Douglas A. Ducey, Governor Jami Snyder, Director

August 5, 2022

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 June 30, 2022

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 June 30, 2022.

Status Summary – Section 6008 of the Families First Coronavirus Response Act (FFCRA) (P.L. 116-127) provides a temporary 6.2 percentage point increase to the Federal Medical Assistance Percentage (FMAP) extending through the last day of the calendar quarter in which the public health emergency (PHE) terminates. One of the conditions of receipt of the enhanced federal match is maintenance of effort (MOE) requirement, prohibiting the agency from terminating the enrollment of any individual that was enrolled in the program as of the date of the beginning of the emergency period, as well as individuals enrolled during the emergency period. On April 13, 2022, the Department of Health and Human Services extended the expiration date for the PHE to an assumed October 13, 2022. As a result, it is assumed that the temporary FMAP increase will continue until at least December 31, 2022, and the MOE will continue until at least October 31, 2022.

This temporary increase in FMAP will result in a FY22 General Fund Surplus. AHCCCS is currently estimating a potential surplus of $75 million. There are several factors that could impact the final expenditures and General Fund reversion amount, including: Final ALTCS spend and county/state match reconciliations; final tobacco tax deposits and reconciliations, and final caseload growth figures. Given these uncertainties, for purposes of this report, projected annual expenditures continue to equal the appropriations.

FY22 Expenditure Authority Supplemental

On March 1, 2022, Governor Ducey signed Laws 2022, Second Regular Session, Chapter 2 (HB 2157) which provided AHCCCS with an additional $1,078,032,800 in Expenditure Authority and $30,121,100 CHIP Fund to meet the funding requirements for the ARPA HCBS program and the extension of the temporary 6.2% FMAP increase as described in the following paragraphs. These supplemental amounts are included in the Appropriations of this report.

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
August 5, 2022
Page 2

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 seniors, individuals with disabilities, individuals living with a serious mental illness, and children with behavioral health needs. To maximize this opportunity, which requires no general fund, AHCCCS requires an estimated $546.3 million federal 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 will require additional federal expenditure authority ($531.7 million) and CHIP Fund ($30.1 million).

Enrollment Update – June 2022 enrollment is 2,411,057 members, a 15,473 member increase over the prior month. Enrollment for July 2022 increased to 2,421,521 members, a 10,464 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 542,561 members or 28.9%.

Major July 2022 changes by eligibility category include: 1931 for Families and
Children/SOBRA – increase of 3,821; Supplemental Security Income – increase of 641; Prop 204 Restoration - increase of 5,475; Adult Expansion – decrease of 1,042; Medicare Cost Sharing – increase of 79; KidsCare – increase of 403; and Federal Emergency Services – increase of 806.

Tobacco Funds Revenue Update - Tobacco tax collections through June 2022 are $700K 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

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 June 30, 2022

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 June 30, 2022
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	$	102,779,100	$	90,853,379	$	90,853,379	$		-	$	102,779,100	$	-	
AHCCCS Prop 204 Administration	23,366,200	20,102,566	20,102,566			-	23,366,200		-	
DES Eligibility	92,874,500	77,902,393	77,902,393			-	92,874,500		-	
DES Prop 204 Eligibility	43,358,700	37,715,782	37,715,782			-	43,358,700		-	
ADOA Data Center	19,495,800	14,080,039	14,080,039			-	19,495,800		-	
School District Suicide Prevention Coordinator	100,000	100,000	100,000			-	100,000		-	
TOTAL ADMINISTRATION		281,974,300 			240,754,160 			240,754,160 			-				281,974,300 			-			

Traditional Medicaid Services	7,274,145,000		6,813,632,965		6,813,632,965		-		7,274,145,000		-	
Proposition 204 Services	6,954,048,300		6,744,917,229		6,744,917,229		-		6,954,048,300		-	
ACA Adult Expansion	1,453,831,900		1,203,218,035		1,203,218,035		-		1,453,831,900		-	
KidsCare Services	171,812,300		169,188,900		169,188,900		-		171,812,300		-	
ALTCS Services	2,286,200,500		2,096,779,146		2,096,779,146		-		2,286,200,500		-	
Disproportionate Share Payments	5,087,100		4,742,816		4,742,816		-		5,087,100		-	
Rural Hospitals	44,649,700		36,068,937		36,068,937		-		44,649,700		-	
Voluntary Political Subdivision Programs	457,698,700		409,365,440		409,365,440		-		457,698,700		-	
DCS-CHP	277,122,500		225,915,484		225,915,484		-		277,122,500		-	
Behavioral Health Services - in Schools	18,003,300		11,047,779		11,047,779		-		18,003,300		-	
Targeted Investment Program	50,000,000		8,381,149		8,381,149		-		50,000,000		-	
Non Medicaid Seriously Mentally Ill Services	83,646,900		79,298,798		79,298,798		-		83,646,900		-	
Supported Housing	65,324,800		4,562,906		4,562,906		-		65,324,800		-	
Crisis Services	16,391,300		16,305,950		16,305,950		-		16,391,300		-	
TOTAL PROGRAMMATIC		19,157,962,300 			17,823,425,534 			17,823,425,534 			-				19,157,962,300 			-		

TOTAL EXPENDITURES

 $  19,439,936,600 

 $ 18,064,179,694 

 $ 18,064,179,694 

 $	-	

 $  19,439,936,600 

 $	-	

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

ANNUAL APPROPRIATION	(A) EXPENDITURE PLAN
YTD	(B)

EXPENDITURES YTD	(A) - (B)

VARIANCE YTD	PROJECTED ANNUAL EXPENDITURES	

ANNUALIZED VARIANCE	

STATE - GENERAL FUND		

Administrative Expenditures	
$	
63,856,500	
$	58,326,049	
$	58,326,049	
-	$	63,856,500	
$	
-	
Proposition 204 - Administrative Expenditures		21,192,900	18,708,539	18,708,539	-	21,192,900		-	

Programmatic Expenditures								
Traditional Medicaid Services	1,248,667,200	1,216,299,126	1,216,299,126	-	1,248,667,200	-	
Proposition 204 Services	128,667,600	128,732,659	128,732,659	-	128,667,600	-	
ACA Adult Expansion	16,643,500	16,643,500	16,643,500	-	16,643,500	-	
KidsCare Services	27,077,200	26,547,425	26,547,425	-	27,077,200	-	
ALTCS Services	236,051,900	236,051,900	236,051,900	-	236,051,900	-	
DSH and Rural Hospitals	8,846,200	8,709,389	8,709,389	-	8,846,200	-	
DCS-CHP	58,514,400	52,373,951	52,373,951	-	58,514,400	-	
Behavior Health Services - in Schools	3,000,000	3,000,000	3,000,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	73,298,798	73,298,798	-	77,646,900	-	
Supported Housing	5,324,800	4,562,906	4,562,906	-	5,324,800	-	
Crisis Services	14,141,100	14,055,750	14,055,750	-	14,141,100	-	
Voluntary Political Subdivision Programs		6,000,000 		- 		- 		- 		6,000,000 		- 	
TOTAL GF EXPENDITURES	1,915,630,200	1,857,309,993	1,857,309,993	-	1,915,630,200	-	
	FEDERAL		
Administrative Expenditures	147,981,900	124,145,157	124,145,157		-	147,981,900	-	
Proposition 204 - Administrative Expenditures	41,394,900	35,033,609	35,033,609		-	41,394,900	-	
Programmatic Expenditures
Traditional Medicaid Services	
4,901,665,300	
4,574,173,034	
4,574,173,034		
-	4,901,665,300	
-	
Proposition 204 Services	6,058,893,300	5,926,776,698	5,926,776,698		-	6,058,893,300	-	
ACA Adult Expansion	1,299,591,000	1,088,930,827	1,088,930,827		-	1,299,591,000	-	
KidsCare Services	129,888,200	140,824,661	140,824,661		-	129,888,200	-	
ALTCS Services and Nursing Facility Assessment	1,554,711,700	1,461,815,329	1,461,815,329		-	1,554,711,700	-	
DSH and Rural Hospitals	40,890,600	32,102,364	32,102,364		-	40,890,600	-	
DCS-CHP	216,007,400	172,185,689	172,185,689		-	216,007,400	-	
Behavior Health Services - in Schools	7,003,300	7,003,300	7,003,300		-	7,003,300	-	
Targeted Investment Program	34,504,800	6,311,811	6,311,811		-	34,504,800	-	
Supported Housing	60,000,000	-	-		-	60,000,000	-	
Voluntary Political Subdivision Programs		337,750,700 		311,270,421 		311,270,421 		- 		337,750,700 		- 	
TOTAL FEDERAL EXPENDITURES	14,830,283,100	13,880,572,900	13,880,572,900	-	14,830,283,100	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF Programmatic Expenditures
Traditional Medicaid Services Acute Care	4,076,200

46,161,700	4,076,200

45,634,000	4,076,200

45,634,000	-

-	4,076,200

46,161,700	-

-	
ALTCS Services		305,872,000 		211,740,564 		211,740,564 		- 		305,872,000 		- 	
TOTAL COUNTY EXPENDITURES	356,109,900	261,450,764	261,450,764
.	-	356,109,900	-	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2022 APPROPRIATION STATUS REPORT
For the Period Ending June 30, 2022 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	65,544,183	65,544,183	-	69,002,100	-	
Proposition 204 Services - Emergency Health Services	17,921,600	17,921,600	17,921,600	-	17,921,600	-	
Proposition 204 Services - Proposition 204 Protection	37,635,400	37,635,400	37,635,400	-	37,635,400	-	
Proposition 204 Services - ATLSF		102,000,000 		102,000,000 		102,000,000 		- 		102,000,000 		- 	
TOTAL TOBACCO EXPENDITURES	226,559,100	223,101,183	223,101,183	-	226,559,100	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program and SMI Housing Trust Fund	999,600	464,606	464,606	-	999,600	-	
Health Care Investment Fund	2,472,300	-	-	-	2,472,300	-	
Programmatic Expenditures							
Traditional Medicaid Services - IGA Fund	50,247,800	2,885,600	2,885,600	-	50,247,800	-	
Traditional Medicaid Services - Health Care Investment Fund	224,678,100	173,816,047	173,816,047	-	224,678,100	-	
Acute Care - Prescription Drug Rebate Program State Match	160,858,600	160,858,600	160,858,600	-	160,858,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	572,638,300	572,638,300	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	8,028,400	7,578,400	7,578,400	-	8,028,400	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	36,422,000	36,422,000	-	36,422,000	-	
Substance Abuse Disorder Services - Prescription Drug Rebate Program State Match	6,000,000	6,000,000	6,000,000	-	6,000,000	-	
Proposition 204 Services - Hospital Assessment	480,627,900	457,830,605	457,830,605	-	480,627,900	-	
Proposition 204 Services - IGA Fund	4,398,100	-	-	-	4,398,100	-	
Proposition 204 Services - Health Care Investment Fund	123,904,400	74,020,266	74,020,266	-	123,904,400	-	
ACA Adult Expansion - Hospital Assessment	128,069,000	89,651,069	89,651,069	-	128,069,000	-	
ACA Adult Expansion - IGA Fund	482,500	-	-	-	482,500	-	
ACA Adult Expansion - Health Care Investment Fund	9,045,900	7,992,639	7,992,639	-	9,045,900	-	
Traditional Medicaid Services - TPL	194,700	1,782,011	1,782,011	-	194,700	-	
ALTCS Services - TPL	-	2,402,144	2,402,144	-	-	-	
ALTCS Services - Nursing Facility Assessment	127,500,100	123,990,821	123,990,821	-	127,500,100	-	
ALTCS Services - Health Care Investment Fund	17,614,400	16,777,987	16,777,987	-	17,614,400	-	
DCS-CHP - Health Care Investment Fund	2,600,700	1,355,844	1,355,844	-	2,600,700	-	
Targeted Investment Program	15,495,200	2,069,338	2,069,338	-	15,495,200	-	
Children's Behavioral Health Services	8,000,000	1,044,479	1,044,479	-	8,000,000	-	
KidsCare Services - IGA Fund	462,900	-	-	-	462,900	-	
KidsCare Services -Health Care Investment Fund	2,232,700	1,812,397	1,812,397	-	2,232,700	-	
KidsCare Services Premiums	12,151,300	4,417	4,417	-	12,151,300	-	
Freedom to Work Premiums	31,200	2,065	2,065	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	2,250,200	2,250,200	-	2,250,200	-	
Voluntary Political Subdivision Programs		113,948,000 		98,095,019 		98,095,019 		- 		113,948,000 		- 	
TOTAL OTHER EXPENDITURES	2,111,354,300	1,841,744,855	1,841,744,855	-	2,111,354,300	-	
	TOTAL		
Administrative Expenditures	281,974,300	240,754,160	240,754,160	-	281,974,300	-	
Acute Care	16,871,761,800	15,726,646,389	15,726,646,389	-	16,871,761,800	-	
Long Term Care		2,286,200,500 		2,096,779,146 		2,096,779,146 		- 		2,286,200,500 		- 	
TOTAL EXPENDITURES	 $	19,439,936,600 	 $	18,064,179,695 	 $	18,064,179,695 	 $	- 	 $	19,439,936,600 	 $	- 	

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

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,347,013,400	$	1,302,978,063	$	1,286,334,563	
Proposition 204 Services & Administrative	149,860,500	147,441,199	221,461,465	
KidsCare Services	27,077,200.00	26,547,425.31	26,547,425	
ALTCS Services	236,051,900	236,051,900	236,051,900	
Behavioral Health Traditional Medicaid Services		155,627,200 		144,291,406 		144,291,406 	
TOTAL	1,915,630,200	1,857,309,993	1,914,686,759	

FEDERAL:
Acute & Administrative	12,929,675,800	12,105,747,221	12,349,327,093	
KidsCare Services	129,888,200	140,824,661	145,002,413	
ALTCS Services	1,554,711,700	1,461,815,329	1,582,684,237	
Behavioral Health Traditional Medicaid Services		216,007,400 		172,185,689 		186,877,568 	
TOTAL	14,830,283,100	13,880,572,900	14,263,891,311	

COUNTY:				
Acute & Administrative	50,237,900		49,710,200		51,251,065	
ALTCS Services		305,872,000 			211,740,564 			283,194,000 	
TOTAL	356,109,900		261,450,764		334,445,065	

TOBACCO FUNDS:						
Traditional Medicaid Services	69,002,100		65,544,183		65,544,183	
Proposition 204 Services		157,557,000 			157,557,000 			157,557,000 	
TOTAL	226,559,100		223,101,183		223,101,183	

OTHER:

Administrative	3,471,900	464,606	464,606	
Traditional Medicaid Services - IGA Fund	50,247,800	2,885,600	2,885,600	
Acute Care - Prescription Drug Rebate Program	733,496,900	733,496,900	733,496,900	
Long Term Care - Prescription Drug Rebate Program	44,450,400	44,000,400	44,000,400	
Hospital Assessment	613,577,500	547,481,674	533,078,105	
Health Care Investment Fund	360,229,100	257,184,796	-	
Substance Abuse Disorder Services	6,000,000	6,000,000	6,000,000	
ALTCS	145,114,500	140,768,808	266,419	
Acute TPL - Note 1	194,700	1,782,011	1,782,011	
LTC TPL - Note 1	-	2,402,144	2,402,144	
KidsCare Services	2,695,600	1,812,397	-	
KidsCare TPL - Note 1	-	-	2,089.00	
Member Premiums - CHIP	12,151,300	4,417	4,417	
Member Premiums - Freedom to Work	31,200	2,065	2,065	
Targeted Investment Program	15,495,200	2,069,338	10,917,104	
Children's Behavioral Health Services	8,000,000	1,044,479	-	
Behavioral Health Traditional Medicaid Services	2,250,200	2,250,200	1,623,002	
Voluntary Political Subdivision - State Match		113,948,000 		98,095,019 		196,513,458 	
TOTAL	2,111,354,300	1,841,744,855	1,533,438,320	

TOTAL REVENUE

$	19,439,936,600

$	18,064,179,695

$	18,269,562,637

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 June 30, 2022

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

$	1,642,176	$

962,434	$

21,112,139	$

14,104,427

LTC	996,730	833,259	14,215,580	11,393,302
KidsCare	459	371	20,423	25,930

Total TPL Collections

 $	2,639,365 

 $	1,796,064 

 $	35,348,142 

 $	25,523,659 

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	116,626	$	91,471	$	1,782,011	$	1,368,879	
LTC		176,344	117,691	2,402,144	1,997,575	
KidsCare		54	46	2,089	(455)	
Total Expenditure Offsets	 $	293,024 		 $	209,208 		 $	4,186,244 		 $	3,365,999 	

June 2022

June 2021

July 1, 2021
June 30, 2022

July 1, 2020
June 30, 2021

Note 2:  Authorized Positions
Actual Positions as of June 30, 2022

`

FY 22 Total

1,163.2
1,097.0

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

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2021	$  4,150,697	
	Revenues	10,117,606	
	Transfers-In		534,740 	
	Total Revenues		10,652,346 	
	Expenditures	10,584,320	
	Transfers-out		1,359,000 	
	Total Expenditures		11,943,320 	
	Ending Balance June 30, 2022	 $  2,859,723 	

Of the $2,859,723 ending balance, $1,939,121 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through July 2022.

