	TANF 45-64 M & F WIT	77,191.29	80,699.24	86,017.53	89,247.29	92,631.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		425,786.41		
1009	TANF 65+ M & F WITH	23,246.54	23,523.62	23,042.82	24,942.48	23,529.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,284.61		
100F	TANF 21-44 MALE WITH	91.26	37.38	37.79	209.13	3,634.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,009.86		
100G	TANF 21-44 FEMALE WI	0.00	182.52	0.00	1,629.11	179.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,991.21		
100H	TANF 45-64 M & F WIT	585.36	118.85	0.00	0.00	1,054.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,758.61		
100J	TANF 65+ M & F WITH	0.00	0.00	76.34	0.00	91.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		168.32		
1011	TANF <1 M & F NON-ME	7,661,151.05	7,941,338.82	8,235,929.02	9,070,609.51	9,374,476.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,283,505.37		
1012	TANF 01-05 M & F NON	4,513,538.88	4,458,769.49	4,361,247.44	4,957,970.77	5,318,372.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,609,898.61		
1013	TANF 06-13 M & F NON	8,535,793.74	8,469,237.57	8,338,891.85	9,395,528.42	9,954,751.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,694,202.98		
1014	TANF 14-20 MALE NON-	3,027,388.33	3,078,596.30	3,114,967.97	3,382,190.18	3,668,266.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,271,409.37		
1015	TANF 14-20 FEMALE N	3,624,871.21	3,666,227.26	3,650,236.00	4,050,636.84	4,223,059.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,215,030.57		
	O																
1016	TANF 21-44 MALE NON-	13,416,596.16	13,432,959.83	13,576,998.91	14,425,196.76	15,100,957.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,952,709.38		
1017	TANF 21-44 FEMALE N	44,928,461.38	44,871,824.26	45,204,832.14	47,863,519.96	49,756,695.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232,625,333.33		
	O																
1018	TANF 45-64 M & F NON	11,486,936.52	11,491,326.95	11,513,932.97	12,221,803.34	12,710,007.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,424,007.27		
1019	TANF 65+ M & F NON-M	57,245.16	57,764.38	59,725.04	62,832.90	63,455.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		301,023.33		
101A	TANF < 1 M & F NON-M	324,970.17	265,210.36	371,239.52	407,432.04	376,991.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,745,843.56		
101B	TANF 01-05 M & F NON	13,164.19	15,795.18	19,123.63	19,420.97	6,834.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,338.92		
101C	TANF 06-13 M & F NON	7,198.83	10,056.07	4,239.86	11,447.53	11,007.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,949.66		
101D	TANF 14-20 MALE NON-	3,237.81	4,045.00	2,268.21	4,403.63	9,096.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,051.05		
101E	TANF 14-20 FEMALE N	2,917.69	8,282.27	6,236.37	8,110.75	3,061.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,608.29		
	O																
101F	TANF 21-44 MALE NON-	158,952.48	126,092.99	129,202.38	144,056.31	127,366.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		685,670.37		
101G	TANF 21-44 FEMALE N	294,636.21	212,415.18	254,922.02	294,801.24	227,313.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,284,088.49		
	O																
101H	TANF 44-64 M & F NON	82,989.45	63,596.88	81,170.82	91,013.19	61,382.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		380,152.44		
101J	TANF 65+ N & F NON-M	55.95	0.00	137.69	462.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		656.50		
1023	TANF 06-13 M & F WIT	131.08	131.08	131.08	143.85	143.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		680.94		
1024	TANF 14-20 MALE WITH	2,727.47	2,727.47	2,727.47	2,741.72	2,741.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,665.85		
1025	TANF 14-20 FEMALE WI	276.42	276.42	276.42	296.68	296.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,422.62		
1026	TANF 21-44 MALE WITH	40,118.54	47,720.97	37,735.64	38,946.07	36,482.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,004.01		
1027	TANF 21-44 FEMALE WI	58,218.98	53,265.42	49,842.12	48,277.73	54,067.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		263,671.47		
1028	TANF 45-64 M & F WIT	64,188.85	67,556.55	70,549.05	77,550.65	85,253.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		365,098.96		
1029	TANF 65+ M & F WITH	14,444.41	14,421.61	15,202.50	17,748.34	17,995.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,811.90		
102F	TANF 21-44 MALE WITH	122.62	190.65	345.64	123.96	9.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		792.73		
102G	TANF 21-44 FEMALE WI	0.00	0.00	14.48	0.00	424.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		438.86		

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102H	TANF 44-64 M & F WIT	152.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152.18		
102J	TANF 65+ M & F WITH	0.00	0.00	58.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.21		
2100	SSI AGED WITH MEDIC	763,800.03	768,532.43	777,797.37	854,111.51	845,265.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,009,506.49		
	A																
210Z	SSI AGED WITH MEDIC	28,421.34	26,272.69	32,512.81	38,034.79	23,868.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149,109.99		
	A																
2110	SSI AGED NON-MEDICA	11,054,428.52	11,242,195.86	11,361,855.36	11,745,411.76	11,949,274.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,353,165.72		
	R																
211Z	SSI AGED NON-MEDICA	129,841.87	113,589.83	107,486.63	144,631.78	165,440.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		660,990.83		
	R																
2120	SSI AGED WITH QMB	6,463,071.68	6,530,887.40	6,584,108.88	7,118,821.17	7,171,675.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,868,564.76		
212Z	SSI AGED WITH QMB P	2,386.49	3,902.80	2,431.14	2,650.08	2,510.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,880.85		
	P																
2200	SSI DISABLED WITH M	2,189,661.88	2,176,126.20	2,220,225.40	2,301,849.54	2,337,123.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,224,986.76		
	E																
220Z	SSI DISABLED WITH M	31,096.75	30,489.07	58,739.40	38,310.93	22,921.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,557.19		
	E																
2210	SSI DISABLED NON-ME	77,983,132.51	77,830,229.35	77,625,544.32	79,140,699.05	79,222,349.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		391,801,955.06		
	D																
221Z	SSI DISABLED NON-ME	875,772.81	737,616.18	873,090.82	748,934.43	620,253.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,855,667.81		
	D																
2220	SSI DISABLED WITH Q	16,141,023.64	16,219,026.29	16,303,359.94	16,535,828.14	16,541,060.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,740,298.04		
	M																
222Z	SSI DISABLED WITH Q	55,236.68	11,887.96	30,569.80	15,415.60	23,643.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,753.09		
	M																
2300	SSI BLIND WITH MEDIC	6,111.90	5,573.58	5,855.05	8,047.18	8,057.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,645.17		
230Z	SSI BLIND WITH MEDIC	116.81	108.98	129.25	9.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		364.93		
2310	SSI BLIND NON-MEDIC	698,029.61	707,319.42	711,090.99	733,850.02	725,597.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,575,887.11		
	A																
231Z	SSI BLIND NON-MEDIC	9,332.14	16,473.19	4,765.43	2,654.63	24,291.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57,517.38		
	A																
2320	SSI BLIND WITH QMB	54,450.83	56,379.72	56,924.63	63,089.68	65,396.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		296,241.43		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	62.71	86.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149.17		
4301	SOBRA CHILD <1 M & F	0.00	110.81	0.00	147.96	147.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406.73		
4302	SOBRA CHILD 01-05 M	137.40	110.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248.21		
4303	SOBRA CHILD 06-13 M	547.58	494.40	272.78	293.38	293.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,901.52		
4305	SOBRA CHILD 14-20 FE	134.72	134.72	136.94	152.17	152.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		710.72		
4311	SOBRA CHILD <1 M & F	19,439,593.18	19,186,982.62	18,720,193.27	20,148,472.64	19,928,999.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,424,241.18		
4312	SOBRA CHILD 01-05 M	42,529,409.46	42,661,971.26	42,354,431.51	44,088,144.05	43,704,722.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,338,678.56		
4313	SOBRA CHILD 06-13 M	52,315,230.94	52,388,592.86	52,229,371.07	54,251,707.46	53,934,208.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		265,119,110.68		
4314	SOBRA CHILD 14-20 MA	15,785,821.26	15,957,029.74	15,956,057.27	16,579,471.87	16,558,633.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,837,013.65		
4315	SOBRA CHILD 14-20 FE	15,595,535.10	15,662,963.31	15,705,788.71	16,320,590.24	16,331,958.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,616,836.19		
431A	SOBRA CHILD < 1 M &	139,418.63	127,236.79	143,838.61	199,083.11	190,176.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		799,753.70		
431B	SOBRA CHILD 01-05 M	255,627.65	219,131.71	248,160.60	274,209.96	199,873.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,197,003.22		
431C	SOBRA CHILD 6-13 M&F	268,230.24	270,396.77	309,346.75	345,478.48	260,679.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,454,131.69		
431D	SOBRA CHILD 14-20 MA	85,627.32	87,020.94	112,781.48	104,866.96	75,228.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		465,525.41		
431E	SOBRA CHILD 14-20 FE	86,245.86	80,318.66	93,844.86	106,837.04	91,927.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		459,174.12		
4322	SOBRA CHILD 01-05 M	271.66	271.66	271.66	299.32	299.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,413.62		
4323	SOBRA CHILD 06-13 M	135.14	135.14	135.14	147.96	147.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		701.34		

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4325	SOBRA CHILD 14-20 FE	389.98	389.98	524.70	515.46	573.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,393.46		
432E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	57.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.88		
5007	SOBRA PREG 21-44 FE	3,694.41	5,558.20	8,757.30	12,780.71	17,331.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,121.66		
	M																
5008	SOBRA PREG 45-64 FE	2,592.33	2,592.33	2,592.33	2,593.76	149.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,520.28		
	M																
500G	SOBRA PREG 21-44 FE	126.08	247.65	566.67	0.00	540.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,480.84		
	M																
5013	SOBRA PREG 09-13 FE	641.87	816.87	802.32	842.64	1,268.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,371.86		
	M																
5015	SOBRA PREG 14-20 FE	448,174.24	457,664.24	460,044.32	469,952.75	466,676.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,302,511.95		
	M																
5017	SOBRA PREG 21-44 FE	6,153,083.06	6,362,081.15	6,633,717.51	6,929,337.75	6,862,890.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,941,109.67		
	M																
5018	SOBRA PREG 45-64 FE	31,891.48	34,819.09	37,419.75	39,345.15	37,375.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		180,851.46		
	M																
501C	SOBRA PREG 09-13 FE	0.00	0.00	0.00	257.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		257.37		
	M																
501E	SOBRA PREG 14-20 FE	23,393.78	20,740.98	25,551.51	30,032.80	22,606.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,325.97		
	M																
501G	SOBRA PREG 21-44 FE	257,035.50	222,352.26	245,629.99	293,471.57	223,765.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,242,254.57		
	M																
501H	SOBRA PREG 45-64 FE	2,524.92	897.07	292.13	4,436.58	785.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,936.38		
	M																
5027	SOBRA PREG 21-44 FE	18,493.01	17,584.84	12,767.94	12,187.09	7,610.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,643.57		
	M																
5028	SOBRA PREG 45-64 FE	3,797.15	3,517.17	3,517.17	3,710.98	3,414.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,956.77		
	M																
502G	SOBRA PREG 21-44 FE	30.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.33		
	M																
SUBTOTAL:	368,425,493.14	368,776,115.38	369,336,726.29	386,502,280.57	390,064,743.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,883,105,358.43		

9910	TANF & SOBRA CHILDR E	3,428,009.16	3,681,612.33	3,097,877.16	3,276,005.54	3,126,850.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	25,888.69	25,516.73	25,927.80	12,906.23	6,442.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	71,444.77	110,479.32	148,378.91	118,726.11	111,708.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	10,416,605.75	10,551,104.62	10,524,714.27	10,613,972.23	10,962,877.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,941,948.37	14,368,713.00	13,796,898.14	14,021,610.11	14,207,878.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,610,354.46	
96,682.21	
560,737.56	
53,069,274.18	
70,337,048.41	

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

82.50

82.50

1106	TANF EXPANDED 21-44	69,075.79	67,473.50	71,746.46	73,618.24	79,141.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	162,032.73	156,224.32	159,711.60	168,955.70	151,272.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	440,432.18	447,081.98	438,955.77	455,380.78	438,874.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	123,346.59	127,834.71	134,042.21	144,789.16	147,863.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	2,126.30	1,099.84	3,285.66	712.63	384.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	3,907.15	1,484.06	5,267.33	2,108.41	3,110.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	4,501.87	4,068.97	2,002.61	3,533.45	1,888.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	2,517.71	2,814.56	3,121.65	2,624.20	2,208.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	393.70	192.87	192.87	419.48	207.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	417.00	417.00	617.83	227.63	656.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	42,543.13	41,313.25	39,037.85	38,895.41	37,393.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

361,055.43	
798,196.60	
2,220,724.89	
677,876.25	
7,609.26	
15,877.28	
15,995.36	
13,286.89	
1,406.59	
2,335.95	
199,182.68	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	257,418.05	247,391.76	236,335.92	229,212.22	223,780.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,194,138.85		
1116	TANF EXPANDED 21-44	11,162,992.42	11,217,653.73	11,165,829.31	11,217,710.28	10,832,616.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,596,802.72		
1117	TANF EXPANDED 21-44	31,527,009.33	31,640,499.96	31,476,104.84	31,569,283.21	30,311,836.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,524,733.55		
1118	TANF EXPANDED 45-64	10,867,731.03	11,007,390.26	10,995,220.87	11,141,061.24	10,832,460.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,843,864.06		
1119	TANF EXPANDED 65+ M	51,108.03	52,173.64	52,353.57	54,307.67	51,621.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		261,563.99		
	&																
111D	TANF EXPANDED 14-20	978.21	762.07	509.99	744.15	1,166.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,161.38		
111E	TANF EXPANDED 14-20	1,020.67	544.51	467.13	1,026.78	471.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,530.68		
111F	TANF EXPANDED 21-44	125,069.53	131,074.38	150,676.33	135,408.46	122,518.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		664,746.76		
111G	TANF EXPANDED 21-44	170,434.10	165,240.91	180,241.09	210,703.59	154,825.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		881,445.49		
111H	TANF EXPANDED 45-64	68,479.73	57,989.20	73,223.46	95,070.87	57,462.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		352,225.27		
111J	TANF EXPANDED 65+ M	357.07	0.00	0.00	955.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,312.50		
	&																
1125	TANF EXPANDED 14-20	141.70	141.70	141.70	149.53	149.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		724.16		
1126	TANF EXPANDED 21-44	333,080.20	335,975.12	330,193.67	337,409.47	333,085.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,669,744.28		
1127	TANF EXPANDED 21-44	797,818.70	811,327.67	806,875.84	797,306.28	800,787.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,014,116.18		
1128	TANF EXPANDED 45-64	1,015,368.70	1,020,268.02	1,021,459.85	1,051,775.97	1,070,468.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,179,341.19		
1129	TANF EXPANDED 65+ M	296,440.00	300,205.65	301,366.48	328,663.84	335,730.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,562,406.30		
	&																
112F	TANF EXPANDED 21-44	379.47	13.07	328.91	86.41	251.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,058.99		
112G	TANF EXPANDED 21-44	161.30	99.61	59.02	464.43	235.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,020.24		
112H	TANF EXPANDED 45-64	296.88	613.90	333.01	397.30	133.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,774.38		
112J	TANF EXPANDED 65+ M	193.90	48.59	126.33	0.00	395.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		764.73		
	&																
2400	SSI AGED EXPANDED	88,524.93	84,272.23	87,938.08	93,993.15	99,074.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453,803.18		
	WI																
240Z	SSI AGED EXPANDED	27,564.79	22,569.42	21,549.37	30,377.59	32,429.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,491.11		
	WI																
2410	SSI AGED EXPANDED N	175,943.39	177,584.18	182,719.11	187,393.03	184,191.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		907,830.82		
	O																
241Z	SSI AGED EXPANDED N	7,694.74	10,720.26	2,806.75	7,613.78	13,591.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,427.38		
	O																
2420	SSI AGED EXPANDED	6,528,864.94	6,564,115.86	6,606,005.78	7,052,376.11	7,110,336.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,861,698.85		
	WI																
242Z	SSI AGED EXPANDED	1,013.05	4,919.56	5,093.08	4,338.68	3,543.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,907.71		
	WI																
2500	SSI BLIND EXPANDED	136.94	136.94	266.78	175.68	152.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		868.51		
	W																
250Z	SSI BLIND EXPANDED	135.14	0.00	138.80	256.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		530.49		
	W																
2510	SSI BLIND EXPANDED	1,229.94	1,229.94	2,636.63	5,422.89	6,872.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,391.45		
	N																
2520	SSI BLIND EXPANDED	4,458.57	5,143.25	6,341.35	10,680.56	12,151.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,775.30		
	W																
2600	SSI DISABLED EXPAND	156,192.51	150,805.10	140,071.89	144,862.85	138,850.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		730,782.88		
	E																
260Z	SSI DISABLED EXPAND	26,254.75	14,558.99	11,224.89	21,009.22	22,520.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,568.50		
	E																
2610	SSI DISABLED EXPAND	1,996,517.36	1,961,623.19	1,937,121.34	1,948,903.97	1,960,844.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,805,010.24		
	E																
261Z	SSI DISABLED EXPAND	8,411.94	22,688.68	24,764.56	28,762.41	25,495.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,123.36		
	E																
2620	SSI DISABLED EXPAND	11,146,612.07	11,128,432.04	11,097,098.87	11,224,169.34	11,245,443.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,841,755.34		
	E																
262Z	SSI DISABLED EXPAND	9,044.55	13,624.36	18,063.76	10,675.74	8,558.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,966.94		
	E																

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	77,706,372.78	78,001,842.81	77,793,670.20	78,834,013.77	76,857,055.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		389,192,954.94		

9911	SB PAYMENT FOR TAN F	1,890,408.88	2,169,712.85	1,976,269.27	1,650,551.90	1,546,603.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	0.00	6,751.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	6,398.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,890,408.88	2,176,464.45	1,982,667.87	1,650,551.90	1,546,603.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,233,546.65	
6,751.60	
6,398.60	
9,246,696.85	

3505	ADULT 40-100% FEMAL E	0.00	0.00	0.00	632.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3506	ADULT 40-100% MALE 2	24,853.90	22,622.60	23,232.02	25,464.52	26,096.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	22,734.89	19,519.17	17,586.70	23,019.44	25,499.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	221,357.49	233,635.81	245,677.97	266,481.38	257,259.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	183,112.02	212,721.13	256,425.53	265,830.96	285,532.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	731.24	0.00	156.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	0.00	0.00	587.56	0.00	23.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	0.00	22.63	0.00	4,137.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	4,331,437.31	4,356,246.35	4,360,416.06	4,488,841.57	4,473,646.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	4,614,114.58	4,641,586.70	4,675,172.87	4,854,312.58	4,865,541.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	19,623,235.34	19,854,496.77	19,983,690.82	20,071,914.64	19,685,716.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	15,989,350.26	16,187,165.31	16,343,645.08	16,586,161.70	16,309,367.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	30,195,096.45	30,369,430.26	30,481,328.45	30,676,354.06	30,044,290.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	18,703.36	21,418.29	23,728.57	30,609.81	35,348.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	20,279.43	16,022.77	15,434.38	35,256.03	22,499.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	26,035.61	28,004.98	25,929.17	34,107.96	26,666.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	226,338.34	204,632.81	155,647.74	167,135.28	181,694.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	146,129.44	154,540.10	159,975.66	169,053.42	152,290.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	336,811.65	280,598.85	318,181.09	343,770.17	276,434.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	3,682.44	10,664.25	0.00	4,014.35	1,296.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3524	ADULT 40-100% MALE 1	752.39	752.39	752.39	1,405.40	772.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	2,343.02	3,095.41	3,095.41	3,103.49	4,722.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	3,438.71	2,100.73	4,659.93	4,686.86	6,305.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	19,838.61	21,066.99	23,198.90	27,252.01	24,298.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	11,242.31	11,920.26	12,473.75	13,359.79	14,937.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352G	ADULT 40-100% FEMAL E	1,254.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	0.00	0.00	925.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	100,063.05	112,294.62	114,641.86	115,716.33	123,731.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	61,368.84	58,290.26	59,449.86	60,596.26	56,443.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	469,701.58	487,911.82	515,743.07	554,897.80	582,018.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

632.45	
122,270.01	
108,360.04	
1,224,412.18	
1,203,622.61	
887.90	
610.93	
4,160.58	
22,010,587.36	
23,650,728.00	
99,219,053.99	
81,415,689.67	
151,766,500.14	
129,808.25	
109,491.61	
140,744.69	
935,449.08	
781,989.43	
1,555,796.15	
19,658.03	
4,435.52	
16,359.68	
21,191.95	
115,655.14	
63,933.96	
1,254.35	
925.04	
566,447.81	
296,148.28	
2,610,272.44	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3709	ADULT <40% EXP M&F	73,748.46	81,904.59	95,292.99	105,440.21	117,145.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		473,532.07		
	6																
370F	ADULT <40% EXP MALE	128.88	167.24	844.38	5,423.38	1,283.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,847.74		
370G	ADULT <40% EXP FEMA	0.00	0.00	0.00	52.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.22		
	L																
370H	ADULT <40% EXP M&F	4,699.09	13,432.93	4,796.88	2,533.24	5,279.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,741.15		
	4																
370J	ADULT <40% EXP M&F	5,431.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,431.66		
	6																
3714	ADULT <40% EXP MALE	9,320,168.94	9,443,394.37	9,729,887.42	10,157,006.24	10,361,848.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,012,305.11		
3715	ADULT <40% EXP FEMA	8,601,942.36	8,795,998.82	9,047,671.52	9,462,152.39	9,650,750.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,558,515.41		
	L																
3716	ADULT <40% EXP MALE	73,995,366.90	75,308,114.89	77,029,972.14	80,247,303.87	82,341,680.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		388,922,438.15		
3717	ADULT <40% EXP FEMA	43,524,815.99	44,200,503.53	45,242,049.33	47,148,205.60	48,319,031.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228,434,605.59		
	L																
3718	ADULT <40% EXP M&F	76,055,286.65	76,991,050.78	78,171,111.65	81,110,841.53	82,869,417.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		395,197,708.03		
	4																
3719	ADULT <40% EXP M&F	37,269.77	37,320.24	42,917.41	39,050.32	45,297.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		201,855.33		
	6																
371D	ADULT <40% EXP MALE	54,092.39	62,506.93	70,726.03	107,171.07	89,656.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384,152.99		
371E	ADULT <40% EXP FEMA	68,445.50	70,113.10	71,331.38	97,959.08	74,612.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		382,461.95		
	L																
371F	ADULT <40% EXP MALE	915,874.56	768,839.68	852,226.01	1,130,070.77	934,289.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,601,300.52		
371G	ADULT <40% EXP FEMA	497,156.16	435,759.81	527,417.43	596,018.82	506,247.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,562,599.87		
	L																
371H	ADULT <40% EXP M&F	771,542.01	702,266.72	793,639.39	990,476.38	880,549.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,138,473.50		
	4																
371J	ADULT <40% EXP M&F	0.00	0.00	740.99	0.00	622.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,363.81		
	6																
3724	ADULT <40% EXP MALE	0.00	0.00	0.00	611.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		611.85		
3726	ADULT <40% EXP MALE	19,747.54	15,900.86	18,784.23	21,689.51	18,994.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,116.63		
3727	ADULT <40% EXP FEMA	3,954.91	5,459.69	8,052.02	5,596.18	7,059.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,122.64		
	L																
3728	ADULT <40% EXP M&F	55,219.43	57,255.49	58,848.36	67,357.98	67,635.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		306,316.73		
	4																
3729	ADULT <40% EXP M&F	1,238.47	1,238.47	1,238.47	632.45	632.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,980.31		
	6																
372F	ADULT <40% EXP MALE	0.00	0.00	109.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109.81		
372H	ADULT <40% EXP M&F	592.90	1,587.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,180.46		
	4																
SUBTOTAL:	290,659,997.94	294,304,308.20	299,589,257.72	310,123,865.96	313,774,470.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,508,451,900.80		

9935	BIRTH SUPP PAYMENT A	368,474.20	441,663.07	356,791.14	411,227.54	358,766.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	950,449.82	913,898.38	1,030,330.08	860,386.83	991,664.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,318,924.02	1,355,561.45	1,387,121.22	1,271,614.37	1,350,431.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,936,922.12	
4,746,729.94	
6,683,652.06	

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	509.30	509.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	487.72	487.72	487.72	511.02	511.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	105,124.76	102,887.13	107,330.03	108,382.22	112,832.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	74,348.29	67,063.25	69,019.50	71,543.13	75,824.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	967,897.09	991,103.64	1,016,952.14	1,102,718.38	1,139,858.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	673,532.31	721,731.33	788,089.47	870,311.42	924,105.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	173.06	0.00	0.00	167.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,018.60	
2,485.20	
536,556.29	
357,798.19	
5,218,530.22	
3,977,769.98	
340.40	

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390H	NEWLY ELIGIBLE M&F	259.23	1,621.12	1,930.24	32.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,843.15		
	4																
3914	NEWLY ELIGIBLE MALE	3,047,757.07	2,959,338.89	2,885,460.12	2,934,293.03	2,857,481.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,684,330.89		
3915	NEWLY ELIGIBLE FEMA	3,244,492.82	3,129,519.67	3,037,025.11	3,089,928.44	3,009,204.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,510,170.26		
	L																
3916	NEWLY ELIGIBLE MALE	17,601,679.01	17,670,092.06	17,801,738.47	18,540,258.12	18,510,304.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,124,072.26		
3917	NEWLY ELIGIBLE FEMA	24,841,265.59	25,115,246.82	25,550,158.92	26,510,586.32	26,322,602.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128,339,860.62		
	L																
3918	NEWLY ELIGIBLE M&F	20,999,876.79	21,004,360.63	21,080,221.65	21,939,916.60	21,780,967.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,805,343.14		
	4																
3919	NEWLY ELIGIBLE M&F	62,880.76	68,069.49	67,689.38	69,904.16	69,884.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		338,428.51		
	6																
391D	NEWLY ELIGIBLE MALE	9,236.66	6,054.65	6,407.56	9,231.96	8,939.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,870.71		
391E	NEWLY ELIGIBLE FEMA	10,544.73	9,035.35	8,162.90	13,133.12	15,040.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,916.49		
	L																
391F	NEWLY ELIGIBLE MALE	123,315.89	74,896.59	107,646.54	137,805.20	112,379.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		556,043.95		
391G	NEWLY ELIGIBLE FEMA	137,385.13	100,067.50	113,302.32	132,473.59	124,309.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		607,537.58		
	L																
391H	NEWLY ELIGIBLE M&F	125,181.38	118,845.84	131,706.54	133,510.05	134,173.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		643,417.43		
	4																
3926	NEWLY ELIGIBLE MALE	436.16	436.16	436.16	440.87	440.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,190.22		
3927	NEWLY ELIGIBLE FEMA	1,363.60	1,363.60	1,363.60	1,932.24	1,932.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,955.28		
	L																
3928	NEWLY ELIGIBLE M&F	11,915.58	12,272.93	14,271.38	14,404.05	12,141.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,005.91		
	4																
3929	NEWLY ELIGIBLE M&F	32,038.03	35,749.13	37,729.22	43,447.11	49,925.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		198,889.06		
	6																
392H	NEWLY ELIGIBLE M&F	0.00	129.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129.26		
	4																
SUBTOTAL:	72,071,191.66	72,190,372.76	72,827,128.97	75,725,440.23	75,263,369.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368,077,503.60		

9939	BIRTH SUPP PAYMENT N	1,054,063.95	1,263,262.19	1,083,947.63	1,153,235.04	1,152,867.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,054,063.95	1,263,262.19	1,083,947.63	1,153,235.04	1,152,867.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,707,376.16

5,707,376.16

4411	SOBRA 100-133% M&F
<	351.80	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	420.49	216.17	414.47	227.63	206.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	8,951,596.75	8,949,421.81	8,649,053.67	9,367,978.45	9,223,264.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	2,863,302.78	2,941,946.21	2,906,085.46	3,118,719.83	3,106,503.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2,793,493.54	2,882,927.60	2,775,769.39	3,026,090.30	3,010,131.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441A	SOBRA 100-133% M&F
<	254.07	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	55,550.52	44,571.03	54,781.87	66,086.61	52,067.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	15,408.66	13,824.63	13,278.08	17,063.81	17,078.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	12,760.59	14,253.83	13,077.07	19,478.46	14,944.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	136.94	136.94	136.94	152.17	152.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14,693,276.14	14,847,298.22	14,412,596.95	15,615,797.26	15,424,347.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

351.80	
1,484.79	
45,141,314.89	
14,936,557.46	
14,488,412.72	
254.07	
273,057.43	
76,654.01	
74,514.18	
715.16	
74,993,316.51	

9944	BIRTH SUPP PAYMENT S	39,041.93	13,151.04	83,516.68	72,214.94	45,961.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39,041.93	13,151.04	83,516.68	72,214.94	45,961.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

253,886.26

253,886.26

4517

BC PATIENT FEMALE 2 1

8,589.64

8,589.64

8,543.10

8,717.47

8,745.29

0.00

0.00	0.00

0.00

0.00

0.00

0.00

43,185.14

ACC CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4	53,291.79	55,238.93	56,732.29	59,520.88	59,232.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		284,016.60		
	5																
4519	BC PATIENT FEMALE 6	1,791.51	2,770.03	2,613.15	1,580.70	2,058.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,813.63		
	5																
451G	BC PATIENT FEMALE 2	433.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		433.61		
	1																
451H	BC PATIENT FEMALE 4	1,048.64	5,211.82	1,996.78	2,741.76	1,872.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,871.37		
	5																
451J	BC PATIENT FEMALE 6	672.37	352.00	1,996.00	106.93	381.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,509.18		
	5																
4617	CC PATIENT FEMALE 2	4,159.64	4,159.64	4,159.64	4,201.52	4,364.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,045.37		
	1																
4618	CC PATIENT FEMALE 4	1,551.32	1,551.32	1,551.32	1,596.65	1,596.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,847.26		
	5																
461G	CC PATIENT FEMALE 2	0.00	0.00	0.00	0.00	213.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		213.70		
	1																
SUBTOTAL:	71,538.52	77,873.38	77,592.28	78,465.91	78,465.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		383,935.86		