Note 4:	Summary of Voluntary Political Subdivision Contribution Expenditures:

As of June 30, 2022 Expenditures

Appropriation	State Match	Federal	Total

DSH Voluntary	$	48,666,500		$	9,366,563		$	26,994,523		$	36,361,086	
GME Voluntary	409,032,200		88,728,456		284,275,898		373,004,355	
Total Voluntary Political Subdivision Program Expenditures	$	457,698,700		$	98,095,019		$	311,270,421		$	409,365,440	

Note 5:	Summary of ARPA HCBS Expenditures:

As of June 30, 2022
Appropriation	Expenditures

Traditional Medicaid Services	$	212,378,800		$	63,494,982	
Proposition 204 Services	86,043,300		42,462,429	
ACA Adult Expansion	8,870,000		4,237,530	
DCS-CHP	33,578,700		17,981	
LTC	203,766,700		92,482,723	
Lump Sum	1,662,500		117,688	
Total ARPA Expenditures	$	546,300,000		$	202,813,332	

Appropriation Status Report
Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending June 30, 2022

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	427,091,416	426,793,020	428,465,760	431,265,948	430,913,389	431,393,852	435,141,070	5,053,128,994	
CAPITATION - AIMHS	499,959	508,769	516,921	523,415	528,615	532,976	560,954	564,322	569,270	573,725	582,042	588,775	6,549,743	
CAPITATION - LTC	311,534,987	312,797,811	312,922,147	328,780,162	329,411,512	329,605,151	330,953,117	331,297,786	332,636,142	334,236,183	335,161,874	338,129,014	3,927,465,887	
MENTAL HEALTH - CHILD	0	-4,177	-795	-819	410	-1,182	-405	-1,538	-4,639	-2,437	-2,043	-3,757	-21,381	
MENTAL HEALTH - ADULT	358,926	335,026	334,344	372,475	397,312	339,427	346,204	334,053	344,560	358,530	359,719	373,490	4,254,066	
MENTAL HEALTH - GENERAL	-1,461	1,869	-3,606	-745	2,068	73	-1,461	-3,086	-642	-14	-1,184	-602	-8,791	
MENTAL HEALTH - DCS-CHP	3,105	-4,462	373	9,818	0	5,581	0	4,172	0	0	0	0	18,587	
MENTAL HEALTH - DD	1,741	0	-1,743	0	0	-3,546	0	0	-6,122	-2,769	0	0	-12,440	
MENTAL HEALTH - RBHA CRISIS	6,436,264	6,466,842	6,508,793	8,405,546	8,472,895	8,531,182	8,585,528	8,643,983	8,677,003	8,701,777	8,744,863	8,788,446	96,963,122	
FEE FOR SERVICE - ACUTE	51,503,190	64,714,701	72,123,684	46,005,167	59,475,217	62,123,053	45,555,717	71,851,346	102,788,852	54,448,744	80,964,135	75,966,899	787,520,704	
FFS - PRIOR QUARTER COVERAGE	191,354	190,653	188,192	148,225	203,121	265,696	175,864	252,099	377,591	193,935	280,392	203,392	2,670,514	
EMERGENCY SERVICES - FEDERAL	3,795,664	2,999,894	3,845,463	3,282,560	3,155,336	4,115,837	3,466,360	4,281,059	4,203,630	3,286,829	3,513,337	3,849,088	43,795,056	
FFS MEDICAID IN PUBLIC SCHOOLS	994,537	559,921	590,617	1,102,922	1,441,406	2,165,777	1,090,158	1,394,921	1,369,289	1,701,284	1,588,280	3,046,316	17,045,428	
QMB - FEE FOR SERVICE	435,180	487,099	843,662	376,845	859,000	530,490	-61,177	474,401	631,115	410,377	459,589	609,971	6,056,554	
STATE ONLY TRBHA FFS	126,690	136,684	170,831	251,538	197,157	184,988	93,236	144,203	113,174	100,123	172,900	148,129	1,839,654	
INPATIENT INMATES FFS	398,924	299,175	306,578	272,297	306,207	371,018	208,553	356,104	347,602	177,801	182,246	519,623	3,746,129	
FFS TRBHA FEE FOR SERVICE	11,550,985	10,288,216	13,849,019	10,648,441	12,654,931	12,952,556	11,312,796	13,777,601	18,425,831	16,497,684	20,301,420	22,245,222	174,504,702	
COCONINO COUNTY INMATES FFS	0	0	0	0	5,884	472	0	0	0	0	0	0	6,356	
YAVAPAI COUNTY INMATES FFS	0	3,010	0	0	0	78	0	0	0	0	0	0	3,088	
PINAL COUNTY INMATES FFS	0	1,846	25,877	313	117	11,034	0	0	208	0	5,114	0	44,509	
PIMA COUNTY INMATES FFS	1,350	36,189	20,025	1,797	21,141	856	20,575	20,929	5,173	7,316	5,488	24,378	165,216	
MOHAVE COUNTY INMATES FFS	0	0	0	0	0	0	898	3,560	0	1,893	3,031	0	9,382	
MARICOPA CTY INMATES FFS	44,024	47,762	24,962	5,377	23,744	88,330	16,695	14,012	22,344	37,555	330	58,216	383,350	
FEE FOR SERVICE - LTC	11,939,262	13,188,397	14,071,541	10,960,743	11,493,550	14,464,508	10,874,163	12,820,581	15,429,673	11,351,870	13,387,945	14,576,083	154,558,316	
LFFS - PRIOR QUARTER COVERAGE	127	3,518	777	0	68	320	0	1,514	3,425	21	0	1,894	11,665	
INPATIENT INMATES LTC FFS	0	0	0	18	0	10	10,341	325	19,297	0	0	16,700	46,691	
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	1,430	0	0	0	0	11,421	
LFFS MEDICAID IN PUBLIC SCHOOLS	998,152	680,777	746,634	1,338,274	1,810,614	2,333,923	1,168,269	1,625,618	1,665,324	1,949,545	1,684,042	3,219,332	19,220,504	
REINSURANCE - ACC	17,723,732	17,310,667	14,746,668	19,274,278	14,666,729	25,020,668	13,244,208	12,369,508	10,296,792	12,508,525	17,675,307	11,771,692	186,608,772	
REINSURANCE - LTC	6,522,995	6,319,518	4,868,013	8,085,292	10,843,927	6,047,676	4,741,550	5,957,563	4,089,137	6,380,176	7,065,565	2,307,525	73,228,939	
SMIB - ACC	19,104,213	19,481,020	19,359,169	19,547,997	19,511,572	19,714,053	22,635,130	22,795,276	22,708,379	22,942,622	23,094,276	23,256,340	254,150,048	
HIB - ACC	1,093,988	1,149,262	1,174,776	1,173,378	1,139,436	1,156,343	1,289,439	1,288,399	1,246,956	1,289,791	1,260,437	1,261,058	14,523,263	
Q1	3,186,885	3,196,654	3,204,188	3,218,204	3,205,932	3,227,454	3,666,086	3,579,408	3,577,381	3,604,886	4,096,996	3,720,511	41,484,584	
SMIB - LTC	4,084,446	4,088,119	4,077,453	4,097,245	4,080,967	4,072,267	4,686,851	4,638,194	4,618,352	4,627,716	4,606,620	4,639,394	52,317,625	
HIB - LTC	372,541	368,920	376,844	366,793	369,878	370,349	393,235	398,015	383,907	410,580	389,521	398,252	4,598,835	
SUBTOTAL	852,631,275	866,329,231	875,224,345	887,147,463	906,759,770	925,318,835	891,825,903	927,351,519	965,804,952	916,707,658	956,976,092	954,856,451	10,926,933,493	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending June 30, 2022

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	398,737,541	400,162,123	403,291,938	410,388,184	413,419,229	417,341,098	421,963,270	4,778,878,588	
CAPITATION - AIMHS	266,281	272,611	279,187	282,398	284,518	287,555	302,189	305,555	309,138	315,212	320,075	323,587	3,548,306	
MENTAL HEALTH - ADULT	324,272	340,920	374,489	460,431	523,899	378,367	420,535	401,120	447,723	467,298	489,334	472,226	5,100,614	
MENTAL HEALTH - GENERAL	-739	142	379	-2,221	1,303	995	-55	-2,473	-41	-1,777	-1,002	-1,473	-6,963	
MENTAL HEALTH - RBHA CRISIS	7,386,408	7,474,384	7,555,611	4,334,461	4,343,964	4,376,574	4,404,751	4,440,983	4,499,771	4,547,801	4,594,520	4,636,850	62,596,078	
FEE FOR SERVICE - ACUTE	60,749,420	71,123,262	79,520,969	51,916,426	64,523,923	68,868,861	54,093,304	76,999,974	107,930,609	63,522,163	91,788,671	91,542,013	882,579,596	
FFS - PRIOR QUARTER COVERAGE	-113	-309	-7,209	1,845	0	0	-74	0	0	0	0	-143	-6,004	
EMERGENCY SERVICES - FEDERAL	3,942,636	3,125,660	4,376,209	3,269,109	3,488,602	5,477,542	4,312,941	4,046,490	4,161,348	4,464,738	3,370,616	4,039,050	48,074,940	
FFS MEDICAID IN PUBLIC SCHOOLS	1,535	1,162	972	809	1,025	1,853	1,003	1,306	1,562	2,059	1,814	2,794	17,893	
FFS TRBHA FEE FOR SERVICE	10,710,586	10,187,265	13,791,530	11,707,851	12,547,356	14,310,280	13,951,152	16,322,684	23,084,731	19,334,687	24,974,196	28,418,711	199,341,028	
INPATIENT INMATES FFS	810,012	856,799	1,147,633	568,639	494,621	646,295	623,236	824,772	730,850	432,722	542,442	731,817	8,409,838	
STATE ONLY TRBHA FFS	487,687	411,171	701,277	524,457	668,807	519,890	400,854	497,584	550,403	448,977	595,111	576,656	6,382,873	
YAVAPAI COUNTY INMATES FFS	30,896	5,315	0	0	0	2,286	0	0	0	0	0	0	38,497	
MARICOPA CTY INMATES FFS	50,607	118,615	141,733	120,681	116,912	240,201	219,113	52,335	272,182	108,486	186,871	216,496	1,844,233	
COCONINO COUNTY INMATES FFS	0	467	0	1,575	5,136	2,272	0	0	0	65	1,194	9	10,717	
MOHAVE COUNTY INMATES FFS	6,474	9,365	638	12,904	0	66	0	2,089	15,730	0	436	0	47,701	
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	18,593	37,186	34,032	91,826	-20,386	40,785	78,402	512,736	
PINAL COUNTY INMATES FFS	19,831	1,120	5,559	11,511	3,758	17,950	1,264	178	364	37,282	11,408	716	110,941	
REINSURANCE - ACC	7,247,946	11,078,691	6,909,613	10,643,746	8,260,899	13,062,622	6,268,809	5,918,839	6,387,723	7,485,951	6,954,346	7,196,971	97,416,155	
SMIB - ACC	8,735,642	8,826,554	8,791,193	8,847,034	8,892,559	8,905,801	10,234,684	10,193,465	10,226,435	10,361,115	10,349,508	10,443,821	114,807,811	
HIB - ACC	5,440	5,440	5,487	4,498	5,440	3,556	5,264	5,264	5,763	6,761	7,260	6,761	66,934	
SUBTOTAL	472,416,078	489,734,734	504,384,804	484,607,483	497,741,830	515,859,098	495,438,280	523,336,134	569,104,302	524,932,384	561,568,683	570,648,531	6,209,772,343	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending June 30, 2022

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	76,308,719	75,752,517	75,389,959	75,188,860	74,538,688	74,399,266	74,332,959	899,695,849	
CAPITATION - AIMHS	39,668	41,162	42,190	42,481	42,599	42,663	44,677	44,886	44,487	44,546	44,354	44,629	518,341	
MENTAL HEALTH - ADULT	34,568	41,196	33,334	33,503	33,474	33,474	32,528	30,880	32,637	38,315	36,068	33,474	413,450	
MENTAL HEALTH - GENERAL	0	0	0	0	0	0	800	-356	0	-3,115	0	0	-2,671	
MENTAL HEALTH - RBHA CRISIS	1,783,151	1,790,056	1,805,041	1,020,760	1,014,382	1,010,027	1,007,093	1,004,164	997,670	993,885	991,321	987,836	14,405,384	
FEE FOR SERVICE - ACUTE	5,825,473	7,828,428	7,645,678	4,831,001	6,553,673	6,031,310	3,876,942	7,697,269	10,221,363	4,491,524	7,939,694	6,468,427	79,410,781	
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	7,805,550	6,584,723	7,295,562	7,260,495	6,063,907	6,402,225	7,805,703	78,795,039	
FFS MEDICAID IN PUBLIC SCHOOLS	76	0	11	23	106	101	23	69	35	81	23	104	652	
INPATIENT INMATES FFS	28,391	46,767	36,606	18,325	26,399	29,933	14,906	50,026	53,808	1,072	18,268	56,807	381,307	
FFS TRBHA FEE FOR SERVICE	386,803	472,001	754,790	490,575	689,884	448,214	380,693	368,157	453,504	534,634	711,887	1,052,620	6,743,762	
STATE ONLY TRBHA FFS	83,084	61,258	70,300	46,282	62,605	30,413	5,972	80,480	32,199	81,494	59,692	31,828	645,607	
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	169	0	0	0	0	0	292	
MARICOPA CTY INMATES FFS	6,340	16,110	39,601	63	662	8,010	48,124	468	2,383	9,501	146	348	131,755	
COCONINO COUNTY INMATES FFS	0	0	0	0	0	201	5,347	0	0	0	9	0	5,557	
REINSURANCE - ACC	402,888	1,794,647	1,513,941	1,393,893	769,651	2,916,236	1,782,536	908,946	831,122	1,192,105	1,276,771	1,128,395	15,911,133	
SMIB - ACC	14,108	14,702	15,147	15,741	19,379	18,267	22,343	23,861	24,721	28,717	28,537	26,496	252,016	
	88,257,103	90,860,844	93,574,755	90,268,464	90,205,510	94,683,116	89,559,391	92,894,369	95,143,283	88,015,354	91,908,259	91,969,626	1,097,340,074	
	1,413,304,456	1,446,924,808	1,473,183,904	1,462,023,410	1,494,707,110	1,535,861,050	1,476,823,574	1,543,582,023	1,630,052,537	1,529,655,395	1,610,453,035	1,617,474,608	18,234,045,910	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
CAPITATION - AIMHS	0	0	0	0	0	0	0	0	0	19	0	0	19	
MENTAL HEALTH - RBHA CRISIS	52	52	81	50	50	58	51	58	51	58	36	43	639	
KidsCare - CAPITATION	11,005,329	11,301,371	13,129,471	12,114,310	12,394,535	12,709,608	12,901,032	13,113,864	13,204,333	13,388,580	13,489,223	13,615,469	152,367,126	
KidsCare - FEE FOR SERVICE	202,286	268,870	303,460	177,992	262,007	407,090	337,668	376,032	538,717	446,172	567,699	534,704	4,422,695	
KidsCare - MENTAL HEALTH	123,237	124,202	126,787	399,446	409,199	418,766	426,649	433,455	436,503	442,469	447,568	449,549	4,237,829	
KidsCare - REINSURANCE	344,676	1,469,000	-200,584	497,697	359,046	307,216	298,087	308,429	348,017	251,125	384,214	144,641	4,511,564	
KidsCare - TRANSPLANT REIN	43,580	0	973,348	142,540	147,957	148,210	306,790	0	55,950	8,425	12,095	257,585	2,096,480	

11,719,160	13,163,495	14,332,563	13,332,034	13,572,794	13,990,948	14,270,276	14,231,838	14,583,570	14,536,848	14,900,833	15,001,991	167,636,351	

TOTAL TITLE XXI

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	150.87	0.00	0.00	0.00	132.81	1,780.29	1,780.29		3,844.26		
1005	TANF 14-20 FEMALE WI	117.20	117.20	117.20	132.81	132.81	132.81	132.81	132.81	132.81	0.00	0.00	0.00		1,148.46		
1006	TANF 21-44 MALE WITH	29,444.45	26,953.29	31,212.32	37,591.15	35,359.42	35,275.04	36,621.41	40,147.88	40,650.87	33,854.79	35,829.05	31,153.19		414,092.86		
1007	TANF 21-44 FEMALE WI	40,581.51	35,879.34	30,736.33	39,424.42	46,366.40	59,117.23	55,933.96	60,277.73	57,681.64	60,915.80	56,675.11	58,320.77		601,910.24		
1008	TANF 45-64 M & F WIT	77,191.29	80,699.24	86,017.53	89,247.29	92,631.06	92,289.76	98,252.84	96,506.51	83,577.15	86,771.95	89,139.58	94,339.21		1,066,663.41		
1009	TANF 65+ M & F WITH	23,246.54	23,523.62	23,042.82	24,942.48	23,529.15	25,158.09	25,354.03	28,162.29	31,399.51	28,527.86	29,193.27	31,421.53		317,501.19		
100D	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	540.93	0.00	0.00	0.00	0.00	0.00	0.00		540.93		
100F	TANF 21-44 MALE WITH	91.26	37.38	37.79	209.13	3,634.30	0.00	479.52	0.00	217.92	115.10	208.92	0.00		5,031.32		
100G	TANF 21-44 FEMALE WI	0.00	182.52	0.00	1,629.11	179.58	0.00	123.44	741.07	2,646.21	0.00	170.35	233.41		5,905.69		
100H	TANF 45-64 M & F WIT	585.36	118.85	0.00	0.00	1,054.40	260.70	83.67	0.00	4,761.44	143.08	1,144.11	8,484.63		16,636.24		
100J	TANF 65+ M & F WITH	0.00	0.00	76.34	0.00	91.98	0.00	0.00	0.00	827.34	0.00	84.07	182.48		1,262.21		
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	9,480,493.99	9,479,479.95	9,587,407.81	9,699,230.50	9,603,739.33	9,458,457.68	9,363,662.66		108,955,977.29		
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	5,580,507.45	5,758,572.16	5,815,490.30	5,734,592.84	5,716,138.89	5,715,842.68	5,683,510.34		63,614,553.27		
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	10,302,580.40	10,620,182.32	10,695,212.20	10,703,161.86	10,753,010.94	10,803,428.36	10,734,471.24		119,306,250.30		
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	3,780,708.38	3,902,382.40	3,940,199.18	3,999,072.18	4,086,618.90	4,124,283.60	4,136,920.50		44,241,594.51		
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	4,376,976.91	4,493,171.41	4,545,378.21	4,575,960.92	4,625,495.38	4,689,301.24	4,673,304.71		51,194,619.35		
	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	15,522,453.58	15,928,450.75	16,214,765.80	16,478,487.33	16,669,645.29	16,834,338.44	17,001,940.72		184,602,791.29		
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	50,910,501.21	52,032,666.10	52,852,755.81	53,534,741.54	54,191,190.71	54,815,302.93	55,349,709.48		606,312,201.11		
	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	13,084,671.14	13,460,656.99	13,755,972.76	13,985,906.22	14,171,888.39	14,359,097.93	14,573,585.86		156,815,786.56		
1019	TANF 65+ M & F NON-M	57,245.16	57,764.38	59,725.04	62,832.90	63,455.85	65,663.72	66,793.69	70,338.53	63,393.08	69,631.51	65,044.17	68,545.28		770,433.31		
101A	TANF < 1 M & F NON-M	324,970.17	265,210.36	371,239.52	407,432.04	376,991.47	368,462.76	421,391.35	417,453.35	499,119.77	382,009.83	375,732.00	466,096.00		4,676,108.62		
101B	TANF 01-05 M & F NON	13,164.19	15,795.18	19,123.63	19,420.97	6,834.95	9,685.46	25,742.45	9,961.94	18,232.46	9,588.05	10,897.21	22,551.26		180,997.75		
101C	TANF 06-13 M & F NON	7,198.83	10,056.07	4,239.86	11,447.53	11,007.37	4,428.38	7,329.46	742.91	8,246.24	3,207.70	2,814.46	3,673.43		74,392.24		
101D	TANF 14-20 MALE NON-	3,237.81	4,045.00	2,268.21	4,403.63	9,096.40	1,721.53	1,814.59	2,394.68	14,022.86	17,721.99	2,747.75	4,785.01		68,259.46		
101E	TANF 14-20 FEMALE N	2,917.69	8,282.27	6,236.37	8,110.75	3,061.21	10,207.23	6,093.25	4,873.61	11,140.58	5,006.12	6,691.65	6,023.27		78,644.00		
	O																
101F	TANF 21-44 MALE NON-	158,952.48	126,092.99	129,202.38	144,056.31	127,366.21	150,971.49	150,632.74	120,196.68	154,283.92	169,497.82	110,344.98	115,353.52		1,656,951.52		
101G	TANF 21-44 FEMALE N	294,636.21	212,415.18	254,922.02	294,801.24	227,313.84	286,807.57	228,400.06	219,615.83	325,416.40	297,557.65	231,981.12	228,421.27		3,102,288.39		
	O																
101H	TANF 44-64 M & F NON	82,989.45	63,596.88	81,170.82	91,013.19	61,382.10	84,254.29	73,291.62	66,858.81	101,591.88	77,962.68	58,990.48	77,384.12		920,486.32		
101J	TANF 65+ N & F NON-M	55.95	0.00	137.69	462.86	0.00	0.00	382.58	48.22	1,402.40	270.23	805.63	208.99		3,774.55		
1023	TANF 06-13 M & F WIT	131.08	131.08	131.08	143.85	143.85	143.85	143.85	143.85	143.85	143.85	143.85	143.85		1,687.89		
1024	TANF 14-20 MALE WITH	2,727.47	2,727.47	2,727.47	2,741.72	2,741.72	2,741.72	2,741.72	2,883.45	2,883.45	2,735.49	2,735.49	2,735.49		33,122.66		
1025	TANF 14-20 FEMALE WI	276.42	276.42	276.42	296.68	296.68	296.68	296.68	296.68	296.68	149.53	149.53	149.53		3,057.93		
1026	TANF 21-44 MALE WITH	40,118.54	47,720.97	37,735.64	38,946.07	36,482.79	39,398.41	42,202.62	41,496.59	43,611.72	44,493.14	46,666.89	54,817.15		513,690.53		
1027	TANF 21-44 FEMALE WI	58,218.98	53,265.42	49,842.12	48,277.73	54,067.22	52,424.44	66,709.70	68,595.53	69,313.15	77,630.98	85,786.79	83,295.62		767,427.68		
1028	TANF 45-64 M & F WIT	64,188.85	67,556.55	70,549.05	77,550.65	85,253.86	83,479.47	75,105.80	68,076.31	70,773.09	72,736.66	74,621.74	75,515.20		885,407.23		
1029	TANF 65+ M & F WITH	14,444.41	14,421.61	15,202.50	17,748.34	17,995.04	18,937.25	20,347.18	18,820.08	19,209.10	19,906.78	19,967.16	19,534.52		216,533.97		

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102F	TANF 21-44 MALE WITH	122.62	190.65	345.64	123.96	9.86	4.57	0.00	0.00	9.55	0.00	4.91	91.37		903.13		
102G	TANF 21-44 FEMALE WI	0.00	0.00	14.48	0.00	424.38	351.26	176.60	262.80	724.57	2,744.75	4.77	0.00		4,703.61		
102H	TANF 44-64 M & F WIT	152.18	0.00	0.00	0.00	0.00	0.00	0.00	92.63	0.00	0.00	0.00	295.80		540.61		
102J	TANF 65+ M & F WITH	0.00	0.00	58.21	0.00	0.00	0.00	0.00	0.00	14.84	0.00	0.00	737.00		810.05		
2100	SSI AGED WITH MEDIC	763,800.03	768,532.43	777,797.37	854,111.51	845,265.15	856,517.10	865,609.68	889,547.37	904,010.34	919,747.66	922,043.04	938,869.43		10,305,851.11		
	A																
210Z	SSI AGED WITH MEDIC	28,421.34	26,272.69	32,512.81	38,034.79	23,868.36	39,178.06	31,254.15	30,630.81	42,215.87	31,838.50	28,727.08	26,476.22		379,430.68		
	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	12,051,336.24	12,160,464.55	12,243,757.37	12,529,144.45	12,653,687.17	12,804,547.57	12,893,455.11		144,689,558.18		
	R																
211Z	SSI AGED NON-MEDICA	129,841.87	113,589.83	107,486.63	144,631.78	165,440.72	169,747.91	181,746.92	167,430.58	179,593.51	169,274.77	143,507.57	189,039.59		1,861,331.68		
	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	7,234,476.54	7,286,900.33	7,343,143.45	7,410,418.39	7,449,084.97	7,513,763.53	7,554,558.03		85,660,910.00		
212Z	SSI AGED WITH QMB P	2,386.49	3,902.80	2,431.14	2,650.08	2,510.34	3,444.74	3,918.22	5,017.08	6,917.60	3,604.51	4,636.60	3,608.47		45,028.07		
	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	2,358,403.65	2,447,705.90	2,454,144.30	2,498,967.16	2,512,860.74	2,525,696.90	2,550,800.26		28,573,565.67		
	E																
220Z	SSI DISABLED WITH M	31,096.75	30,489.07	58,739.40	38,310.93	22,921.04	63,882.21	34,785.52	33,544.43	47,074.87	30,465.31	41,918.30	42,863.38		476,091.21		
	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	79,093,522.03	78,951,671.02	78,891,056.96	78,693,138.61	78,606,654.35	78,630,721.27	78,692,273.25		943,360,992.55		
	D																
221Z	SSI DISABLED NON-ME	875,772.81	737,616.18	873,090.82	748,934.43	620,253.57	652,858.81	675,547.44	718,993.77	813,826.84	814,741.04	813,883.83	770,653.82		9,116,173.36		
	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	16,564,890.42	16,542,850.41	16,434,796.86	16,442,767.01	16,398,677.92	16,338,885.75	16,321,820.36		196,784,986.77		
	M																
222Z	SSI DISABLED WITH Q	55,236.68	11,887.96	30,569.80	15,415.60	23,643.05	48,361.21	17,047.61	15,091.03	79,497.81	15,555.56	39,896.61	12,796.98		364,999.90		
	M																
2300	SSI BLIND WITH MEDIC	6,111.90	5,573.58	5,855.05	8,047.18	8,057.46	8,988.10	9,095.66	8,962.75	9,424.00	9,201.92	9,837.61	10,350.23		99,505.44		
230Z	SSI BLIND WITH MEDIC	116.81	108.98	129.25	9.89	0.00	368.12	138.41	0.00	0.00	39.87	0.00	158.41		1,069.74		
2310	SSI BLIND NON-MEDIC	698,029.61	707,319.42	711,090.99	733,850.02	725,597.07	725,839.89	728,550.14	733,897.60	721,339.08	724,239.50	723,403.12	744,007.81		8,677,164.25		
	A																
231Z	SSI BLIND NON-MEDIC	9,332.14	16,473.19	4,765.43	2,654.63	24,291.99	7,669.94	26,736.57	1,618.86	6,856.12	2,105.98	1,890.62	38,638.53		143,034.00		
	A																
2320	SSI BLIND WITH QMB	54,450.83	56,379.72	56,924.63	63,089.68	65,396.57	66,636.97	69,429.90	66,645.79	65,725.35	67,740.27	67,371.65	65,841.84		765,633.20		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	62.71	86.46	357.30	0.00	0.00	0.00	0.00	0.00	0.00		506.47		
4301	SOBRA CHILD <1 M & F	0.00	110.81	0.00	147.96	147.96	147.96	147.96	147.96	147.96	147.96	286.42	214.39		1,647.34		
4302	SOBRA CHILD 01-05 M	137.40	110.81	0.00	0.00	0.00	0.00	0.00	0.00	149.10	149.10	149.10	149.10		844.61		
4303	SOBRA CHILD 06-13 M	547.58	494.40	272.78	293.38	293.38	149.53	1,471.75	1,760.13	1,770.81	1,770.81	661.85	601.89		10,088.29		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	-132.81	132.81	0.00	0.00	0.00	0.00		0.00		
4305	SOBRA CHILD 14-20 FE	134.72	134.72	136.94	152.17	152.17	152.17	152.17	152.17	157.12	152.17	152.17	152.17		1,780.86		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	152.81	0.00		152.81		
430C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	39.62	0.00	0.00	0.00	0.00		39.62		
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	20,044,360.31	19,841,851.80	19,932,731.90	20,006,428.25	20,084,982.36	20,198,247.20	20,456,607.87		237,989,450.87		
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	43,485,813.27	43,318,617.96	43,312,016.82	43,431,382.11	43,310,334.37	43,278,583.50	43,380,712.28		518,856,138.87		
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	53,759,468.87	53,452,436.49	53,583,482.48	53,817,595.67	53,709,238.06	53,750,291.64	54,093,197.10		641,284,820.99		
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	16,673,708.80	16,650,557.59	16,895,937.20	16,878,089.45	16,836,321.10	16,887,005.12	17,053,542.94		198,712,175.85		
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	16,373,066.73	16,387,893.98	16,599,945.95	16,636,591.34	16,577,247.18	16,629,880.82	16,772,538.80		195,594,000.99		
431A	SOBRA CHILD < 1 M &	139,418.63	127,236.79	143,838.61	199,083.11	190,176.56	240,234.84	186,615.05	188,591.60	224,389.63	182,928.48	188,399.66	166,728.03		2,177,640.99		
431B	SOBRA CHILD 01-05 M	255,627.65	219,131.71	248,160.60	274,209.96	199,873.30	290,697.16	233,614.80	240,953.47	282,062.49	250,709.22	221,016.17	218,816.57		2,934,873.10		