8600	SSI BLIND FREEDOM/W O	559.54	559.54	974.42	1,050.12	1,050.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	1,319.86	1,319.86	1,319.86	1,336.38	1,336.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W O	278.64	278.64	136.94	152.17	152.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO
M	1,633,057.24	1,631,190.60	1,632,171.66	1,590,737.89	1,649,728.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	19,905.78	4,595.49	4,591.62	25,453.10	9,585.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	495,367.43	513,441.23	513,476.38	521,400.98	538,394.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	8,997.19	10,218.27	16,015.20	14,411.00	3,685.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	397,499.60	417,368.77	426,646.27	443,648.28	454,263.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	924.22	1,799.42	335.14	169.57	5.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,557,909.50	2,580,771.82	2,595,667.49	2,598,359.49	2,658,202.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,193.74	
6,632.34	
998.56	
8,136,886.38	
64,131.01	
2,582,080.99	
53,327.01	
2,139,426.72	
3,234.23	
12,990,910.98	

4,329,424,623.36

844,430,183.33	849,955,751.20	854,966,807.94	887,647,466.05	892,424,414.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1005	TANF 14-20 FEMALE WI	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1006	TANF 21-44 MALE WITH	89.32	88.66	90.72	94.58	82.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		445.68		
1007	TANF 21-44 FEMALE WI	111.74	108.64	106.00	122.95	117.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567.03		
1008	TANF 45-64 M & F WIT	240.76	232.59	235.00	248.95	254.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,211.92		
1009	TANF 65+ M & F WITH	142.00	144.00	140.49	142.06	139.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		707.95		
100F	TANF 21-44 MALE WITH	0.67	0.25	0.26	1.41	3.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.32		
100G	TANF 21-44 FEMALE WI	0.00	1.35	0.00	2.02	1.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.67		
100H	TANF 45-64 M & F WIT	0.22	0.83	0.00	0.00	2.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.14		
100J	TANF 65+ M & F WITH	0.00	0.00	0.56	0.00	0.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.16		
1011	TANF <1 M & F NON-ME	11,976.29	12,400.56	12,842.21	13,158.83	13,597.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63,974.96		
1012	TANF 01-05 M & F NON	21,810.42	21,533.69	21,072.48	22,931.69	24,636.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		111,985.14		
1013	TANF 06-13 M & F NON	41,986.95	41,611.68	40,995.81	44,110.57	46,748.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215,453.35		
1014	TANF 14-20 MALE NON-	13,996.55	14,089.63	14,217.36	15,031.92	16,009.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,344.72		
1015	TANF 14-20 FEMALE N	16,612.81	16,749.44	16,681.04	17,694.13	18,485.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,223.40		
	O																
1016	TANF 21-44 MALE NON-	31,920.98	31,948.92	32,228.19	33,323.51	34,906.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164,328.22		
1017	TANF 21-44 FEMALE N	105,104.14	104,866.87	105,631.93	108,838.25	113,241.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		537,682.48		
	O																
1018	TANF 45-64 M & F NON	26,940.10	26,998.10	27,105.42	28,000.96	29,141.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		138,185.95		
1019	TANF 65+ M & F NON-M	132.29	133.99	138.99	142.76	144.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		692.37		
101A	TANF < 1 M & F NON-M	523.18	428.69	598.99	646.09	587.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,784.87		
101B	TANF 01-05 M & F NON	65.85	70.06	83.15	95.64	32.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347.64		
101C	TANF 06-13 M & F NON	34.60	51.73	16.00	51.46	53.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206.96		
101D	TANF 14-20 MALE NON-	15.64	19.10	9.56	19.26	42.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		105.79		
101E	TANF 14-20 FEMALE N	14.32	41.02	29.63	37.44	14.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.74		
	O																
101F	TANF 21-44 MALE NON-	389.94	267.95	310.18	353.69	305.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,627.52		
101G	TANF 21-44 FEMALE N	724.45	507.09	624.68	691.74	543.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,091.22		
	O																
101H	TANF 44-64 M & F NON	207.24	152.59	182.37	215.05	147.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		904.67		
101J	TANF 65+ N & F NON-M	0.12	0.00	0.33	1.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.67		
1023	TANF 06-13 M & F WIT	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1024	TANF 14-20 MALE WITH	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1025	TANF 14-20 FEMALE WI	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1026	TANF 21-44 MALE WITH	86.14	87.58	80.63	88.07	87.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		430.30		
1027	TANF 21-44 FEMALE WI	130.80	130.00	122.90	121.00	131.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		636.65		
1028	TANF 45-64 M & F WIT	170.47	165.00	169.30	168.00	177.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		849.77		
1029	TANF 65+ M & F WITH	95.00	95.00	100.56	110.00	111.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		512.17		
102F	TANF 21-44 MALE WITH	0.93	1.41	0.13	0.83	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.36		
102G	TANF 21-44 FEMALE WI	0.00	0.00	0.10	0.00	1.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.29		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102H	TANF 44-64 M & F WIT	0.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.51		
102J	TANF 65+ M & F WITH	0.00	0.00	0.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.43		
2100	SSI AGED WITH MEDIC	4,609.78	4,614.00	4,672.60	4,769.36	4,723.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,389.39		
	A																
210Z	SSI AGED WITH MEDIC	201.36	153.86	202.79	236.09	161.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		955.41		
	A																
2110	SSI AGED NON-MEDICA	8,498.21	8,637.66	8,726.86	8,780.60	8,937.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,580.45		
	R																
211Z	SSI AGED NON-MEDICA	101.24	85.80	80.93	112.19	122.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		502.67		
	R																
2120	SSI AGED WITH QMB	37,809.68	38,210.70	38,528.18	38,901.54	39,213.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192,663.87		
212Z	SSI AGED WITH QMB P	16.95	20.00	17.62	17.07	17.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88.65		
	P																
2200	SSI DISABLED WITH M	4,248.88	4,232.70	4,279.29	4,337.77	4,383.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,481.93		
	E																
220Z	SSI DISABLED WITH M	104.93	98.87	111.17	100.16	70.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		485.42		
	E																
2210	SSI DISABLED NON-ME	54,047.14	53,979.72	53,855.66	53,904.08	53,928.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269,714.79		
	D																
221Z	SSI DISABLED NON-ME	675.76	561.20	666.52	555.15	467.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,926.60		
	D																
2220	SSI DISABLED WITH Q	27,391.96	27,518.09	27,576.75	27,550.34	27,527.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		137,564.46		
	M																
222Z	SSI DISABLED WITH Q	40.28	18.77	45.86	23.27	46.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		174.41		
	M																
2300	SSI BLIND WITH MEDIC	34.19	30.15	32.43	34.83	35.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.63		
230Z	SSI BLIND WITH MEDIC	0.80	0.80	0.97	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.63		
2310	SSI BLIND NON-MEDIC	525.97	533.33	534.39	539.85	532.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,665.85		
	A																
231Z	SSI BLIND NON-MEDIC	7.57	13.15	3.79	2.04	18.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45.51		
	A																
2320	SSI BLIND WITH QMB	234.62	241.65	245.82	252.56	256.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,231.35		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.41	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.44		
4301	SOBRA CHILD <1 M & F	0.00	0.80	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.80		
4302	SOBRA CHILD 01-05 M	1.00	0.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.80		
4303	SOBRA CHILD 06-13 M	4.00	3.61	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.61		
4305	SOBRA CHILD 14-20 FE	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4311	SOBRA CHILD <1 M & F	30,201.03	29,809.56	29,065.54	29,141.98	28,830.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,048.60		
4312	SOBRA CHILD 01-05 M	183,445.08	183,765.04	182,608.31	183,796.75	182,118.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		915,733.67		
4313	SOBRA CHILD 06-13 M	232,199.07	232,346.15	231,702.05	232,016.63	230,465.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,158,729.54		
4314	SOBRA CHILD 14-20 MA	69,577.77	70,258.90	70,365.10	70,591.89	70,565.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		351,359.42		
4315	SOBRA CHILD 14-20 FE	68,802.05	69,147.61	69,457.09	69,574.43	69,550.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		346,531.90		
431A	SOBRA CHILD < 1 M &	214.60	200.73	226.68	296.76	280.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,219.39		
431B	SOBRA CHILD 01-05 M	1,190.00	997.79	1,151.87	1,201.62	926.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,467.44		
431C	SOBRA CHILD 6-13 M&F	1,257.85	1,252.51	1,485.36	1,570.58	1,173.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,739.31		
431D	SOBRA CHILD 14-20 MA	371.46	371.93	489.55	469.05	336.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,038.59		
431E	SOBRA CHILD 14-20 FE	377.44	368.44	420.91	465.47	422.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,055.00		
4322	SOBRA CHILD 01-05 M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
4323	SOBRA CHILD 06-13 M	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4325	SOBRA CHILD 14-20 FE	3.00	3.00	4.00	3.61	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.61		
432E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.38		
5007	SOBRA PREG 21-44 FE	23.92	22.80	24.97	27.00	31.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129.98		
	M																
5008	SOBRA PREG 45-64 FE	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
	M																
500G	SOBRA PREG 21-44 FE	0.92	1.66	4.28	0.00	3.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.55		
	M																
5013	SOBRA PREG 09-13 FE	3.00	4.00	4.00	3.96	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.96		
	M																
5015	SOBRA PREG 14-20 FE	2,112.59	2,137.44	2,157.16	2,111.06	2,115.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,633.32		
	M																
5017	SOBRA PREG 21-44 FE	14,797.31	15,298.58	15,916.97	16,148.52	16,050.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,211.94		
	M																
5018	SOBRA PREG 45-64 FE	61.09	65.42	66.22	65.66	64.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322.39		
	M																
501C	SOBRA PREG 09-13 FE	0.00	0.00	0.00	1.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.25		
	M																
501E	SOBRA PREG 14-20 FE	114.84	100.77	125.36	141.46	105.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		588.23		
	M																
501G	SOBRA PREG 21-44 FE	635.99	552.79	605.71	696.99	537.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,028.95		
	M																
501H	SOBRA PREG 45-64 FE	2.89	2.22	0.73	3.30	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.14		
	M																
5027	SOBRA PREG 21-44 FE	28.62	28.25	29.00	29.99	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147.86		
	M																
5028	SOBRA PREG 45-64 FE	6.00	4.00	4.00	5.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
	M																
502G	SOBRA PREG 21-44 FE	0.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.22		
	M																
SUBTOTAL:	1,017,516.49	1,018,632.67	1,019,324.89	1,034,938.79	1,043,830.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,134,243.33		

9910	TANF & SOBRA CHILDR E	529.00	569.00	479.00	502.00	480.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	4.00	4.00	4.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	11.00	17.00	23.00	18.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	1,607.00	1,627.00	1,625.00	1,626.00	1,679.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,151.00	2,217.00	2,131.00	2,148.00	2,177.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,559.00	
15.00	
86.00	
8,164.00	
10,824.00	

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

5.00

5.00

1106	TANF EXPANDED 21-44	251.07	250.27	246.32	240.00	239.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	430.73	418.18	418.45	416.98	399.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	1,407.06	1,440.35	1,440.49	1,462.98	1,458.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	848.48	883.58	917.91	917.08	938.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	15.87	7.98	12.36	5.26	2.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110G	TANF EXPANDED 21-44	11.63	10.88	20.07	15.00	10.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	29.39	29.63	15.08	25.07	12.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	8.68	20.47	22.72	18.33	15.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	2.00	1.00	1.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	2.00	2.00	3.00	1.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	209.00	203.06	192.30	183.35	176.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,227.28	
2,084.28	
7,209.48	
4,505.70	
44.06	
68.57	
111.90	
85.38	
7.00	
11.00	
964.12	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	1,265.60	1,201.44	1,139.15	1,054.78	1,030.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,691.68		
1116	TANF EXPANDED 21-44	27,210.25	27,343.12	27,260.46	26,601.11	25,656.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,071.41		
1117	TANF EXPANDED 21-44	75,461.79	75,803.41	75,484.92	73,727.60	70,779.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		371,257.26		
1118	TANF EXPANDED 45-64	26,012.11	26,330.36	26,352.40	25,953.73	25,231.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129,880.28		
1119	TANF EXPANDED 65+ M	127.48	130.00	130.00	131.38	125.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		644.22		
	&																
111D	TANF EXPANDED 14-20	4.69	3.74	2.52	3.62	5.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.08		
111E	TANF EXPANDED 14-20	5.03	2.70	2.22	4.88	2.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.02		
111F	TANF EXPANDED 21-44	312.61	306.23	361.99	331.63	278.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,590.73		
111G	TANF EXPANDED 21-44	426.01	406.06	431.56	504.44	376.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,144.07		
111H	TANF EXPANDED 45-64	171.26	141.46	182.65	234.98	140.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		870.40		
111J	TANF EXPANDED 65+ M	0.84	0.00	0.00	2.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.09		
	&																
1125	TANF EXPANDED 14-20	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1126	TANF EXPANDED 21-44	753.86	760.27	758.64	759.90	743.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,776.32		
1127	TANF EXPANDED 21-44	1,644.78	1,656.79	1,654.36	1,629.51	1,627.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,212.58		
1128	TANF EXPANDED 45-64	2,877.94	2,895.62	2,901.32	2,888.83	2,915.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,479.32		
1129	TANF EXPANDED 65+ M	1,907.46	1,925.73	1,934.55	1,964.90	1,981.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,714.08		
	&																
112F	TANF EXPANDED 21-44	2.88	0.09	1.83	0.03	1.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.52		
112G	TANF EXPANDED 21-44	1.19	0.38	0.49	3.29	1.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.91		
112H	TANF EXPANDED 45-64	2.29	4.52	2.45	1.50	0.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.75		
112J	TANF EXPANDED 65+ M	1.41	0.35	0.99	0.00	2.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.31		
	&																
2400	SSI AGED EXPANDED	476.27	459.50	483.75	496.71	529.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,445.89		
	WI																
240Z	SSI AGED EXPANDED	172.66	114.94	151.04	199.22	195.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		833.23		
	WI																
2410	SSI AGED EXPANDED N	136.96	137.97	141.86	142.02	138.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		697.79		
	O																
241Z	SSI AGED EXPANDED N	6.02	5.39	2.12	6.18	10.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.51		
	O																
2420	SSI AGED EXPANDED	31,267.63	31,461.12	31,581.95	31,889.17	32,133.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,333.80		
	WI																
242Z	SSI AGED EXPANDED	6.27	29.37	27.21	19.68	23.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106.33		
	WI																
2500	SSI BLIND EXPANDED	1.00	1.00	1.96	1.16	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.12		
	W																
250Z	SSI BLIND EXPANDED	1.00	0.00	1.03	1.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.86		
	W																
2510	SSI BLIND EXPANDED	1.00	1.00	2.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
	N																
2520	SSI BLIND EXPANDED	15.00	20.00	29.00	46.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.00		
	W																
2600	SSI DISABLED EXPAND	391.69	399.99	383.05	383.34	386.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,944.15		
	E																
260Z	SSI DISABLED EXPAND	63.00	51.39	49.16	70.14	81.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315.02		
	E																
2610	SSI DISABLED EXPAND	1,502.93	1,472.11	1,449.27	1,428.25	1,436.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,288.63		
	E																
261Z	SSI DISABLED EXPAND	6.82	16.99	19.01	22.54	19.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.03		
	E																
2620	SSI DISABLED EXPAND	17,113.47	17,153.75	17,172.09	17,131.56	17,080.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,651.32		
	E																
262Z	SSI DISABLED EXPAND	12.30	28.20	18.92	16.16	6.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.28		
	E																

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	192,580.41	193,533.39	193,406.62	190,944.37	186,264.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		956,729.76		

9911	SB PAYMENT FOR TAN F	292.00	335.00	305.00	253.00	237.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9923	SB PAYMENT FOR SSI E	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	292.00	336.00	306.00	253.00	237.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,422.00	
1.00	
1.00	
1,424.00	

3505	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3506	ADULT 40-100% MALE 2	25.43	25.00	26.00	29.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	24.00	20.80	18.00	21.83	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	300.66	320.00	337.49	355.80	338.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	264.59	307.95	372.35	380.41	409.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350G	ADULT 40-100% FEMAL E	0.00	1.19	0.00	0.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	0.00	0.00	0.86	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350J	ADULT 40-100% M&F 65	0.00	0.03	0.00	5.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	6,291.40	6,323.37	6,336.58	6,388.19	6,374.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	6,683.57	6,723.61	6,776.51	6,892.91	6,910.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	27,275.52	27,572.97	27,765.49	27,402.31	26,887.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	22,333.03	22,605.01	22,840.77	22,785.56	22,435.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	43,114.80	43,369.65	43,511.86	43,053.14	42,183.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	28.00	32.00	36.00	44.83	52.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	30.09	23.83	22.72	50.90	31.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	37.60	40.84	38.61	49.90	38.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	314.58	276.08	226.28	241.14	259.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	210.02	194.87	233.83	245.80	218.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351H	ADULT 40-100% M&F 45	483.77	419.32	469.51	486.55	401.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	6.00	16.00	0.00	6.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3524	ADULT 40-100% MALE 1	1.00	1.00	1.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	2.00	3.00	3.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	3.51	3.00	3.96	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	30.00	32.00	35.43	38.79	34.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	14.00	15.00	16.00	17.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352G	ADULT 40-100% FEMAL E	0.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	0.00	0.00	1.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	81.44	85.05	89.39	94.46	96.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	49.96	48.00	50.23	50.79	49.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	569.78	594.78	623.09	661.91	692.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
135.43	
109.63	
1,652.79	
1,735.29	
1.28	
0.89	
5.51	
31,713.55	
33,987.55	
136,903.69	
112,999.99	
215,232.66	
192.83	
158.79	
205.22	
1,317.66	
1,103.41	
2,260.32	
30.00	
6.00	
15.00	
19.47	
171.14	
81.00	
0.48	
1.56	
447.07	
247.98	
3,141.69	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3709	ADULT <40% EXP M&F	109.24	121.00	141.00	153.38	170.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		695.48		
	6																
370F	ADULT <40% EXP MALE	0.09	0.06	1.12	2.14	1.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.24		
370G	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.03		
	L																
370H	ADULT <40% EXP M&F	3.75	7.02	3.15	2.26	4.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.60		
	4																
370J	ADULT <40% EXP M&F	7.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.74		
	6																
3714	ADULT <40% EXP MALE	13,379.24	13,576.66	13,987.06	14,309.39	14,591.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,843.60		
3715	ADULT <40% EXP FEMA	12,330.60	12,612.08	12,975.19	13,295.55	13,567.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,780.99		
	L																
3716	ADULT <40% EXP MALE	98,393.99	100,231.13	102,607.08	105,312.43	107,930.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		514,475.55		
3717	ADULT <40% EXP FEMA	57,331.05	58,269.71	59,745.07	61,281.23	62,819.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299,446.92		
	L																
3718	ADULT <40% EXP M&F	102,764.72	104,106.01	105,638.78	107,725.39	110,063.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		530,298.13		
	4																
3719	ADULT <40% EXP M&F	47.59	49.00	62.60	55.00	63.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277.92		
	6																
371D	ADULT <40% EXP MALE	78.94	85.59	103.70	148.17	125.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		541.53		
371E	ADULT <40% EXP FEMA	95.91	103.85	102.11	136.02	108.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		546.07		
	L																
371F	ADULT <40% EXP MALE	1,230.72	1,057.63	1,194.63	1,559.05	1,238.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,280.34		
371G	ADULT <40% EXP FEMA	690.98	606.96	736.76	848.97	702.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,586.13		
	L																
371H	ADULT <40% EXP M&F	1,061.89	969.24	1,126.07	1,397.53	1,242.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,796.81		
	4																
371J	ADULT <40% EXP M&F	0.00	0.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
	6																
3724	ADULT <40% EXP MALE	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3726	ADULT <40% EXP MALE	18.00	16.51	18.79	19.00	17.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.26		
3727	ADULT <40% EXP FEMA	6.00	8.00	9.00	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
	L																
3728	ADULT <40% EXP M&F	73.03	75.64	78.00	82.99	83.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		392.96		
	4																
3729	ADULT <40% EXP M&F	2.00	2.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
	6																
372F	ADULT <40% EXP MALE	0.00	0.00	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.06		
372H	ADULT <40% EXP M&F	0.96	2.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.31		
	4																
SUBTOTAL:	395,801.67	400,954.79	408,369.69	415,651.32	420,243.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,041,020.55		

9935	BIRTH SUPP PAYMENT A	57.00	68.00	55.00	63.00	55.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	147.00	141.00	159.00	132.00	152.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	204.00	209.00	214.00	195.00	207.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

298.00	
731.00	
1,029.00	

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	122.64	118.03	123.00	123.72	128.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	84.00	79.99	84.00	84.00	84.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	1,643.68	1,684.68	1,716.70	1,801.77	1,863.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	1,344.17	1,441.48	1,576.52	1,662.44	1,763.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.35	0.00	0.00	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
5.00	
615.39	
415.99	
8,710.48	
7,788.25	
0.41	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
390H	NEWLY ELIGIBLE M&F	0.10	0.67	0.79	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.62		
	4																
3914	NEWLY ELIGIBLE MALE	6,329.74	6,150.41	5,993.22	5,824.81	5,663.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,961.63		
3915	NEWLY ELIGIBLE FEMA	6,685.35	6,450.40	6,256.81	6,066.50	5,905.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,364.62		
	L																
3916	NEWLY ELIGIBLE MALE	34,840.80	35,024.17	35,323.57	35,321.36	35,256.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,766.58		
3917	NEWLY ELIGIBLE FEMA	49,682.90	50,247.66	51,126.23	50,872.40	50,514.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		252,444.09		
	L																
3918	NEWLY ELIGIBLE M&F	41,600.09	41,624.86	41,789.27	41,720.32	41,457.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,191.72		
	4																
3919	NEWLY ELIGIBLE M&F	132.00	143.00	142.00	140.00	140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		697.00		
	6																
391D	NEWLY ELIGIBLE MALE	19.27	12.52	13.19	18.50	17.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81.39		
391E	NEWLY ELIGIBLE FEMA	21.89	18.50	17.16	27.31	30.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115.29		
	L																
391F	NEWLY ELIGIBLE MALE	245.69	151.61	211.70	275.09	228.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,112.41		
391G	NEWLY ELIGIBLE FEMA	268.86	207.83	230.86	265.30	249.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,222.44		
	L																
391H	NEWLY ELIGIBLE M&F	249.31	241.12	270.30	266.10	268.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,295.25		
	4																
3926	NEWLY ELIGIBLE MALE	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
3927	NEWLY ELIGIBLE FEMA	3.00	3.00	3.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
	L																
3928	NEWLY ELIGIBLE M&F	20.00	20.74	25.00	22.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107.74		
	4																
3929	NEWLY ELIGIBLE M&F	68.00	73.00	77.00	84.99	96.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		398.99		
	6																
392H	NEWLY ELIGIBLE M&F	0.00	0.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.25		
	4																
SUBTOTAL:	143,363.84	143,695.92	144,982.32	144,583.73	143,694.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		720,320.54		

9939	BIRTH SUPP PAYMENT N	163.00	195.00	167.00	177.00	177.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	163.00	195.00	167.00	177.00	177.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

879.00

879.00

4411	SOBRA 100-133% M&F
<	0.58	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	2.00	1.00	2.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	44,116.21	44,077.31	42,532.90	44,094.38	43,400.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	14,078.65	14,479.94	14,271.99	14,658.41	14,579.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	13,664.39	14,102.03	13,566.78	14,138.29	14,054.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441A	SOBRA 100-133% M&F
<	0.41	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	271.91	219.19	268.53	320.49	245.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	75.47	67.61	65.09	81.69	80.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	61.69	70.63	63.69	94.28	70.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	72,272.31	73,018.71	70,771.98	73,389.54	72,432.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.58	
7.00	
218,221.32	
72,068.95	
69,525.54	
0.41	
1,326.01	
370.05	
360.61	
5.00	
361,885.47	

9944	BIRTH SUPP PAYMENT S	6.00	2.00	13.00	11.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6.00	2.00	13.00	11.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

39.00

39.00

4517

BC PATIENT FEMALE 2 1

21.00

21.00

21.00

20.76

21.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

104.76

ACC CAPITATION - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4	130.82	133.94	138.27	140.12	138.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		681.85		
	5																
4519	BC PATIENT FEMALE 6	4.38	6.81	6.46	3.74	4.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.33		
	5																
451G	BC PATIENT FEMALE 2	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		
	1																
451H	BC PATIENT FEMALE 4	2.48	12.84	3.77	5.66	4.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.02		
	5																
451J	BC PATIENT FEMALE 6	1.78	0.88	5.31	0.24	0.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.06		
	5																
4617	CC PATIENT FEMALE 2	5.00	5.00	5.00	5.00	5.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.43		
	1																
4618	CC PATIENT FEMALE 4	4.00	4.00	4.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
	5																
461G	CC PATIENT FEMALE 2	0.00	0.00	0.00	0.00	0.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.56		
	1																
SUBTOTAL:	170.46	184.47	183.81	179.52	179.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		898.01		

8600	SSI BLIND FREEDOM/W O	4.00	4.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W O	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO
M	2,310.09	2,327.98	2,342.21	2,320.57	2,347.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	26.14	16.78	11.33	24.16	13.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	354.90	367.24	366.79	365.90	372.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	7.04	7.73	13.07	11.48	2.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	581.16	591.19	596.75	609.32	634.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	6.37	12.41	2.43	1.16	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,292.70	3,330.33	3,341.58	3,341.59	3,380.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

29.00	
5.00	
7.00	
11,648.21	
92.05	
1,827.70	
42.18	
3,012.77	
22.40	
16,686.31	

TOTAL:	1,827,814.88	1,836,310.28	1,843,212.89	1,865,813.86	1,872,832.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,245,983.97		

ACUTE CAPITATION - AMERICAN INDIAN A - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1018	TANF 45-64 M & F NON	15.87	15.87	15.87	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.35		
2220	SSI DISABLED WITH Q M	15.87	15.87	15.87	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.35		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.74		
5017	SOBRA PREG 21-44 FE M	0.00	15.87	15.87	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.48		
SUBTOTAL:	31.74	47.61	47.61	63.48	63.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253.92		

1118	TANF EXPANDED 45-64	31.74	31.74	31.74	31.74	31.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	47.61	47.61	47.61	47.61	47.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	79.35	79.35	79.35	79.35	79.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

158.70	
238.05	
396.75	

3516	ADULT 40-100% MALE 2	15.87	15.87	15.87	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	15.87	15.87	15.87	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	31.74	31.74	31.74	31.74	31.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

79.35	
79.35	
158.70	

3917	NEWLY ELIGIBLE FEMA L	15.87	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	15.87	15.87	15.87	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	31.74	15.87	15.87	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15.87	
79.35	
95.22	

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

47.61

47.61

952.20

190.44	190.44	190.44	190.44	190.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN A - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1018	TANF 45-64 M & F NON	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2220	SSI DISABLED WITH Q M	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5017	SOBRA PREG 21-44 FE M	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
SUBTOTAL:	2.00	3.00	3.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		

1118	TANF EXPANDED 45-64	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	3.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5.00	5.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10.00	
15.00	
25.00	

3516	ADULT 40-100% MALE 2	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.00	
5.00	
10.00	

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

1.00	
5.00	
6.00	

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

3.00

3.00

TOTAL:	12.00	12.00	12.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.00		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	18.27	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.35		
1007	TANF 21-44 FEMALE WI	0.00	0.00	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.81		
1008	TANF 45-64 M & F WIT	36.54	36.54	36.54	36.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146.16		
1009	TANF 65+ M & F WITH	36.54	54.81	54.81	73.08	91.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		310.59		
1011	TANF <1 M & F NON-ME	2,064.51	2,228.94	2,174.13	2,302.02	2,375.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,144.70		
1012	TANF 01-05 M & F NON	2,831.85	2,667.42	2,557.80	2,630.88	2,868.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,556.34		
1013	TANF 06-13 M & F NON	2,758.77	2,685.69	2,777.04	3,178.98	3,599.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,999.67		
1014	TANF 14-20 MALE NON-	895.23	913.50	1,059.66	1,205.82	1,297.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,371.38		
1015	TANF 14-20 FEMALE N	1,151.01	1,077.93	1,059.66	1,096.20	1,351.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,736.78		
	O																
1016	TANF 21-44 MALE NON-	3,800.16	3,854.97	3,928.05	3,964.59	4,092.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,640.25		
1017	TANF 21-44 FEMALE N	12,551.49	12,588.03	12,807.27	13,190.94	13,592.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,730.61		
	O																
1018	TANF 45-64 M & F NON	5,060.79	5,005.98	4,896.36	4,914.63	5,115.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,993.36		
1019	TANF 65+ M & F NON-M	18.27	18.27	36.54	36.54	54.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.43		
1026	TANF 21-44 MALE WITH	0.00	0.00	18.27	0.00	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.54		
1028	TANF 45-64 M & F WIT	36.54	36.54	36.54	36.54	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.43		
1029	TANF 65+ M & F WITH	91.35	91.35	73.08	73.08	54.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		383.67		
2100	SSI AGED WITH MEDIC	255.78	237.51	237.51	255.78	255.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,242.36		
	A																
2110	SSI AGED NON-MEDICA	310.59	310.59	365.40	401.94	383.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,772.19		
	R																
2120	SSI AGED WITH QMB	2,119.32	2,228.94	2,265.48	2,247.21	2,283.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,144.70		
2200	SSI DISABLED WITH M	712.53	694.26	694.26	712.53	657.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,471.30		
	E																
2210	SSI DISABLED NON-ME	10,596.60	10,523.52	10,870.65	10,943.73	10,870.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,805.15		
	D																
2220	SSI DISABLED WITH Q	4,074.21	4,110.75	4,147.29	4,147.29	4,202.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,681.64		
	M																
2300	SSI BLIND WITH MEDIC	18.27	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.35		
2310	SSI BLIND NON-MEDIC	127.89	127.89	146.16	146.16	146.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		694.26		
	A																
2320	SSI BLIND WITH QMB	18.27	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.35		
4311	SOBRA CHILD <1 M & F	4,348.26	4,275.18	3,946.32	3,873.24	3,654.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,097.00		
4312	SOBRA CHILD 01-05 M	28,720.44	29,085.84	29,542.59	29,707.02	29,469.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		146,525.40		
4313	SOBRA CHILD 06-13 M	27,039.60	27,806.94	28,336.77	28,245.42	27,953.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		139,381.83		
4314	SOBRA CHILD 14-20 MA	7,454.16	7,673.40	7,983.99	8,020.53	8,020.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,152.61		
4315	SOBRA CHILD 14-20 FE	7,070.49	7,472.43	7,819.56	7,910.91	7,929.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,202.57		
5015	SOBRA PREG 14-20 FE	54.81	73.08	54.81	91.35	127.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		401.94		
	M																
5017	SOBRA PREG 21-44 FE	1,151.01	1,114.47	1,187.55	1,187.55	1,096.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,736.78		
	M																
SUBTOTAL:	125,423.55	127,049.58	129,187.17	130,703.58	131,653.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		644,017.50		

36.54

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	18.27	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

91.35

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	91.35	127.89	109.62	127.89	164.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		621.18		
1109	TANF EXPANDED 65+ M	164.43	164.43	200.97	200.97	146.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		876.96		
	&																
1114	TANF EXPANDED 14-20	18.27	18.27	18.27	36.54	36.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127.89		
1115	TANF EXPANDED 14-20	127.89	164.43	146.16	127.89	109.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		675.99		
1116	TANF EXPANDED 21-44	2,247.21	2,247.21	2,320.29	2,283.75	2,192.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,290.86		
1117	TANF EXPANDED 21-44	6,211.80	6,339.69	6,394.50	6,175.26	5,882.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,004.19		
1118	TANF EXPANDED 45-64	2,868.39	2,996.28	3,087.63	3,124.17	3,032.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,109.29		
1119	TANF EXPANDED 65+ M	0.00	0.00	0.00	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.27		
	&																
1126	TANF EXPANDED 21-44	109.62	109.62	109.62	109.62	91.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		529.83		
1127	TANF EXPANDED 21-44	18.27	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.35		
1128	TANF EXPANDED 45-64	548.10	511.56	529.83	548.10	511.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,649.15		
1129	TANF EXPANDED 65+ M	493.29	493.29	493.29	584.64	657.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,722.23		
	&																
2400	SSI AGED EXPANDED	36.54	36.54	54.81	54.81	73.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255.78		
	WI																
2410	SSI AGED EXPANDED N	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.81		
	O																
2420	SSI AGED EXPANDED	2,557.80	2,576.07	2,685.69	2,722.23	2,831.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,373.64		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36.54		
	W																
2600	SSI DISABLED EXPAND	18.27	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.35		
	E																
2610	SSI DISABLED EXPAND	237.51	255.78	237.51	219.24	219.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,169.28		
	E																
2620	SSI DISABLED EXPAND	1,370.25	1,370.25	1,351.98	1,370.25	1,388.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,851.25		
	E																
SUBTOTAL:	17,155.53	17,484.39	17,831.52	17,794.98	17,411.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87,677.73		

3506	ADULT 40-100% MALE 2	18.27	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	36.54	36.54	36.54	36.54	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	383.67	401.94	401.94	438.48	456.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	365.40	347.13	383.67	401.94	401.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	1,589.49	1,626.03	1,699.11	1,626.03	1,626.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	1,096.20	1,169.28	1,187.55	1,242.36	1,242.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	3,343.41	3,361.68	3,453.03	3,379.95	3,434.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	18.27	36.54	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	1,114.47	1,205.82	1,297.17	1,278.90	1,406.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	1,278.90	1,351.98	1,388.52	1,461.60	1,498.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	12,533.22	13,008.24	13,264.02	13,519.80	13,702.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	6,540.66	6,686.82	6,851.25	6,997.41	7,289.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	14,067.90	14,250.60	14,689.08	15,036.21	15,346.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

91.35	
164.43	
73.08	
2,082.78	
1,900.08	
8,166.69	
5,937.75	
16,972.83	
109.62	
6,303.15	
6,979.14	
66,027.78	
34,365.87	
73,390.59	
54.81	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3728	ADULT <40% EXP M&F 4	18.27	18.27	18.27	18.27	36.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109.62		
SUBTOTAL:	42,404.67	43,555.68	44,743.23	45,510.57	46,515.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		222,729.57		

3908	NEWLY ELIGIBLE M&F 4	146.16	146.16	127.89	164.43	146.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	127.89	127.89	109.62	109.62	146.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	164.43	146.16	146.16	164.43	164.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	347.13	365.40	401.94	365.40	347.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	2,101.05	2,137.59	2,247.21	2,302.02	2,393.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	3,416.49	3,599.19	3,654.00	3,727.08	3,654.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	4,366.53	4,439.61	4,622.31	4,494.42	4,403.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	18.27	18.27	18.27	18.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,669.68	10,980.27	11,327.40	11,345.67	11,272.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

730.80	
621.18	
785.61	
1,827.00	
11,181.24	
18,050.76	
22,325.94	
73.08	
55,595.61	

4413	SOBRA 100-133% M&F
6	2,557.80	2,667.42	2,813.58	2,777.04	2,576.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	1,114.47	1,151.01	1,169.28	1,151.01	1,096.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	986.58	1,004.85	1,077.93	1,077.93	1,096.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,658.85	4,823.28	5,060.79	5,005.98	4,768.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13,391.91	
5,681.97	
5,243.49	
24,317.37	

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

91.35

91.35

8700	SSI DISABLED FREEDO M	109.62	127.89	146.16	146.16	146.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	73.08	54.81	36.54	54.81	73.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	36.54	36.54	36.54	36.54	36.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	219.24	219.24	219.24	237.51	255.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

675.99	
292.32	
182.70	
1,151.01	

1,035,580.14

200,549.79	204,130.71	208,387.62	210,616.56	211,895.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
1008	TANF 45-64 M & F WIT	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1009	TANF 65+ M & F WITH	2.00	3.00	3.00	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
1011	TANF <1 M & F NON-ME	113.00	122.00	119.00	126.00	130.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		610.00		
1012	TANF 01-05 M & F NON	155.00	146.00	140.00	144.00	157.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		742.00		
1013	TANF 06-13 M & F NON	151.00	147.00	152.00	174.00	197.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		821.00		
1014	TANF 14-20 MALE NON-	49.00	50.00	58.00	66.00	71.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		294.00		
1015	TANF 14-20 FEMALE N	63.00	59.00	58.00	60.00	74.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.00		
	O																
1016	TANF 21-44 MALE NON-	208.00	211.00	215.00	217.00	224.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,075.00		
1017	TANF 21-44 FEMALE N	687.00	689.00	701.00	722.00	744.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,543.00		
	O																
1018	TANF 45-64 M & F NON	277.00	274.00	268.00	269.00	280.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,368.00		
1019	TANF 65+ M & F NON-M	1.00	1.00	2.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1026	TANF 21-44 MALE WITH	0.00	0.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1028	TANF 45-64 M & F WIT	2.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1029	TANF 65+ M & F WITH	5.00	5.00	4.00	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
2100	SSI AGED WITH MEDIC	14.00	13.00	13.00	14.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68.00		
	A																
2110	SSI AGED NON-MEDICA	17.00	17.00	20.00	22.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97.00		
	R																
2120	SSI AGED WITH QMB	116.00	122.00	124.00	123.00	125.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		610.00		
2200	SSI DISABLED WITH M	39.00	38.00	38.00	39.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190.00		
	E																
2210	SSI DISABLED NON-ME	580.00	576.00	595.00	599.00	595.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,945.00		
	D																
2220	SSI DISABLED WITH Q	223.00	225.00	227.00	227.00	230.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,132.00		
	M																
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2310	SSI BLIND NON-MEDIC	7.00	7.00	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.00		
	A																
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
4311	SOBRA CHILD <1 M & F	238.00	234.00	216.00	212.00	200.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,100.00		
4312	SOBRA CHILD 01-05 M	1,572.00	1,592.00	1,617.00	1,626.00	1,613.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,020.00		
4313	SOBRA CHILD 06-13 M	1,480.00	1,522.00	1,551.00	1,546.00	1,530.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,629.00		
4314	SOBRA CHILD 14-20 MA	408.00	420.00	437.00	439.00	439.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,143.00		
4315	SOBRA CHILD 14-20 FE	387.00	409.00	428.00	433.00	434.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,091.00		
5015	SOBRA PREG 14-20 FE	3.00	4.00	3.00	5.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
	M																
5017	SOBRA PREG 21-44 FE	63.00	61.00	65.00	65.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		314.00		
	M																
SUBTOTAL:	6,865.00	6,954.00	7,071.00	7,154.00	7,206.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,250.00		

2.00

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

5.00

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	5.00	7.00	6.00	7.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00		
1109	TANF EXPANDED 65+ M	9.00	9.00	11.00	11.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.00		
	&																
1114	TANF EXPANDED 14-20	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
1115	TANF EXPANDED 14-20	7.00	9.00	8.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.00		
1116	TANF EXPANDED 21-44	123.00	123.00	127.00	125.00	120.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		618.00		
1117	TANF EXPANDED 21-44	340.00	347.00	350.00	338.00	322.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,697.00		
1118	TANF EXPANDED 45-64	157.00	164.00	169.00	171.00	166.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		827.00		
1119	TANF EXPANDED 65+ M	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
	&																
1126	TANF EXPANDED 21-44	6.00	6.00	6.00	6.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
1127	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1128	TANF EXPANDED 45-64	30.00	28.00	29.00	30.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145.00		
1129	TANF EXPANDED 65+ M	27.00	27.00	27.00	32.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149.00		
	&																
2400	SSI AGED EXPANDED	2.00	2.00	3.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
	WI																
2410	SSI AGED EXPANDED N	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		
	O																
2420	SSI AGED EXPANDED	140.00	141.00	147.00	149.00	155.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		732.00		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
	W																
2600	SSI DISABLED EXPAND	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
	E																
2610	SSI DISABLED EXPAND	13.00	14.00	13.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.00		
	E																
2620	SSI DISABLED EXPAND	75.00	75.00	74.00	75.00	76.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		375.00		
	E																
SUBTOTAL:	939.00	957.00	976.00	974.00	953.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,799.00		

3506	ADULT 40-100% MALE 2	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	2.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	21.00	22.00	22.00	24.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	20.00	19.00	21.00	22.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	87.00	89.00	93.00	89.00	89.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	60.00	64.00	65.00	68.00	68.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	183.00	184.00	189.00	185.00	188.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	1.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	61.00	66.00	71.00	70.00	77.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	70.00	74.00	76.00	80.00	82.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	686.00	712.00	726.00	740.00	750.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	358.00	366.00	375.00	383.00	399.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	770.00	780.00	804.00	823.00	840.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.00	
9.00	
4.00	
114.00	
104.00	
447.00	
325.00	
929.00	
6.00	
345.00	
382.00	
3,614.00	
1,881.00	
4,017.00	
3.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3728	ADULT <40% EXP M&F 4	1.00	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
SUBTOTAL:	2,321.00	2,384.00	2,449.00	2,491.00	2,546.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,191.00		

3908	NEWLY ELIGIBLE M&F 4	8.00	8.00	7.00	9.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	7.00	7.00	6.00	6.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	9.00	8.00	8.00	9.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	19.00	20.00	22.00	20.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	115.00	117.00	123.00	126.00	131.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	187.00	197.00	200.00	204.00	200.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	239.00	243.00	253.00	246.00	241.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	584.00	601.00	620.00	621.00	617.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

40.00	
34.00	
43.00	
100.00	
612.00	
988.00	
1,222.00	
4.00	
3,043.00	

4413	SOBRA 100-133% M&F
6	140.00	146.00	154.00	152.00	141.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	61.00	63.00	64.00	63.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	54.00	55.00	59.00	59.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	255.00	264.00	277.00	274.00	261.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

733.00	
311.00	
287.00	
1,331.00	

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

5.00

5.00

8700	SSI DISABLED FREEDO M	6.00	7.00	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	4.00	3.00	2.00	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12.00	12.00	12.00	13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

37.00	
16.00	
10.00	
63.00	

TOTAL:	10,977.00	11,173.00	11,406.00	11,528.00	11,598.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,682.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.50		
1008	TANF 45-64 M & F WIT	27.25	54.50	81.75	54.50	81.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299.75		
1009	TANF 65+ M & F WITH	54.50	81.75	81.75	109.00	109.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		436.00		
1011	TANF <1 M & F NON-ME	1,962.00	2,071.00	2,207.25	2,125.50	2,016.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,382.25		
1012	TANF 01-05 M & F NON	4,142.00	3,951.25	3,733.25	4,223.75	4,496.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,546.50		
1013	TANF 06-13 M & F NON	5,804.25	5,967.75	6,158.50	6,948.75	7,630.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,509.25		
1014	TANF 14-20 MALE NON-	1,798.50	1,880.25	1,907.50	2,071.00	2,152.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,810.00		
1015	TANF 14-20 FEMALE N	3,106.50	3,433.50	3,488.00	3,787.75	3,815.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,630.75		
	O																
1016	TANF 21-44 MALE NON-	11,881.00	12,344.25	12,916.50	13,161.75	13,788.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,092.00		
1017	TANF 21-44 FEMALE N	49,322.50	49,731.25	50,276.25	52,211.00	53,628.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,169.00		
	O																
1018	TANF 45-64 M & F NON	18,121.25	18,884.25	19,320.25	19,783.50	20,246.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,356.00		
1019	TANF 65+ M & F NON-M	136.25	109.00	109.00	109.00	54.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		517.75		
1028	TANF 45-64 M & F WIT	54.50	54.50	54.50	54.50	54.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272.50		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.25		
2100	SSI AGED WITH MEDIC	2,697.75	2,697.75	2,697.75	2,725.00	2,861.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,679.50		
	A																
2110	SSI AGED NON-MEDICA	1,226.25	1,171.75	1,226.25	1,199.00	1,280.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,104.00		
	R																
2120	SSI AGED WITH QMB	13,325.25	13,597.75	14,006.50	14,170.00	14,388.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,487.50		
2200	SSI DISABLED WITH M	6,921.50	7,003.25	7,003.25	6,976.00	7,166.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,070.75		
	E																
2210	SSI DISABLED NON-ME	34,553.00	34,934.50	35,152.50	35,452.25	35,670.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175,762.50		
	D																
2220	SSI DISABLED WITH Q	16,431.75	16,568.00	16,513.50	16,595.25	16,758.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,867.25		
	M																
2300	SSI BLIND WITH MEDIC	27.25	27.25	27.25	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136.25		
2310	SSI BLIND NON-MEDIC	626.75	654.00	681.25	681.25	708.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,351.75		
	A																
2320	SSI BLIND WITH QMB	272.50	272.50	299.75	327.00	327.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,498.75		
4302	SOBRA CHILD 01-05 M	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.50		
4311	SOBRA CHILD <1 M & F	2,997.50	3,024.75	3,351.75	3,133.75	3,460.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,968.50		
4312	SOBRA CHILD 01-05 M	54,282.00	54,908.75	55,399.25	54,936.00	54,500.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,026.00		
4313	SOBRA CHILD 06-13 M	79,379.25	80,469.25	81,123.25	81,477.50	81,259.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		403,708.75		
4314	SOBRA CHILD 14-20 MA	20,873.50	21,745.50	21,936.25	22,372.25	22,672.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		109,599.50		
4315	SOBRA CHILD 14-20 FE	22,999.00	23,598.50	24,388.75	24,361.50	24,279.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,627.50		
5013	SOBRA PREG 09-13 FE	27.25	27.25	27.25	27.25	54.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		163.50		
	M																
5015	SOBRA PREG 14-20 FE	654.00	626.75	599.50	763.00	872.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,515.25		
	M																
5017	SOBRA PREG 21-44 FE	4,823.25	5,368.25	6,131.25	5,777.00	5,777.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,876.75		
	M																
SUBTOTAL:	358,582.75	365,313.50	370,899.75	375,641.25	380,164.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,850,602.00		

327.00

1106	TANF EXPANDED 21-44	54.50	54.50	54.50	81.75	81.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	54.50	54.50	54.50	54.50	54.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

272.50

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	436.00	436.00	436.00	436.00	436.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,180.00		
1109	TANF EXPANDED 65+ M	545.00	545.00	545.00	572.25	599.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,806.75		
	&																
1114	TANF EXPANDED 14-20	27.25	27.25	54.50	54.50	54.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		218.00		
1115	TANF EXPANDED 14-20	299.75	245.25	272.50	272.50	245.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,335.25		
1116	TANF EXPANDED 21-44	6,649.00	6,703.50	6,785.25	6,567.25	6,458.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,163.25		
1117	TANF EXPANDED 21-44	23,653.00	23,980.00	23,653.00	23,080.75	22,644.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117,011.50		
1118	TANF EXPANDED 45-64	12,453.25	12,862.00	13,243.50	13,134.50	13,216.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,909.50		
1119	TANF EXPANDED 65+ M	54.50	81.75	81.75	81.75	81.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381.50		
	&																
1126	TANF EXPANDED 21-44	245.25	218.00	218.00	218.00	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,117.25		
1127	TANF EXPANDED 21-44	272.50	272.50	272.50	272.50	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,308.00		
1128	TANF EXPANDED 45-64	1,280.75	1,335.25	1,308.00	1,335.25	1,444.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,703.50		
1129	TANF EXPANDED 65+ M	1,335.25	1,471.50	1,526.00	1,553.25	1,526.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,412.00		
	&																
2400	SSI AGED EXPANDED	190.75	190.75	218.00	218.00	245.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,062.75		
	WI																
2410	SSI AGED EXPANDED N	190.75	190.75	163.50	190.75	163.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		899.25		
	O																
2420	SSI AGED EXPANDED	8,638.25	8,829.00	8,938.00	9,156.00	9,292.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,853.50		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	0.00	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.50		
	W																
2610	SSI DISABLED EXPAND	463.25	463.25	463.25	545.00	517.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,452.50		
	E																
2620	SSI DISABLED EXPAND	3,624.25	3,651.50	3,678.75	3,624.25	3,488.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,066.75		
	E																
SUBTOTAL:	60,467.75	61,612.25	61,966.50	61,476.00	61,012.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		306,535.25		

3508	ADULT 40-100% M&F 45	54.50	27.25	109.00	27.25	54.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	81.75	54.50	81.75	81.75	81.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	1,144.50	1,062.75	1,144.50	1,144.50	1,062.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1,580.50	1,389.75	1,308.00	1,471.50	1,635.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	4,550.75	4,687.00	4,632.50	4,687.00	4,687.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	4,060.25	4,223.75	4,523.50	4,441.75	4,360.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	9,782.75	9,946.25	10,218.75	10,218.75	9,946.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	27.25	27.25	27.25	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	54.50	54.50	54.50	54.50	54.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	218.00	218.00	299.75	299.75	272.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F
6	27.25	27.25	27.25	54.50	81.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	4,905.00	4,932.25	5,313.75	5,368.25	5,368.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	5,940.50	6,213.00	6,540.00	6,649.00	6,240.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	42,101.25	43,818.00	45,126.00	46,107.00	46,543.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	22,726.50	23,080.75	24,170.75	24,988.25	25,860.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	48,859.25	50,031.00	50,903.00	51,802.25	53,110.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

272.50	
381.50	
5,559.00	
7,384.75	
23,244.25	
21,609.25	
50,112.75	
136.25	
272.50	
1,308.00	
218.00	
25,887.50	
31,582.75	
223,695.25	
120,826.50	
254,705.75	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3719	ADULT <40% EXP M&F 6	27.25	54.50	54.50	81.75	81.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299.75		
SUBTOTAL:	146,141.75	149,847.75	154,534.75	157,505.00	159,467.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		767,496.25		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	408.75	436.00	545.00	545.00	545.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	408.75	436.00	381.50	517.75	545.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	844.75	872.00	763.00	681.25	763.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	1,226.25	1,199.00	1,253.50	1,226.25	1,199.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	5,450.00	5,640.75	5,722.50	5,749.75	5,804.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	9,864.50	10,355.00	10,709.25	10,818.25	10,627.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	10,709.25	11,172.50	11,417.75	11,472.25	11,717.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	27.25	27.25	27.25	54.50	54.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	27.25	27.25	27.25	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28,966.75	30,165.75	30,847.00	31,119.50	31,310.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

54.50	
2,479.75	
2,289.00	
3,924.00	
6,104.00	
28,367.25	
52,374.50	
56,489.25	
190.75	
136.25	
152,409.25	

4413	SOBRA 100-133% M&F
6	6,376.50	6,512.75	6,594.50	6,730.75	6,540.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	1,934.75	1,989.25	2,234.50	2,452.50	2,616.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2,370.75	2,425.25	2,261.75	2,180.00	2,152.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,682.00	10,927.25	11,090.75	11,363.25	11,308.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

32,754.50	
11,227.00	
11,390.50	
55,372.00	

4518	BC PATIENT FEMALE 4 5	27.25	27.25	27.25	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	27.25	27.25	27.25	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

136.25

136.25

8700	SSI DISABLED FREEDO M	218.00	190.75	190.75	190.75	190.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	81.75	109.00	136.25	136.25	136.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	27.25	27.25	27.25	27.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	299.75	327.00	354.25	354.25	354.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

981.00	
599.50	
109.00	
1,689.50	

3,134,240.50

605,168.00	618,220.75	629,720.25	637,486.50	643,645.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	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		
1008	TANF 45-64 M & F WIT	1.00	2.00	3.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
1009	TANF 65+ M & F WITH	2.00	3.00	3.00	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
1011	TANF <1 M & F NON-ME	72.00	76.00	81.00	78.00	74.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		381.00		
1012	TANF 01-05 M & F NON	152.00	145.00	137.00	155.00	165.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		754.00		
1013	TANF 06-13 M & F NON	213.00	219.00	226.00	255.00	280.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,193.00		
1014	TANF 14-20 MALE NON-	66.00	69.00	70.00	76.00	79.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		360.00		
1015	TANF 14-20 FEMALE N	114.00	126.00	128.00	139.00	140.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		647.00		
	O																
1016	TANF 21-44 MALE NON-	436.00	453.00	474.00	483.00	506.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,352.00		
1017	TANF 21-44 FEMALE N	1,810.00	1,825.00	1,845.00	1,916.00	1,968.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,364.00		
	O																
1018	TANF 45-64 M & F NON	665.00	693.00	709.00	726.00	743.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,536.00		
1019	TANF 65+ M & F NON-M	5.00	4.00	4.00	4.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19.00		
1028	TANF 45-64 M & F WIT	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1029	TANF 65+ M & F WITH	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		
2100	SSI AGED WITH MEDIC	99.00	99.00	99.00	100.00	105.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		502.00		
	A																
2110	SSI AGED NON-MEDICA	45.00	43.00	45.00	44.00	47.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224.00		
	R																
2120	SSI AGED WITH QMB	489.00	499.00	514.00	520.00	528.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,550.00		
2200	SSI DISABLED WITH M	254.00	257.00	257.00	256.00	263.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,287.00		
	E																
2210	SSI DISABLED NON-ME	1,268.00	1,282.00	1,290.00	1,301.00	1,309.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,450.00		
	D																
2220	SSI DISABLED WITH Q	603.00	608.00	606.00	609.00	615.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,041.00		
	M																
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2310	SSI BLIND NON-MEDIC	23.00	24.00	25.00	25.00	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.00		
	A																
2320	SSI BLIND WITH QMB	10.00	10.00	11.00	12.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.00		
4302	SOBRA CHILD 01-05 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		
4311	SOBRA CHILD <1 M & F	110.00	111.00	123.00	115.00	127.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		586.00		
4312	SOBRA CHILD 01-05 M	1,992.00	2,015.00	2,033.00	2,016.00	2,000.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,056.00		
4313	SOBRA CHILD 06-13 M	2,913.00	2,953.00	2,977.00	2,990.00	2,982.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,815.00		
4314	SOBRA CHILD 14-20 MA	766.00	798.00	805.00	821.00	832.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,022.00		
4315	SOBRA CHILD 14-20 FE	844.00	866.00	895.00	894.00	891.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,390.00		
5013	SOBRA PREG 09-13 FE	1.00	1.00	1.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
	M																
5015	SOBRA PREG 14-20 FE	24.00	23.00	22.00	28.00	32.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129.00		
	M																
5017	SOBRA PREG 21-44 FE	177.00	197.00	225.00	212.00	212.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,023.00		
	M																
SUBTOTAL:	13,159.00	13,406.00	13,611.00	13,785.00	13,951.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,912.00		

12.00

1106	TANF EXPANDED 21-44	2.00	2.00	2.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	16.00	16.00	16.00	16.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80.00		
1109	TANF EXPANDED 65+ M	20.00	20.00	20.00	21.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103.00		
	&																
1114	TANF EXPANDED 14-20	1.00	1.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1115	TANF EXPANDED 14-20	11.00	9.00	10.00	10.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49.00		
1116	TANF EXPANDED 21-44	244.00	246.00	249.00	241.00	237.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,217.00		
1117	TANF EXPANDED 21-44	868.00	880.00	868.00	847.00	831.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,294.00		
1118	TANF EXPANDED 45-64	457.00	472.00	486.00	482.00	485.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,382.00		
1119	TANF EXPANDED 65+ M	2.00	3.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
	&																
1126	TANF EXPANDED 21-44	9.00	8.00	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
1127	TANF EXPANDED 21-44	10.00	10.00	10.00	10.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.00		
1128	TANF EXPANDED 45-64	47.00	49.00	48.00	49.00	53.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		246.00		
1129	TANF EXPANDED 65+ M	49.00	54.00	56.00	57.00	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		272.00		
	&																
2400	SSI AGED EXPANDED	7.00	7.00	8.00	8.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39.00		
	WI																
2410	SSI AGED EXPANDED N	7.00	7.00	6.00	7.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
	O																
2420	SSI AGED EXPANDED	317.00	324.00	328.00	336.00	341.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,646.00		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
	W																
2610	SSI DISABLED EXPAND	17.00	17.00	17.00	20.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.00		
	E																
2620	SSI DISABLED EXPAND	133.00	134.00	135.00	133.00	128.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		663.00		
	E																
SUBTOTAL:	2,219.00	2,261.00	2,274.00	2,256.00	2,239.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,249.00		

3508	ADULT 40-100% M&F 45	2.00	1.00	4.00	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	3.00	2.00	3.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	42.00	39.00	42.00	42.00	39.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	58.00	51.00	48.00	54.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	167.00	172.00	170.00	172.00	172.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	149.00	155.00	166.00	163.00	160.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	359.00	365.00	375.00	375.00	365.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	8.00	8.00	11.00	11.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F
6	1.00	1.00	1.00	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	180.00	181.00	195.00	197.00	197.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	218.00	228.00	240.00	244.00	229.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1,545.00	1,608.00	1,656.00	1,692.00	1,708.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	834.00	847.00	887.00	917.00	949.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	1,793.00	1,836.00	1,868.00	1,901.00	1,949.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10.00	
14.00	
204.00	
271.00	
853.00	
793.00	
1,839.00	
5.00	
10.00	
48.00	
8.00	
950.00	
1,159.00	
8,209.00	
4,434.00	
9,347.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3719	ADULT <40% EXP M&F 6	1.00	2.00	2.00	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
SUBTOTAL:	5,363.00	5,499.00	5,671.00	5,780.00	5,852.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,165.00		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	15.00	16.00	20.00	20.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	15.00	16.00	14.00	19.00	20.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	31.00	32.00	28.00	25.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	45.00	44.00	46.00	45.00	44.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	200.00	207.00	210.00	211.00	213.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	362.00	380.00	393.00	397.00	390.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	393.00	410.00	419.00	421.00	430.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	1.00	1.00	1.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,063.00	1,107.00	1,132.00	1,142.00	1,149.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
91.00	
84.00	
144.00	
224.00	
1,041.00	
1,922.00	
2,073.00	
7.00	
5.00	
5,593.00	

4413	SOBRA 100-133% M&F
6	234.00	239.00	242.00	247.00	240.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	71.00	73.00	82.00	90.00	96.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	87.00	89.00	83.00	80.00	79.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	392.00	401.00	407.00	417.00	415.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,202.00	
412.00	
418.00	
2,032.00	

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

5.00

5.00

8700	SSI DISABLED FREEDO M	8.00	7.00	7.00	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	3.00	4.00	5.00	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	0.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11.00	12.00	13.00	13.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