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431C	SOBRA CHILD 6-13 M&F	268,230.24	270,396.77	309,346.75	345,478.48	260,679.45	309,403.07	255,052.60	289,619.94	306,545.88	320,594.40	232,975.10	229,516.41		3,397,839.09		
431D	SOBRA CHILD 14-20 MA	85,627.32	87,020.94	112,781.48	104,866.96	75,228.71	99,590.41	83,212.09	77,298.63	102,898.10	104,628.44	70,851.12	74,542.53		1,078,546.73		
431E	SOBRA CHILD 14-20 FE	86,245.86	80,318.66	93,844.86	106,837.04	91,927.70	104,819.37	89,638.03	87,459.21	106,408.91	101,744.91	73,496.62	68,557.47		1,091,298.64		
4322	SOBRA CHILD 01-05 M	271.66	271.66	271.66	299.32	299.32	299.32	299.32	299.32	147.15	147.15	147.15	147.15		2,900.18		
4323	SOBRA CHILD 06-13 M	135.14	135.14	135.14	147.96	147.96	147.96	147.96	280.77	280.77	427.92	304.50	280.77		2,571.99		
4325	SOBRA CHILD 14-20 FE	389.98	389.98	524.70	515.46	573.34	423.81	423.81	291.00	291.00	291.00	291.00	147.15		4,552.23		
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		
5005	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	153.30	153.30	0.00	0.00	0.00	0.00		306.60		
	M																
5007	SOBRA PREG 21-44 FE	3,694.41	5,558.20	8,757.30	12,780.71	17,331.04	14,855.67	11,001.77	9,828.12	10,326.66	6,850.45	6,957.38	9,245.24		117,186.95		
	M																
5008	SOBRA PREG 45-64 FE	2,592.33	2,592.33	2,592.33	2,593.76	149.53	149.53	149.53	149.53	192.49	149.53	0.00	145.74		11,456.63		
	M																
500G	SOBRA PREG 21-44 FE	126.08	247.65	566.67	0.00	540.44	318.03	427.77	184.67	152.17	0.00	237.14	4.98		2,805.60		
	M																
500H	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	105.00	0.00	0.00	0.00		105.00		
	M																
5013	SOBRA PREG 09-13 FE	641.87	816.87	802.32	842.64	1,268.16	920.71	1,270.79	1,263.25	1,053.20	923.19	1,263.37	632.18		11,698.55		
	M																
5015	SOBRA PREG 14-20 FE	448,174.24	457,664.24	460,044.32	469,952.75	466,676.40	469,792.73	459,704.06	476,215.86	469,307.22	443,447.45	435,763.83	460,412.03		5,517,155.13		
	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	7,028,871.19	6,815,177.10	7,044,192.09	7,046,912.09	6,805,619.77	6,776,999.02	7,101,346.25		81,560,227.18		
	M																
5018	SOBRA PREG 45-64 FE	31,891.48	34,819.09	37,419.75	39,345.15	37,375.99	35,594.51	30,675.59	31,398.55	32,466.95	30,099.27	30,731.38	33,752.74		405,570.45		
	M																
501C	SOBRA PREG 09-13 FE	0.00	0.00	0.00	257.37	0.00	133.98	0.00	0.00	0.00	134.15	0.00	0.00		525.50		
	M																
501E	SOBRA PREG 14-20 FE	23,393.78	20,740.98	25,551.51	30,032.80	22,606.90	27,631.31	29,156.14	25,702.94	27,550.06	26,571.24	23,736.22	23,095.39		305,769.27		
	M																
501G	SOBRA PREG 21-44 FE	257,035.50	222,352.26	245,629.99	293,471.57	223,765.25	290,162.93	260,351.06	246,982.37	298,461.82	292,380.21	241,295.81	252,904.81		3,124,793.58		
	M																
501H	SOBRA PREG 45-64 FE	2,524.92	897.07	292.13	4,436.58	785.68	307.47	156.91	369.72	222.29	1,667.30	316.62	876.73		12,853.42		
	M																
5025	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	153.30	0.00	0.00	0.00		153.30		
	M																
5027	SOBRA PREG 21-44 FE	18,493.01	17,584.84	12,767.94	12,187.09	7,610.69	8,135.73	15,535.22	15,642.30	18,084.25	12,895.18	16,158.18	21,213.48		176,307.91		
	M																
5028	SOBRA PREG 45-64 FE	3,797.15	3,517.17	3,517.17	3,710.98	3,414.30	3,562.26	3,709.41	3,842.22	3,709.41	3,561.45	3,709.41	3,709.41		43,760.34		
	M																
502G	SOBRA PREG 21-44 FE	30.33	0.00	0.00	0.00	0.00	70.52	1,618.86	664.29	274.79	2,161.47	0.00	0.00		4,820.26		
	M																
SUBTOTAL:	368,425,493.14	368,776,115.38	369,336,726.29	386,502,280.57	390,064,743.05	393,641,267.96	395,246,680.19	397,852,312.04	400,492,102.32	400,798,979.31	401,791,199.55	404,253,382.02		4,677,181,281.82		

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	3,391,750.58	3,299,504.98	2,898,628.91	3,110,169.42	3,038,657.40	2,831,406.04	3,408,399.56	
9920	SSI W/MEDICARE KICK	25,888.69	25,516.73	25,927.80	12,906.23	6,442.76	13,342.35	26,058.49	38,995.32	39,113.39	26,345.94	13,172.97	32,501.25	
9921	SSI W/O MEDICARE KIC	71,444.77	110,479.32	148,378.91	118,726.11	111,708.45	124,137.14	158,701.85	136,904.59	85,193.13	111,929.14	124,357.83	104,233.96	
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	11,672,417.32	9,911,187.32	9,329,797.11	9,316,004.04	8,815,734.08	8,365,752.20	9,016,372.51	
SUBTOTAL:	13,941,948.37	14,368,713.00	13,796,898.14	14,021,610.11	14,207,878.79	15,201,647.39	13,395,452.64	12,404,325.93	12,550,479.98	11,992,666.56	11,334,689.04	12,561,507.28	

38,588,871.35	
286,211.92	
1,406,195.20	
119,496,538.76	
159,777,817.23	

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

198.00

198.00

1106	TANF EXPANDED 21-44	69,075.79	67,473.50	71,746.46	73,618.24	79,141.44	78,453.12	75,590.73	71,966.58	70,681.94	66,919.53	58,413.35	57,907.40	
1107	TANF EXPANDED 21-44	162,032.73	156,224.32	159,711.60	168,955.70	151,272.25	156,441.76	152,642.35	150,649.35	159,497.33	163,812.50	159,182.36	155,031.12	
1108	TANF EXPANDED 45-64	440,432.18	447,081.98	438,955.77	455,380.78	438,874.18	441,441.38	446,949.50	443,655.58	452,797.65	463,248.33	459,855.47	458,723.51	

840,988.08	
1,895,453.37	
5,387,396.31	

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+ M	123,346.59	127,834.71	134,042.21	144,789.16	147,863.58	148,903.92	147,920.83	149,331.80	153,370.95	153,914.10	155,646.49	159,126.51		1,746,090.85		
	&																
110F	TANF EXPANDED 21-44	2,126.30	1,099.84	3,285.66	712.63	384.83	199.87	174.06	403.61	1,076.08	515.09	719.19	370.35		11,067.51		
110G	TANF EXPANDED 21-44	3,907.15	1,484.06	5,267.33	2,108.41	3,110.33	6,094.08	1,829.33	18,791.43	3,362.38	2,826.85	1,362.55	3,262.40		53,406.30		
110H	TANF EXPANDED 45-64	4,501.87	4,068.97	2,002.61	3,533.45	1,888.46	4,236.56	3,367.03	5,636.81	4,765.57	10,141.10	1,189.75	8,001.20		53,333.38		
110J	TANF EXPANDED 65+ M	2,517.71	2,814.56	3,121.65	2,624.20	2,208.77	2,319.15	3,867.41	2,026.09	5,103.45	4,511.62	2,960.58	4,293.30		38,368.49		
	&																
1112	TANF EXPANDED 01-05	393.70	192.87	192.87	419.48	207.67	207.67	207.67	418.86	207.67	207.67	207.67	0.00		2,863.80		
1113	TANF EXPANDED 06-13	417.00	417.00	617.83	227.63	656.49	656.49	656.49	862.45	862.45	660.78	875.12	441.97		7,351.70		
1114	TANF EXPANDED 14-20	42,543.13	41,313.25	39,037.85	38,895.41	37,393.04	37,377.47	35,105.01	31,746.21	30,486.56	30,118.06	30,739.96	32,393.63		427,149.58		
1115	TANF EXPANDED 14-20	257,418.05	247,391.76	236,335.92	229,212.22	223,780.90	219,223.26	211,720.05	207,203.50	208,652.34	206,649.83	197,443.78	197,167.28		2,642,198.89		
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	10,708,367.73	10,428,360.43	10,350,974.29	10,385,956.49	10,344,390.30	10,342,031.08	10,362,443.96		128,519,327.00		
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	29,844,524.10	29,340,343.11	29,190,124.88	29,364,732.17	29,334,141.51	29,342,318.16	29,260,611.61		362,201,529.09		
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	10,766,571.42	10,567,674.53	10,659,252.28	10,689,454.35	10,636,179.32	10,651,175.74	10,753,490.86		129,567,662.56		
1119	TANF EXPANDED 65+ M	51,108.03	52,173.64	52,353.57	54,307.67	51,621.08	54,822.94	59,408.32	60,098.17	60,807.08	61,937.02	60,472.36	61,293.30		680,403.18		
	&																
111D	TANF EXPANDED 14-20	978.21	762.07	509.99	744.15	1,166.96	559.83	1,714.41	397.21	345.28	654.04	214.95	257.21		8,304.31		
111E	TANF EXPANDED 14-20	1,020.67	544.51	467.13	1,026.78	471.59	494.07	699.90	766.27	814.94	593.23	1,132.28	1,292.30		9,323.67		
111F	TANF EXPANDED 21-44	125,069.53	131,074.38	150,676.33	135,408.46	122,518.06	120,837.29	108,717.20	98,400.73	133,974.47	94,987.79	117,763.80	87,461.63		1,426,889.67		
111G	TANF EXPANDED 21-44	170,434.10	165,240.91	180,241.09	210,703.59	154,825.80	173,100.15	135,692.42	156,735.79	169,936.28	182,674.68	128,320.10	142,660.30		1,970,565.21		
111H	TANF EXPANDED 45-64	68,479.73	57,989.20	73,223.46	95,070.87	57,462.01	74,375.14	77,476.37	69,845.47	69,729.65	77,503.21	61,930.68	51,883.68		834,969.47		
111J	TANF EXPANDED 65+ M	357.07	0.00	0.00	955.43	0.00	0.00	235.36	466.56	783.91	0.00	2,052.77	0.00		4,851.10		
	&																
1125	TANF EXPANDED 14-20	141.70	141.70	141.70	149.53	149.53	0.00	0.00	0.00	0.00	153.30	153.30	153.30		1,184.06		
1126	TANF EXPANDED 21-44	333,080.20	335,975.12	330,193.67	337,409.47	333,085.82	332,130.86	321,399.73	325,369.99	328,811.28	334,506.44	330,474.01	309,799.15		3,952,235.74		
1127	TANF EXPANDED 21-44	797,818.70	811,327.67	806,875.84	797,306.28	800,787.69	796,476.26	778,258.32	778,904.38	783,468.55	779,282.95	785,532.40	778,779.22		9,494,818.26		
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	1,069,933.61	1,065,084.41	1,079,142.46	1,084,290.75	1,086,852.31	1,100,989.89	1,109,110.62		12,774,745.24		
1129	TANF EXPANDED 65+ M	296,440.00	300,205.65	301,366.48	328,663.84	335,730.33	335,933.37	336,880.39	345,925.80	351,119.40	359,781.62	364,661.03	373,272.04		4,029,979.95		
	&																
112F	TANF EXPANDED 21-44	379.47	13.07	328.91	86.41	251.13	42.72	1,076.06	839.19	417.77	98.76	762.92	300.58		4,596.99		
112G	TANF EXPANDED 21-44	161.30	99.61	59.02	464.43	235.88	4.57	805.74	20.95	1,222.32	3,789.68	62.64	265.04		7,191.18		
112H	TANF EXPANDED 45-64	296.88	613.90	333.01	397.30	133.29	626.66	0.00	968.11	346.45	568.58	1,625.24	1,356.51		7,265.93		
112J	TANF EXPANDED 65+ M	193.90	48.59	126.33	0.00	395.91	48.08	296.33	1,559.69	61.48	399.97	656.37	106.88		3,893.53		
	&																
2400	SSI AGED EXPANDED	88,524.93	84,272.23	87,938.08	93,993.15	99,074.79	93,130.62	88,820.85	90,879.24	96,595.54	100,672.75	98,294.86	94,020.25		1,116,217.29		
	WI																
240Z	SSI AGED EXPANDED	27,564.79	22,569.42	21,549.37	30,377.59	32,429.94	28,553.68	39,671.90	23,603.18	32,231.50	28,906.88	21,578.42	15,777.77		324,814.44		
	WI																
2410	SSI AGED EXPANDED N	175,943.39	177,584.18	182,719.11	187,393.03	184,191.11	187,989.91	176,330.44	166,865.27	176,096.81	171,603.15	179,728.98	183,614.71		2,150,060.09		
	O																
241Z	SSI AGED EXPANDED N	7,694.74	10,720.26	2,806.75	7,613.78	13,591.85	4,029.26	2,363.38	3,330.83	2,050.39	4,648.72	1,587.83	3,805.76		64,243.55		
	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	7,152,316.16	7,170,581.64	7,212,505.58	7,287,444.83	7,349,782.63	7,432,466.88	7,440,136.80		84,906,933.37		
	WI																
242Z	SSI AGED EXPANDED	1,013.05	4,919.56	5,093.08	4,338.68	3,543.34	8,035.66	2,910.88	19,404.60	3,586.02	6,308.10	2,764.43	2,454.27		64,371.67		
	WI																
2500	SSI BLIND EXPANDED	136.94	136.94	266.78	175.68	152.17	383.39	282.03	210.30	193.93	152.17	0.00	101.82		2,192.15		
	W																
250Z	SSI BLIND EXPANDED	135.14	0.00	138.80	256.55	0.00	69.23	19.24	292.58	102.09	0.00	0.00	86.68		1,100.31		
	W																

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2510	SSI BLIND EXPANDED	1,229.94	1,229.94	2,636.63	5,422.89	6,872.05	3,973.73	7,695.83	10,145.27	8,887.38	8,957.27	7,584.17	4,736.57		69,371.67		
	N																
251Z	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	5,003.56	0.00	0.00	0.00	0.00	0.00		5,003.56		
	N																
2520	SSI BLIND EXPANDED	4,458.57	5,143.25	6,341.35	10,680.56	12,151.57	11,988.67	14,154.15	14,620.95	17,988.91	19,167.33	19,408.01	19,478.34		155,581.66		
	W																
252Z	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	38.33	0.00	0.00	0.00	0.00		38.33		
	W																
2600	SSI DISABLED EXPAND	156,192.51	150,805.10	140,071.89	144,862.85	138,850.53	144,557.01	149,036.08	158,772.76	148,079.39	133,385.19	139,654.31	144,015.31		1,748,282.93		
	E																
260Z	SSI DISABLED EXPAND	26,254.75	14,558.99	11,224.89	21,009.22	22,520.65	26,022.71	32,481.73	36,141.29	25,104.57	21,624.51	16,174.15	23,209.16		276,326.62		
	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	1,901,588.44	1,852,330.76	1,845,709.45	1,807,932.12	1,798,859.58	1,795,447.31	1,736,489.34		22,543,367.24		
	E																
261Z	SSI DISABLED EXPAND	8,411.94	22,688.68	24,764.56	28,762.41	25,495.77	27,010.43	22,043.45	16,810.52	23,165.66	15,864.55	16,292.45	25,022.20		256,332.62		
	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	11,235,917.66	11,163,767.61	11,106,758.61	11,108,475.25	11,093,499.66	11,090,558.91	10,963,934.63		133,604,667.67		
	E																
262Z	SSI DISABLED EXPAND	9,044.55	13,624.36	18,063.76	10,675.74	8,558.53	3,697.02	10,145.67	2,520.63	11,505.80	12,687.86	3,571.85	5,209.44		109,305.21		
	E																
SUBTOTAL:	77,706,372.78	78,001,842.81	77,793,670.20	78,834,013.77	76,857,055.38	76,203,667.11	75,041,792.69	74,911,093.88	75,266,577.18	75,168,140.52	75,186,038.55	75,033,349.91		916,003,614.78		

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	1,407,486.73	1,360,082.76	1,306,496.93	1,448,679.03	1,109,241.14	1,245,350.14	1,493,845.11	
9922	SB PAYMENT FOR SSI
E	0.00	6,751.60	0.00	0.00	0.00	0.00	0.00	6,442.76	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	1,407,486.73	1,360,082.76	1,312,939.69	1,448,679.03	1,109,241.14	1,245,350.14	1,493,845.11	