36.00	
22.00	
4.00	
62.00	

TOTAL:	22,208.00	22,687.00	23,109.00	23,394.00	23,620.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,018.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	3,563,305.50	3,563,088.62	3,578,565.84	3,680,024.75	3,661,980.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,046,965.26		
2100	SSI AGED WITH MEDIC	34,035,341.75	34,170,882.81	34,112,231.56	38,445,825.64	38,604,947.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		179,369,229.24		
	A																
210Z	SSI AGED WITH MEDIC	1,632,956.97	1,717,649.84	1,545,671.27	1,877,106.42	1,814,142.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,587,526.87		
	A																
2110	SSI AGED NON-MEDICA	3,831,250.55	3,903,525.15	3,874,195.65	4,109,976.29	4,087,663.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,806,611.32		
	R																
211Z	SSI AGED NON-MEDICA	38,321.33	176,069.53	206,795.82	34,577.05	30,172.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		485,936.05		
	R																
2120	SSI AGED WITH QMB	28,962,276.41	29,083,977.84	28,803,789.63	32,391,127.13	32,301,094.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151,542,265.52		
212Z	SSI AGED WITH QMB P	38,684.17	36,279.73	88,506.41	93,118.91	55,521.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		312,110.31		
	P																
2200	SSI DISABLED WITH M	17,793,837.49	17,832,576.22	18,040,675.47	19,203,484.11	19,221,857.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,092,430.62		
	E																
220Z	SSI DISABLED WITH M	198,326.27	167,396.77	129,934.00	188,619.07	245,045.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		929,321.11		
	E																
2210	SSI DISABLED NON-ME	183,070,501.97	183,736,586.99	184,067,259.47	188,753,561.17	189,252,691.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		928,880,601.39		
	D																
221Z	SSI DISABLED NON-ME	240,975.38	219,514.90	211,929.19	111,215.27	258,997.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,042,632.69		
	D																
2220	SSI DISABLED WITH Q	37,253,549.14	37,244,965.89	37,192,091.53	38,657,146.65	38,624,539.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		188,972,292.65		
	M																
222Z	SSI DISABLED WITH Q	9,979.18	995.74	8,005.85	7,703.47	8,159.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,843.87		
	M																
2300	SSI BLIND WITH MEDIC	25,162.19	39,639.50	64,488.62	69,433.44	80,929.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		279,653.64		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	5,643.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,643.56		
2310	SSI BLIND NON-MEDIC	159,832.92	197,516.88	234,946.75	317,507.07	348,185.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,257,989.33		
	A																
231Z	SSI BLIND NON-MEDIC	0.00	0.00	22,893.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,893.69		
	A																
2320	SSI BLIND WITH QMB	53,912.55	83,024.98	119,538.98	161,000.41	156,595.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		574,072.06		
SUBTOTAL:	310,908,213.77	312,173,691.39	312,301,519.73	328,107,070.41	328,752,523.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,592,243,019.18		

8700	SSI DISABLED FREEDO M	251,617.80	254,909.36	251,416.34	281,598.86	267,474.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	7,216.11	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	257,484.42	258,755.65	258,755.65	276,603.06	276,624.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	110,455.08	110,455.08	110,455.08	114,889.60	114,889.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	626,773.41	624,120.09	620,627.07	673,091.52	658,988.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,307,016.79	
7,216.11	
1,328,222.88	
561,144.44	
3,203,600.22	

1,595,446,619.40

311,534,987.18	312,797,811.48	312,922,146.80	328,780,161.93	329,411,512.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	666.46	666.43	669.35	679.77	676.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,358.42		
2100	SSI AGED WITH MEDIC	9,997.53	10,030.92	10,007.76	10,003.60	10,055.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,095.32		
	A																
210Z	SSI AGED WITH MEDIC	460.84	483.79	442.16	512.90	475.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,375.34		
	A																
2110	SSI AGED NON-MEDICA	496.50	506.10	501.65	494.14	492.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,490.49		
	R																
211Z	SSI AGED NON-MEDICA	5.24	23.69	27.08	4.17	3.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.58		
	R																
2120	SSI AGED WITH QMB	8,810.57	8,835.11	8,735.99	8,746.88	8,714.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,843.54		
212Z	SSI AGED WITH QMB P	11.92	9.74	24.26	25.48	14.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.80		
	P																
2200	SSI DISABLED WITH M	4,130.72	4,133.33	4,172.15	4,184.12	4,191.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,811.47		
	E																
220Z	SSI DISABLED WITH M	54.61	48.77	38.05	51.58	64.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		257.24		
	E																
2210	SSI DISABLED NON-ME	32,814.59	32,928.94	32,990.18	33,086.50	33,190.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165,010.85		
	D																
221Z	SSI DISABLED NON-ME	29.71	28.33	27.06	13.55	30.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129.60		
	D																
2220	SSI DISABLED WITH Q	8,067.13	8,065.26	8,060.21	8,030.02	8,021.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,244.31		
	M																
222Z	SSI DISABLED WITH Q	2.57	0.25	2.15	2.31	1.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.19		
	M																
2300	SSI BLIND WITH MEDIC	5.00	8.00	13.00	13.61	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.61		
230Z	SSI BLIND WITH MEDIC	0.00	0.00	0.00	1.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.70		
2310	SSI BLIND NON-MEDIC	28.00	33.93	40.06	51.41	55.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		209.26		
	A																
231Z	SSI BLIND NON-MEDIC	0.00	0.00	2.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.56		
	A																
2320	SSI BLIND WITH QMB	12.93	19.03	26.76	34.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		125.72		
SUBTOTAL:	65,594.32	65,821.62	65,780.43	65,935.74	66,037.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		329,170.00		

8700	SSI DISABLED FREEDO M	56.16	57.00	56.00	58.99	56.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	1.83	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	35.00	35.00	35.00	35.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	24.00	24.00	24.00	24.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	116.99	116.00	115.00	117.99	115.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

284.15	
1.83	
175.00	
120.00	
580.98	

TOTAL:	65,711.31	65,937.62	65,895.43	66,053.73	66,152.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		329,750.98		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending November 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	-8.26	266.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	-57.78	-7.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-65.59		
1013	TANF 06-13 M & F NON	0.00	122.25	0.00	-703.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-581.26		
1014	TANF 14-20 MALE NON-	0.00	-136.32	-337.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-473.34		
1015	TANF 14-20 FEMALE N O	0.00	0.00	-448.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-448.35		
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	-49.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-49.31		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	164.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.97		
4312	SOBRA CHILD 01-05 M	0.00	-169.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-169.15		
4313	SOBRA CHILD 06-13 M	0.00	-1,119.97	0.00	0.00	-9.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,129.93		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	-3.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3.32		
4315	SOBRA CHILD 14-20 FE	0.00	-154.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-154.30		
SUBTOTAL:	0.00	-1,457.49	-785.37	-818.86	410.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,651.58		

4413	SOBRA 100-133% M&F
6	0.00	-692.27	-9.52	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	-610.36	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	-1,416.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-2,719.52	-9.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-701.79	
-610.36	
-1,416.89	
-2,729.04	

-5,380.62

0.00	-4,177.01	-794.89	-818.86	410.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending November 30, 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		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

0.00	
0.00	
0.00	
0.00	

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 - ADULT
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	42,483.72	42,483.72	44,124.79	41,693.28	58,874.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		229,660.21		
1014	TANF 14-20 MALE NON-	0.00	0.00	345.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		345.64		
1015	TANF 14-20 FEMALE N	896.57	155.44	2,581.18	1,338.71	-332.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,639.55		
	O																
1016	TANF 21-44 MALE NON-	0.00	0.00	2,344.25	920.36	2,334.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,598.99		
1017	TANF 21-44 FEMALE N	3,202.28	52.94	0.00	3,288.86	-1,729.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,814.90		
	O																
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	1,004.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,004.04		
101E	TANF 14-20 FEMALE N	0.00	0.00	0.00	83.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.67		
	O																
101F	TANF 21-44 MALE NON-	172.82	1,005.82	0.00	83.67	-778.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		484.18		
101G	TANF 21-44 FEMALE N	2,054.35	0.00	3,974.90	220.48	86.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,336.19		
	O																
101H	TANF 44-64 M & F NON	0.00	0.00	0.00	83.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.67		
211Z	SSI AGED NON-MEDICA	0.00	0.00	0.00	0.00	690.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		690.88		
	R																
2120	SSI AGED WITH QMB	3,247.31	138.46	1,641.07	1,618.86	1,618.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,264.56		
2200	SSI DISABLED WITH M	7,411.05	4,818.72	4,818.72	7,536.20	7,536.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,120.89		
	E																
220Z	SSI DISABLED WITH M	4,326.12	1,376.38	691.29	0.00	86.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,480.25		
	E																
2210	SSI DISABLED NON-ME	185,919.85	186,666.30	184,757.12	209,485.01	215,254.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		982,082.72		
	D																
221Z	SSI DISABLED NON-ME	3,652.70	0.00	52.94	3,303.85	-53.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,955.53		
	D																
2220	SSI DISABLED WITH Q	80,064.56	90,631.31	85,303.74	89,428.04	85,925.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		431,352.78		
	M																
222Z	SSI DISABLED WITH Q	250.87	0.00	0.00	219.56	86.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		556.89		
	M																
2310	SSI BLIND NON-MEDIC	1,641.07	1,641.07	109.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,391.54		
	A																
231Z	SSI BLIND NON-MEDIC	0.00	0.00	0.00	3,094.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,094.35		
	A																
4310	SOBRA CHILD NON-ME	5,184.66	2,592.33	2,592.33	8,425.24	6,806.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,600.94		
	DI																
4314	SOBRA CHILD 14-20 MA	0.00	836.24	345.64	0.00	161.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,343.77		
4315	SOBRA CHILD 14-20 FE	1,672.47	0.00	1,136.22	-1,096.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,712.04		
5000	SOBRA PREGNANT WO	1,641.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,641.07		
	MAN																
5007	SOBRA PREG 21-44 FE	5,184.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,184.66		
	M																
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	1,723.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,723.30		
	M																
501G	SOBRA PREG 21-44 FE	0.00	0.00	0.00	104.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.44		
	M																
SUBTOTAL:	349,006.13	332,398.73	334,819.23	372,558.94	376,568.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,765,351.65		

1100	TANF EXPANDED FPR FI	2,592.33	2,592.33	2,592.33	2,593.76	2,593.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR
FI	24,274.99	29,459.65	22,633.92	22,825.06	26,091.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	2,341.46	0.00	502.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	-1,923.34	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	83.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	4,888.38	6,529.45	6,529.45	6,504.06	6,504.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112G	TANF EXPANDED 21-44	0.00	0.00	0.00	2,319.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,964.51	
125,285.02	
2,843.48	
-1,923.34	
83.67	
30,955.40	
2,319.95	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2420	SSI AGED EXPANDED	6,790.90	6,790.90	6,790.90	6,835.00	6,835.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,042.70		
	WI																
2600	SSI DISABLED EXPAND	2,592.33	2,592.33	2,592.33	2,593.76	2,593.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,964.51		
	E																
260Z	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	864.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		864.59		
	E																
2610	SSI DISABLED EXPAND	0.00	0.00	2,098.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,098.09		
	E																
2620	SSI DISABLED EXPAND	20,815.07	20,146.08	21,752.32	31,130.17	37,176.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,019.64		
	E																
262Z	SSI DISABLED EXPAND	0.00	0.00	0.00	522.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		522.79		
	E																
SUBTOTAL:	61,954.00	68,528.86	64,989.34	75,910.24	82,658.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		354,041.01		

3510	ADULT 40-100% FOR FI	28,909.16	30,515.40	27,923.07	32,139.34	40,564.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	1,987.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	1,295.35	-1,756.09	518.47	3,179.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	7,523.33	0.00	0.00	259.38	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	4,430.89	669.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	83.62	0.00	167.34	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	158.81	83.67	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	4,434.50	-585.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
370F	ADULT <40% EXP MALE	0.00	0.00	0.00	167.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED FO	225,777.86	209,568.90	229,714.98	245,217.38	360,680.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	9,182.93	1,506.05	2,504.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	0.00	1,554.43	0.00	920.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	2,006.95	7,696.21	15,745.52	52,630.04	20,895.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	-250.87	4,771.79	3,588.47	17,251.00	9,662.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	-1,003.48	9,699.48	11,814.16	18,910.94	6,194.43	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	83.67	86.46	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	83.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371F	ADULT <40% EXP MALE	1,839.72	2,734.27	3,052.21	3,900.45	-318.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371G	ADULT <40% EXP FEMA L	1,449.43	0.00	1,382.58	2,517.88	172.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F
4	2,293.90	0.00	0.00	658.68	864.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	259.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	262,318.02	272,391.34	309,499.54	384,521.12	441,240.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

160,051.55	
1,987.45	
3,237.17	
7,782.71	
5,100.25	
250.96	
242.48	
3,848.81	
167.34	
1,270,959.88	
13,193.49	
2,474.80	
98,974.17	
35,022.65	
45,615.53	
170.13	
83.67	
11,208.14	
5,522.81	
3,817.17	
259.38	
1,669,970.54	

3900	NEWLY ELIGIBLE FOR F	2,592.33	2,592.33	2,592.33	2,593.76	5,187.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR
F	28,149.69	34,975.42	30,742.02	29,905.14	25,692.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	264.69	-423.50	0.00	0.00	2,593.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	3,561.37	4,051.50	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	1,004.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	34,568.08	41,195.75	33,334.35	33,502.94	33,473.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15,558.27	
149,464.79	
2,434.95	
7,612.87	
1,004.04	
176,074.92	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4410	SOBRA 100-133% FOR F	1,641.07	1,641.07	1,641.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,923.21		
SUBTOTAL:	1,641.07	1,641.07	1,641.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,923.21		

870Z	SSI DISABLED FREEDO M	5,686.40	0.00	-4,708.74	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	2,420.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	15,728.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	2,592.33	2,592.33	2,592.33	2,593.76	2,593.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8,278.73	2,592.33	-2,116.41	2,593.76	20,742.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

977.66	
2,420.84	
15,728.33	
12,964.51	
32,091.34	

S000	STATE-ONLY BHS	0.00	-1,606.24	0.00	-2,677.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-1,606.24	0.00	-2,677.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-4,283.67

-4,283.67

3,998,169.00

717,766.03	717,141.84	742,167.12	866,409.57	954,684.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT

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

For The Period Ending November 30, 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

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

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

211Z	SSI AGED NON-MEDICA
R
2120	SSI AGED WITH QMB

2200	SSI DISABLED WITH M
E
220Z	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

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

n. 0.00	0.00

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

221Z

2220

222Z

2310

231Z

4310

4314

4315

5000

5007

5017

501G

SSI DISABLED NON-ME D
SSI DISABLED WITH Q
M
SSI DISABLED WITH Q
M
SSI BLIND NON-MEDIC
A
SSI BLIND NON-MEDIC
A
SOBRA CHILD NON-ME
DI
SOBRA CHILD 14-20 MA

SOBRA CHILD 14-20 FE

SOBRA PREGNANT WO MAN
SOBRA PREG 21-44 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	
1110	TANF EXPANDED FOR
FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
112G	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 November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	
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	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
370F	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	
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	
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

Current and prior month data is under revision.

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	
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	
391G	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4410	SOBRA 100-133% FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

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	
871Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	

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

0.00

0.00

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending November 30, 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	-70.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-70.53		
	O																
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	-1,309.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,309.57		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2120	SSI AGED WITH QMB	0.00	0.00	-1,492.63	0.00	2,067.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		574.92		
2200	SSI DISABLED WITH M	0.00	141.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141.92		
	E																
2210	SSI DISABLED NON-ME	-1,460.62	1,656.04	-141.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.36		
	D																
221Z	SSI DISABLED NON-ME	0.00	70.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70.96		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	564.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		564.24		
	M																
4314	SOBRA CHILD 14-20 MA	0.00	0.00	-1,337.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,337.10		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	-564.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-564.24		
SUBTOTAL:	-1,460.62	1,868.92	-3,605.56	-745.33	2,067.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,875.04		

1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	1,309.57	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	-158.51	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	-1,460.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	141.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N O	0.00	0.00	1,854.45	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	568.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	141.92	2,423.32	-1,619.13	1,309.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,309.57	
-158.51	
-1,460.62	
141.92	
1,854.45	
568.87	
2,255.68	

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	-352.65	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	-1,621.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	-880.25	0.00	0.00	-9.40	-6.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	141.06	0.00	-336.72	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	-155.02	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	-86.46	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	-84.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-739.19	0.00	-2,044.37	-601.93	-6.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-352.65	
-1,621.19	
-895.91	
-195.66	
-155.02	
-86.46	
-84.86	
-3,391.75	

-3,011.11

-2,199.81	2,010.84	-3,226.61	-2,966.39	3,370.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending November 30, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	O																
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		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
	E																
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																
221Z	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																
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		
	M																
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		
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		

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	
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	
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	
2410	SSI AGED EXPANDED N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	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	

Current and prior month data is under revision.

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

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

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 - DCS-CHP
For The Period Ending November 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	-614.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-614.65		
101D	TANF 14-20 MALE NON-	0.00	-146.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-146.30		
4313	SOBRA CHILD 06-13 M	-414.23	0.00	0.00	5,509.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,094.90		
4314	SOBRA CHILD 14-20 MA	0.00	-11,806.99	0.00	606.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-11,200.10		
431B	SOBRA CHILD 01-05 M	0.00	8,106.21	372.81	3,701.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,180.82		
431C	SOBRA CHILD 6-13 M&F	755.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		755.47		
431D	SOBRA CHILD 14-20 MA	631.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		631.68		
431E	SOBRA CHILD 14-20 FE	2,132.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,132.37		
SUBTOTAL:	3,105.29	-4,461.73	372.81	9,817.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,834.19		

8,834.19

3,105.29	-4,461.73	372.81	9,817.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - DCS-CHP
For The Period Ending November 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	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		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - DD
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2200	SSI DISABLED WITH M E	1,740.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,740.54		
2210	SSI DISABLED NON-ME
D	0.00	0.00	-1,743.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,743.48		
SUBTOTAL:	1,740.54	0.00	-1,743.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2.94		

-2.94

1,740.54	0.00	-1,743.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1005	TANF 14-20 FEMALE WI	5.68	5.68	5.68	4.13	4.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.30		
1006	TANF 21-44 MALE WITH	1,074.23	1,074.23	1,105.56	657.65	634.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,546.51		
1007	TANF 21-44 FEMALE WI	1,394.71	1,311.57	1,345.26	856.88	824.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,733.01		
1008	TANF 45-64 M & F WIT	2,924.31	2,895.80	2,944.40	1,753.69	1,752.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,271.08		
1009	TANF 65+ M & F WITH	1,810.65	1,843.07	1,802.27	1,069.75	1,040.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,566.53		
1010	TANF NON-MEDICARE	1,295.76	1,291.31	1,290.84	4,608.98	4,637.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,124.03		
1011	TANF <1 M & F NON-ME	21,640.95	22,233.06	22,888.52	92,336.79	95,317.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		254,416.89		
1012	TANF 01-05 M & F NON	38,884.77	38,645.46	38,797.56	162,431.26	174,958.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453,717.95		
1013	TANF 06-13 M & F NON	75,603.36	75,418.01	75,586.55	311,394.37	330,205.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		868,207.54		
1014	TANF 14-20 MALE NON-	71,039.41	73,009.06	75,999.09	106,616.03	113,066.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		439,729.84		
1015	TANF 14-20 FEMALE N	102,751.77	103,566.02	105,237.36	125,849.82	131,510.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		568,915.35		
	O																
1016	TANF 21-44 MALE NON-	407,163.72	408,211.05	410,905.98	242,517.02	253,710.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,722,508.31		
1017	TANF 21-44 FEMALE N	1,362,222.98	1,360,193.45	1,369,162.24	797,271.23	829,796.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,718,646.27		
	O																
1018	TANF 45-64 M & F NON	349,386.16	350,259.73	351,704.88	207,060.49	215,299.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,473,710.33		
1019	TANF 65+ M & F NON-M	1,777.08	1,794.12	1,832.33	1,093.35	1,104.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,601.40		
1023	TANF 06-13 M & F WIT	4.18	4.18	4.18	7.46	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.46		
1024	TANF 14-20 MALE WITH	14.43	14.43	14.43	14.08	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.45		
1025	TANF 14-20 FEMALE WI	25.19	25.19	25.19	14.50	14.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104.57		
1026	TANF 21-44 MALE WITH	1,006.35	1,049.04	1,029.53	602.09	651.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,338.38		
1027	TANF 21-44 FEMALE WI	1,625.10	1,629.23	1,534.38	847.72	914.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,550.84		
1028	TANF 45-64 M & F WIT	2,169.62	2,123.26	2,192.46	1,221.67	1,275.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,982.93		
1029	TANF 65+ M & F WITH	1,218.05	1,216.16	1,296.10	826.66	848.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,405.59		
2100	SSI AGED WITH MEDIC	174,819.66	175,160.24	176,168.45	99,674.59	99,799.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		725,622.44		
	A																
2110	SSI AGED NON-MEDICA	116,703.65	117,582.26	118,537.53	66,438.53	67,571.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		486,833.24		
	R																
2120	SSI AGED WITH QMB	566,269.97	570,577.53	574,907.09	333,751.43	336,323.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,381,829.79		
2200	SSI DISABLED WITH M	105,597.57	105,433.82	106,658.15	61,258.77	61,503.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		440,451.85		
	E																
2210	SSI DISABLED NON-ME	771,094.17	771,630.83	772,149.44	616,715.54	617,648.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,549,238.91		
	D																
2220	SSI DISABLED WITH Q	435,771.54	436,494.18	437,429.48	252,167.32	251,978.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,813,841.43		
	M																
2300	SSI BLIND WITH MEDIC	530.20	530.20	595.84	359.42	385.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,400.75		
2310	SSI BLIND NON-MEDIC	6,462.40	6,569.99	6,645.44	4,598.17	4,592.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,868.78		
	A																
2320	SSI BLIND WITH QMB	3,204.68	3,361.73	3,487.45	2,125.48	2,151.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,330.49		
4301	SOBRA CHILD <1 M & F	0.00	0.83	0.00	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.91		
4302	SOBRA CHILD 01-05 M	5.01	5.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.02		
4303	SOBRA CHILD 06-13 M	10.02	10.02	8.36	14.92	14.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.24		
4305	SOBRA CHILD 14-20 FE	0.83	0.83	4.18	7.46	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.76		
4311	SOBRA CHILD <1 M & F	51,218.81	50,684.41	50,200.79	201,029.09	197,694.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		550,827.63		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4312	SOBRA CHILD 01-05 M	333,951.36	335,474.23	336,368.04	1,329,372.87	1,317,030.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,652,197.09		
4313	SOBRA CHILD 06-13 M	424,731.44	425,232.81	426,096.85	1,686,731.41	1,674,152.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,636,944.98		
4314	SOBRA CHILD 14-20 MA	275,794.71	279,860.47	280,370.15	513,828.77	513,776.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,863,631.05		
4315	SOBRA CHILD 14-20 FE	276,006.13	278,045.08	279,386.60	506,252.78	505,726.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,845,417.56		
4322	SOBRA CHILD 01-05 M	1.66	1.66	1.66	14.08	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.14		
4323	SOBRA CHILD 06-13 M	0.83	0.83	0.83	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.57		
4325	SOBRA CHILD 14-20 FE	21.45	21.45	29.69	18.63	26.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117.31		
5007	SOBRA PREG 21-44 FE	260.91	265.16	298.04	203.30	206.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,233.62		
	M																
5008	SOBRA PREG 45-64 FE	13.60	13.60	13.60	7.04	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.30		
	M																
5013	SOBRA PREG 09-13 FE	13.25	10.73	8.92	36.84	62.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132.67		
	M																
5015	SOBRA PREG 14-20 FE	23,441.55	23,870.48	23,958.23	14,853.60	14,731.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,855.31		
	M																
5017	SOBRA PREG 21-44 FE	184,904.86	192,300.97	199,397.98	114,243.08	113,569.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		804,416.87		
	M																
5018	SOBRA PREG 45-64 FE	753.59	795.36	821.13	443.91	436.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,250.86		
	M																
5027	SOBRA PREG 21-44 FE	352.78	348.53	342.62	197.94	211.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,453.47		
	M																
5028	SOBRA PREG 45-64 FE	71.67	44.47	44.47	33.13	18.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		212.37		
	M																
SUBTOTAL:	6,197,046.76	6,222,140.82	6,260,635.80	7,863,447.80	7,937,247.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,480,518.97		

3100

TRANSPLANT OPTION 1

25.30

25.30

5.68	5.68	5.68	4.13	4.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
5.68	5.68	5.68	4.13	4.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1106	TANF EXPANDED 21-44	3,041.47	2,981.51	2,968.26	1,669.33	1,715.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	5,253.15	5,106.26	5,013.30	2,861.67	2,731.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	17,304.13	17,785.94	17,876.43	10,306.48	10,262.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	10,852.64	11,123.12	11,515.42	6,865.80	6,946.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	1.66	0.83	0.83	14.08	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	5.01	5.01	5.84	7.46	18.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	2,572.90	2,482.30	2,412.29	1,318.63	1,285.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	16,030.03	15,323.12	14,530.75	7,671.14	7,401.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	335,614.45	337,335.76	335,668.81	188,394.74	181,317.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	950,610.58	956,423.69	950,212.59	527,295.40	506,040.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	328,959.81	333,039.48	333,462.10	187,342.37	182,804.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	1,658.59	1,701.17	1,724.70	994.31	944.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1125	TANF EXPANDED 14-20	11.59	11.59	11.59	7.46	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	9,134.93	9,183.07	9,239.83	5,277.11	5,195.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	20,450.95	20,531.85	20,560.48	11,418.65	11,418.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	35,814.01	36,065.45	36,101.27	20,788.60	20,943.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	25,237.97	25,250.65	25,421.77	15,098.13	15,178.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,376.30	
20,966.01	
73,535.50	
47,303.51	
24.44	
41.95	
10,072.05	
60,956.20	
1,378,331.43	
3,890,582.85	
1,365,607.96	
7,023.00	
49.69	
38,030.11	
84,380.15	
149,712.33	
106,186.72	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	SSI AGED EXPANDED	4,650.68	4,762.45	4,867.81	2,855.01	2,894.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,030.23		
	WI																
2410	SSI AGED EXPANDED N	1,727.09	1,706.03	1,810.81	1,026.58	992.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,263.50		
	O																
2420	SSI AGED EXPANDED	378,475.43	380,629.35	382,995.39	224,242.82	226,324.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,592,667.33		
	WI																
2500	SSI BLIND EXPANDED	13.60	13.60	13.60	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.88		
	W																
2510	SSI BLIND EXPANDED	11.59	11.59	25.19	29.00	36.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113.41		
	N																
2520	SSI BLIND EXPANDED	203.30	284.55	406.37	350.74	413.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,658.25		
	W																
2600	SSI DISABLED EXPAND	4,406.88	4,524.91	4,328.73	2,401.19	2,361.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,022.73		
	E																
2610	SSI DISABLED EXPAND	18,026.56	17,441.23	17,294.92	9,922.11	9,908.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,593.33		
	E																
2620	SSI DISABLED EXPAND	206,887.26	207,251.76	207,656.43	119,127.98	118,915.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		859,838.86		
	E																
SUBTOTAL:	2,376,956.26	2,390,976.27	2,386,125.51	1,347,293.83	1,316,070.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,817,422.72		

3505	ADULT 40-100% FEMAL E	0.00	0.00	0.00	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3506	ADULT 40-100% MALE 2	334.93	305.72	317.31	208.35	215.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	290.46	242.09	206.97	149.93	170.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	3,710.08	3,813.12	4,077.23	2,422.38	2,312.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	3,217.04	3,757.86	4,551.44	2,655.27	2,856.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	79,907.04	80,195.95	80,455.05	45,496.46	45,480.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	84,744.66	85,099.31	85,671.02	49,003.53	49,251.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	346,020.47	349,705.40	353,175.36	197,238.69	193,148.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	282,437.16	285,893.74	289,079.52	162,718.13	160,345.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	525,336.49	529,153.28	530,749.09	301,243.54	295,223.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	357.88	423.64	458.18	347.83	381.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3524	ADULT 40-100% MALE 1	13.60	13.60	13.60	14.50	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	25.19	38.79	38.79	21.54	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	40.80	40.80	54.40	21.12	35.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	363.56	369.24	406.02	272.88	247.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	166.52	180.12	189.70	116.38	130.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	1,046.53	1,057.89	1,135.47	652.65	680.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	604.46	579.27	610.14	340.38	323.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	6,819.51	7,282.98	7,675.01	4,658.90	4,891.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	1,283.94	1,401.98	1,665.36	1,082.40	1,212.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	174,259.45	176,966.61	181,513.76	105,254.05	107,361.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	160,747.18	164,661.26	168,914.46	98,237.19	99,935.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	1,290,469.36	1,315,719.94	1,345,410.63	784,324.79	803,730.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	742,977.91	757,598.87	774,866.09	450,302.30	462,140.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	1,302,549.14	1,316,979.72	1,336,071.24	779,147.63	796,503.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.46	
1,382.12	
1,060.08	
16,334.97	
17,037.72	
331,534.74	
353,770.08	
1,439,288.35	
1,180,473.99	
2,181,705.85	
1,969.33	
62.34	
153.31	
192.74	
1,659.33	
782.76	
4,573.35	
2,458.06	
31,328.08	
6,646.49	
745,355.32	
692,495.64	
5,539,654.82	
3,187,885.54	
5,531,251.04	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F	506.67	651.44	839.36	444.35	481.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,923.43		
	6																
3724	ADULT <40% EXP MALE	0.00	0.00	0.00	4.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.13		
3726	ADULT <40% EXP MALE	216.90	203.30	216.90	130.46	120.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		887.65		
3727	ADULT <40% EXP FEMA	69.66	96.86	110.46	54.25	68.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		399.56		
	L																
3728	ADULT <40% EXP M&F	911.61	952.18	989.31	588.02	601.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,042.42		
	4																
3729	ADULT <40% EXP M&F	23.18	23.18	23.18	7.46	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84.46		
	6																
SUBTOTAL:	5,009,451.38	5,083,408.14	5,169,485.05	2,987,166.95	3,027,893.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,277,405.16		

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	4.13	4.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	13.60	13.60	13.60	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	1,448.07	1,405.26	1,449.73	849.73	875.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	1,044.29	986.22	1,019.10	575.64	576.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	19,804.68	20,393.25	20,943.48	12,592.05	12,994.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	16,111.70	17,251.96	18,816.13	11,506.62	12,267.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	80,467.12	78,188.05	76,444.18	41,564.92	40,481.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	84,802.34	81,889.33	79,511.79	43,313.10	42,150.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	438,158.33	440,631.19	443,860.55	251,858.40	251,353.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	627,863.05	635,104.07	646,045.06	362,913.30	360,283.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	510,704.17	511,244.98	513,862.23	293,785.60	291,526.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	1,639.43	1,765.15	1,773.07	1,002.11	1,006.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	25.19	25.19	25.19	14.50	14.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	36.78	36.78	36.78	29.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	239.51	259.02	301.48	154.82	137.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	792.30	862.31	938.23	589.23	676.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,783,150.56	1,790,056.36	1,805,040.60	1,020,760.19	1,014,382.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8.26	
54.88	
6,027.81	
4,201.73	
86,727.55	
75,953.73	
317,145.68	
331,666.90	
1,825,861.47	
2,632,208.82	
2,121,123.76	
7,186.42	
104.57	
168.34	
1,091.86	
3,858.30	
7,413,390.08	

4412	SOBRA 100-133% M&F
1	8.36	4.18	5.01	7.46	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	77,864.70	78,493.49	79,008.12	312,161.39	306,679.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	59,246.96	61,682.51	62,682.69	104,270.69	103,663.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	58,389.54	60,234.07	61,959.93	100,601.96	100,001.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.83	0.83	0.83	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	195,510.39	200,415.08	203,656.58	517,048.54	510,358.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

32.05	
854,206.83	
391,546.60	
381,186.96	
16.57	
1,626,989.01	

4517	BC PATIENT FEMALE 2 1	257.82	271.42	269.41	154.45	147.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	1,493.04	1,467.85	1,535.73	901.06	921.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	25.19	25.19	25.19	14.50	14.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	58.07	58.07	58.07	32.71	32.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	50.38	50.38	50.38	29.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,100.93	
6,319.44	
104.57	
239.63	
209.14	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1,884.50	1,872.91	1,938.78	1,131.72	1,145.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,973.71		

8600	SSI BLIND FREEDOM/W	54.40	54.40	95.20	49.28	49.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
	O														
8610	SSI BLIND FREEDOM/W	13.60	13.60	13.60	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
	O														
8620	SSI BLIND FREEDOM/W	25.19	25.19	13.60	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
	O														
8700	SSI DISABLED FREEDO	29,320.29	29,647.30	29,742.39	16,680.13	16,684.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
	M														
8710	SSI DISABLED FREEDO	4,978.17	5,094.31	5,059.07	2,793.23	2,855.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
	M														
8720	SSI DISABLED FREEDO	7,425.33	7,572.57	7,632.53	4,377.38	4,535.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
	M														
SUBTOTAL:	41,816.98	42,407.37	42,556.39	23,914.10	24,138.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

302.56	
54.88	
78.06	
122,074.27	
20,780.17	
31,543.43	
174,833.37	

6013	KIDS 6-13 M & F NON-	0.00	0.00	1.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	25.19	25.19	38.79	29.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	27.20	27.20	40.80	21.12	21.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	52.39	52.39	81.01	50.12	50.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.42	
147.17	
137.44	
286.03	

74,798,844.35

15,605,874.90	15,731,335.02	15,869,525.40	13,760,817.38	13,831,291.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

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

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE		TOTAL	
1005	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1015

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

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
1017

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	

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

1024	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2100

2110	SSI AGED WITH MEDIC A
SSI AGED NON-MEDICA	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	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	R
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

2210	SSI DISABLED WITH M E
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

0.00	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	D
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	

2300	M
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

2320	SSI BLIND NON-MEDIC A
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

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
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	

1019

1023

TANF 65+ M & F NON-M

TANF 06-13 M & F WIT

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

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

3100

TRANSPLANT OPTION 1

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

RATE CODE	DESCRIPTION

4312

SOBRA CHILD 01-05 M

4313

SOBRA CHILD 06-13 M

4314

SOBRA CHILD 14-20 MA

4315

4322

SOBRA CHILD 14-20 FE

SOBRA CHILD 01-05 M

4323

SOBRA CHILD 06-13 M

4325

SOBRA CHILD 14-20 FE

5007

5008

5013

5015

5017

5018

5027

5028

SOBRA PREG 21-44 FE M
SOBRA PREG 45-64 FE
M
SOBRA PREG 09-13 FE
M
SOBRA PREG 14-20 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE
M
SOBRA PREG 21-44 FE
M
SOBRA PREG 45-64 FE

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

data is

0.00

0.00

under re

0.00

0.00

visio

0.00

n.

0.00

0.00

M
SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

SUBTOTAL:

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	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																
2410	SSI AGED EXPANDED 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																
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																
2500	SSI BLIND 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		
	W																
2510	SSI BLIND 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		
	N																
2520	SSI BLIND 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		
	W																
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																
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																
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		

3505	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	
3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3524	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	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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																
3724	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		
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	0.00	0.00	0.00	0.00	0.00		0.00		
	4																
3729	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																
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		

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3927	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

Current and prior month data is under revision.

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

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	

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

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	
8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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	

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

Current and prior month data is under revision.

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	7,775.51	6,723.48	11,624.23	5,518.05	3,314.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,956.10		
1007	TANF 21-44 FEMALE WI	2,344.68	3,883.48	1,715.06	2,619.31	4,268.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,831.16		
1008	TANF 45-64 M & F WIT	25,526.79	20,753.50	39,154.69	13,049.27	17,392.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,876.46		
1009	TANF 65+ M & F WITH	4,555.05	10,223.86	11,782.87	6,219.48	16,476.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,257.76		
1011	TANF <1 M & F NON-ME	1,106,915.21	1,216,978.44	1,706,318.99	1,259,910.11	1,063,160.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,353,283.17		
1012	TANF 01-05 M & F NON	218,987.02	387,489.81	458,317.96	301,286.82	354,252.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,720,333.95		
1013	TANF 06-13 M & F NON	430,508.15	675,349.59	791,204.52	559,058.37	707,850.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,163,971.34		
1014	TANF 14-20 MALE NON-	354,609.87	347,439.79	348,732.18	264,087.42	316,592.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,631,461.52		
1015	TANF 14-20 FEMALE N	508,656.09	544,497.32	719,924.16	453,905.29	652,069.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,879,052.65		
	O																
1016	TANF 21-44 MALE NON-	2,588,370.71	3,053,399.35	3,582,566.50	2,738,415.57	3,147,669.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,110,421.35		
1017	TANF 21-44 FEMALE N	8,734,300.88	11,215,643.05	12,413,128.31	7,909,971.85	10,653,522.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,926,566.93		
	O																
1018	TANF 45-64 M & F NON	3,826,994.58	4,966,144.19	5,085,747.60	2,889,177.03	4,489,466.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,257,530.05		
1019	TANF 65+ M & F NON-M	35,671.33	20,810.34	17,660.93	7,553.66	11,173.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,870.18		
1026	TANF 21-44 MALE WITH	1,623.60	0.00	1,038.00	15.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,676.87		
1027	TANF 21-44 FEMALE WI	1,787.67	2,318.32	4,002.58	2,144.04	3,844.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,096.68		
1028	TANF 45-64 M & F WIT	8,927.86	16,761.17	7,626.87	25,079.50	21,525.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,920.77		
1029	TANF 65+ M & F WITH	7,346.06	7,001.81	7,403.77	1,887.58	6,086.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,725.78		
2100	SSI AGED WITH MEDIC	255,964.05	270,549.48	277,961.82	185,963.58	290,420.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,280,859.37		
	A																
2110	SSI AGED NON-MEDICA	310,045.67	446,886.05	463,985.83	330,759.15	434,445.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,986,122.39		
	R																
2120	SSI AGED WITH QMB	936,169.83	1,302,776.00	1,092,335.30	586,608.14	925,028.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,842,917.86		
2200	SSI DISABLED WITH M	778,233.51	827,764.83	968,299.73	486,365.08	658,002.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,718,665.90		
	E																
2210	SSI DISABLED NON-ME	10,416,314.38	12,852,972.93	12,464,532.92	7,146,404.74	10,498,570.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,378,795.33		
	D																
2220	SSI DISABLED WITH Q	1,932,664.67	2,160,654.42	2,526,549.54	1,490,077.48	2,092,398.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,202,344.48		
	M																
2300	SSI BLIND WITH MEDIC	8,661.85	7,051.30	4,343.76	573.84	11,995.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,625.91		
2310	SSI BLIND NON-MEDIC	158,293.34	160,526.18	138,716.55	91,767.90	224,334.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		773,638.37		
	A																
2320	SSI BLIND WITH QMB	21,995.35	14,885.83	21,077.82	11,613.11	24,863.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		94,435.84		
4311	SOBRA CHILD <1 M & F	2,065,287.90	1,795,377.79	2,457,365.46	1,372,344.29	1,593,655.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,284,031.16		
4312	SOBRA CHILD 01-05 M	3,235,104.81	4,396,106.82	5,444,861.80	3,495,038.44	4,252,471.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,823,583.25		
4313	SOBRA CHILD 06-13 M	5,738,184.96	8,045,040.16	9,172,214.10	6,378,133.84	7,507,211.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,840,784.79		
4314	SOBRA CHILD 14-20 MA	2,236,179.66	2,802,506.88	3,361,014.21	2,396,050.81	2,934,270.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,730,022.18		
4315	SOBRA CHILD 14-20 FE	2,575,801.59	3,397,444.00	4,030,487.49	2,669,532.48	3,007,935.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,681,201.34		
5007	SOBRA PREG 21-44 FE	4,628.05	10,473.59	9,324.42	1,367.58	1,557.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,351.33		
	M																
5013	SOBRA PREG 09-13 FE	519.00	0.00	0.00	0.00	1,895.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,414.02		
	M																
5015	SOBRA PREG 14-20 FE	197,969.03	290,298.97	306,644.95	185,218.68	228,759.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,208,891.39		
	M																
5017	SOBRA PREG 21-44 FE	1,772,002.09	1,973,623.44	2,413,665.89	1,661,305.73	2,034,536.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,855,133.23		
	M																
5018	SOBRA PREG 45-64 FE	-1,024.09	5,127.50	2,236.27	519.00	2,012.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,870.68		
	M																

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	50,507,896.71	63,255,483.67	70,363,567.08	44,929,542.49	58,193,031.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287,249,521.54		

1106	TANF EXPANDED 21-44	7,993.91	6,480.43	10,812.39	7,037.12	6,830.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	7,940.12	6,054.63	5,286.25	1,788.28	2,043.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	54,825.32	81,878.65	78,589.67	38,916.58	62,355.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	63,425.03	89,100.40	87,116.63	60,440.82	66,686.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	519.00	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	22,659.84	8,464.41	3,789.83	1,413.55	4,469.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	52,208.78	59,020.80	56,244.99	37,861.65	49,238.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	1,306,468.26	1,534,206.78	1,855,636.79	1,034,955.45	1,058,160.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	4,069,943.93	4,653,462.62	5,356,585.89	3,209,876.60	4,034,812.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	2,279,244.03	3,005,018.36	2,989,307.07	1,459,993.21	2,252,716.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	12,852.80	19,798.86	18,154.87	12,690.29	34,603.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	22,671.29	25,880.87	21,112.21	15,140.14	17,223.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	52,545.51	60,653.01	64,030.77	60,670.45	79,525.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	155,261.45	188,912.72	214,732.29	113,956.10	157,023.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	137,416.27	189,820.40	161,415.67	108,438.17	204,353.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	11,541.53	14,383.97	13,622.09	10,367.73	28,334.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	38,873.31	86,611.80	41,342.92	12,252.65	28,403.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	729,630.08	1,112,499.01	1,083,835.62	530,415.04	844,758.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED
W	103.61	773.52	4,598.34	6,047.77	1,499.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	8,250.79	11,161.38	20,293.90	26,336.77	45,474.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND
E	145,351.78	224,911.14	162,087.04	104,221.58	166,005.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	668,815.93	657,308.64	673,128.64	349,712.39	588,354.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,848,542.57	12,036,402.40	12,921,723.87	7,202,532.34	9,732,874.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

39,154.46	
23,113.02	
316,565.40	
366,769.78	
519.00	
40,796.70	
254,574.95	
6,789,427.47	
21,324,681.27	
11,986,279.21	
98,100.12	
102,028.31	
317,425.37	
829,885.74	
801,444.34	
78,249.35	
207,484.61	
4,301,138.45	
13,022.68	
111,517.63	
802,577.21	
2,937,320.55	
51,742,075.62	

3616	AHC CARE/MI MALE 21-	0.00	-546.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	-491.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-1,038.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-546.80	
-491.76	
-1,038.56	

3506	ADULT 40-100% MALE 2	4,646.37	3,569.24	10,728.25	6,319.12	7,262.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	1,038.00	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	14,537.63	13,393.79	21,624.44	7,144.82	12,841.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	6,297.74	8,786.24	15,772.24	3,299.33	8,388.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	128,903.50	116,959.21	159,757.94	137,842.69	101,289.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	129,870.25	126,253.51	145,831.83	93,574.42	123,011.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	2,004,235.85	2,283,425.49	2,864,954.67	1,690,260.58	1,976,531.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	1,041,959.06	1,237,700.17	1,507,192.95	914,412.88	1,332,456.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

32,525.66	
1,038.00	
69,541.85	
42,543.74	
644,752.81	
618,541.35	
10,819,408.58	
6,033,721.49	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	3,009,467.97	4,378,618.90	4,156,837.24	2,232,772.16	3,292,914.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,070,611.09		
3519	ADULT 40-100% M&F 65	2,221.47	3,092.85	13,217.96	10,002.73	38,268.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,803.93		
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	24.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.32		
3528	ADULT 40-100% M&F 45	1,734.15	558.12	2,757.00	619.18	1,987.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,656.31		
3706	ADULT <40% EXP MALE	10,633.94	23,984.56	4,669.80	750.93	505.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,544.33		
3707	ADULT <40% EXP FEMA	1.99	2,403.00	0.00	18.37	42.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,465.59		
	L																
3708	ADULT <40% EXP M&F	45,125.52	49,384.54	32,831.93	19,112.06	30,772.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,227.03		
	4																
3709	ADULT <40% EXP M&F	2,803.98	28,164.39	6,431.16	4,981.90	7,160.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,542.13		
	6																
3714	ADULT <40% EXP MALE	621,360.59	554,889.29	876,545.69	493,194.81	454,993.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,000,983.64		
3715	ADULT <40% EXP FEMA	643,610.77	820,674.39	951,536.69	609,655.14	751,093.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,776,570.13		
	L																
3716	ADULT <40% EXP MALE	17,184,768.45	18,416,210.28	22,659,213.91	15,543,124.87	18,394,073.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,197,390.78		
3717	ADULT <40% EXP FEMA	7,543,611.93	8,920,826.22	10,455,848.84	7,585,791.13	9,260,479.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43,766,557.77		
	L																
3718	ADULT <40% EXP M&F	18,454,421.96	22,069,303.72	22,686,397.95	15,343,510.28	18,966,225.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,519,859.08		
	4																
3719	ADULT <40% EXP M&F	5,868.72	10,073.43	7,031.23	3,378.82	15,282.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,634.29		
	6																
3726	ADULT <40% EXP MALE	0.00	89.78	26.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.42		
3728	ADULT <40% EXP M&F	43,757.41	19,537.11	20,036.99	14,127.59	15,443.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,902.69		
	4																
SUBTOTAL:	50,900,877.25	59,087,898.23	66,599,245.35	44,713,893.81	54,791,048.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		276,092,963.01		

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	928.48	1,133.52	372.57	1,554.82	4,615.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	1,667.42	2,453.02	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	45,188.51	85,144.19	54,253.45	38,548.85	41,052.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	36,961.32	36,807.33	39,166.58	20,667.00	41,510.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	110,275.43	85,315.24	77,577.86	56,747.93	60,614.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	101,112.74	154,557.83	144,259.07	94,182.08	115,249.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,095,766.22	1,219,994.12	1,574,243.01	1,026,197.50	1,389,497.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	1,520,412.09	2,201,444.35	2,087,325.47	1,502,340.87	1,908,973.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	2,903,030.25	4,032,327.06	3,655,984.94	2,083,965.85	2,979,063.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	8,020.21	6,386.64	6,052.30	5,611.34	8,474.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	917.91	1,274.01	1,910.08	39.23	2,049.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	436.84	797.94	3,202.38	940.60	613.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F
6	755.41	792.88	1,329.98	204.89	1,441.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,825,472.83	7,828,428.13	7,645,677.69	4,831,000.96	6,553,672.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

519.00	
8,604.59	
4,120.44	
264,187.01	
175,112.24	
390,530.57	
609,361.11	
6,305,698.30	
9,220,495.97	
15,654,372.08	
34,544.80	
6,190.92	
5,990.91	
4,524.61	
32,684,252.55	

4413	SOBRA 100-133% M&F
6	468,186.79	696,749.93	871,033.75	548,623.98	620,691.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	193,865.89	275,272.41	332,214.72	241,936.40	293,437.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	257,007.26	345,910.41	485,010.88	251,057.77	295,204.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,205,285.97	
1,336,727.30	
1,634,190.40	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	919,059.94	1,317,932.75	1,688,259.35	1,041,618.15	1,209,333.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,176,203.67		

4517	BC PATIENT FEMALE 2 1	9,490.94	1,210.35	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
4518	BC PATIENT FEMALE 4
5	2,886.76	4,235.11	3,896.43	2,032.08	3,593.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
SUBTOTAL:	12,377.70	5,445.46	4,375.43	2,032.08	3,593.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

11,180.29	
16,643.38	
27,823.67	

8700	SSI DISABLED FREEDO M	29,292.48	37,923.07	38,553.81	17,731.06	31,293.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	25,450.96	47,158.52	28,356.43	13,454.75	34,091.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	7,369.22	1,805.95	7,047.13	788.29	3,873.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	62,112.66	86,887.54	73,957.37	31,974.10	69,258.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

154,793.51	
148,512.63	
20,883.97	
324,190.11	

S000	STATE-ONLY BHS	1,742.57	48,951.66	-6,474.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,742.57	48,951.66	-6,474.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

44,219.46

44,219.46

654,340,211.07

118,078,082.23	143,666,391.28	159,290,331.37	102,752,593.93	130,552,812.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	653.16	1,147.41	4,053.48	1,583.93	1,769.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,207.73		
1012	TANF 01-05 M & F NON	0.00	584.30	1,551.41	319.12	156.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,611.24		
1013	TANF 06-13 M & F NON	0.00	108.81	0.00	616.91	199.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		925.63		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	185.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185.98		
1015	TANF 14-20 FEMALE N	0.00	34.56	0.00	156.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190.97		
	O																
1017	TANF 21-44 FEMALE N	8,697.66	1,003.09	7,548.27	18,217.45	14,156.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,623.30		
	O																
1018	TANF 45-64 M & F NON	4,404.76	1,235.11	626.13	0.00	140.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,406.77		
2210	SSI DISABLED NON-ME	-2,106.39	58.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,048.16		
	D																
4311	SOBRA CHILD <1 M & F	27,757.92	12,275.67	20,057.46	4,438.92	22,168.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,698.70		
4312	SOBRA CHILD 01-05 M	5,456.38	16,221.91	24,716.50	10,659.31	33,768.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90,822.77		
4313	SOBRA CHILD 06-13 M	37,828.14	30,961.06	14,000.54	4,399.19	9,601.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,790.55		
4314	SOBRA CHILD 14-20 MA	15,311.62	14,097.42	16,295.62	6,937.85	2,334.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,976.66		
4315	SOBRA CHILD 14-20 FE	16,279.08	21,793.44	5,675.13	964.19	2,456.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,168.23		
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	11.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.02		
	M																
5015	SOBRA PREG 14-20 FE	15,222.45	17,478.11	14,911.24	8,978.69	16,140.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72,731.22		
	M																
5017	SOBRA PREG 21-44 FE	39,336.78	65,516.68	74,710.59	84,873.11	72,645.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		337,082.52		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	6,140.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,140.07		
	M																
5027	SOBRA PREG 21-44 FE	73.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.42		
	M																
SUBTOTAL:	168,914.98	182,515.80	184,146.37	142,342.08	181,679.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		859,598.62		

1109	TANF EXPANDED 65+ M
&	0.00	0.00	-564.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	-113.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-113.35	0.00	-564.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-564.30	
-113.35	
-677.65	

3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1,844.56	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	-41.07	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	8.44	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	-276.26	-6,644.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-308.89	-6,644.75	1,844.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,844.56	
-41.07	
8.44	
-6,921.01	
-5,109.08	

3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	107.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	-774.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-666.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

107.73	
-774.26	
-666.53	

4413	SOBRA 100-133% M&F
6	19,118.97	7,750.78	2,681.38	765.26	20,733.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	753.65	0.00	311.12	0.00	708.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	2,565.94	386.03	1,053.61	5,117.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	22,438.56	8,136.81	4,046.11	5,883.17	21,442.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

51,049.93	
1,773.25	
9,123.49	
61,946.67	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	191,240.19	190,343.72	180,316.90	150,069.81	203,121.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		915,092.03		

FEDERAL EMERGENCY SERVICES
For The Period Ending November 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	378.71	814.68	6,752.95	8,563.37	74,861.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,371.48		
1012	TANF 01-05 M & F NON	15,297.23	9,075.54	7,755.84	4,105.07	15,206.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,440.01		
1013	TANF 06-13 M & F NON	59,826.19	66,110.48	47,837.56	239,651.05	31,614.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		445,039.42		
1014	TANF 14-20 MALE NON-	278,180.05	31,321.08	34,537.75	82,949.79	179,349.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		606,338.00		
1015	TANF 14-20 FEMALE N	189,513.40	152,543.86	194,485.94	129,570.88	145,796.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		811,910.70		
	O																
1016	TANF 21-44 MALE NON-	395.02	58.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		453.72		
1017	TANF 21-44 FEMALE N	1,417,510.35	1,214,627.23	1,835,908.07	1,497,348.67	1,381,938.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,347,332.47		
	O																
1018	TANF 45-64 M & F NON	2,748.27	2,056.06	7,502.32	16,638.26	6,606.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,551.16		
2100	SSI AGED WITH MEDIC	31,697.85	19,353.33	35,356.56	18,752.05	8,835.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,995.15		
	A																
2110	SSI AGED NON-MEDICA	1,786,735.18	1,482,814.10	1,667,647.21	1,276,042.34	1,299,884.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,513,123.79		
	R																
2200	SSI DISABLED WITH M	3,601.48	1.02	1,981.67	105.29	734.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,423.97		
	E																
2210	SSI DISABLED NON-ME	9,746.22	21,117.57	5,696.80	8,816.00	9,691.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,068.30		
	D																
2220	SSI DISABLED WITH Q	34.30	0.00	0.00	16.86	817.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		868.27		
	M																
SUBTOTAL:	3,795,664.25	2,999,893.65	3,845,462.67	3,282,559.63	3,155,336.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,078,916.44		

1107	TANF EXPANDED 21-44	0.00	1,644.35	80.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	3,654.82	1,512.44	0.00	802.54	61.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	294.36	19.89	0.00	430.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	156.41	0.00	0.00	0.00	358.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	21,962.65	8,746.94	7,951.94	8,397.53	15,921.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	1,048,326.70	533,095.41	836,204.67	534,727.26	809,351.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,696,327.19	1,415,154.56	1,860,565.16	1,499,204.04	1,514,797.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,140,212.08	1,016,337.09	1,655,859.60	1,209,090.25	1,096,377.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	6,248.58	98,287.60	3,205.64	5,835.12	20,772.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	0.00	750.24	0.00	0.00	6,642.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	23,075.05	47,015.76	9,193.87	9,065.70	23,191.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	2,672.63	2,821.03	3,103.16	1,986.63	672.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	0.00	0.00	25.52	0.00	25.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,942,636.11	3,125,659.78	4,376,209.45	3,269,109.07	3,488,601.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,724.35	
6,031.48	
744.87	
514.83	
62,980.37	
3,761,705.09	
7,986,048.13	
6,117,876.71	
134,349.30	
7,392.91	
111,541.53	
11,255.45	
51.04	
18,202,216.06	

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	39.36	0.00	2,080.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	5,103.28	11,405.62	3,222.06	13,888.28	13,299.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	57,585.65	38,174.24	165,495.15	36,091.71	46,227.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	115,785.62	25,600.25	56,584.36	47,504.16	34,340.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,618,808.94	1,156,470.36	2,006,997.01	1,533,863.67	1,013,151.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	724,167.62	367,395.52	849,627.24	505,272.52	493,415.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	3,988,044.64	3,696,310.77	4,622,976.98	3,345,313.00	2,971,660.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,119.40	
46,919.11	
343,574.40	
279,814.94	
7,329,291.28	
2,939,878.79	
18,624,305.45	

FEDERAL EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3919	NEWLY ELIGIBLE M&F 6	3,916.65	3,165.63	1,799.11	1,462.01	627.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,970.87		
SUBTOTAL:	6,513,412.40	5,298,522.39	7,706,741.27	5,483,395.35	4,574,802.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,576,874.24		

64,858,006.74

14,251,712.76	11,424,075.82	15,928,413.39	12,035,064.05	11,218,740.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	423,513.20	473,672.22	826,789.50	373,198.00	858,483.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,955,656.02		
8040	SLMB	10,591.96	13,331.67	16,872.58	3,135.34	517.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,448.92		
8050	QI1	1,075.12	95.19	0.00	511.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,681.88		
SUBTOTAL:	435,180.28	487,099.08	843,662.08	376,844.91	859,000.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,001,786.82		

TOTAL:	435,180.28	487,099.08	843,662.08	376,844.91	859,000.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,001,786.82		

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 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	102.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102.48		
1008	TANF 45-64 M & F WIT	0.00	0.00	22,210.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,210.23		
1009	TANF 65+ M & F WITH	0.00	0.00	4,215.20	6,322.80	6,531.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,069.00		
1011	TANF <1 M & F NON-ME	4,905.00	10,954.40	8,750.19	13,943.22	26,824.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,377.09		
1012	TANF 01-05 M & F NON	5,626.25	2,786.30	1,277.85	1,562.27	3,970.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,223.07		
1013	TANF 06-13 M & F NON	81,451.13	58,519.56	118,487.21	90,405.60	87,630.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		436,494.15		
1014	TANF 14-20 MALE NON-	42,132.88	29,288.97	33,590.99	38,137.38	30,326.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		173,476.88		
1015	TANF 14-20 FEMALE N	64,001.10	120,115.95	102,020.64	100,057.47	69,999.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00		456,194.49		
	O																
1016	TANF 21-44 MALE NON-	561,748.49	571,592.94	961,699.66	604,489.67	977,875.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,677,406.40		
1017	TANF 21-44 FEMALE N	2,302,618.57	2,186,765.49	3,294,841.16	2,675,063.02	2,898,300.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,357,589.14		
	O																
1018	TANF 45-64 M & F NON	545,048.85	491,200.28	994,927.74	702,988.29	936,687.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,670,852.94		
2100	SSI AGED WITH MEDIC	10,326.36	9,475.12	24,032.04	15,449.54	20,149.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,432.46		
	A																
2110	SSI AGED NON-MEDICA	5,557.30	5,133.50	16,103.90	11,521.38	3,181.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,497.15		
	R																
2120	SSI AGED WITH QMB	89,006.32	31,344.36	35,253.28	75,170.03	87,339.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318,113.12		
2200	SSI DISABLED WITH M	83,719.93	59,115.36	60,831.81	46,621.41	71,228.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321,516.67		
	E																
2210	SSI DISABLED NON-ME	2,058,289.49	1,884,225.92	2,254,730.95	1,681,143.94	2,175,928.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,054,318.66		
	D																
2220	SSI DISABLED WITH Q	339,374.02	322,783.65	373,624.51	324,036.72	528,720.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,888,539.33		
	M																
2310	SSI BLIND NON-MEDIC	18,109.19	36,079.45	24,510.44	35,785.32	70,438.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		184,923.13		
	A																
2320	SSI BLIND WITH QMB	337.66	8,098.45	511.59	32,128.21	41,322.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,398.48		
4311	SOBRA CHILD <1 M & F	9,013.41	6,950.60	7,985.24	9,734.34	6,480.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,164.45		
4312	SOBRA CHILD 01-05 M	298,186.88	150,684.59	277,660.34	162,264.21	166,010.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,054,806.87		
4313	SOBRA CHILD 06-13 M	3,085,169.05	2,267,798.12	2,809,204.93	2,339,823.27	2,434,935.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,936,930.88		
4314	SOBRA CHILD 14-20 MA	743,015.80	820,032.78	973,546.02	673,453.34	880,837.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,090,885.68		
4315	SOBRA CHILD 14-20 FE	845,608.70	867,812.66	1,009,568.80	729,754.98	834,451.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,287,196.37		
5013	SOBRA PREG 09-13 FE	0.00	0.00	0.00	0.00	519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		519.00		
	M																
5015	SOBRA PREG 14-20 FE	2,125.75	3,488.58	2,425.22	2,562.24	3,945.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,547.62		
	M																
5017	SOBRA PREG 21-44 FE	147,608.78	173,502.35	242,786.68	115,235.44	146,821.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		825,954.62		
	M																
SUBTOTAL:	11,342,980.91	10,117,749.38	13,654,796.62	10,487,756.57	12,510,456.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,113,740.36		