18,604,728.49	
13,194.36	
6,398.60	
18,624,321.45	

3504	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	632.45	632.45	632.45	632.45	632.45	632.45	
3505	ADULT 40-100% FEMAL E	0.00	0.00	0.00	632.45	0.00	0.00	0.00	0.00	0.00	611.85	611.85	611.85	
3506	ADULT 40-100% MALE 2	24,853.90	22,622.60	23,232.02	25,464.52	26,096.97	25,240.11	20,972.97	23,078.61	20,073.87	21,187.01	19,472.49	23,466.45	
3507	ADULT 40-100% FEMAL E	22,734.89	19,519.17	17,586.70	23,019.44	25,499.84	29,137.08	24,724.09	24,599.70	22,005.94	22,854.10	19,972.98	19,757.19	
3508	ADULT 40-100% M&F 45	221,357.49	233,635.81	245,677.97	266,481.38	257,259.53	283,421.87	340,404.97	335,954.20	309,253.68	300,482.09	313,658.17	320,053.23	
3509	ADULT 40-100% M&F 65	183,112.02	212,721.13	256,425.53	265,830.96	285,532.97	305,718.28	334,394.88	408,570.59	400,775.15	401,543.13	412,503.13	441,000.87	
350F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	20.40	0.00	0.00	45.13	0.00	0.00	1,398.98	
350G	ADULT 40-100% FEMAL E	0.00	731.24	0.00	156.66	0.00	0.00	3,179.45	1,423.36	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	882.02	25,437.18	77.57	0.00	788.40	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	20.09	0.00	8,729.71	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	4,482,538.14	4,455,458.25	4,348,340.45	4,509,221.90	4,637,653.57	4,763,458.21	4,797,631.71	
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	4,845,610.48	4,829,413.84	4,722,345.14	4,883,337.08	5,021,514.23	5,099,468.88	5,103,182.32	
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	19,780,535.04	19,486,715.04	19,597,122.63	19,515,892.58	19,512,900.66	19,542,663.60	19,659,782.58	
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	16,434,089.64	16,318,990.10	16,420,636.74	16,572,299.05	16,678,062.27	16,891,736.22	17,012,060.18	
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	29,971,751.18	29,450,193.75	29,486,787.83	29,403,967.05	29,368,116.27	29,315,475.75	29,400,146.00	
3519	ADULT 40-100% M&F 65	18,703.36	21,418.29	23,728.57	30,609.81	35,348.22	31,440.60	30,608.89	44,552.42	25,287.73	34,339.42	22,447.52	30,115.77	
351D	ADULT 40-100% MALE 1	20,279.43	16,022.77	15,434.38	35,256.03	22,499.00	23,134.18	26,637.36	21,431.44	22,311.27	24,176.09	26,147.98	16,654.59	
351E	ADULT 40-100% FEMAL E	26,035.61	28,004.98	25,929.17	34,107.96	26,666.97	29,787.02	26,748.56	34,691.22	45,306.98	25,442.19	25,045.14	28,694.68	
351F	ADULT 40-100% MALE 2	226,338.34	204,632.81	155,647.74	167,135.28	181,694.91	186,543.54	170,451.51	150,003.65	175,993.51	166,386.87	151,652.07	126,703.72	
351G	ADULT 40-100% FEMAL E	146,129.44	154,540.10	159,975.66	169,053.42	152,290.81	164,106.99	156,761.42	118,234.24	151,585.31	119,951.24	142,351.56	110,298.95	

3,794.70	
2,468.00	
275,761.52	
271,411.12	
3,427,640.39	
3,908,128.64	
1,464.51	
5,490.71	
27,796.10	
12,910.38	
54,004,889.59	
58,155,599.97	
236,314,666.12	
197,743,563.87	
358,162,937.97	
348,600.60	
269,984.52	
356,460.48	
2,063,183.95	
1,745,279.14	

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351H	ADULT 40-100% M&F 45	336,811.65	280,598.85	318,181.09	343,770.17	276,434.39	375,105.87	349,539.77	323,358.86	296,033.83	261,309.46	265,365.07	218,948.39		3,645,457.40		
351J	ADULT 40-100% M&F 65	3,682.44	10,664.25	0.00	4,014.35	1,296.99	2,028.15	5,608.07	0.00	15,055.55	7,612.97	3,114.10	1,230.48		54,307.35		
3524	ADULT 40-100% MALE 1	752.39	752.39	752.39	1,405.40	772.95	772.95	0.00	0.00	0.00	690.71	1,463.66	1,463.66		8,826.50		
3526	ADULT 40-100% MALE 2	2,343.02	3,095.41	3,095.41	3,103.49	4,722.35	4,722.35	8,737.97	8,638.14	9,318.63	9,952.04	9,952.04	9,952.04		77,632.89		
3527	ADULT 40-100% FEMAL	3,438.71	2,100.73	4,659.93	4,686.86	6,305.72	6,849.09	13,275.26	13,275.26	13,275.26	13,364.12	12,037.20	12,037.20		105,305.34		
	E																
3528	ADULT 40-100% M&F 45	19,838.61	21,066.99	23,198.90	27,252.01	24,298.63	27,893.64	36,001.13	36,712.86	32,860.71	36,340.73	35,805.29	41,273.88		362,543.38		
3529	ADULT 40-100% M&F 65	11,242.31	11,920.26	12,473.75	13,359.79	14,937.85	14,945.43	14,876.79	18,488.66	19,497.03	16,215.97	18,231.79	21,537.23		187,726.86		
352G	ADULT 40-100% FEMAL	1,254.35	0.00	0.00	0.00	0.00	1,338.71	0.00	0.00	0.00	0.00	0.00	0.00		2,593.06		
	E																
352H	ADULT 40-100% M&F 45	0.00	0.00	925.04	0.00	0.00	0.00	0.00	358.87	0.00	676.17	573.48	0.00		2,533.56		
3705	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	711.68	711.68	711.68	553.72	0.00	0.00		2,688.76		
	L																
3706	ADULT <40% EXP MALE	100,063.05	112,294.62	114,641.86	115,716.33	123,731.95	118,557.92	106,881.11	116,081.68	115,219.24	97,740.72	99,868.49	89,558.32		1,310,355.29		
3707	ADULT <40% EXP FEMA	61,368.84	58,290.26	59,449.86	60,596.26	56,443.06	55,919.62	51,298.21	51,213.46	56,587.48	62,666.69	60,145.39	63,589.76		697,568.89		
	L																
3708	ADULT <40% EXP M&F	469,701.58	487,911.82	515,743.07	554,897.80	582,018.17	626,722.13	654,538.05	665,085.86	702,810.28	676,701.96	724,510.39	768,018.22		7,428,659.33		
	4																
3709	ADULT <40% EXP M&F	73,748.46	81,904.59	95,292.99	105,440.21	117,145.82	134,632.78	152,909.18	179,338.20	181,063.41	173,499.84	183,500.25	211,744.09		1,690,219.82		
	6																
370F	ADULT <40% EXP MALE	128.88	167.24	844.38	5,423.38	1,283.86	4,287.53	1,150.83	7,079.12	750.89	296.31	133.54	1,323.38		22,869.34		
370G	ADULT <40% EXP FEMA	0.00	0.00	0.00	52.22	0.00	0.00	0.00	1,574.78	1,255.05	1,123.96	112.82	0.00		4,118.83		
	L																
370H	ADULT <40% EXP M&F	4,699.09	13,432.93	4,796.88	2,533.24	5,279.01	1,865.89	1,078.27	25.42	3,476.42	5,284.63	4,411.66	116.74		47,000.18		
	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	10,557,528.38	10,619,793.70	10,514,244.88	10,977,442.33	11,227,917.43	11,328,058.14	11,449,386.09		125,686,676.06		
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	9,770,706.17	9,816,442.61	9,694,656.57	10,152,794.90	10,398,763.33	10,557,854.29	10,735,465.97		116,685,199.25		
	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	84,450,827.13	85,734,058.91	87,349,233.27	89,621,168.31	90,976,349.37	92,366,057.23	94,221,859.49		1,013,641,991.86		
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	49,538,497.30	50,432,316.82	51,415,925.33	52,479,620.64	53,363,870.53	54,196,708.07	55,125,335.19		594,986,879.47		
	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	84,325,449.43	85,586,090.41	86,902,282.32	88,341,039.41	89,247,713.90	90,296,950.23	91,436,819.53		1,011,334,053.26		
	4																
3719	ADULT <40% EXP M&F	37,269.77	37,320.24	42,917.41	39,050.32	45,297.59	52,516.37	53,191.07	119,217.71	55,379.05	55,511.43	51,450.96	52,238.73		641,360.65		
	6																
371D	ADULT <40% EXP MALE	54,092.39	62,506.93	70,726.03	107,171.07	89,656.57	77,406.42	67,731.85	81,611.70	87,337.91	91,804.37	71,291.05	71,644.89		932,981.18		
371E	ADULT <40% EXP FEMA	68,445.50	70,113.10	71,331.38	97,959.08	74,612.89	69,051.76	71,888.73	69,085.66	102,724.79	83,850.01	78,980.72	79,985.31		938,028.93		
	L																
371F	ADULT <40% EXP MALE	915,874.56	768,839.68	852,226.01	1,130,070.77	934,289.50	1,142,469.22	1,126,144.09	1,015,499.55	1,127,570.35	1,128,240.08	986,142.27	919,948.79		12,047,314.87		
371G	ADULT <40% EXP FEMA	497,156.16	435,759.81	527,417.43	596,018.82	506,247.65	609,545.83	588,431.69	521,400.42	615,844.16	568,995.97	529,182.46	462,111.91		6,458,112.31		
	L																
371H	ADULT <40% EXP M&F	771,542.01	702,266.72	793,639.39	990,476.38	880,549.00	1,078,278.66	1,016,917.57	887,171.65	1,011,875.61	976,516.13	782,590.30	788,004.97		10,679,828.39		
	4																
371J	ADULT <40% EXP M&F	0.00	0.00	740.99	0.00	622.82	1,411.17	1,869.24	2,460.96	0.00	0.00	5,951.29	711.68		13,768.15		
	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	22,771.20	34,445.30	38,147.02	46,806.51	42,778.62	42,720.13	46,387.61		369,173.02		
3727	ADULT <40% EXP FEMA	3,954.91	5,459.69	8,052.02	5,596.18	7,059.84	6,286.89	16,107.85	18,741.53	22,130.21	24,036.99	24,514.66	26,069.23		168,010.00		
	L																
3728	ADULT <40% EXP M&F	55,219.43	57,255.49	58,848.36	67,357.98	67,635.47	67,852.63	89,665.19	95,326.54	116,240.95	120,256.64	122,848.09	129,648.24		1,048,155.01		
	4																
3729	ADULT <40% EXP M&F	1,238.47	1,238.47	1,238.47	632.45	632.45	632.45	1,344.13	2,743.11	2,743.11	3,516.06	6,255.75	6,245.16		28,460.08		
	6																
372F	ADULT <40% EXP MALE	0.00	0.00	109.81	0.00	0.00	22.96	1,283.30	520.16	0.00	0.00	0.00	86.46		2,022.69		

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
372G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	840.02	0.00	259.54	5,780.21	0.00		6,879.77		
372H	ADULT <40% EXP M&F
4	592.90	1,587.56	0.00	0.00	0.00	1,854.38	90.26	271.35	4,091.96	1,989.54	2,068.35	1,587.40		14,133.70		
SUBTOTAL:	290,659,997.94	294,304,308.20	299,589,257.72	310,123,865.96	313,774,470.98	319,742,706.98	322,356,143.75	325,889,804.84	332,270,734.43	336,013,041.78	339,630,657.08	344,086,521.56		3,828,441,511.22		

9935	BIRTH SUPP PAYMENT A	368,474.20	441,663.07	356,791.14	411,227.54	358,766.17	352,087.27	462,933.37	299,513.46	345,644.51	267,941.32	300,781.33	378,720.66	
9937	BIRTH SUPP PAYMENT
A	950,449.82	913,898.38	1,030,330.08	860,386.83	991,664.83	1,031,593.10	941,169.93	878,585.89	1,056,549.26	860,864.24	978,271.17	970,832.54	
SUBTOTAL:	1,318,924.02	1,355,561.45	1,387,121.22	1,271,614.37	1,350,431.00	1,383,680.37	1,404,103.30	1,178,099.35	1,402,193.77	1,128,805.56	1,279,052.50	1,349,553.20	

4,344,544.04	
11,464,596.07	
15,809,140.11	

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	509.30	509.30	509.30	509.30	509.30	509.30	509.30	509.30	509.30	
3905	NEWLY ELIGIBLE FEMA L	487.72	487.72	487.72	511.02	511.02	511.02	511.02	511.02	1,022.04	511.02	511.02	1,039.14	
3906	NEWLY ELIGIBLE MALE	105,124.76	102,887.13	107,330.03	108,382.22	112,832.15	111,896.84	113,621.12	117,802.94	120,102.30	113,086.27	114,550.19	122,791.00	
3907	NEWLY ELIGIBLE FEMA L	74,348.29	67,063.25	69,019.50	71,543.13	75,824.02	71,337.08	73,362.83	75,870.50	78,825.63	69,563.65	72,603.13	80,822.35	
3908	NEWLY ELIGIBLE M&F
4	967,897.09	991,103.64	1,016,952.14	1,102,718.38	1,139,858.97	1,169,261.86	1,200,569.55	1,236,552.50	1,262,544.29	1,227,280.64	1,238,346.31	1,265,308.80	
3909	NEWLY ELIGIBLE M&F 6	673,532.31	721,731.33	788,089.47	870,311.42	924,105.45	985,158.09	1,049,118.47	1,110,738.32	1,161,329.76	1,078,355.55	1,111,801.25	1,163,738.55	
390F	NEWLY ELIGIBLE MALE	173.06	0.00	0.00	167.34	0.00	0.00	0.00	54.75	0.00	0.00	0.00	17.03	
390G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	83.67	0.00	139.71	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	259.23	1,621.12	1,930.24	32.56	0.00	16.18	436.60	428.81	3,418.04	3,697.01	1,269.81	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	3,557.63	4,260.94	18.27	0.00	0.00	0.00	3,734.27	
3914	NEWLY ELIGIBLE MALE	3,047,757.07	2,959,338.89	2,885,460.12	2,934,293.03	2,857,481.78	2,792,617.70	2,740,727.32	2,618,527.88	2,590,841.20	2,547,999.75	2,489,477.33	2,425,264.07	
3915	NEWLY ELIGIBLE FEMA L	3,244,492.82	3,129,519.67	3,037,025.11	3,089,928.44	3,009,204.22	2,929,682.01	2,837,224.30	2,692,238.31	2,667,022.10	2,644,705.33	2,577,399.02	2,494,359.58	
3916	NEWLY ELIGIBLE MALE	17,601,679.01	17,670,092.06	17,801,738.47	18,540,258.12	18,510,304.60	18,501,405.43	18,476,071.41	18,486,172.87	18,440,529.61	18,398,488.58	18,423,236.85	18,442,260.71	
3917	NEWLY ELIGIBLE FEMA L	24,841,265.59	25,115,246.82	25,550,158.92	26,510,586.32	26,322,602.97	26,224,953.45	26,022,713.42	25,947,428.66	25,676,310.97	25,541,151.44	25,443,030.48	25,369,480.63	
3918	NEWLY ELIGIBLE M&F
4	20,999,876.79	21,004,360.63	21,080,221.65	21,939,916.60	21,780,967.47	21,688,446.17	21,604,353.90	21,593,268.42	21,470,664.31	21,396,927.87	21,385,431.75	21,301,712.77	
3919	NEWLY ELIGIBLE M&F 6	62,880.76	68,069.49	67,689.38	69,904.16	69,884.72	73,908.36	79,508.71	86,491.13	79,329.98	86,064.03	83,936.38	86,218.89	
391D	NEWLY ELIGIBLE MALE	9,236.66	6,054.65	6,407.56	9,231.96	8,939.88	9,595.01	7,788.60	7,903.98	11,233.33	7,780.53	11,620.53	8,603.11	
391E	NEWLY ELIGIBLE FEMA L	10,544.73	9,035.35	8,162.90	13,133.12	15,040.39	8,241.38	20,420.18	12,065.08	14,296.31	14,366.04	9,822.54	13,690.94	
391F	NEWLY ELIGIBLE MALE	123,315.89	74,896.59	107,646.54	137,805.20	112,379.73	127,773.44	141,505.94	107,841.44	133,975.26	103,780.35	96,302.09	117,996.06	
391G	NEWLY ELIGIBLE FEMA L	137,385.13	100,067.50	113,302.32	132,473.59	124,309.04	160,015.21	140,100.07	140,184.11	162,605.83	146,555.99	92,137.50	125,823.41	
391H	NEWLY ELIGIBLE M&F
4	125,181.38	118,845.84	131,706.54	133,510.05	134,173.62	208,199.23	174,348.43	150,796.82	146,390.75	139,265.32	112,446.45	110,606.26	
391J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	511.02	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	436.16	436.16	436.16	440.87	440.87	440.87	3,000.46	3,000.46	2,559.59	2,559.59	2,559.59	2,559.59	
3927	NEWLY ELIGIBLE FEMA L	1,363.60	1,363.60	1,363.60	1,932.24	1,932.24	1,421.22	1,921.27	2,421.55	2,932.57	4,659.35	2,932.57	5,051.48	
3928	NEWLY ELIGIBLE M&F
4	11,915.58	12,272.93	14,271.38	14,404.05	12,141.97	12,864.20	13,317.25	13,823.25	22,952.05	18,484.46	15,654.69	17,103.64	
3929	NEWLY ELIGIBLE M&F 6	32,038.03	35,749.13	37,729.22	43,447.11	49,925.57	49,748.55	50,463.64	53,187.45	59,199.93	59,989.40	63,144.18	61,679.20	
392G	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,510.94	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	0.00	129.26	0.00	0.00	0.00	0.00	0.00	392.90	0.00	0.00	0.00	0.00	
SUBTOTAL:	72,071,191.66	72,190,372.76	72,827,128.97	75,725,440.23	75,263,369.98	75,131,560.23	74,755,938.40	74,458,230.72	74,109,245.88	73,607,292.41	73,348,722.96	73,220,370.78	