1106	TANF EXPANDED 21-44	0.00	0.00	17.97	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	65.07	55.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	13.62	0.00	1,946.05	0.00	583.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	230.94	5.59	9,013.27	5,695.54	7,992.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	1,142.07	611.90	1,586.16	1,627.42	559.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	272,049.59	175,061.87	281,363.54	263,129.24	366,265.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	458,809.63	514,553.07	935,673.82	568,045.27	749,898.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

17.97	
120.90	
2,543.00	
22,938.31	
5,527.39	
1,357,869.40	
3,226,980.66	

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1118	TANF EXPANDED 45-64	253,873.87	194,394.89	330,740.11	181,849.54	233,985.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,194,843.86		
1119	TANF EXPANDED 65+ M	0.00	0.00	0.00	335.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		335.08		
	&																
1126	TANF EXPANDED 21-44	1,710.63	1,166.27	2,317.05	739.10	1,880.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,813.31		
1127	TANF EXPANDED 21-44	15.12	15.12	0.00	327.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		358.10		
1128	TANF EXPANDED 45-64	18,358.18	11,238.13	25,467.96	20,429.52	11,286.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,780.13		
1129	TANF EXPANDED 65+ M	102.28	104.18	61,907.98	17,801.67	26,597.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,514.07		
	&																
2400	SSI AGED EXPANDED	0.00	0.00	0.00	7.82	9,801.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,808.89		
	WI																
2410	SSI AGED EXPANDED N	0.00	0.00	1,038.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,038.00		
	O																
2420	SSI AGED EXPANDED	69,367.06	45,800.06	32,700.12	29,715.01	164,642.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		342,225.21		
	WI																
2600	SSI DISABLED EXPAND	1,109.28	995.10	2,610.51	718.96	1,629.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,063.11		
	E																
2610	SSI DISABLED EXPAND	41,283.35	1,714.54	1,431.35	2,916.07	14,757.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,102.36		
	E																
2620	SSI DISABLED EXPAND	87,019.81	87,596.69	66,251.65	75,767.10	96,182.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		412,817.83		
	E																
SUBTOTAL:	1,205,085.43	1,033,322.48	1,754,121.37	1,169,105.20	1,686,063.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,847,697.58		

3514	ADULT 40-100% MALE 1	6,635.93	16,975.08	116,931.15	32,841.66	42,097.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	6,426.89	9,649.17	11,116.51	7,844.51	13,198.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	278,067.16	207,478.03	321,849.35	357,881.54	208,556.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	101,424.52	124,454.19	138,604.14	94,824.36	126,473.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	181,723.59	98,013.88	90,702.39	98,653.37	147,608.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	759.66	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	1,870.46	3,390.02	791.80	167.54	1,032.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	189,769.08	209,305.38	248,578.51	326,550.88	302,417.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	76,578.54	74,351.22	138,343.70	69,099.80	82,258.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	4,443,741.74	4,413,250.86	5,478,717.25	4,840,976.44	4,888,422.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	2,095,859.68	1,971,275.88	2,629,401.17	2,241,476.14	2,505,380.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	2,123,402.51	2,025,038.69	2,862,372.73	2,468,429.64	2,543,845.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	9,505,500.10	9,153,942.06	12,037,408.70	10,538,745.88	10,861,293.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

215,481.81	
48,235.88	
1,373,832.10	
585,780.90	
616,702.08	
759.66	
7,252.60	
1,276,621.70	
440,631.28	
24,065,109.28	
11,443,393.34	
12,023,089.29	
52,096,889.92	

3906	NEWLY ELIGIBLE MALE	310.70	37.04	23,722.10	8,716.90	8,935.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	84.18	33.70	798.93	38.32	171.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F
6	765.78	345.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	7,811.01	4,785.44	9,403.64	4,692.17	5,192.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	23,987.07	21,740.20	31,576.35	18,918.93	22,995.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	91,395.28	145,417.00	191,831.99	114,272.65	150,023.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	120,692.21	124,826.77	241,826.52	206,654.66	293,178.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	139,993.60	173,373.25	254,348.02	135,038.08	207,465.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	1,762.97	1,442.43	1,282.16	2,243.78	1,923.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

41,721.89	
1,126.18	
1,111.12	
31,884.60	
119,217.71	
692,940.03	
987,178.86	
910,217.98	
8,654.58	

FFS TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	386,802.80	472,001.17	754,789.71	490,575.49	689,883.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,794,052.95		

4413	SOBRA 100-133% M&F
6	122,467.39	68,119.05	89,856.83	57,358.28	65,309.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
4414	SOBRA 100-133% MALE	50,573.74	62,321.59	67,965.08	59,381.36	52,822.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
4415	SOBRA 100-133% FEMA L	33,189.36	38,442.32	32,477.64	17,271.82	10,983.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
SUBTOTAL:	206,230.49	168,882.96	190,299.55	134,011.46	129,115.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

403,110.66	
293,064.16	
132,365.00	
828,539.82	

4518

BC PATIENT FEMALE 4 5

519.00

519.00

519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	811.78	1,350.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	581.74	519.00	2,348.74	581.74	1,100.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	672.96	1,064.35	1,574.30	25,279.06	12,907.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,254.70	1,583.35	3,923.04	26,672.58	15,359.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,162.64	
5,131.96	
41,498.25	
48,792.85	

120,730,232.48

22,648,373.43	20,947,481.40	28,395,338.99	22,846,867.18	25,892,171.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	12,457.41	30,840.13	7,270.01	29,719.75	67,013.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,300.40		
1017	TANF 21-44 FEMALE N	70,091.96	48,521.90	37,027.06	81,355.38	18,856.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,853.27		
	O																
1018	TANF 45-64 M & F NON	0.00	9,671.26	19,755.39	16,022.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		45,449.64		
2200	SSI DISABLED WITH M	0.00	0.00	2,559.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,559.39		
	E																
2210	SSI DISABLED NON-ME	42,656.50	40,852.26	98,085.86	109,265.89	109,987.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		400,847.82		
	D																
2220	SSI DISABLED WITH Q	1,484.00	6,798.00	1,868.00	1,524.00	1,300.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,974.00		
	M																
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	8,531.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,531.30		
	M																
SUBTOTAL:	126,689.87	136,683.55	166,565.71	246,419.31	197,157.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		873,515.82		

1116	TANF EXPANDED 21-44	6,825.04	6,665.10	9,677.77	8,904.61	1,706.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	23,247.88	13,863.45	44,365.52	23,208.08	36,839.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	2,559.39	0.00	5,118.78	10,237.56	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	1,484.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	1,484.00	1,484.00	3,325.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	32,632.31	22,012.55	60,646.07	47,159.63	38,545.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

33,778.78	
141,523.97	
17,915.73	
1,484.00	
6,293.38	
200,995.86	

3516	ADULT 40-100% MALE 2	23,516.51	31,405.87	14,810.18	36,129.44	42,461.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	3,412.52	2,959.48	13,863.45	11,170.90	7,448.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	6,825.04	4,265.65	5,118.78	3,412.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	226,799.33	204,742.58	369,743.69	238,148.77	333,401.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	92,837.14	67,136.59	138,731.06	88,240.02	115,392.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	101,663.69	78,648.25	98,364.05	100,195.45	131,559.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	455,054.23	389,158.42	640,631.21	477,297.10	630,262.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

148,323.51	
38,854.51	
19,621.99	
1,372,835.50	
502,336.94	
510,430.67	
2,592,403.12	

3916	NEWLY ELIGIBLE MALE	31,043.50	11,943.82	39,990.60	38,070.97	57,193.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	36,684.59	19,755.39	5,971.91	6,505.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	15,356.34	29,558.76	24,337.56	1,706.26	5,412.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	83,084.43	61,257.97	70,300.07	46,282.39	62,605.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

178,242.13	
68,917.05	
76,371.04	
323,530.22	

8710

SSI DISABLED FREEDO M

4,265.65

4,265.65

0.00	0.00	4,265.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	0.00	4,265.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

S000	STATE-ONLY BHS	0.00	0.00	0.00	5,118.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	5,118.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,118.78

5,118.78

TOTAL:	697,460.84	609,112.49	942,408.71	822,277.21	928,570.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,999,829.45		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	3,498.18	46,815.64	3,826.51	342.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,483.17		
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	6,063.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,063.67		
	O																
1028	TANF 45-64 M & F WIT	1,926.51	4,854.96	3,906.23	972.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,659.85		
2100	SSI AGED WITH MEDIC	98,739.64	75,979.38	112,867.92	120,745.26	52,836.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		461,168.39		
	A																
2110	SSI AGED NON-MEDICA	221,793.66	73,454.17	58,967.17	66,735.86	118,878.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		539,829.73		
	R																
2120	SSI AGED WITH QMB	10,933.93	9,243.06	1,175.56	0.00	11,593.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,945.85		
2200	SSI DISABLED WITH M	54,393.61	73,203.41	70,926.99	71,537.79	95,895.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		365,957.66		
	E																
2210	SSI DISABLED NON-ME	-875.99	4,285.35	35,665.98	2,509.47	692.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,277.20		
	D																
2220	SSI DISABLED WITH Q	4,617.92	3,125.93	779.17	4,199.49	20,180.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,902.96		
	M																
5017	SOBRA PREG 21-44 FE	3,896.89	8,213.49	18,462.64	5,253.80	66.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,893.03		
	M																
SUBTOTAL:	398,924.35	299,175.39	306,578.17	272,296.66	306,206.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,583,181.51		

2610	SSI DISABLED EXPAND E	6,482.67	512.06	59.64	96.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,482.67	512.06	59.64	96.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,150.42

7,150.42

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	234.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	4,774.47	437.85	3,513.11	190.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	3,836.08	93.42	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	246.94	66.21	0.00	1,462.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	264,047.05	431,779.28	432,630.19	190,559.00	132,040.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	50,748.03	8,892.95	17,517.66	6,055.17	6,652.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	479,876.78	414,766.29	693,911.97	370,041.52	355,927.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	0.00	250.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	803,529.35	856,286.83	1,147,572.93	568,542.81	494,620.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

234.11	
8,916.20	
3,929.50	
1,775.39	
1,451,055.86	
89,866.40	
2,314,524.52	
250.83	
3,870,552.81	

3908	NEWLY ELIGIBLE M&F 4	0.00	75.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	12,373.56	16,755.86	34,543.13	4,961.72	20,212.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	16,017.70	29,935.32	2,063.35	13,363.67	6,186.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28,391.26	46,766.66	36,606.48	18,325.39	26,398.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

75.48	
88,846.55	
67,566.49	
156,488.52	

5,617,373.26

1,237,327.63	1,202,740.94	1,490,817.22	859,260.91	827,226.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 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	5,883.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,883.65		
SUBTOTAL:	0.00	0.00	0.00	0.00	5,883.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,883.65		

3716	ADULT <40% EXP MALE	0.00	466.52	0.00	1,574.95	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	5,135.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	466.52	0.00	1,574.95	5,135.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,041.47	
5,135.85	
7,177.32	

TOTAL:	0.00	466.52	0.00	1,574.95	11,019.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,060.97		

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 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	0.00	3,826.64	77.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,904.41		
1016	TANF 21-44 MALE NON-	3,461.80	40,823.31	4,974.07	0.00	151.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,410.99		
1017	TANF 21-44 FEMALE N	3,964.82	4,869.30	6,565.76	4,423.65	10,190.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,014.33		
	O																
1018	TANF 45-64 M & F NON	0.00	0.00	9,761.46	9.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,770.57		
2210	SSI DISABLED NON-ME	10,928.39	453.96	-166.20	866.51	13,401.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,483.73		
	D																
4314	SOBRA CHILD 14-20 MA	25,668.80	1,615.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,284.66		
SUBTOTAL:	44,023.81	47,762.43	24,961.73	5,377.04	23,743.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,868.69		

1114	TANF EXPANDED 14-20	1,673.02	9.02	65.55	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	29,141.17	241.47	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	2,686.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,673.02	29,150.19	2,993.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,747.59	
29,382.64	
2,686.58	
33,816.81	

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	11,814.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	57.36	383.76	11,329.39	6,431.74	4,963.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	23.32	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	9,233.09	0.00	0.00	4,353.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	27.06	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	5,160.65	7,186.98	4,221.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	33,660.99	53,727.97	67,680.64	79,535.70	47,551.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	739.50	3,504.90	17,526.29	21,065.42	5,648.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	14,476.50	22,588.30	37,018.74	6,461.28	38,360.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	48,934.35	89,465.08	138,739.03	120,681.12	116,912.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,814.17	
23,165.61	
23.32	
13,586.12	
27.06	
16,569.00	
282,156.53	
48,484.93	
118,905.09	
514,731.83	

3914	NEWLY ELIGIBLE MALE	0.00	35.37	218.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	6,339.89	373.62	8,304.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	0.00	15,700.83	31,078.02	62.53	661.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,339.89	16,109.82	39,601.42	62.53	661.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

254.05	
15,018.23	
47,503.21	
62,775.49	

757,192.82

206,295.78	126,120.69	141,317.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

100,971.07

182,487.52

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEMA L	6,474.45	8,419.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,894.00		
3716	ADULT <40% EXP MALE	0.00	0.00	638.13	12,903.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,541.64		
3717	ADULT <40% EXP FEMA L	0.00	945.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		945.71		
SUBTOTAL:	6,474.45	9,365.26	638.13	12,903.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,381.35		

3918

NEWLY ELIGIBLE M&F 4

123.63

123.63

0.00	123.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
0.00	123.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

TOTAL:	6,474.45	9,488.89	638.13	12,903.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,504.98		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 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	10,722.99	1,615.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,338.39		
2210	SSI DISABLED NON-ME	0.00	28,815.66	4,084.32	0.00	16,809.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,709.04		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	4,331.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,331.73		
	M																
4314	SOBRA CHILD 14-20 MA	255.05	4,452.12	0.00	182.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,889.21		
5017	SOBRA PREG 21-44 FE	1,094.71	2,920.89	5,217.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,233.18		
	M																
SUBTOTAL:	1,349.76	36,188.67	20,024.89	1,797.44	21,140.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,501.55		

3714	ADULT <40% EXP MALE	0.00	-69.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	63,239.22	10,923.87	12,529.00	21,390.84	19,199.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	397.62	369.92	0.00	0.00	15,358.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	1,917.96	46,698.86	24,287.91	64.90	15,988.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	65,554.80	57,923.37	36,816.91	21,455.74	50,546.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-69.28	
127,282.45	
16,126.29	
88,957.99	
232,297.45	

3916	NEWLY ELIGIBLE MALE	13,884.57	2,236.37	192.72	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	275.32	13,736.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,884.57	2,236.37	468.04	13,736.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,313.66	
14,012.10	
30,325.76	

36,989.96

0.00

0.00

0.00

TOTAL:

80,789.13

96,348.41

57,309.84

71,687.42

0.00

0.00

0.00

0.00

343,124.76

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 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	1,845.57	25,876.66	313.14	117.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,152.41		
SUBTOTAL:	0.00	1,845.57	25,876.66	313.14	117.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,152.41		

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	5,166.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	5,166.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,166.40

5,166.40

3516	ADULT 40-100% MALE 2	6,412.21	0.00	0.00	5,237.28	177.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	775.54	0.00	1,107.29	3,086.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	13,419.03	344.78	5,558.70	0.00	493.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	19,831.24	1,120.32	5,558.70	6,344.57	3,757.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,827.35	
4,969.24	
19,815.89	
36,612.48	

TOTAL:	19,831.24	2,965.89	31,435.36	11,824.11	3,874.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,931.29		

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4314	SOBRA CHILD 14-20 MA	0.00	3,010.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,010.12		
SUBTOTAL:	0.00	3,010.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,010.12		

3718	ADULT <40% EXP M&F 4	30,896.08	5,314.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,210.61	
SUBTOTAL:	30,896.08	5,314.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,210.61	
																
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	495.83	9.11	1,656.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,161.80	
SUBTOTAL:	0.00	0.00	495.83	9.11	1,656.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,161.80	
																
TOTAL:		30,896.08	8,324.65	495.83	9.11	1,656.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,382.53	

YUMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3718	ADULT <40% EXP M&F 4	0.00	0.00	0.00	-170.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-170.22		
SUBTOTAL:	0.00	0.00	0.00	-170.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-170.22		

TOTAL:	0.00	0.00	0.00	-170.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-170.22		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending November 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	1,038.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,038.00		
2100	SSI AGED WITH MEDIC	2,656,996.69	2,762,026.75	3,130,726.68	2,474,929.30	2,475,359.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,500,038.97		
	A																
2110	SSI AGED NON-MEDICA	178,092.13	183,838.11	146,870.10	124,194.15	108,431.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		741,425.88		
	R																
2120	SSI AGED WITH QMB	4,111,836.09	4,391,722.94	4,658,855.73	3,846,163.38	3,963,980.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,972,558.90		
2200	SSI DISABLED WITH M	399,573.10	455,641.98	525,687.24	388,274.54	432,642.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,201,819.78		
	E																
2210	SSI DISABLED NON-ME	3,562,198.42	4,371,156.23	4,415,400.55	3,168,188.82	3,639,296.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,156,240.87		
	D																
2220	SSI DISABLED WITH Q	1,026,312.95	1,007,788.62	1,183,265.75	952,334.50	867,333.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,037,034.83		
	M																
2310	SSI BLIND NON-MEDIC	0.00	1,820.00	1,415.68	479.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,193.68		
	A																
2320	SSI BLIND WITH QMB	731.80	10,880.62	5,798.46	1,777.74	1,906.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,094.84		
SUBTOTAL:	11,935,741.18	13,184,875.25	14,068,020.19	10,956,341.43	11,490,467.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,635,445.75		

8720	SSI DISABLED FREEDO M	3,521.28	3,521.28	3,521.28	4,401.60	3,082.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,521.28	3,521.28	3,521.28	4,401.60	3,082.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

18,047.52

18,047.52

61,653,493.27

11,939,262.46	13,188,396.53	14,071,541.47	10,960,743.03	11,493,549.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending November 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	0.00	-583.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-583.95		
2200	SSI DISABLED WITH M
E	0.00	0.00	-57.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-57.78		
2210	SSI DISABLED NON-ME D	127.43	3,517.92	1,418.78	0.00	68.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,132.55		
SUBTOTAL:	127.43	3,517.92	777.05	0.00	68.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,490.82		

TOTAL:	127.43	3,517.92	777.05	0.00	68.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,490.82		

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending November 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	18.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.04		
SUBTOTAL:	0.00	0.00	0.00	18.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.04		

18.04

0.00	0.00	0.00	18.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending November 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	9,991.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,991.55		
SUBTOTAL:	0.00	0.00	0.00	9,991.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,991.55		

TOTAL:	0.00	0.00	0.00	9,991.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,991.55		

PIMA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2200	SSI DISABLED WITH M E	0.00	161.45	0.00	0.00	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.53		
SUBTOTAL:	0.00	161.45	0.00	0.00	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00		175.53		

175.53

0.00	161.45	0.00	0.00	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PINAL COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	289.08	11,450.74	29,921.98	1,170.40	1,394.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,226.89		
SUBTOTAL:	289.08	11,450.74	29,921.98	1,170.40	1,394.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,226.89		

TOTAL:	289.08	11,450.74	29,921.98	1,170.40	1,394.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44,226.89		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending November 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	29,153.27	21,087.29		21,856.91		37,126.64		40,533.03		0.00		0.00		0.00		0.00		0.00	0.00		0.00	149,757.14

1013

1014

1015

1017

2210

2220

2310

4305

4312

4313

4314

4315

4325

5015

TANF 06-13 M & F NON TANF 14-20 MALE NON-
TANF 14-20 FEMALE N O
TANF 21-44 FEMALE N
O
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI BLIND NON-MEDIC
A
SOBRA CHILD 14-20 FE

SOBRA CHILD 01-05 M SOBRA CHILD 06-13 M SOBRA CHILD 14-20 MA SOBRA CHILD 14-20 FE SOBRA CHILD 14-20 FE
SOBRA PREG 14-20 FE M

91,066.17

5,228.32

5,475.16

0.00

173,115.72

0.00

4,120.81

0.00

157,326.02

399,774.67

25,904.55

14,245.41

60.16

0.00

51,026.88

4,431.35

5,342.85

0.00

125,794.88

0.00

1,176.86

30.08

111,327.12

177,621.98

13,026.73

6,872.40

0.00

0.00

47,818.32

4,752.40

4,993.58

0.00

133,327.71

0.00

473.50

0.00

99,245.24

205,347.01

18,187.11

9,131.42

0.00

0.00

94,962.32

8,855.55

5,683.72

0.00

252,867.20

512.35

3,427.34

0.00

177,308.85

398,372.60

30,810.36

12,461.72

0.00

0.00

136,044.10

11,088.59

8,746.28

7.25

329,879.22

0.00

3,422.63

0.00

212,878.67

524,772.66

42,121.88

18,855.29

0.00

41.55

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

420,917.79

34,356.21

30,241.59

7.25

1,014,984.73

512.35

12,621.14

30.08

758,085.90

1,705,888.92

130,050.63

61,566.24

60.16

41.55

SUBTOTAL:

905,470.26

517,738.42	545,133.20

1,022,388.65	1,328,391.15	0.00	0.00

0.00

0.00

0.00

0.00

0.00

4,319,121.68

163.66	0.00	441.98	0.00	36.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
163.66	0.00	441.98	0.00	36.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2610	SSI DISABLED EXPAND	 		642.26	
SUBTOTAL:		642.26	

E

3514	ADULT 40-100% MALE 1	140.34	0.00	77.55	276.03	181.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	106.33	104.74	0.00	68.47	48.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	79.56	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	731.76	987.15	361.71	387.49	379.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	313.22	69.69	90.71	77.02	378.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,371.21	1,161.58	529.97	809.01	988.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

675.29	
328.35	
79.56	
2,847.79	
929.31	
4,860.30	

3914	NEWLY ELIGIBLE MALE	42.18	0.00	11.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	34.23	0.00	0.00	22.82	105.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	76.41	0.00	11.41	22.82	105.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

53.59	
162.75	
216.34	

4413	SOBRA 100-133% M&F
6	82,220.16	38,167.34	38,948.73	72,538.71	101,128.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	5,272.95	3,158.75	4,123.25	5,942.35	8,374.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	1,573.92	856.33	2,411.40	2,051.96	3,511.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	89,067.03	42,182.42	45,483.38	80,533.02	113,014.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

333,003.57	
26,871.95	
10,405.21	
370,280.73	

4,695,121.31

996,148.57	561,082.42	591,599.94	1,103,753.50	1,442,536.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,189.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,189.20		
1010	TANF NON-MEDICARE	23,867.09	21,130.31	18,490.93	37,414.68	49,619.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,522.13		
2200	SSI DISABLED WITH M	2,547.47	1,921.95	942.37	1,659.83	2,202.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,274.20		
	E																
2210	SSI DISABLED NON-ME	966,696.62	654,574.85	724,198.91	1,296,862.59	1,753,486.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,395,819.19		
	D																
2220	SSI DISABLED WITH Q	3,663.92	3,004.47	2,057.76	797.68	1,645.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,169.54		
	M																
2310	SSI BLIND NON-MEDIC	187.21	145.89	944.52	1,539.66	3,660.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,477.65		
	A																
SUBTOTAL:	998,151.51	680,777.47	746,634.49	1,338,274.44	1,810,614.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,574,451.91		

TOTAL:	998,151.51	680,777.47	746,634.49	1,338,274.44	1,810,614.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,574,451.91		

ACC REINSURANCE
For The Period Ending November 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	26,023.34	-26,023.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	-9,742.00	2,360.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-7,381.92		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	7,407.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,407.77		
1011	TANF <1 M & F NON-ME	387,004.03	825,313.76	1,050,953.88	792,077.13	1,143,968.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,199,317.05		
1012	TANF 01-05 M & F NON	219,605.16	48,868.07	87,834.76	-24,221.41	564,671.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		896,758.15		
1013	TANF 06-13 M & F NON	143,739.01	225,159.36	342,722.34	286,015.36	357,865.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,355,501.98		
1014	TANF 14-20 MALE NON-	79,170.51	522,389.71	204,866.45	241,961.66	132,744.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,181,132.46		
1015	TANF 14-20 FEMALE N	-530,028.71	592,137.54	358,417.57	153,705.39	480,314.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,054,546.56		
	O																
1016	TANF 21-44 MALE NON-	299,099.48	449,500.21	468,492.48	288,542.51	64,928.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,570,563.58		
1017	TANF 21-44 FEMALE N	263,457.21	511,045.35	184,348.08	884,786.44	172,730.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,016,367.52		
	O																
1018	TANF 45-64 M & F NON	1,651.63	401,313.63	153,928.36	266,957.26	301,898.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,125,749.72		
1019	TANF 65+ M & F NON-M	37,390.48	0.00	0.00	16,144.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,534.66		
2100	SSI AGED WITH MEDIC	24,312.30	16,698.38	22,574.32	239,444.83	52,168.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355,198.04		
	A																
2110	SSI AGED NON-MEDICA	202,250.07	225,724.82	194,027.46	240,847.48	49,115.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00		911,965.00		
	R																
2200	SSI DISABLED WITH M	53,510.85	95,381.23	97,192.30	49,047.40	7,039.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302,171.51		
	E																
2210	SSI DISABLED NON-ME	7,259,098.00	5,527,724.78	6,037,747.18	6,310,907.27	5,343,030.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,478,507.48		
	D																
2310	SSI BLIND NON-MEDIC	19,560.32	29,509.77	26,853.29	28,824.76	25,349.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,098.13		
	A																
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	8,221.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,221.93		
4311	SOBRA CHILD <1 M & F	1,850,869.89	3,134,102.30	2,626,960.83	2,335,680.58	672,909.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,620,523.31		
4312	SOBRA CHILD 01-05 M	779,395.01	1,066,279.07	-129,925.64	3,691,086.51	450,542.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,857,377.51		
4313	SOBRA CHILD 06-13 M	3,683,616.19	1,395,973.56	1,259,934.25	1,117,710.77	1,861,500.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,318,735.15		
4314	SOBRA CHILD 14-20 MA	859,529.87	1,127,354.33	886,840.97	1,195,205.19	1,234,020.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,302,951.05		
4315	SOBRA CHILD 14-20 FE	443,365.60	402,560.90	279,339.42	391,832.75	445,325.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,962,423.97		
5015	SOBRA PREG 14-20 FE	97,527.92	-28.98	-2,902.18	5.23	4,278.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,880.50		
	M																
5017	SOBRA PREG 21-44 FE	39,140.95	-482.98	171,036.30	4,144.65	73,802.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287,641.07		
	M																
SUBTOTAL:	16,203,523.77	16,598,884.89	14,321,242.42	18,544,137.05	13,420,404.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,088,192.18		

3100

TRANSPLANT OPTION 1

52,502.80

52,502.80

52,502.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
52,502.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

1106	TANF EXPANDED 21-44	0.00	12.88	0.00	0.00	87.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	36.86	71.15	37.56	12.10	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	19.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	105.76	623.96	358.97	0.00	0.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	145,844.18	274,112.45	117,332.35	447,863.20	165,737.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	261,613.22	227,437.15	209,902.26	283,627.40	333,655.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	294,930.77	449,226.15	203,686.40	253,376.86	120,044.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

100.02	
157.67	
19.43	
1,088.70	
1,150,889.60	
1,316,235.38	
1,321,264.55	

ACC REINSURANCE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	SSI AGED EXPANDED WI	-72,844.44	86,521.49	-42,799.09	202.11	11.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-28,908.75		
2410	SSI AGED EXPANDED N
O	0.00	5,416.60	81,462.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,878.86		
2600	SSI DISABLED EXPAND E	774.39	19,691.00	89,494.48	4,054.69	-42,816.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,198.15		
2610	SSI DISABLED EXPAND
E	5,792.60	377,120.15	18,303.26	113,137.66	80,068.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		594,422.15		
SUBTOTAL:	636,216.48	1,440,198.69	677,812.04	1,102,318.91	656,799.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,513,345.76		

3508	ADULT 40-100% M&F 45	2,565.88	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	77,957.72	100,633.40	191,656.52	67,711.66	58,079.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	25,736.61	20,014.15	77.43	20,051.19	31,648.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	348,938.56	289,328.58	604,804.85	454,102.58	235,666.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	101,009.97	226,175.55	37,660.57	117,370.16	81,347.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	975,205.30	1,273,861.24	486,674.85	938,264.03	701,095.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	-954.60	0.00	0.00	13,396.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	-1,770.62	10,391.20	0.00	1,135.71	-1,135.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	17,983.99	0.00	-17,210.32	77,139.37	-72,677.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	95,231.87	116,706.62	138,464.69	109,107.32	-19,413.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	7,172.81	5,208.09	65,079.84	36,674.55	359,586.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	2,133,629.17	3,139,989.82	1,640,933.84	2,968,790.20	2,488,819.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	310,370.74	947,673.73	413,033.48	903,648.55	646,530.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	2,518,651.72	3,508,510.00	2,670,625.29	3,834,034.87	3,094,551.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,611,729.12	9,638,492.38	6,231,801.04	9,541,426.61	7,604,099.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,565.88	
496,038.48	
97,527.51	
1,932,841.36	
563,563.83	
4,375,100.79	
12,441.82	
8,620.58	
5,235.87	
440,097.00	
473,721.83	
12,372,162.98	
3,221,256.90	
15,626,373.40	
39,627,548.23	

3906	NEWLY ELIGIBLE MALE	-752.29	757.99	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	475.99	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	-5,101.89	364.27	126.19	1,132.51	1,170.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	-94.89	1,733.52	7,826.76	24,020.92	-104,289.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	113,111.60	96,419.13	30,309.85	147,839.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	212,173.30	186,229.89	592,799.98	305,378.93	110,585.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	-71,941.78	724,590.55	299,249.50	367,089.84	270,007.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	268,129.98	767,859.53	517,519.66	665,960.60	344,337.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	402,888.42	1,794,647.35	1,513,941.22	1,393,892.65	769,651.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5.70	
475.99	
-2,308.32	
-70,803.14	
387,680.49	
1,407,167.20	
1,588,995.33	
2,563,807.46	
5,875,020.71	