4,583.70	
7,101.48	
1,350,406.95	
880,183.36	
13,818,394.17	
11,638,009.97	
412.18	
223.38	
13,109.60	
11,571.11	
32,889,786.14	
34,352,800.91	
219,292,237.72	
308,564,929.67	
257,246,148.33	
913,885.99	
104,395.80	
148,818.96	
1,385,218.53	
1,574,959.70	
1,685,470.69	
511.02	
18,870.37	
29,295.29	
179,205.45	
596,301.41	
1,510.94	
522.16	
886,708,864.98	

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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	1,177,158.99	996,578.91	931,728.49	1,079,614.39	931,395.84	1,050,542.92	1,112,588.71		12,986,984.41		
SUBTOTAL:	1,054,063.95	1,263,262.19	1,083,947.63	1,153,235.04	1,152,867.35	1,177,158.99	996,578.91	931,728.49	1,079,614.39	931,395.84	1,050,542.92	1,112,588.71		12,986,984.41		

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	153.30	153.30	153.30	153.30	153.30	
4405	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	39.24	
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	673.70	
4412	SOBRA 100-133% M&F
1	420.49	216.17	414.47	227.63	206.03	206.03	211.81	211.81	0.00	423.00	211.81	423.62	
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	9,136,221.93	9,052,407.65	8,995,069.38	8,940,234.23	8,893,321.15	8,910,915.83	8,878,449.94	
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	3,126,328.98	3,145,338.59	3,196,643.96	3,174,205.26	3,158,632.08	3,200,970.65	3,233,579.60	
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	3,027,643.40	3,049,745.95	3,090,595.48	3,086,442.17	3,094,089.78	3,114,160.77	3,129,145.58	
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	62,081.19	50,054.93	44,969.20	57,238.79	57,153.45	35,338.51	55,362.26	
441D	SOBRA 100-133% MALE	15,408.66	13,824.63	13,278.08	17,063.81	17,078.83	12,045.73	14,097.83	18,210.51	17,692.22	29,698.65	12,037.43	14,341.86	
441E	SOBRA 100-133% FEMA L	12,760.59	14,253.83	13,077.07	19,478.46	14,944.23	18,641.85	14,387.53	20,322.83	21,220.87	20,370.95	10,237.70	17,744.81	
4424	SOBRA 100-133% MALE	136.94	136.94	136.94	152.17	152.17	152.17	152.17	152.17	152.17	152.17	152.17	152.17	
SUBTOTAL:	14,693,276.14	14,847,298.22	14,412,596.95	15,615,797.26	15,424,347.94	15,383,321.28	15,326,396.46	15,366,328.64	15,297,339.01	15,253,994.53	15,284,178.17	15,330,066.08	

766.50	
39.24	
1,025.50	
3,172.87	
107,947,935.00	
37,172,256.58	
36,080,235.85	
254.07	
635,255.76	
194,778.24	
197,440.72	
1,780.35	
182,234,940.68	

9944

BIRTH SUPP PAYMENT S

679,453.00

679,453.00

39,041.93	13,151.04	83,516.68	72,214.94	45,961.67	64,906.49	45,674.22	79,089.13	91,805.27	46,249.12	51,880.84	45,961.67	
39,041.93	13,151.04	83,516.68	72,214.94	45,961.67	64,906.49	45,674.22	79,089.13	91,805.27	46,249.12	51,880.84	45,961.67	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	8,589.64	8,589.64	8,543.10	8,717.47	8,745.29	8,686.21	8,713.18	8,592.09	7,927.48	7,927.48	7,652.97	6,119.57	
4518	BC PATIENT FEMALE 4
5	53,291.79	55,238.93	56,732.29	59,520.88	59,232.71	61,143.68	60,972.74	58,111.85	55,483.30	54,055.83	54,545.98	55,073.27	
4519	BC PATIENT FEMALE 6 5	1,791.51	2,770.03	2,613.15	1,580.70	2,058.24	1,660.90	1,568.49	2,688.01	2,898.46	5,323.19	5,668.57	7,073.55	
451G	BC PATIENT FEMALE 2
1	433.61	0.00	0.00	0.00	0.00	444.95	0.00	0.00	0.00	0.00	72.60	44.04	
451H	BC PATIENT FEMALE 4 5	1,048.64	5,211.82	1,996.78	2,741.76	1,872.37	2,311.32	441.61	5,359.23	4,685.00	1,630.06	579.73	1,398.87	
451J	BC PATIENT FEMALE 6
5	672.37	352.00	1,996.00	106.93	381.88	26.73	2,238.92	4,368.59	31,152.28	1,929.11	1,912.84	167.70	
4617	CC PATIENT FEMALE 2 1	4,159.64	4,159.64	4,159.64	4,201.52	4,364.93	4,578.63	4,578.63	4,578.63	4,578.63	4,578.63	4,578.63	4,578.63	
4618	CC PATIENT FEMALE 4
5	1,551.32	1,551.32	1,551.32	1,596.65	1,596.65	1,596.65	1,596.65	1,218.09	1,668.18	1,668.18	2,153.72	2,527.24	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	213.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,250.45	0.00	1,232.58	0.00	
SUBTOTAL:	71,538.52	77,873.38	77,592.28	78,465.91	78,465.77	80,449.07	80,110.22	84,916.49	110,643.78	77,112.48	78,397.62	76,982.87	

98,804.12	
683,403.25	
37,694.80	
995.20	
29,277.19	
45,305.35	
53,095.78	
20,275.97	
213.70	
3,483.03	
972,548.39	

8600	SSI BLIND FREEDOM/W O	559.54	559.54	974.42	1,050.12	1,050.12	1,350.57	1,503.87	4,282.88	7,368.55	6,990.43	6,837.13	7,284.73	
860Z	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	141.20	4,490.51	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	1,336.38	1,336.38	1,336.38	1,336.38	1,336.38	1,336.38	1,336.38	
8620	SSI BLIND FREEDOM/W
O	278.64	278.64	136.94	152.17	152.17	328.60	176.43	176.43	176.43	328.60	472.45	472.45	
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	1,646,518.91	1,655,237.50	1,653,287.74	1,665,084.85	1,645,251.72	1,657,188.12	1,676,592.38	
870Z	SSI DISABLED FREEDO
M	19,905.78	4,595.49	4,591.62	25,453.10	9,585.02	29,638.21	28,288.22	13,710.63	7,812.72	8,218.21	52,530.38	22,301.02	

39,811.90	
4,631.71	
15,987.00	
3,129.95	
19,736,047.60	
226,630.40	

ACC CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	495,367.43	513,441.23	513,476.38	521,400.98	538,394.97	550,270.16	539,081.22	534,746.97	557,044.60	576,526.00	612,030.24	622,531.24		6,574,311.42		
871Z	SSI DISABLED FREEDO
M	8,997.19	10,218.27	16,015.20	14,411.00	3,685.35	38,211.35	15,287.15	7,940.65	7,309.23	15,794.67	841.52	4,575.19		143,286.77		
8720	SSI DISABLED FREEDO M	397,499.60	417,368.77	426,646.27	443,648.28	454,263.80	449,057.00	457,778.68	462,845.62	472,505.49	489,131.56	522,028.33	536,760.32		5,529,533.72		
872Z	SSI DISABLED FREEDO
M	924.22	1,799.42	335.14	169.57	5.88	3,096.29	0.00	303.11	432.61	792.57	225.66	1,299.73		9,384.20		
SUBTOTAL:	2,557,909.50	2,580,771.82	2,595,667.49	2,598,359.49	2,658,202.68	2,719,807.47	2,698,689.45	2,678,771.61	2,723,561.37	2,744,370.14	2,853,490.21	2,873,153.44		32,282,754.67		

10,731,703,430.74

844,430,183.33	849,955,751.20	854,966,807.94	887,647,466.05	892,424,414.84	902,137,676.57	902,707,659.49	907,147,657.31	916,842,992.91	918,871,305.89	923,134,216.08	931,437,299.13	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	1.06	0.00	0.00	0.00	1.00	2.00	2.00		6.06		
1005	TANF 14-20 FEMALE WI	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00		9.00		
1006	TANF 21-44 MALE WITH	89.32	88.66	90.72	94.58	82.40	98.99	106.73	109.00	112.41	103.13	99.62	94.89		1,170.45		
1007	TANF 21-44 FEMALE WI	111.74	108.64	106.00	122.95	117.70	124.53	113.12	116.56	118.66	130.99	134.66	140.79		1,446.34		
1008	TANF 45-64 M & F WIT	240.76	232.59	235.00	248.95	254.62	259.22	275.54	288.00	277.14	282.06	284.89	302.31		3,181.08		
1009	TANF 65+ M & F WITH	142.00	144.00	140.49	142.06	139.40	150.67	162.00	171.00	193.48	172.96	187.45	202.76		1,948.27		
100D	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	3.93	0.00	0.00	0.00	0.00	0.00	0.00		3.93		
100F	TANF 21-44 MALE WITH	0.67	0.25	0.26	1.41	3.73	0.00	3.14	0.00	1.44	0.86	1.44	0.00		13.20		
100G	TANF 21-44 FEMALE WI	0.00	1.35	0.00	2.02	1.30	0.00	0.87	0.28	1.34	0.00	1.12	1.49		9.77		
100H	TANF 45-64 M & F WIT	0.22	0.83	0.00	0.00	2.09	1.74	0.03	0.00	6.96	0.93	1.31	7.18		21.29		
100J	TANF 65+ M & F WITH	0.00	0.00	0.56	0.00	0.60	0.00	0.00	0.00	5.58	0.00	0.54	1.23		8.51		
1011	TANF <1 M & F NON-ME	11,976.29	12,400.56	12,842.21	13,158.83	13,597.07	13,750.15	13,753.98	13,897.75	14,072.11	13,946.24	13,732.09	13,591.21		160,718.49		
1012	TANF 01-05 M & F NON	21,810.42	21,533.69	21,072.48	22,931.69	24,636.86	25,781.52	26,539.81	26,835.64	26,428.09	26,332.76	26,349.40	26,270.50		296,522.86		
1013	TANF 06-13 M & F NON	41,986.95	41,611.68	40,995.81	44,110.57	46,748.34	48,362.86	49,845.70	50,186.33	50,211.10	50,479.03	50,752.41	50,407.00		565,697.78		
1014	TANF 14-20 MALE NON-	13,996.55	14,089.63	14,217.36	15,031.92	16,009.26	16,550.57	17,112.41	17,348.51	17,519.18	17,847.41	17,965.22	18,030.28		195,718.30		
1015	TANF 14-20 FEMALE N	16,612.81	16,749.44	16,681.04	17,694.13	18,485.98	19,077.48	19,591.71	19,838.35	20,058.63	20,241.91	20,519.04	20,557.82		226,108.34		
	O																
1016	TANF 21-44 MALE NON-	31,920.98	31,948.92	32,228.19	33,323.51	34,906.62	35,921.35	36,889.91	37,646.35	38,199.86	38,632.69	39,040.78	39,430.73		430,089.89		
1017	TANF 21-44 FEMALE N	105,104.14	104,866.87	105,631.93	108,838.25	113,241.29	116,018.18	118,720.38	120,598.01	122,205.80	123,702.29	125,182.18	126,347.56		1,390,456.88		
	O																
1018	TANF 45-64 M & F NON	26,940.10	26,998.10	27,105.42	28,000.96	29,141.37	30,021.57	30,838.26	31,529.09	32,069.47	32,525.72	32,931.17	33,407.67		361,508.90		
1019	TANF 65+ M & F NON-M	132.29	133.99	138.99	142.76	144.34	149.30	152.12	161.14	144.57	159.56	148.89	157.50		1,765.45		
101A	TANF < 1 M & F NON-M	523.18	428.69	598.99	646.09	587.92	564.89	641.88	630.52	745.81	576.44	564.13	697.18		7,205.72		
101B	TANF 01-05 M & F NON	65.85	70.06	83.15	95.64	32.94	47.16	124.61	47.76	86.63	46.09	50.93	106.38		857.20		
101C	TANF 06-13 M & F NON	34.60	51.73	16.00	51.46	53.17	20.15	34.39	3.48	32.05	15.36	11.98	17.13		341.50		
101D	TANF 14-20 MALE NON-	15.64	19.10	9.56	19.26	42.23	8.70	8.09	7.55	31.82	84.63	11.39	11.68		269.65		
101E	TANF 14-20 FEMALE N	14.32	41.02	29.63	37.44	14.33	49.05	26.69	23.02	47.17	22.91	28.01	27.37		360.96		
	O																
101F	TANF 21-44 MALE NON-	389.94	267.95	310.18	353.69	305.76	358.43	360.37	291.28	374.54	401.16	263.99	278.04		3,955.33		
101G	TANF 21-44 FEMALE N	724.45	507.09	624.68	691.74	543.26	674.32	534.36	517.97	749.42	701.77	538.02	534.92		7,342.00		
	O																
101H	TANF 44-64 M & F NON	207.24	152.59	182.37	215.05	147.42	195.51	177.74	163.47	238.65	182.09	134.66	180.39		2,177.18		
101J	TANF 65+ N & F NON-M	0.12	0.00	0.33	1.22	0.00	0.00	0.98	0.10	3.47	0.66	2.02	0.50		9.40		
1023	TANF 06-13 M & F WIT	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		12.00		
1024	TANF 14-20 MALE WITH	2.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	3.00	2.00	2.00	2.00		26.00		
1025	TANF 14-20 FEMALE WI	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00		21.00		
1026	TANF 21-44 MALE WITH	86.14	87.58	80.63	88.07	87.88	97.70	100.03	95.00	92.92	92.46	100.83	107.09		1,116.33		
1027	TANF 21-44 FEMALE WI	130.80	130.00	122.90	121.00	131.95	135.80	152.79	148.84	138.35	156.78	159.52	159.44		1,688.17		
1028	TANF 45-64 M & F WIT	170.47	165.00	169.30	168.00	177.00	181.54	182.63	177.29	187.19	193.97	200.35	196.34		2,169.08		
1029	TANF 65+ M & F WITH	95.00	95.00	100.56	110.00	111.61	118.00	117.51	117.12	119.77	124.53	125.00	122.09		1,356.19		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102F	TANF 21-44 MALE WITH	0.93	1.41	0.13	0.83	0.06	0.03	0.00	0.00	0.06	0.00	0.03	0.06		3.54		
102G	TANF 21-44 FEMALE WI	0.00	0.00	0.10	0.00	1.19	2.38	1.18	1.71	4.08	18.56	0.03	0.00		29.23		
102H	TANF 44-64 M & F WIT	0.51	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00	0.00	1.99		2.53		
102J	TANF 65+ M & F WITH	0.00	0.00	0.43	0.00	0.00	0.00	0.00	0.00	0.09	0.00	0.00	5.20		5.72		
2100	SSI AGED WITH MEDIC	4,609.78	4,614.00	4,672.60	4,769.36	4,723.65	4,773.71	4,803.92	4,888.01	4,936.40	5,017.72	5,006.18	5,071.31		57,886.64		
	A																
210Z	SSI AGED WITH MEDIC	201.36	153.86	202.79	236.09	161.31	225.26	176.02	192.69	243.02	217.38	162.21	151.83		2,323.82		
	A																
2110	SSI AGED NON-MEDICA	8,498.21	8,637.66	8,726.86	8,780.60	8,937.12	9,014.67	9,100.44	9,164.03	9,382.85	9,481.30	9,596.36	9,665.10		108,985.20		
	R																
211Z	SSI AGED NON-MEDICA	101.24	85.80	80.93	112.19	122.51	131.45	138.32	127.34	138.86	130.30	108.67	147.09		1,424.70		
	R																
2120	SSI AGED WITH QMB	37,809.68	38,210.70	38,528.18	38,901.54	39,213.77	39,581.45	39,955.74	40,234.45	40,569.38	40,836.77	41,241.27	41,414.03		476,496.96		
212Z	SSI AGED WITH QMB P	16.95	20.00	17.62	17.07	17.01	23.62	27.70	29.00	38.73	24.51	24.22	23.33		279.76		
	P																
2200	SSI DISABLED WITH M	4,248.88	4,232.70	4,279.29	4,337.77	4,383.29	4,422.84	4,579.03	4,640.95	4,725.43	4,746.24	4,773.31	4,861.69		54,231.42		
	E																
220Z	SSI DISABLED WITH M	104.93	98.87	111.17	100.16	70.29	116.24	85.98	106.56	129.28	98.33	104.82	89.52		1,216.15		
	E																
2210	SSI DISABLED NON-ME	54,047.14	53,979.72	53,855.66	53,904.08	53,928.19	53,847.76	53,759.35	53,729.55	53,597.08	53,559.09	53,604.63	53,642.43		645,454.68		
	D																
221Z	SSI DISABLED NON-ME	675.76	561.20	666.52	555.15	467.97	487.75	484.64	533.42	617.97	604.30	581.08	579.66		6,815.42		
	D																
2220	SSI DISABLED WITH Q	27,391.96	27,518.09	27,576.75	27,550.34	27,527.32	27,579.86	27,537.52	27,482.91	27,423.56	27,407.29	27,378.10	27,334.77		329,708.47		
	M																
222Z	SSI DISABLED WITH Q	40.28	18.77	45.86	23.27	46.23	30.52	36.63	18.61	42.58	36.97	31.42	18.84		389.98		
	M																
2300	SSI BLIND WITH MEDIC	34.19	30.15	32.43	34.83	35.03	41.36	42.06	41.00	44.22	42.66	47.00	49.96		474.89		
230Z	SSI BLIND WITH MEDIC	0.80	0.80	0.97	0.06	0.00	2.44	0.93	0.00	0.00	0.26	0.00	1.03		7.29		
2310	SSI BLIND NON-MEDIC	525.97	533.33	534.39	539.85	532.31	533.70	534.51	538.49	529.08	531.64	530.93	546.23		6,410.43		
	A																
231Z	SSI BLIND NON-MEDIC	7.57	13.15	3.79	2.04	18.96	6.06	21.76	1.00	4.89	1.59	1.37	30.72		112.90		
	A																
2320	SSI BLIND WITH QMB	234.62	241.65	245.82	252.56	256.70	259.92	262.25	255.59	259.71	261.00	258.35	258.00		3,046.17		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.00	0.41	0.03	2.45	0.00	0.00	0.00	0.00	0.00	0.00		2.89		
4301	SOBRA CHILD <1 M & F	0.00	0.80	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.90	1.43		11.13		
4302	SOBRA CHILD 01-05 M	1.00	0.80	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00		5.80		
4303	SOBRA CHILD 06-13 M	4.00	3.61	2.00	2.00	2.00	1.00	2.00	3.92	4.00	4.00	3.16	4.00		35.69		
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	-1.00	1.00	0.00	0.00	0.00	0.00		0.00		
4305	SOBRA CHILD 14-20 FE	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.03	1.00	1.00	1.00		12.03		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.99	0.00		0.99		
430C	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.26	0.00	0.00	0.00	0.00		0.26		
4311	SOBRA CHILD <1 M & F	30,201.03	29,809.56	29,065.54	29,141.98	28,830.49	29,015.09	28,720.60	28,867.01	29,018.14	29,197.41	29,387.38	29,774.33		351,028.56		
4312	SOBRA CHILD 01-05 M	183,445.08	183,765.04	182,608.31	183,796.75	182,118.49	181,523.88	180,734.88	180,995.62	181,765.66	181,744.78	181,426.87	182,112.95		2,186,038.31		
4313	SOBRA CHILD 06-13 M	232,199.07	232,346.15	231,702.05	232,016.63	230,465.64	229,981.06	228,631.16	229,385.09	230,810.90	230,803.67	231,067.33	232,725.43		2,772,134.18		
4314	SOBRA CHILD 14-20 MA	69,577.77	70,258.90	70,365.10	70,591.89	70,565.76	70,870.30	70,760.34	71,832.86	71,957.69	71,790.89	72,079.79	72,878.20		853,529.49		
4315	SOBRA CHILD 14-20 FE	68,802.05	69,147.61	69,457.09	69,574.43	69,550.72	69,787.99	69,856.18	70,909.43	70,923.10	70,816.43	70,989.08	71,617.46		841,431.57		
431A	SOBRA CHILD < 1 M &	214.60	200.73	226.68	296.76	280.62	349.99	271.18	277.24	329.81	271.12	275.60	247.44		3,241.77		
431B	SOBRA CHILD 01-05 M	1,190.00	997.79	1,151.87	1,201.62	926.16	1,241.94	1,083.31	1,054.49	1,235.17	1,158.73	896.03	884.93		13,022.04		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
431C	SOBRA CHILD 6-13 M&F	1,257.85	1,252.51	1,485.36	1,570.58	1,173.01	1,411.85	1,165.85	1,205.30	1,399.32	1,488.30	989.08	1,027.72		15,426.73		
431D	SOBRA CHILD 14-20 MA	371.46	371.93	489.55	469.05	336.60	438.59	362.85	328.96	431.96	422.16	299.11	335.87		4,658.09		
431E	SOBRA CHILD 14-20 FE	377.44	368.44	420.91	465.47	422.74	432.33	402.24	353.78	433.29	432.15	314.87	312.45		4,736.11		
4322	SOBRA CHILD 01-05 M	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00	1.00		20.00		
4323	SOBRA CHILD 06-13 M	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	2.00	3.00	2.16	2.00		18.16		
4325	SOBRA CHILD 14-20 FE	3.00	3.00	4.00	3.61	4.00	3.00	3.00	2.00	2.00	2.00	2.00	1.00		32.61		
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		
5005	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00		2.00		
	M																
5007	SOBRA PREG 21-44 FE	23.92	22.80	24.97	27.00	31.29	30.83	28.92	30.03	33.44	30.00	30.56	33.96		347.72		
	M																
5008	SOBRA PREG 45-64 FE	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.29	1.00	0.00	1.00		11.29		
	M																
500G	SOBRA PREG 21-44 FE	0.92	1.66	4.28	0.00	3.69	2.15	2.05	1.24	1.00	0.00	1.57	0.03		18.59		
	M																
500H	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.70	0.00	0.00	0.00		0.70		
	M																
5013	SOBRA PREG 09-13 FE	3.00	4.00	4.00	3.96	6.00	4.35	6.00	6.00	5.00	4.36	6.00	3.00		55.67		
	M																
5015	SOBRA PREG 14-20 FE	2,112.59	2,137.44	2,157.16	2,111.06	2,115.07	2,115.45	2,051.79	2,108.73	2,101.12	1,990.63	1,942.53	2,034.68		24,978.25		
	M																
5017	SOBRA PREG 21-44 FE	14,797.31	15,298.58	15,916.97	16,148.52	16,050.56	16,423.55	15,899.46	16,433.49	16,410.54	15,891.75	15,825.28	16,579.42		191,675.43		
	M																
5018	SOBRA PREG 45-64 FE	61.09	65.42	66.22	65.66	64.00	65.21	58.19	60.13	62.45	53.71	55.22	64.88		742.18		
	M																
501C	SOBRA PREG 09-13 FE	0.00	0.00	0.00	1.25	0.00	0.64	0.00	0.00	0.00	0.63	0.00	0.00		2.52		
	M																
501E	SOBRA PREG 14-20 FE	114.84	100.77	125.36	141.46	105.80	129.59	136.64	120.26	128.79	124.72	110.91	107.91		1,447.05		
	M																
501G	SOBRA PREG 21-44 FE	635.99	552.79	605.71	696.99	537.47	696.71	626.97	591.39	707.19	698.49	578.64	611.26		7,539.60		
	M																
501H	SOBRA PREG 45-64 FE	2.89	2.22	0.73	3.30	2.00	0.77	0.38	0.82	0.54	4.05	0.77	2.08		20.55		
	M																
5025	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00		1.00		
	M																
5027	SOBRA PREG 21-44 FE	28.62	28.25	29.00	29.99	32.00	35.51	36.00	30.64	32.96	28.16	30.00	31.00		372.13		
	M																
5028	SOBRA PREG 45-64 FE	6.00	4.00	4.00	5.00	3.00	4.00	5.00	6.00	5.00	4.00	5.00	5.00		56.00		
	M																
502G	SOBRA PREG 21-44 FE	0.22	0.00	0.00	0.00	0.00	0.48	1.00	0.35	2.02	0.83	0.00	0.00		4.90		
	M																
SUBTOTAL:	1,017,516.49	1,018,632.67	1,019,324.89	1,034,938.79	1,043,830.49	1,054,386.10	1,058,973.75	1,067,555.79	1,074,977.99	1,077,149.27	1,079,303.85	1,086,690.69		12,633,280.77		

9910	TANF & SOBRA CHILDR E	529.00	569.00	479.00	502.00	480.00	520.00	506.00	445.00	477.00	466.00	434.00	523.00	
9920	SSI W/MEDICARE KICK	4.00	4.00	4.00	2.00	1.00	2.00	4.00	6.00	6.00	4.00	2.00	5.00	
9921	SSI W/O MEDICARE KIC	11.00	17.00	23.00	18.00	17.00	19.00	24.00	21.00	13.00	17.00	19.00	16.00	
9950	S.O.B.R.A. KICK PAYM	1,607.00	1,627.00	1,625.00	1,626.00	1,679.00	1,789.00	1,520.00	1,429.00	1,427.00	1,351.00	1,281.00	1,381.00	
SUBTOTAL:	2,151.00	2,217.00	2,131.00	2,148.00	2,177.00	2,330.00	2,054.00	1,901.00	1,923.00	1,838.00	1,736.00	1,925.00	

5,930.00	
44.00	
215.00	
18,342.00	
24,531.00	

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

12.00

12.00

1106	TANF EXPANDED 21-44	251.07	250.27	246.32	240.00	239.62	243.06	226.88	229.23	236.42	227.85	219.84	216.38	
1107	TANF EXPANDED 21-44	430.73	418.18	418.45	416.98	399.94	391.59	385.66	392.87	399.76	392.01	386.54	379.75	
1108	TANF EXPANDED 45-64	1,407.06	1,440.35	1,440.49	1,462.98	1,458.60	1,463.25	1,474.21	1,475.81	1,483.30	1,461.51	1,469.47	1,469.45	

2,826.94	
4,812.46	
17,506.48	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+ M	848.48	883.58	917.91	917.08	938.65	946.44	937.92	949.42	969.07	981.29	982.53	996.71		11,269.08		
	&																
110F	TANF EXPANDED 21-44	15.87	7.98	12.36	5.26	2.59	1.37	1.15	2.74	7.16	3.42	4.77	2.56		67.23		
110G	TANF EXPANDED 21-44	11.63	10.88	20.07	15.00	10.99	8.68	6.90	19.07	6.61	7.04	4.02	5.63		126.52		
110H	TANF EXPANDED 45-64	29.39	29.63	15.08	25.07	12.73	14.59	16.32	9.84	17.54	18.13	8.10	21.60		218.02		
110J	TANF EXPANDED 65+ M	8.68	20.47	22.72	18.33	15.18	16.24	18.04	13.63	15.20	29.83	19.54	29.73		227.59		
	&																
1112	TANF EXPANDED 01-05	2.00	1.00	1.00	2.00	1.00	1.00	1.00	2.00	1.00	1.00	1.00	0.00		14.00		
1113	TANF EXPANDED 06-13	2.00	2.00	3.00	1.00	3.00	3.00	3.00	4.00	4.00	3.00	4.00	2.00		34.00		
1114	TANF EXPANDED 14-20	209.00	203.06	192.30	183.35	176.41	176.33	165.71	150.05	144.13	142.25	144.89	152.80		2,040.28		
1115	TANF EXPANDED 14-20	1,265.60	1,201.44	1,139.15	1,054.78	1,030.71	1,008.64	972.85	940.29	939.18	929.95	915.52	914.94		12,313.05		
1116	TANF EXPANDED 21-44	27,210.25	27,343.12	27,260.46	26,601.11	25,656.47	25,355.97	24,739.06	24,592.28	24,704.06	24,633.57	24,648.81	24,706.50		307,451.66		
1117	TANF EXPANDED 21-44	75,461.79	75,803.41	75,484.92	73,727.60	70,779.54	69,728.67	68,549.66	68,242.45	68,670.17	68,666.42	68,688.65	68,556.80		852,360.08		
1118	TANF EXPANDED 45-64	26,012.11	26,330.36	26,352.40	25,953.73	25,231.68	25,099.95	24,679.33	24,907.14	24,940.54	24,814.72	24,907.35	25,124.72		304,354.03		
1119	TANF EXPANDED 65+ M	127.48	130.00	130.00	131.38	125.36	130.31	136.41	138.56	140.14	142.63	142.16	144.66		1,619.09		
	&																
111D	TANF EXPANDED 14-20	4.69	3.74	2.52	3.62	5.51	2.58	8.25	1.92	1.63	3.02	0.99	1.20		39.67		
111E	TANF EXPANDED 14-20	5.03	2.70	2.22	4.88	2.19	2.31	3.27	3.62	3.84	2.72	5.27	5.85		43.90		
111F	TANF EXPANDED 21-44	312.61	306.23	361.99	331.63	278.27	294.55	264.63	236.76	324.64	231.14	284.20	214.05		3,440.70		
111G	TANF EXPANDED 21-44	426.01	406.06	431.56	504.44	376.00	421.43	326.22	373.43	413.70	426.43	309.55	348.64		4,763.47		
111H	TANF EXPANDED 45-64	171.26	141.46	182.65	234.98	140.05	173.85	184.08	171.00	170.61	190.65	150.80	122.31		2,033.70		
111J	TANF EXPANDED 65+ M	0.84	0.00	0.00	2.25	0.00	0.00	0.58	1.28	2.00	0.00	4.83	0.00		11.78		
	&																
1125	TANF EXPANDED 14-20	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00		8.00		
1126	TANF EXPANDED 21-44	753.86	760.27	758.64	759.90	743.65	731.15	719.96	731.98	739.41	746.90	753.22	738.65		8,937.59		
1127	TANF EXPANDED 21-44	1,644.78	1,656.79	1,654.36	1,629.51	1,627.14	1,614.11	1,603.25	1,592.13	1,594.49	1,585.28	1,581.92	1,567.79		19,351.55		
1128	TANF EXPANDED 45-64	2,877.94	2,895.62	2,901.32	2,888.83	2,915.61	2,920.56	2,903.35	2,898.07	2,921.20	2,923.79	2,914.98	2,939.75		34,901.02		
1129	TANF EXPANDED 65+ M	1,907.46	1,925.73	1,934.55	1,964.90	1,981.44	1,981.08	1,998.08	2,028.94	2,057.94	2,090.67	2,097.06	2,138.86		24,106.71		
	&																
112F	TANF EXPANDED 21-44	2.88	0.09	1.83	0.03	1.69	0.29	8.40	0.35	0.25	0.72	0.35	1.76		18.64		
112G	TANF EXPANDED 21-44	1.19	0.38	0.49	3.29	1.56	0.03	2.24	0.13	0.74	2.42	0.09	0.89		13.45		
112H	TANF EXPANDED 45-64	2.29	4.52	2.45	1.50	0.99	4.24	0.00	5.42	1.83	3.85	3.65	9.16		39.90		
112J	TANF EXPANDED 65+ M	1.41	0.35	0.99	0.00	2.56	0.31	2.03	10.45	0.41	2.76	4.40	0.73		26.40		
	&																
2400	SSI AGED EXPANDED	476.27	459.50	483.75	496.71	529.66	516.64	471.63	498.53	521.83	518.05	505.72	494.60		5,972.89		
	WI																
240Z	SSI AGED EXPANDED	172.66	114.94	151.04	199.22	195.37	183.75	185.96	159.21	180.41	158.59	127.60	106.04		1,934.79		
	WI																
2410	SSI AGED EXPANDED N	136.96	137.97	141.86	142.02	138.98	142.17	135.77	127.46	135.17	131.52	136.41	139.29		1,645.58		
	O																
241Z	SSI AGED EXPANDED N	6.02	5.39	2.12	6.18	10.80	2.99	1.86	2.53	1.57	3.46	1.18	2.69		46.79		
	O																
2420	SSI AGED EXPANDED	31,267.63	31,461.12	31,581.95	31,889.17	32,133.93	32,447.16	32,399.05	32,604.29	32,922.16	33,252.13	33,548.17	33,652.90		389,159.66		
	WI																
242Z	SSI AGED EXPANDED	6.27	29.37	27.21	19.68	23.80	32.54	18.95	19.67	23.39	33.37	18.56	16.80		269.61		
	WI																
2500	SSI BLIND EXPANDED	1.00	1.00	1.96	1.16	1.00	2.54	1.87	1.39	1.29	1.00	0.00	0.76		14.97		
	W																
250Z	SSI BLIND EXPANDED	1.00	0.00	1.03	1.83	0.00	0.45	0.12	1.92	0.70	0.00	0.00	0.64		7.69		
	W																