4413	SOBRA 100-133% M&F
6	1,081,973.95	316,533.84	164,632.00	500,536.04	926,834.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	275,120.22	349,953.71	236,665.37	118,963.50	101,287.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	90,194.19	35,082.85	16,267.47	72,860.77	184,220.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,447,288.36	701,570.40	417,564.84	692,360.31	1,212,342.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,990,510.50	
1,081,989.81	
398,625.66	
4,471,125.97	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

0.00

0.00

33,195.52

0.00

0.00	0.00

0.00

0.00

0.00

0.00

33,195.52

ACC REINSURANCE
For The Period Ending November 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	10,200.21	0.00	10,570.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,770.99		
SUBTOTAL:	0.00	10,200.21	0.00	10,570.78	33,195.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,966.51		

8700	SSI DISABLED FREEDO M	10.08	11.93	25.88	170.47	787.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	20,406.89	0.00	7,834.36	27,039.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,416.97	11.93	7,860.24	27,209.50	787.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,005.60	
55,280.28	
56,285.88	

133,737,988.04

23,170,221.80	31,311,915.81	23,697,278.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

25,374,565.92

30,184,005.85

LONG TERM CARE REINSURANCE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	86,884.32	98,109.76	89,407.68	88,264.98	84,343.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		447,009.96		
2100	SSI AGED WITH MEDIC	84,134.87	290,782.74	147,944.75	381,822.47	56,672.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00		961,357.48		
	A																
2110	SSI AGED NON-MEDICA	56,842.01	-26,366.84	78,327.52	832.41	-26,593.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,041.56		
	R																
2200	SSI DISABLED WITH M	455,169.54	338,840.81	137,969.98	840,107.26	426,955.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,199,042.63		
	E																
2210	SSI DISABLED NON-ME	5,712,874.90	5,576,297.01	4,277,320.87	6,750,037.87	10,283,541.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,600,071.80		
	D																
SUBTOTAL:	6,395,905.64	6,277,663.48	4,730,970.80	8,061,064.99	10,824,918.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,290,523.43		

8710

SSI DISABLED FREEDO M

349,223.01

349,223.01

127,089.85	41,854.60	137,042.44	24,227.16	19,008.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
127,089.85	41,854.60	137,042.44	24,227.16	19,008.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

TOTAL:	6,522,995.49	6,319,518.08	4,868,013.24	8,085,292.15	10,843,927.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,639,746.44		

ACC SMIB
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	39,369.80	35,629.80	39,991.40	39,204.00	39,204.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193,399.00		
1010	TANF NON-MEDICARE	445.50	594.00	594.00	594.00	594.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,821.50		
1020	TANF WITH QMB	51,959.40	48,407.10	44,272.50	48,708.00	51,388.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,735.80		
2100	SSI AGED WITH MEDIC	92,265.00	95,363.60	93,915.60	93,204.50	97,225.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471,974.40		
	A																
2110	SSI AGED NON-MEDICA	584,071.10	596,524.30	575,977.90	592,815.90	576,492.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,925,881.80		
	R																
2120	SSI AGED WITH QMB	5,641,680.60	5,755,233.20	5,735,701.30	5,816,695.90	5,868,298.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,817,609.60		
2200	SSI DISABLED WITH M	99,770.80	98,655.00	92,255.60	97,400.50	103,660.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		491,742.70		
	E																
2210	SSI DISABLED NON-ME	503,769.90	509,549.70	506,306.10	524,841.60	494,707.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,539,174.50		
	D																
2220	SSI DISABLED WITH Q	4,323,045.10	4,318,566.90	4,337,725.80	4,341,389.60	4,326,630.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,647,357.70		
	M																
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	594.00	148.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		742.50		
2310	SSI BLIND NON-MEDIC	4,455.00	2,177.80	4,603.50	4,752.00	4,603.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,591.80		
	A																
2320	SSI BLIND WITH QMB	38,910.90	39,352.50	41,134.50	41,283.00	43,061.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,742.00		
4320	SOBRA CHILD WITH Q	1,039.50	891.00	594.00	1,782.00	891.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,197.50		
	MB																
5020	SOBRA PREGNANT WO	3,861.00	4,888.80	4,900.50	3,861.00	3,118.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,629.80		
	MAN																
8020	QMB ONLY	1,050,878.90	1,054,919.70	1,043,080.30	1,042,820.20	1,045,476.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,237,175.10		
8040	SLMB	6,483,083.80	6,541,858.20	6,524,451.00	6,541,455.10	6,580,667.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,671,515.90		
8888	SMIB ONLY NOT ELIGIB	-17,559.20	-14,668.20	-20,626.30	-14,115.00	-30,842.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-97,811.20		
9999	SMIB ONLY NOT ELIGIB	120,096.40	308,510.70	248,682.00	286,289.40	218,558.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,182,136.50		
SUBTOTAL:	19,021,143.50	19,396,454.10	19,273,559.70	19,463,575.70	19,423,883.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,578,616.90		

1100	TANF EXPANDED FPR FI	259,941.30	264,920.70	266,025.50	262,408.00	270,836.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1110	TANF EXPANDED FOR
FI	148.50	148.50	148.50	445.50	297.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	1,108,237.20	1,117,422.10	1,111,355.50	1,113,077.80	1,122,773.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED
WI	34,517.10	35,398.60	29,822.00	33,056.10	30,813.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N O	594.00	594.00	742.50	1,188.00	594.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	4,713,624.40	4,765,251.90	4,780,672.20	4,808,361.60	4,858,162.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED W	0.00	148.50	148.50	148.50	148.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED
W	1,633.50	3,118.50	4,455.00	6,979.50	7,682.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	27,007.50	25,987.50	26,433.00	25,096.50	22,275.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	2,569,525.90	2,589,746.60	2,549,480.90	2,573,483.00	2,553,456.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8,715,229.40	8,802,736.90	8,769,283.60	8,824,244.50	8,867,038.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,324,131.50	
1,188.00	
5,572,866.40	
163,606.80	
3,712.50	
23,926,073.00	
594.00	
23,868.50	
126,799.50	
12,835,692.70	
43,978,532.90	

3520	ADULT 40-100% FOR FI	7,385.00	7,682.00	7,682.00	8,573.00	9,315.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	13,028.00	16,134.80	14,227.70	14,216.00	16,205.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	20,413.00	23,816.80	21,909.70	22,789.00	25,520.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

40,637.50	
73,811.50	
114,449.00	

3920	NEWLY ELIGIBLE FOR F	14,107.50	14,701.50	15,147.00	15,741.00	19,378.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

79,075.50

ACC SMIB
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	14,107.50	14,701.50	15,147.00	15,741.00	19,378.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,075.50		

8620	SSI BLIND FREEDOM/W O	148.50	594.00	297.00	148.50	148.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO
M	82,920.90	83,972.10	85,312.50	84,273.00	87,540.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	83,069.40	84,566.10	85,609.50	84,421.50	87,688.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,336.50	
424,018.50	
425,355.00	

141,176,029.30

27,853,962.80	28,322,275.40	28,165,509.50	28,410,771.70	28,423,509.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC HIB
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1020	TANF WITH QMB	1,931.10	1,931.10	1,413.00	423.90	3,297.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,996.10		
2100	SSI AGED WITH MEDIC	-471.00	3,768.00	2,355.00	471.00	2,355.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,478.00		
	A																
2110	SSI AGED NON-MEDICA	1,413.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,413.00		
	R																
2120	SSI AGED WITH QMB	749,466.20	786,766.40	796,893.00	787,737.60	769,868.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,890,731.60		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	471.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471.00		
	E																
2210	SSI DISABLED NON-ME	0.00	1,413.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,413.00		
	D																
2220	SSI DISABLED WITH Q	340,500.60	353,217.20	366,650.00	374,218.80	367,848.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,802,434.90		
	M																
2320	SSI BLIND WITH QMB	3,085.00	3,085.00	3,085.00	3,085.00	3,085.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,425.00		
8020	QMB ONLY	7,559.20	6,570.20	7,512.20	7,041.20	6,570.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,253.00		
9999	SMIB ONLY NOT ELIGIB	-9,496.40	-7,488.90	-3,132.00	-70.70	-13,588.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-33,776.30		
SUBTOTAL:	1,093,987.70	1,149,262.00	1,174,776.20	1,173,377.80	1,139,435.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,730,839.30		

1100	TANF EXPANDED FPR FI	0.00	0.00	989.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR
FI	942.00	942.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	4,498.00	4,498.00	4,498.00	4,498.00	5,440.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,440.00	5,440.00	5,487.10	4,498.00	5,440.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

989.10	
1,884.00	
23,432.00	
26,305.10	

TOTAL:	1,099,427.70	1,154,702.00	1,180,263.30	1,177,875.80	1,144,875.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,757,144.40		

Q1
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	3,100,161.50	3,109,499.40	3,122,018.70	3,139,698.30	3,134,260.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,605,638.70		
9999	SMIB ONLY NOT ELIGIB	86,723.80	87,154.30	82,169.50	78,505.90	71,671.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		406,224.50		
SUBTOTAL:	3,186,885.30	3,196,653.70	3,204,188.20	3,218,204.20	3,205,931.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,011,863.20		

16,011,863.20

3,186,885.30	3,196,653.70	3,204,188.20	3,218,204.20	3,205,931.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC SMIB
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC	994,059.60	997,938.00	998,255.70	1,008,503.40	1,003,832.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,002,589.50		
	A																
2110	SSI AGED NON-MEDICA	225,559.80	224,680.50	216,938.10	227,947.50	228,096.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,123,221.90		
	R																
2120	SSI AGED WITH QMB	1,292,480.80	1,286,470.40	1,286,966.60	1,280,256.50	1,271,630.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,417,804.60		
2200	SSI DISABLED WITH M	379,137.50	380,173.10	379,796.00	385,058.00	388,409.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,912,573.60		
	E																
2210	SSI DISABLED NON-ME	5,197.50	6,979.50	15,163.50	7,425.00	7,128.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,893.50		
	D																
2220	SSI DISABLED WITH Q	1,183,704.60	1,185,937.20	1,173,353.60	1,179,739.00	1,172,663.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,895,397.90		
	M																
2300	SSI BLIND WITH MEDIC	445.50	742.50	891.00	1,485.00	1,633.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,197.50		
2320	SSI BLIND WITH QMB	891.00	1,930.50	3,118.50	3,861.00	4,603.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,404.50		
SUBTOTAL:	4,081,476.30	4,084,851.70	4,074,483.00	4,094,275.40	4,077,996.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,413,083.00		

8720	SSI DISABLED FREEDO M	2,970.00	3,267.00	2,970.00	2,970.00	2,970.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,970.00	3,267.00	2,970.00	2,970.00	2,970.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

15,147.00

15,147.00

TOTAL:	4,084,446.30	4,088,118.70	4,077,453.00	4,097,245.40	4,080,966.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,428,230.00		

LTC HIB
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC A	-989.10	1,413.00	942.00	235.50	-47.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,554.30		
2120	SSI AGED WITH QMB	369,762.40	362,538.00	369,943.90	361,282.30	362,859.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,826,386.40		
2200	SSI DISABLED WITH M E	471.00	-471.00	942.00	730.00	-259.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,413.00		
2220	SSI DISABLED WITH Q
M	3,297.00	5,440.00	5,016.10	4,545.10	7,324.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,622.20		
SUBTOTAL:	372,541.30	368,920.00	376,844.00	366,792.90	369,877.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,854,975.90		

1,854,975.90

372,541.30	368,920.00	376,844.00	366,792.90	369,877.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	28.26	3,258.52	8,819.97	0.00	1,038.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,144.75		
1007	TANF 21-44 FEMALE WI	1,061.40	2,994.24	1,644.07	2,050.98	4,089.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,839.88		
1008	TANF 45-64 M & F WIT	11,881.80	9,793.67	31,205.96	5,027.02	9,501.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,409.87		
1009	TANF 65+ M & F WITH	4,333.46	9,212.25	10,094.10	3,648.79	14,627.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,916.24		
1011	TANF <1 M & F NON-ME	525,201.59	613,922.09	736,678.46	481,331.69	515,193.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,872,327.17		
1012	TANF 01-05 M & F NON	169,929.14	310,833.38	332,843.42	204,676.49	250,955.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,269,237.57		
1013	TANF 06-13 M & F NON	296,826.59	526,741.64	614,784.21	397,757.29	512,384.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,348,494.47		
1014	TANF 14-20 MALE NON-	154,040.74	222,795.34	215,330.97	124,809.64	161,560.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		878,536.73		
1015	TANF 14-20 FEMALE N	197,282.57	308,878.29	423,150.58	220,744.15	318,551.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,468,607.58		
	O																
1016	TANF 21-44 MALE NON-	1,210,201.69	1,532,829.24	1,713,368.51	1,080,178.07	1,215,559.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,752,136.79		
1017	TANF 21-44 FEMALE N	4,472,336.01	6,569,310.75	7,193,052.60	3,491,928.67	5,311,032.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,037,660.70		
	O																
1018	TANF 45-64 M & F NON	2,199,689.96	3,261,208.69	3,200,237.85	1,329,528.27	2,469,993.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,460,658.60		
1019	TANF 65+ M & F NON-M	29,568.92	16,943.08	13,494.00	4,222.41	9,744.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73,973.19		
1026	TANF 21-44 MALE WITH	1,038.00	0.00	1,038.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,076.00		
1027	TANF 21-44 FEMALE WI	1,787.67	2,277.92	2,096.76	208.10	3,984.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,354.50		
1028	TANF 45-64 M & F WIT	4,427.76	12,707.27	4,195.62	2,276.68	3,496.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,103.74		
1029	TANF 65+ M & F WITH	3,849.95	3,316.13	4,884.13	356.92	6,053.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,461.03		
2100	SSI AGED WITH MEDIC	91,253.04	127,115.47	160,678.72	34,338.80	154,505.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		567,891.50		
	A																
2110	SSI AGED NON-MEDICA	162,099.48	234,117.25	266,337.32	96,438.97	209,759.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		968,752.42		
	R																
2120	SSI AGED WITH QMB	494,968.66	813,541.23	625,538.14	179,336.10	532,240.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,645,624.52		
2200	SSI DISABLED WITH M	355,126.49	407,617.53	349,163.59	110,709.42	253,368.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,475,985.55		
	E																
2210	SSI DISABLED NON-ME	4,659,596.11	6,780,318.19	6,359,869.97	3,029,657.33	4,942,570.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,772,012.17		
	D																
2220	SSI DISABLED WITH Q	676,032.85	1,109,381.07	824,558.41	263,321.80	726,470.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,599,764.42		
	M																
2300	SSI BLIND WITH MEDIC	807.30	6,282.05	3,343.23	93.82	5,776.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,302.79		
2310	SSI BLIND NON-MEDIC	80,164.12	120,088.45	90,468.26	47,831.64	133,124.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		471,676.59		
	A																
2320	SSI BLIND WITH QMB	10,927.99	9,036.92	7,520.25	4,341.44	15,326.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,153.59		
4311	SOBRA CHILD <1 M & F	958,167.28	1,020,153.99	1,232,627.59	811,668.78	934,721.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,957,339.32		
4312	SOBRA CHILD 01-05 M	2,262,702.71	3,352,754.76	3,918,981.04	2,307,766.19	2,934,790.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,776,994.76		
4313	SOBRA CHILD 06-13 M	3,614,416.23	5,340,669.27	6,432,454.94	4,154,587.18	4,951,706.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,493,834.19		
4314	SOBRA CHILD 14-20 MA	1,173,154.71	1,783,722.81	2,292,553.53	1,472,768.00	1,685,963.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,408,163.04		
4315	SOBRA CHILD 14-20 FE	1,484,565.14	2,315,420.17	2,746,937.21	1,623,730.90	1,842,277.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,012,931.29		
5007	SOBRA PREG 21-44 FE	132.57	1,038.00	804.40	11.02	1,159.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,145.42		
	M																
5013	SOBRA PREG 09-13 FE	519.00	0.00	0.00	0.00	1,895.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,414.02		
	M																
5015	SOBRA PREG 14-20 FE	127,286.50	223,424.67	217,271.20	99,516.91	147,840.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		815,340.16		
	M																
5017	SOBRA PREG 21-44 FE	927,060.14	1,143,505.54	1,368,545.76	757,393.94	1,077,469.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,273,974.86		
	M																
5018	SOBRA PREG 45-64 FE	-1,789.32	4,839.32	2,076.00	519.00	2,012.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,657.00		
	M																

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	26,360,676.51	38,200,049.19	41,406,648.77	22,342,776.41	31,360,745.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,670,896.42		

1106	TANF EXPANDED 21-44	2,141.13	6,248.87	4,831.25	1,996.36	3,484.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	3,768.06	4,757.95	2,979.96	959.55	1,778.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	19,652.04	43,930.14	31,828.78	10,887.09	27,668.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	27,288.27	51,442.24	33,629.57	7,856.53	26,255.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	519.00	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	1,981.86	1,555.74	2,735.97	0.00	519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	26,621.95	30,863.61	30,613.19	20,366.02	31,445.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	604,674.80	971,127.14	1,076,231.31	497,025.15	628,958.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	2,271,266.97	3,191,420.16	3,426,016.46	1,757,992.87	2,598,802.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	1,569,030.92	2,269,021.84	2,258,563.91	847,565.83	1,622,696.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	11,937.00	19,658.75	16,480.00	7,785.00	22,087.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	7,561.31	14,386.47	7,040.11	5,495.26	9,450.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	17,413.86	24,887.45	14,916.40	6,891.09	10,952.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	70,166.43	115,595.00	80,480.48	24,417.72	62,582.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	76,465.14	123,669.50	83,597.78	26,889.21	79,724.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	5,874.59	11,160.02	11,556.25	6,265.35	15,633.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	27,794.17	46,691.46	22,387.57	11,930.85	23,538.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	398,264.41	708,169.48	488,600.44	159,454.96	469,469.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED
W	0.00	317.98	1,260.60	433.24	768.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	5,884.00	7,018.57	12,600.34	9,963.07	24,018.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND
E	89,695.00	133,083.14	104,157.90	31,228.81	72,078.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	196,173.58	317,376.45	223,308.00	66,762.96	204,896.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,434,174.49	8,092,381.96	7,933,816.27	3,502,166.92	5,936,809.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

18,702.53	
14,243.68	
133,966.77	
146,472.08	
519.00	
6,792.57	
139,910.62	
3,778,016.51	
13,245,499.09	
8,566,879.29	
77,947.83	
43,933.48	
75,060.96	
353,241.82	
390,345.65	
50,489.55	
132,342.75	
2,223,958.93	
2,780.77	
59,484.19	
430,243.49	
1,008,517.17	
30,899,348.73	

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

3506	ADULT 40-100% MALE 2	165.60	896.30	992.99	248.40	1,252.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3507	ADULT 40-100% FEMAL E	1,038.00	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	3,598.57	6,022.17	7,409.66	141.10	3,940.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	4,057.01	3,872.90	4,959.57	1,838.72	5,282.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	69,387.94	79,951.30	95,542.99	59,276.59	55,194.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	102,402.53	94,821.55	112,513.09	56,549.09	101,620.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	701,144.58	981,566.21	1,025,560.17	523,661.69	798,362.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	538,146.16	761,032.73	891,240.94	378,639.16	647,516.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,555.53	
1,038.00	
21,112.49	
20,010.73	
359,353.80	
467,906.41	
4,030,295.29	
3,216,575.78	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	1,749,351.18	2,933,041.61	2,478,573.89	1,097,639.56	1,879,311.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,137,917.50		
3519	ADULT 40-100% M&F 65	1,631.66	2,076.00	7,381.21	2,076.00	3,633.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,797.87		
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	801.43	233.89	614.86	299.60	831.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,781.14		
3706	ADULT <40% EXP MALE	1,369.20	5,371.87	1,948.80	750.93	497.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,938.48		
3707	ADULT <40% EXP FEMA	1.99	2,403.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,404.99		
	L																
3708	ADULT <40% EXP M&F	8,384.38	27,515.76	20,025.60	8,894.22	17,830.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,650.17		
	4																
3709	ADULT <40% EXP M&F	1,175.38	1,838.48	1,804.43	1,801.09	1,168.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,788.10		
	6																
3714	ADULT <40% EXP MALE	235,096.31	292,525.63	448,953.34	195,179.59	234,271.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,406,026.82		
3715	ADULT <40% EXP FEMA	335,188.89	489,997.28	592,804.11	289,302.05	402,079.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,109,372.20		
	L																
3716	ADULT <40% EXP MALE	4,579,667.99	6,357,477.99	6,759,088.48	3,551,005.23	4,818,105.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,065,345.40		
3717	ADULT <40% EXP FEMA	2,509,368.33	3,815,962.31	3,939,465.60	2,162,312.28	2,818,166.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,245,275.07		
	L																
3718	ADULT <40% EXP M&F	6,960,484.70	10,920,556.14	9,910,748.46	5,080,458.75	7,905,238.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,777,486.34		
	4																
3719	ADULT <40% EXP M&F	4,267.21	9,570.80	6,247.52	612.85	10,917.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,615.66		
	6																
3726	ADULT <40% EXP MALE	0.00	89.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		89.78		
3728	ADULT <40% EXP M&F	1,701.99	1,864.92	2,257.08	2,731.12	3,593.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,149.06		
	4																
SUBTOTAL:	17,808,431.03	26,788,688.62	26,308,132.79	13,413,418.02	19,708,816.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		104,027,486.61		

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	751.58	1,054.45	304.42	17.98	890.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	737.72	455.00	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	16,070.55	27,952.59	22,844.56	15,286.33	29,377.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	21,413.98	28,515.33	30,231.74	13,869.40	24,853.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	40,125.82	44,615.64	50,062.71	36,082.00	47,758.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	64,491.39	71,696.34	106,084.49	54,459.47	74,157.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	535,939.67	754,062.16	908,490.15	443,663.90	599,677.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	997,769.63	1,507,925.27	1,519,017.72	831,472.02	1,339,770.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,810,663.52	2,715,173.32	2,387,906.20	1,178,639.66	1,957,489.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	5,797.52	3,114.00	3,633.00	3,633.00	3,713.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	76.36	0.00	1,058.89	119.42	519.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F
6	755.41	775.26	373.04	204.89	747.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,494,593.15	5,155,339.36	5,030,525.92	2,577,448.07	4,079,473.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

519.00	
3,019.11	
1,192.72	
111,531.90	
118,883.83	
218,644.74	
370,889.09	
3,241,833.19	
6,195,955.23	
10,049,872.27	
19,890.52	
519.00	
1,773.67	
2,856.07	
20,337,380.34	

4413	SOBRA 100-133% M&F
6	329,247.64	475,397.11	668,840.08	432,812.49	458,840.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	109,006.07	210,348.00	261,621.65	162,138.67	216,638.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	171,230.65	249,819.01	301,954.69	187,754.46	215,470.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,365,137.89	
959,752.61	
1,126,229.03	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	609,484.36	935,564.12	1,232,416.42	782,705.62	890,949.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,451,119.53		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
4518	BC PATIENT FEMALE 4
5	1,557.00	3,401.00	3,896.43	1,477.00	3,593.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
SUBTOTAL:	1,557.00	3,401.00	4,375.43	1,477.00	3,593.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

479.00	
13,924.43	
14,403.43	

8700	SSI DISABLED FREEDO M	14,610.46	23,510.46	16,676.32	4,767.20	14,279.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	11,418.00	29,128.18	16,568.00	8,304.00	14,093.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	1,971.00	1,805.95	5,663.21	459.24	2,313.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	27,999.46	54,444.59	38,907.53	13,530.44	30,685.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

73,843.48	
79,511.18	
12,212.66	
165,567.32	

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:	53,736,916.00	79,229,868.84	81,954,823.13	42,633,522.48	62,011,071.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		319,566,202.38		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	26,047.91	39,808.93	44,537.62	32,003.21	36,652.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		179,050.50		
8040	SLMB	438.70	305.87	1,035.48	610.39	246.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,636.44		
8050	QI1	8.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.90		
SUBTOTAL:	26,495.51	40,114.80	45,573.10	32,613.60	36,898.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,695.84		

32,613.60

0.00

0.00

0.00

TOTAL:

26,495.51

40,114.80

45,573.10

36,898.83

0.00

0.00

0.00

0.00

181,695.84

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	5,411.00	6,785.83	105,698.13	1,216.37	21,646.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,758.23		
1012	TANF 01-05 M & F NON	99.89	860.92	630.84	0.00	150.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,742.32		
1013	TANF 06-13 M & F NON	0.00	0.00	89.47	100.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189.47		
1014	TANF 14-20 MALE NON-	0.00	0.00	87.21	0.00	151.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239.14		
1015	TANF 14-20 FEMALE N	2,590.30	141.65	0.00	0.00	70.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,802.09		
	O																
1016	TANF 21-44 MALE NON-	1,114.79	8,635.85	15,957.91	9,395.62	5,385.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,489.26		
1017	TANF 21-44 FEMALE N	2,043.82	4,803.99	3,331.64	949.05	3,808.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,937.36		
	O																
1018	TANF 45-64 M & F NON	13,225.63	12,087.26	1,374.68	6,354.16	4,507.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,549.41		
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	675.30	1,444.79	768.38	1,707.96	722.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,318.64		
	A																
2110	SSI AGED NON-MEDICA	1,794.27	46,370.20	18,360.68	5,170.30	9,861.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,556.70		
	R																
2120	SSI AGED WITH QMB	1,010.93	1,323.05	34.20	736.78	146.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,251.46		
2200	SSI DISABLED WITH M	552.93	1,456.66	2,901.31	1,763.21	550.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,224.31		
	E																
2210	SSI DISABLED NON-ME	110,466.44	17,889.57	115,151.37	20,746.04	23,705.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287,958.45		
	D																
2220	SSI DISABLED WITH Q	359.19	2,141.94	85.85	536.32	2,072.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,195.46		
	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	31,112.41	2,518.12	19,249.57	11,109.91	19,564.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,554.46		
4312	SOBRA CHILD 01-05 M	6,391.81	3,280.49	2,289.08	6,096.28	744.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,802.40		
4313	SOBRA CHILD 06-13 M	1,479.36	975.86	1,898.94	643.56	13,021.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,018.88		
4314	SOBRA CHILD 14-20 MA	2,684.63	1,094.83	1,922.69	2,268.08	4,609.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,579.46		
4315	SOBRA CHILD 14-20 FE	4,356.84	6,216.94	4,306.22	841.43	1,689.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,411.37		
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	4,011.32	2,354.87	0.00	0.00	184.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,551.07		
	M																
5017	SOBRA PREG 21-44 FE	14,845.21	10,086.86	18,930.46	41,196.05	28,992.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114,050.81		
	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 November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	204,226.07	130,469.68	313,068.63	110,831.12	141,585.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		900,180.75		

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	4,344.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	315.80	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	15,304.86	1,958.88	4,688.05	1,188.54	13,306.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	4,674.57	2,883.06	7,326.39	2,161.95	4,043.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	15,302.75	5,437.66	6,034.25	55,775.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	608.48	0.00	0.00	0.00	2,104.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	131.84	0.00	-98.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED
W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
2610	SSI DISABLED EXPAND
E	60.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	44.60	0.28	0.00	153.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36,127.40	10,279.88	17,949.74	63,623.50	19,770.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,344.00	
0.00	
0.00	
315.80	
0.00	
0.00	
0.00	
36,447.02	
21,089.64	
82,550.22	
0.00	
0.00	
0.00	
0.00	
0.00	
2,713.00	
0.00	
32.89	
0.00	
0.00	
60.30	
198.33	
147,751.20	

3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

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	25.07	1,526.03	17.64	303.36	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	644.13	239.80	574.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	3,500.98	6,370.35	4,687.74	4,818.70	34,252.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	-2,278.80	32,841.17	7,813.39	7,533.48	5,901.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
1,872.10	
0.00	
1,458.48	
53,630.11	
51,811.10	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	6,321.70	5,284.26	34,872.18	22,804.70	22,411.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91,694.52		
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	24.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24.32		
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	41.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.69		
3707	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																
3708	ADULT <40% EXP M&F	788.41	988.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,776.59		
	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	395.81	755.00	911.53	2,628.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,690.97		
3715	ADULT <40% EXP FEMA	493.24	0.00	127.16	0.00	421.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,042.03		
	L																
3716	ADULT <40% EXP MALE	84,556.81	61,039.82	105,345.67	41,671.02	46,561.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		339,174.61		
3717	ADULT <40% EXP FEMA	13,093.01	17,172.28	35,388.38	55,457.34	11,515.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,626.77		
	L																
3718	ADULT <40% EXP M&F	142,483.33	-59,507.68	259,783.72	258,119.00	101,385.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		702,263.59		
	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		
3728	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		
	4																
SUBTOTAL:	250,065.38	66,709.21	449,521.96	393,336.23	222,474.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,382,106.88		

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	1,917.24	165.43	935.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	375.57	0.00	96.96	187.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	19,779.02	2,691.49	4,306.23	26,703.95	2,373.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	18,827.19	4,429.18	7,108.49	7,318.00	224.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	13,670.08	42,060.22	54,084.19	4,527.02	12,281.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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:	54,569.10	49,346.32	66,530.98	38,736.53	14,880.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
3,017.78	
660.09	
55,854.41	
37,907.34	
126,623.46	
0.00	
0.00	
0.00	
0.00	
224,063.08	

4413	SOBRA 100-133% M&F
6	1,362.28	51.82	1,691.84	200.00	80.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	264.60	-136.89	0.00	0.00	83.00	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	186.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,385.94	
210.71	
186.58	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	1,626.88	-85.07	1,691.84	386.58	163.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,783.23		

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
4518	BC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
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	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	76.43	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:	76.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
76.43	
0.00	
76.43	

S000	STATE-ONLY BHS	1,742.57	5,676.45	-6,474.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,742.57	5,676.45	-6,474.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

944.25

944.25

TOTAL:	548,433.83	262,396.47	842,288.38	606,913.96	398,873.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,658,905.82		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	397,438.76	433,863.29	782,251.88	341,194.79	820,966.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,775,715.08		
8040	SLMB	10,153.26	13,025.80	15,154.86	2,524.95	271.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,130.24		
8050	QI1	1,066.22	95.19	0.00	511.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,672.98		
SUBTOTAL:	408,658.24	446,984.28	797,406.74	344,231.31	821,237.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,818,518.30		

344,231.31

0.00

0.00

0.00

TOTAL:

408,658.24

446,984.28

797,406.74

821,237.73

0.00

0.00

0.00

0.00

2,818,518.30

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending November 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	1,038.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,038.00		
2100	SSI AGED WITH MEDIC	477,605.14	638,635.22	522,769.41	356,422.86	457,100.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,452,533.59		
	A																
2110	SSI AGED NON-MEDICA	69,557.92	78,739.29	82,660.80	53,230.67	63,035.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347,224.03		
	R																
2120	SSI AGED WITH QMB	665,719.14	919,902.30	757,555.35	426,766.51	654,577.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,424,520.71		
2200	SSI DISABLED WITH M	115,099.39	121,216.11	126,077.60	93,414.56	139,833.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		595,641.57		
	E																
2210	SSI DISABLED NON-ME	847,990.95	1,285,024.65	1,357,146.54	709,874.82	966,892.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,166,929.37		
	D																
2220	SSI DISABLED WITH Q	161,448.52	204,127.73	194,978.26	70,038.18	129,989.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		760,582.42		
	M																
2310	SSI BLIND NON-MEDIC	0.00	1,820.00	1,415.68	479.00	479.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,193.68		
	A																
2320	SSI BLIND WITH QMB	0.00	2,954.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,954.00		
SUBTOTAL:	2,337,421.06	3,252,419.30	3,042,603.64	1,710,226.60	2,412,946.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,755,617.37		

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

0.00

0.00

TOTAL:	2,337,421.06	3,252,419.30	3,042,603.64	1,710,226.60	2,412,946.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,755,617.37		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending November 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	7,532.14	17,384.41	14,691.56	3,303.91	9,400.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,312.31		
	A																
2110	SSI AGED NON-MEDICA	1,733.06	-260.82	668.08	0.00	1,175.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,315.55		
	R																
2120	SSI AGED WITH QMB	5,137.41	-38.81	2.81	4,981.35	2,082.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,165.17		
2200	SSI DISABLED WITH M	1,075.79	2,104.59	5,774.65	4,172.76	253.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,381.16		
	E																
2210	SSI DISABLED NON-ME	25,090.04	26,946.78	77,216.01	43,008.85	122,140.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		294,402.21		
	D																
2220	SSI DISABLED WITH Q	1,733.99	264.51	1,488.43	2,589.83	2,998.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,075.42		
	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:	42,302.43	46,400.66	99,841.54	58,056.70	138,050.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384,651.82		

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

384,651.82

42,302.43	46,400.66	99,841.54	58,056.70	138,050.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	7,747.25	3,464.96	2,804.26	5,518.05	2,276.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,811.35		
1007	TANF 21-44 FEMALE WI	1,283.28	889.24	70.99	568.33	179.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,991.28		
1008	TANF 45-64 M & F WIT	13,644.99	10,959.83	7,948.73	8,022.25	7,890.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,466.59		
1009	TANF 65+ M & F WITH	221.59	1,011.61	1,688.77	2,570.69	1,848.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,341.52		
1011	TANF <1 M & F NON-ME	576,302.62	596,270.52	863,942.40	777,362.05	526,320.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,340,197.77		
1012	TANF 01-05 M & F NON	48,957.99	75,795.51	124,843.70	96,610.33	103,146.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00		449,354.06		
1013	TANF 06-13 M & F NON	133,681.56	148,607.95	176,330.84	161,201.08	195,465.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		815,287.40		
1014	TANF 14-20 MALE NON-	200,569.13	124,644.45	133,314.00	139,277.78	154,880.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00		752,685.65		
1015	TANF 14-20 FEMALE N	308,783.22	235,477.38	296,773.58	233,161.14	333,447.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,407,642.98		
	O																
1016	TANF 21-44 MALE NON-	1,377,054.23	1,511,934.26	1,853,240.08	1,648,841.88	1,926,724.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,317,795.30		
1017	TANF 21-44 FEMALE N	4,259,921.05	4,641,528.31	5,216,744.07	4,417,094.13	5,338,681.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,873,968.87		
	O																
1018	TANF 45-64 M & F NON	1,614,078.99	1,692,848.24	1,884,135.07	1,553,294.60	2,014,965.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,759,322.04		
1019	TANF 65+ M & F NON-M	6,102.41	3,867.26	4,166.93	3,331.25	1,429.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,896.99		
1026	TANF 21-44 MALE WITH	585.60	0.00	0.00	15.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		600.87		
1027	TANF 21-44 FEMALE WI	0.00	40.40	1,905.82	1,935.94	-139.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,742.18		
1028	TANF 45-64 M & F WIT	4,500.10	4,053.90	3,431.25	22,802.82	18,028.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,817.03		
1029	TANF 65+ M & F WITH	3,496.11	3,685.68	2,519.64	1,530.66	32.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,264.75		
2100	SSI AGED WITH MEDIC	164,035.71	141,989.22	116,514.72	149,916.82	135,192.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		707,649.23		
	A																
2110	SSI AGED NON-MEDICA	146,151.92	166,398.60	179,287.83	229,149.88	214,825.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00		935,813.27		
	R																
2120	SSI AGED WITH QMB	440,190.24	487,911.72	466,762.96	406,535.26	392,641.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,194,041.88		
2200	SSI DISABLED WITH M	422,554.09	418,690.64	616,234.83	373,892.45	404,084.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,235,456.04		
	E																
2210	SSI DISABLED NON-ME	5,646,251.83	6,054,765.17	5,989,511.58	4,096,001.37	5,532,294.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,318,824.71		
	D																
2220	SSI DISABLED WITH Q	1,256,272.63	1,049,131.41	1,701,905.28	1,226,219.36	1,363,855.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,597,384.60		
	M																
2300	SSI BLIND WITH MEDIC	7,854.55	769.25	1,000.53	480.02	6,218.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,323.12		
2310	SSI BLIND NON-MEDIC	78,129.22	40,437.73	48,248.29	43,936.26	91,210.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		301,961.78		
	A																
2320	SSI BLIND WITH QMB	11,067.36	5,848.91	13,557.57	7,271.67	9,536.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,282.25		
4311	SOBRA CHILD <1 M & F	1,076,008.21	772,705.68	1,205,488.30	549,565.60	639,369.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,243,137.38		
4312	SOBRA CHILD 01-05 M	966,010.29	1,040,071.57	1,523,591.68	1,181,175.97	1,316,936.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,027,786.09		
4313	SOBRA CHILD 06-13 M	2,122,289.37	2,703,395.03	2,737,860.22	2,222,903.10	2,542,484.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,328,931.72		
4314	SOBRA CHILD 14-20 MA	1,060,340.32	1,017,689.24	1,066,537.99	921,014.73	1,243,697.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,309,279.68		
4315	SOBRA CHILD 14-20 FE	1,086,879.61	1,075,806.89	1,279,244.06	1,044,960.15	1,163,967.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,650,858.68		
5007	SOBRA PREG 21-44 FE	4,495.48	9,435.59	8,520.02	1,356.56	398.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,205.91		
	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	66,671.21	64,519.43	89,373.75	85,701.77	80,734.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		387,000.16		
	M																
5017	SOBRA PREG 21-44 FE	830,096.74	820,031.04	1,026,189.67	862,715.74	928,074.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,467,107.56		
	M																
5018	SOBRA PREG 45-64 FE	765.23	288.18	160.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,213.68		
	M																

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	23,942,994.13	24,924,964.80	28,643,849.68	22,475,934.96	26,690,700.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00		126,678,444.37		

1106	TANF EXPANDED 21-44	5,852.78	231.56	5,981.14	696.76	3,345.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	4,172.06	1,296.68	2,306.29	828.73	265.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	35,173.28	37,948.51	46,760.89	28,029.49	34,686.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	36,136.76	37,658.16	53,487.06	52,584.29	40,115.63	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	20,677.98	6,908.67	1,053.86	1,413.55	3,950.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	25,586.83	28,157.19	25,631.80	17,495.63	17,792.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	686,488.60	561,120.76	774,717.43	536,741.76	415,895.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,794,002.39	1,459,159.40	1,923,243.04	1,449,721.78	1,431,965.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	694,910.36	730,558.86	724,708.91	556,651.82	630,019.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	915.80	140.11	1,674.87	4,905.29	12,516.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	15,109.98	11,494.40	14,072.10	9,644.88	7,773.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	35,131.65	35,765.56	49,114.37	53,779.36	68,573.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	85,095.02	73,317.72	134,251.81	89,538.38	94,440.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	60,951.13	66,150.90	77,817.89	81,548.96	124,629.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2400	SSI AGED EXPANDED WI	5,058.46	3,223.95	2,065.84	4,102.38	10,596.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2410	SSI AGED EXPANDED N
O	11,079.14	39,920.34	18,955.35	321.80	4,865.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	331,233.83	404,329.53	595,334.13	370,960.08	375,289.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED
W	103.61	455.54	3,337.74	5,614.53	730.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	2,366.79	4,142.81	7,693.56	16,373.70	21,456.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND
E	55,596.48	91,828.00	57,929.14	72,992.77	93,927.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	472,597.75	339,931.91	449,820.64	282,795.98	383,458.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,378,240.68	3,933,740.56	4,969,957.86	3,636,741.92	3,776,294.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,107.93	
8,869.34	
182,598.63	
219,981.90	
0.00	
34,004.13	
114,664.33	
2,974,963.94	
8,058,092.54	
3,336,849.70	
20,152.29	
58,094.83	
242,364.41	
476,643.92	
411,098.69	
25,046.80	
75,141.86	
2,077,146.63	
10,241.91	
52,033.44	
372,273.42	
1,928,605.05	
20,694,975.69	

3616	AHC CARE/MI MALE 21-	0.00	-546.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	-491.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-1,038.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-546.80	
-491.76	
-1,038.56	

3506	ADULT 40-100% MALE 2	4,480.77	2,672.94	9,735.26	6,070.72	6,010.44	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	10,939.06	7,371.62	14,214.78	7,003.72	8,900.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	2,215.66	3,387.31	10,795.03	1,157.25	3,105.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	59,515.56	37,007.91	64,214.95	78,566.10	46,094.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	26,823.59	31,192.16	32,744.19	37,025.33	21,391.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	1,299,590.29	1,295,488.93	1,834,706.76	1,161,780.19	1,143,917.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	506,091.70	443,826.27	608,138.62	528,240.24	679,037.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

28,970.13	
0.00	
48,429.36	
20,660.91	
285,399.01	
149,176.46	
6,735,483.18	
2,765,334.61	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	1,253,795.09	1,440,293.03	1,643,391.17	1,112,327.90	1,391,191.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,840,999.07		
3519	ADULT 40-100% M&F 65	589.81	1,016.85	5,836.75	7,926.73	34,635.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,006.06		
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	932.72	324.23	2,142.14	319.58	1,156.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,875.17		
3706	ADULT <40% EXP MALE	9,223.05	18,612.69	2,721.00	0.00	7.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,564.16		
3707	ADULT <40% EXP FEMA	0.00	0.00	0.00	18.37	42.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.60		
	L																
3708	ADULT <40% EXP M&F	35,952.73	20,880.60	12,806.33	10,217.84	12,942.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,800.27		
	4																
3709	ADULT <40% EXP M&F	1,628.60	26,325.91	4,626.73	3,180.81	5,991.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,754.03		
	6																
3714	ADULT <40% EXP MALE	385,868.47	261,608.66	426,680.82	295,386.59	220,721.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,590,265.85		
3715	ADULT <40% EXP FEMA	307,928.64	330,677.11	358,605.42	320,353.09	348,591.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,666,155.90		
	L																
3716	ADULT <40% EXP MALE	12,520,543.65	11,997,692.47	15,794,779.76	11,950,448.62	13,529,406.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,792,870.77		
3717	ADULT <40% EXP FEMA	5,021,150.59	5,087,691.63	6,480,994.86	5,368,021.51	6,430,797.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,388,655.93		
	L																
3718	ADULT <40% EXP M&F	11,351,453.93	11,208,255.26	12,515,865.77	10,004,932.53	10,959,601.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,040,109.15		
	4																
3719	ADULT <40% EXP M&F	1,601.51	502.63	783.71	2,765.97	4,364.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,018.63		
	6																
3726	ADULT <40% EXP MALE	0.00	0.00	26.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26.64		
3728	ADULT <40% EXP M&F	42,055.42	17,672.19	17,779.91	11,396.47	11,849.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,753.63		
	4																
SUBTOTAL:	32,842,380.84	32,232,500.40	39,841,590.60	30,907,139.56	34,859,758.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00		170,683,369.52		

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	176.90	79.07	68.15	1,536.84	3,724.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	929.70	1,998.02	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	29,117.96	57,191.60	31,408.89	23,262.52	11,674.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3909	NEWLY ELIGIBLE M&F 6	15,547.34	8,292.00	8,934.84	6,797.60	16,656.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	68,232.37	40,534.17	26,580.04	20,665.93	12,855.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	36,245.78	82,861.49	38,077.62	39,535.05	41,091.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	540,047.53	463,240.47	661,446.63	555,829.65	787,446.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	503,815.27	689,089.90	561,199.26	663,550.85	568,978.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,078,696.65	1,275,093.52	1,213,994.55	900,799.17	1,009,292.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3919	NEWLY ELIGIBLE M&F 6	2,222.69	3,272.64	2,419.30	1,978.34	4,761.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	917.91	1,274.01	1,391.08	39.23	2,049.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F 4	360.48	797.94	2,143.49	821.18	94.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3929	NEWLY ELIGIBLE M&F
6	0.00	17.62	956.94	0.00	693.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,276,310.58	2,623,742.45	2,548,620.79	2,214,816.36	2,459,318.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
5,585.48	
2,927.72	
152,655.11	
56,228.41	
168,868.05	
237,811.93	
3,008,010.70	
2,986,633.40	
5,477,876.35	
14,654.28	
5,671.92	
4,217.24	
1,668.54	
12,122,809.13	

4413	SOBRA 100-133% M&F
6	137,576.87	221,301.00	200,501.83	115,611.49	161,770.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	84,595.22	65,061.30	70,593.07	79,797.73	76,716.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	85,776.61	96,091.40	183,056.19	63,116.73	79,733.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

836,762.14	
376,763.98	
507,774.79	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	307,948.70	382,453.70	454,151.09	258,525.95	318,221.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,721,300.91		

4517	BC PATIENT FEMALE 2 1	9,490.94	1,210.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
4518	BC PATIENT FEMALE 4
5	1,329.76	834.11	0.00	555.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		
SUBTOTAL:	10,820.70	2,044.46	0.00	555.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		

10,701.29	
2,718.95	
13,420.24	

8700	SSI DISABLED FREEDO M	14,682.02	14,412.61	21,877.49	12,963.86	17,014.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	13,956.53	18,030.34	11,788.43	5,150.75	19,998.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	5,398.22	0.00	1,383.92	329.05	1,560.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	34,036.77	32,442.95	35,049.84	18,443.66	38,573.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

80,950.03	
68,925.02	
8,671.31	
158,546.36	

S000	STATE-ONLY BHS	0.00	43,275.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	43,275.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

43,275.21

43,275.21

TOTAL:	63,792,732.40	64,174,125.97	76,493,219.86	59,512,157.49	68,142,867.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00		332,115,102.87		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 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	2,171,859.41	2,106,007.12	2,593,265.71	2,115,202.53	2,008,858.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,995,193.07		
	A																
2110	SSI AGED NON-MEDICA	106,801.15	105,359.64	63,541.22	70,963.48	44,220.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390,886.30		
	R																
2120	SSI AGED WITH QMB	3,440,979.54	3,471,859.45	3,901,297.57	3,414,415.52	3,307,320.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,535,873.02		
2200	SSI DISABLED WITH M	283,397.92	332,321.28	393,834.99	290,687.22	292,555.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,592,797.05		
	E																
2210	SSI DISABLED NON-ME	2,689,117.43	3,059,184.80	2,981,038.00	2,415,305.15	2,550,263.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,694,909.29		
	D																
2220	SSI DISABLED WITH Q	863,130.44	803,396.38	986,799.06	879,706.49	734,344.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,267,376.99		
	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	731.80	7,926.62	5,798.46	1,777.74	1,906.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,140.84		
SUBTOTAL:	9,556,017.69	9,886,055.29	10,925,575.01	9,188,058.13	8,939,470.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,495,176.56		

8720	SSI DISABLED FREEDO M	3,521.28	3,521.28	3,521.28	4,401.60	3,082.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,521.28	3,521.28	3,521.28	4,401.60	3,082.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

18,047.52

18,047.52

48,513,224.08

9,559,538.97	9,889,576.57	10,929,096.29	9,192,459.73	8,942,552.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	0.00	0.00	0.00	0.00	863.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		863.91		
8040	SLMB	0.00	0.00	682.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		682.24		
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:	0.00	0.00	682.24	0.00	863.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,546.15		

TOTAL:	0.00	0.00	682.24	0.00	863.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,546.15		

KidsCare - CAPITATION AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	208,212.91	188,828.20	184,930.48	210,545.53	215,078.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,007,595.15		
	C																
6012	KIDS 1-5 M & F NON-M	2,621,693.20	2,660,216.03	3,194,408.30	2,820,577.07	2,881,464.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,178,359.57		
6013	KIDS 6-13 M & F NON-	5,135,608.06	5,303,884.15	6,183,956.40	5,672,044.26	5,810,861.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,106,354.27		
6014	KIDS 14-19 MALE NON-	1,521,662.49	1,587,698.81	1,770,088.60	1,703,746.26	1,753,190.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,336,386.71		
6015	KIDS 14-19 FEMALE NO	1,486,162.57	1,560,744.02	1,770,493.06	1,668,740.24	1,714,612.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,200,752.10		
9960	KIDSCARE KICK PAYME	31,989.83	0.00	25,594.40	38,656.56	19,328.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00		115,569.07		
	N																
SUBTOTAL:	11,005,329.06	11,301,371.21	13,129,471.24	12,114,309.92	12,394,535.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,945,016.87		

59,945,016.87

11,005,329.06	11,301,371.21	13,129,471.24	12,114,309.92	12,394,535.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	337.70	306.26	299.63	315.43	321.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,580.92		
	C																
6012	KIDS 1-5 M & F NON-M	12,930.55	13,128.32	15,819.65	13,281.87	13,569.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,729.40		
6013	KIDS 6-13 M & F NON-	25,317.92	26,183.49	30,599.47	26,712.00	27,366.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,179.67		
6014	KIDS 14-19 MALE NON-	7,478.10	7,815.20	8,723.08	7,981.22	8,214.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,212.01		
6015	KIDS 14-19 FEMALE NO	7,298.96	7,675.06	8,725.21	7,821.96	8,036.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,558.18		
9960	KIDSCARE KICK PAYME	5.00	0.00	4.00	6.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
	N																
SUBTOTAL:	53,368.23	55,108.33	64,171.04	56,118.48	57,512.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,278.18		

TOTAL:	53,368.23	55,108.33	64,171.04	56,118.48	57,512.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,278.18		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	549.20	533.40	509.03	2,222.92	2,263.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,078.53		
	C																
6012	KIDS 1-5 M & F NON-M	21,775.23	21,787.37	22,029.86	94,016.18	96,003.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00		255,612.54		
6013	KIDS 6-13 M & F NON-	43,242.68	43,788.47	44,422.82	189,798.78	194,517.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00		515,770.00		
6014	KIDS 14-19 MALE NON-	29,087.98	29,653.90	30,313.07	57,137.98	58,819.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205,012.78		
6015	KIDS 14-19 FEMALE NO	28,581.97	28,438.89	29,511.89	56,269.83	57,593.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200,396.54		
SUBTOTAL:	123,237.06	124,202.03	126,786.67	399,445.69	409,198.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,182,870.39		

1,182,870.39

126,786.67	399,445.69	409,198.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

123,237.06

124,202.03

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	344.00	329.00	324.00	329.00	333.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,659.00		
	C																
6012	KIDS 1-5 M & F NON-M	13,353.00	13,377.00	13,460.00	13,738.00	14,025.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,953.00		
6013	KIDS 6-13 M & F NON-	26,266.00	26,507.00	26,872.00	27,726.00	28,400.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		135,771.00		
6014	KIDS 14-19 MALE NON-	7,806.00	7,919.00	8,112.00	8,351.00	8,593.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,781.00		
6015	KIDS 14-19 FEMALE NO	7,661.00	7,750.00	7,951.00	8,238.00	8,440.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,040.00		
SUBTOTAL:	55,430.00	55,882.00	56,719.00	58,382.00	59,791.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,204.00		

TOTAL:	55,430.00	55,882.00	56,719.00	58,382.00	59,791.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286,204.00		

KidsCare - FEE FOR SERVICE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	13,524.09	4,411.22	2,791.45	1,987.72	2,638.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,353.24		
	C																
6012	KIDS 1-5 M & F NON-M	22,373.20	31,277.24	36,527.43	32,544.80	29,729.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152,452.21		
6013	KIDS 6-13 M & F NON-	63,485.29	87,613.42	106,116.78	74,257.91	109,919.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441,393.00		
6014	KIDS 14-19 MALE NON-	18,415.53	39,190.11	67,120.33	33,745.67	46,409.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00		204,881.38		
6015	KIDS 14-19 FEMALE NO	84,488.19	106,377.93	90,904.13	35,455.49	73,309.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390,534.97		
SUBTOTAL:	202,286.30	268,869.92	303,460.12	177,991.59	262,006.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,214,614.80		

1,214,614.80

303,460.12	177,991.59	262,006.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

202,286.30

268,869.92

KidsCare - REINSURANCE
For The Period Ending November 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	48,788.39	52,476.14	40,568.12	67.33	-10,946.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,953.71		
6013	KIDS 6-13 M & F NON-	150,067.69	196,176.95	226,795.86	117,268.47	118,331.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00		808,640.74		
6014	KIDS 14-19 MALE NON-	117,438.31	48,871.56	231,096.19	376,007.17	-132,514.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00		640,899.17		
6015	KIDS 14-19 FEMALE NO	28,381.76	1,171,474.89	-699,044.59	4,353.61	384,174.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		889,340.42		
SUBTOTAL:	344,676.15	1,468,999.54	-200,584.42	497,696.58	359,046.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,469,834.04		

TOTAL:	344,676.15	1,468,999.54	-200,584.42	497,696.58	359,046.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,469,834.04		

KidsCare - TRANSPLANT REINSURANCE
For The Period Ending November 30, 2021	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	147,956.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,956.93		
6015	KIDS 14-19 FEMALE NO	43,579.50	0.00	973,347.89	142,540.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,159,467.78		
SUBTOTAL:	43,579.50	0.00	973,347.89	142,540.39	147,956.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,307,424.71		

1,307,424.71

43,579.50	0.00	973,347.89	142,540.39	147,956.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

28

0

0

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending November 30, 2021

RJAuTEnCeO3DE0, 202DE0SCRIPTION

JULY

AUGUST  SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

																
1010	TANF NON-MEDICARE	657.46	657.43	660.35	670.77	667.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,313.42	
2100	SSI AGED WITH MEDICA	289.35	289.16	291.12	294.54	293.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,457.59	
2110	SSI AGED NON-MEDICAR	11.00	11.00	10.00	10.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.00	
2120	SSI AGED WITH QMB	462.87	465.26	463.71	462.68	461.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,315.94	
2200	SSI DISABLED WITH ME	1,944.80	1,953.08	1,990.06	1,994.79	1,998.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,881.44	
2210	SSI DISABLED NON-MED	28,375.96	28,475.39	28,524.03	28,633.86	28,746.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142,755.99	
2220	SSI DISABLED WITH QM	5,245.82	5,253.18	5,244.37	5,234.92	5,229.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,207.89	
2300	SSI BLIND WITH MEDIC	4.00	6.00	10.00	10.32	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42.32	
2310	SSI BLIND NON-MEDICA	23.00	26.93	31.36	38.41	40.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.53	
2320	SSI BLIND WITH QMB	6.00	11.00	16.00	18.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.00	
8700	SSI DISABLED FREEDOM	30.00	30.00	30.00	32.99	31.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		153.99	
8710	SSI DISABLED FREEDOM	8.00	8.00	8.00	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.00	
8720	SSI DISABLED FREEDOM	16.00	16.00	16.00	16.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80.00	
SUBTOTAL:	37,074.26	37,202.43	37,295.00	37,425.28	37,535.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00		186,532.11	
TOTAL:	37,074.26	37,202.43	37,295.00	37,425.	37,535.14	0.0	0.00	0.00	0.00	0.0	0.00	0.00		186,532.11	

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

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	385,275.37	382,399.87	379,530.53	379,528.14	378,628.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,905,362.07	
EPD	114,298,940.29	114,887,545.38	114,523,533.95	127,410,250.77	127,450,037.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	598,570,307.69	
TOTAL AHCCCS LTC	114,684,215.66	115,269,945.25	114,903,064.48	127,789,778.91	127,828,665.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	600,475,669.76	
DES/DD	196,850,771.52	197,527,866.23	198,019,082.32	200,990,383.02	201,582,846.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	994,970,949.64	
TOTAL DES LTC	196,850,771.52	197,527,866.23	198,019,082.32	200,990,383.02	201,582,846.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	994,970,949.64	
TOTAL LTC - CAP	311,534,987.18	312,797,811.48	312,922,146.80	328,780,161.93	329,411,512.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,595,446,619.40	

EPD/DD FEE-FOR-SERVICE	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	11,939,262.46	13,188,396.53	14,071,541.47	10,960,743.03	11,493,549.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,653,493.27	
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	11,939,262.46	13,188,396.53	14,071,541.47	10,960,743.03	11,493,549.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	61,653,493.27	

EPD/DD REINSURANCE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	3,737,826.11	3,967,243.53	2,604,072.93	5,445,529.62	3,115,890.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,870,562.87	
DES/DD	2,785,169.38	2,352,274.55	2,263,940.31	2,639,762.53	7,728,036.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,769,183.57	
TOTAL DES LTC	2,785,169.38	2,352,274.55	2,263,940.31	2,639,762.53	7,728,036.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,769,183.57	
TOTAL LTC - REIN	6,522,995.49	6,319,518.08	4,868,013.24	8,085,292.15	10,843,927.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	36,639,746.44	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	4,456,987.60	4,457,038.70	4,454,297.00	4,464,038.30	4,450,844.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,283,205.90	

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

BEHAVIORAL HEALTH EXPENDITURES BY RBHA - CAPITATION AMOUNTS
For the Period Ending November 30, 2021

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

00010306	MERCY CARE - RBHA CRISIS CAP AMOUNTS	9,497,094.87	9,581,071.79	9,674,338.34	8,292,106.24	8,335,500.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45,380,112.04	

00010422	AZ COMPLETE HEALTH CARE - RBHA CRISIS CAP AMOUNTS	5,033,375.69	5,069,308.11	5,107,120.58	4,330,119.70	4,353,618.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,893,542.78	

00010497	STEWARD HEALTH CHOICE AZ - RBHA CRISIS CAP AMOUNTS	1,075,404.34	1,080,955.12	1,088,066.48	1,138,591.44	1,142,172.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,525,189.53	

00010705	HEALTH CHOICE RBHA - CAP AMOUNTS	0.00	903.40	-1,640.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-737.26	

00010730	CENPATICO RBHA - CAP AMOUNTS	860.29	1,060.00	-723.96	-239.16	505.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,462.72	

00010789	MERCY MARICOPA RBHA - CAP AMOUNTS	-1,319.56	-4,332.55	-1,647.36	-3,471.87	3,377.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7,394.22	
			
Subtotal		
	15,605,415.63	15,728,965.87	15,865,513.42	13,757,106.35	13,835,174.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,792,175.59	

15,605,415.63	15,728,965.87	15,865,513.42	13,757,106.35	13,835,174.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	74,792,175.59	

GRAND TOTAL

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

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

00010306	MERCY CARE - RBHA CRISIS CAP MEMBER MONTHS	1,153,894.00	1,161,650.00	1,170,090.00	1,177,856.00	1,184,020.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,847,510.00	
			
00010422	AZ COMPLETE HEALTH CARE - RBHA CRISIS CAP MEMBER MONTHS	569,579.00	573,084.00	576,881.00	580,445.00	583,595.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,883,584.00	
			
00010497	STEWARD HEALTH CHOICE AZ - RBHA CRISIS CAP MEMBER MONTHS	271,846.00	272,874.00	274,329.00	275,688.00	276,555.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,371,292.00	
			
00010705	HEALTH CHOICE RBHA - CAP MEMBER MONTHS	0.00	16.51	-27.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-11.23	
			
00010730	CENPATICO RBHA - CAP MEMBER MONTHS	0.97	17.04	-8.26	-2.99	9.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.95	
			
00010789	MERCY MARICOPA RBHA - CAP MEMBER MONTHS	-22.00	-129.14	-31.99	-69.13	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-195.26	
			
Subtotal	1,995,297.97	2,007,512.41	2,021,232.01	2,033,916.88	2,044,236.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,102,195.46	

1,995,297.97	2,007,512.41	2,021,232.01	2,033,916.88	2,044,236.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,102,195.46	

GRAND TOTAL