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2510	SSI BLIND EXPANDED	1.00	1.00	2.00	4.00	5.00	3.00	6.00	8.00	6.99	7.00	6.00	3.70		53.69		
	N																
251Z	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	4.00	0.00	0.00	0.00	0.00	0.00		4.00		
	N																
2520	SSI BLIND EXPANDED	15.00	20.00	29.00	46.00	56.00	54.96	69.64	72.75	79.00	87.00	88.64	89.20		707.19		
	W																
252Z	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.25	0.00	0.00	0.00	0.00		0.25		
	W																
2600	SSI DISABLED EXPAND	391.69	399.99	383.05	383.34	386.08	390.77	407.59	429.02	399.76	391.38	392.24	407.91		4,762.82		
	E																
260Z	SSI DISABLED EXPAND	63.00	51.39	49.16	70.14	81.33	61.11	72.22	70.67	73.47	51.09	40.05	70.04		753.67		
	E																
2610	SSI DISABLED EXPAND	1,502.93	1,472.11	1,449.27	1,428.25	1,436.07	1,394.30	1,362.69	1,356.46	1,325.62	1,315.16	1,309.93	1,272.78		16,625.57		
	E																
261Z	SSI DISABLED EXPAND	6.82	16.99	19.01	22.54	19.67	20.53	16.87	12.78	18.22	12.48	12.22	19.53		197.66		
	E																
2620	SSI DISABLED EXPAND	17,113.47	17,153.75	17,172.09	17,131.56	17,080.45	17,132.70	17,019.20	16,903.95	16,949.77	16,944.83	16,926.94	16,800.36		204,329.07		
	E																
262Z	SSI DISABLED EXPAND	12.30	28.20	18.92	16.16	6.70	17.39	13.41	10.73	31.16	20.34	7.39	12.59		195.29		
	E																
SUBTOTAL:	192,580.41	193,533.39	193,406.62	190,944.37	186,264.97	185,138.58	182,525.27	182,404.47	183,581.48	183,593.37	183,780.55	183,904.70		2,241,658.18		

9911	SB PAYMENT FOR TAN F	292.00	335.00	305.00	253.00	237.00	216.00	208.00	200.00	222.00	170.00	191.00	229.00	
9922	SB PAYMENT FOR SSI
E	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	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	216.00	208.00	201.00	222.00	170.00	191.00	229.00	

2,858.00	
2.00	
1.00	
2,861.00	

3504	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	
3505	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	
3506	ADULT 40-100% MALE 2	25.43	25.00	26.00	29.00	30.00	28.63	25.00	28.00	26.18	24.00	23.00	26.00	
3507	ADULT 40-100% FEMAL E	24.00	20.80	18.00	21.83	25.00	29.00	22.77	22.00	21.00	21.00	18.00	19.63	
3508	ADULT 40-100% M&F 45	300.66	320.00	337.49	355.80	338.84	378.73	465.31	451.43	406.67	397.32	420.73	426.79	
3509	ADULT 40-100% M&F 65	264.59	307.95	372.35	380.41	409.99	436.01	479.17	589.33	572.44	570.38	584.92	626.01	
350F	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.00	0.06	0.00	0.00	2.00	
350G	ADULT 40-100% FEMAL E	0.00	1.19	0.00	0.09	0.00	0.00	1.22	2.00	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	1.25	15.54	0.10	0.00	1.12	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	0.03	0.00	14.52	0.00	
3514	ADULT 40-100% MALE 1	6,291.40	6,323.37	6,336.58	6,388.19	6,374.01	6,382.61	6,334.51	6,187.10	6,420.49	6,594.58	6,766.77	6,803.00	
3515	ADULT 40-100% FEMAL E	6,683.57	6,723.61	6,776.51	6,892.91	6,910.95	6,892.14	6,882.44	6,727.99	6,963.11	7,154.47	7,267.63	7,267.52	
3516	ADULT 40-100% MALE 2	27,275.52	27,572.97	27,765.49	27,402.31	26,887.40	27,052.69	26,696.97	26,876.59	26,775.91	26,823.18	26,892.07	27,079.61	
3517	ADULT 40-100% FEMAL E	22,333.03	22,605.01	22,840.77	22,785.56	22,435.62	22,634.76	22,470.46	22,631.55	22,863.09	23,029.71	23,315.19	23,489.17	
3518	ADULT 40-100% M&F 45	43,114.80	43,369.65	43,511.86	43,053.14	42,183.21	42,109.25	41,429.85	41,483.49	41,378.26	41,341.40	41,291.26	41,413.93	
3519	ADULT 40-100% M&F 65	28.00	32.00	36.00	44.83	52.00	46.00	45.09	65.00	36.97	50.00	32.00	44.00	
351D	ADULT 40-100% MALE 1	30.09	23.83	22.72	50.90	31.25	33.95	38.05	32.55	32.40	34.33	38.07	21.66	
351E	ADULT 40-100% FEMAL E	37.60	40.84	38.61	49.90	38.27	43.77	39.09	50.29	65.93	36.70	35.78	40.22	
351F	ADULT 40-100% MALE 2	314.58	276.08	226.28	241.14	259.58	269.61	236.69	207.87	238.72	218.04	213.48	179.50	
351G	ADULT 40-100% FEMAL E	210.02	194.87	233.83	245.80	218.89	239.02	225.19	172.98	213.04	166.16	209.56	150.73	

6.00	
4.00	
316.24	
263.03	
4,599.77	
5,593.55	
2.09	
4.50	
18.90	
20.06	
77,202.61	
83,142.85	
325,100.71	
273,433.92	
505,680.10	
511.89	
389.80	
517.00	
2,881.57	
2,480.09	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
351H	ADULT 40-100% M&F 45	483.77	419.32	469.51	486.55	401.17	550.94	501.61	467.60	435.48	382.73	380.58	318.34		5,297.60		
351J	ADULT 40-100% M&F 65	6.00	16.00	0.00	6.00	2.00	3.00	9.00	0.00	24.00	11.00	5.00	2.00		84.00		
3524	ADULT 40-100% MALE 1	1.00	1.00	1.00	2.00	1.00	1.00	0.00	0.00	0.00	1.00	2.00	2.00		12.00		
3526	ADULT 40-100% MALE 2	2.00	3.00	3.00	3.00	4.00	4.00	10.00	10.00	11.00	12.00	12.00	12.00		86.00		
3527	ADULT 40-100% FEMAL	3.51	3.00	3.96	4.00	5.00	4.48	10.00	10.00	10.00	10.00	8.00	8.00		79.95		
	E																
3528	ADULT 40-100% M&F 45	30.00	32.00	35.43	38.79	34.92	40.00	48.00	50.53	49.00	54.03	53.25	58.25		524.20		
3529	ADULT 40-100% M&F 65	14.00	15.00	16.00	17.00	19.00	19.00	19.00	23.00	26.00	24.00	27.00	29.00		248.00		
352G	ADULT 40-100% FEMAL	0.48	0.00	0.00	0.00	0.00	0.51	0.00	0.00	0.00	0.00	0.00	0.00		0.99		
	E																
352H	ADULT 40-100% M&F 45	0.00	0.00	1.56	0.00	0.00	0.00	0.00	0.46	0.00	0.96	0.74	0.00		3.72		
3705	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.90	0.00	0.00		3.90		
	L																
3706	ADULT <40% EXP MALE	81.44	85.05	89.39	94.46	96.73	97.13	87.69	97.27	97.78	84.78	87.31	80.68		1,079.71		
3707	ADULT <40% EXP FEMA	49.96	48.00	50.23	50.79	49.00	50.22	50.00	51.39	54.51	57.11	55.46	55.00		621.67		
	L																
3708	ADULT <40% EXP M&F	569.78	594.78	623.09	661.91	692.13	737.63	781.62	804.53	839.71	821.25	880.02	945.41		8,951.86		
	4																
3709	ADULT <40% EXP M&F	109.24	121.00	141.00	153.38	170.86	193.56	219.77	259.00	258.35	248.27	259.70	297.96		2,432.09		
	6																
370F	ADULT <40% EXP MALE	0.09	0.06	1.12	2.14	1.83	1.66	1.63	5.74	1.09	0.33	0.09	1.85		17.63		
370G	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.03	0.00	0.00	0.00	0.60	0.48	0.43	0.16	0.00		1.70		
	L																
370H	ADULT <40% EXP M&F	3.75	7.02	3.15	2.26	4.42	2.04	1.54	0.03	2.26	3.40	2.08	0.16		32.11		
	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	14,890.46	15,019.98	14,856.31	15,489.64	15,860.31	16,018.76	16,197.81		178,176.87		
3715	ADULT <40% EXP FEMA	12,330.60	12,612.08	12,975.19	13,295.55	13,567.57	13,735.30	13,815.32	13,653.15	14,302.80	14,655.73	14,866.85	15,111.34		164,921.48		
	L																
3716	ADULT <40% EXP MALE	98,393.99	100,231.13	102,607.08	105,312.43	107,930.92	110,683.96	112,560.90	114,932.35	117,711.02	119,698.74	121,457.44	123,895.19		1,335,415.15		
3717	ADULT <40% EXP FEMA	57,331.05	58,269.71	59,745.07	61,281.23	62,819.86	64,407.62	65,704.81	67,057.88	68,502.73	69,675.56	70,828.64	72,087.01		777,711.17		
	L																
3718	ADULT <40% EXP M&F	102,764.72	104,106.01	105,638.78	107,725.39	110,063.23	112,137.58	113,793.78	115,605.62	117,682.25	118,852.06	120,255.01	121,759.34		1,350,383.77		
	4																
3719	ADULT <40% EXP M&F	47.59	49.00	62.60	55.00	63.73	71.32	74.26	163.77	78.00	78.99	73.00	74.00		891.26		
	6																
371D	ADULT <40% EXP MALE	78.94	85.59	103.70	148.17	125.13	106.45	97.95	111.94	120.22	134.34	100.91	101.56		1,314.90		
371E	ADULT <40% EXP FEMA	95.91	103.85	102.11	136.02	108.18	96.36	104.42	97.12	148.23	118.32	112.87	110.49		1,333.88		
	L																
371F	ADULT <40% EXP MALE	1,230.72	1,057.63	1,194.63	1,559.05	1,238.31	1,523.41	1,511.09	1,373.51	1,521.46	1,514.24	1,313.29	1,255.15		16,292.49		
371G	ADULT <40% EXP FEMA	690.98	606.96	736.76	848.97	702.46	816.56	824.07	718.16	830.59	793.26	710.67	632.86		8,912.30		
	L																
371H	ADULT <40% EXP M&F	1,061.89	969.24	1,126.07	1,397.53	1,242.08	1,532.96	1,432.83	1,254.90	1,420.37	1,357.02	1,108.01	1,105.38		15,008.28		
	4																
371J	ADULT <40% EXP M&F	0.00	0.00	1.00	0.00	1.00	2.00	3.03	4.00	0.00	0.00	7.80	1.00		19.83		
	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	19.22	33.42	37.21	44.07	40.99	42.00	44.56		351.73		
3727	ADULT <40% EXP FEMA	6.00	8.00	9.00	8.00	10.00	9.00	15.00	17.88	19.83	21.36	21.66	24.00		169.73		
	L																
3728	ADULT <40% EXP M&F	73.03	75.64	78.00	82.99	83.30	83.88	108.70	116.55	139.47	144.37	150.29	157.46		1,293.68		
	4																
3729	ADULT <40% EXP M&F	2.00	2.00	2.00	1.00	1.00	1.00	2.00	4.00	4.00	5.00	9.00	9.00		42.00		
	6																
372F	ADULT <40% EXP MALE	0.00	0.00	0.06	0.00	0.00	0.03	1.18	0.78	0.00	0.00	0.00	0.03		2.08		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
372G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.56	0.00	0.36	9.32	0.00		10.24		
372H	ADULT <40% EXP M&F
4	0.96	2.35	0.00	0.00	0.00	2.58	0.12	0.39	4.50	3.13	2.92	1.36		18.31		
SUBTOTAL:	395,801.67	400,954.79	408,369.69	415,651.32	420,243.08	428,402.31	432,252.07	437,316.50	445,845.14	451,130.36	455,986.81	461,969.96		5,153,923.70		

9935	BIRTH SUPP PAYMENT A	57.00	68.00	55.00	63.00	55.00	54.00	71.00	46.00	53.00	41.00	46.00	58.00	
9937	BIRTH SUPP PAYMENT
A	147.00	141.00	159.00	132.00	152.00	158.00	144.00	135.00	162.00	132.00	150.00	149.00	
SUBTOTAL:	204.00	209.00	214.00	195.00	207.00	212.00	215.00	181.00	215.00	173.00	196.00	207.00	

667.00	
1,761.00	
2,428.00	

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	
3905	NEWLY ELIGIBLE FEMA L	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	1.00	1.00	2.00	
3906	NEWLY ELIGIBLE MALE	122.64	118.03	123.00	123.72	128.00	128.00	126.22	130.91	135.96	125.95	127.54	134.46	
3907	NEWLY ELIGIBLE FEMA L	84.00	79.99	84.00	84.00	84.00	77.03	79.83	80.00	85.74	78.00	82.00	86.32	
3908	NEWLY ELIGIBLE M&F
4	1,643.68	1,684.68	1,716.70	1,801.77	1,863.65	1,889.72	1,958.41	2,019.37	2,077.97	2,019.62	2,028.01	2,105.64	
3909	NEWLY ELIGIBLE M&F 6	1,344.17	1,441.48	1,576.52	1,662.44	1,763.64	1,880.27	2,002.48	2,120.40	2,223.91	2,067.50	2,133.83	2,235.99	
390F	NEWLY ELIGIBLE MALE	0.35	0.00	0.00	0.06	0.00	0.00	0.00	0.10	0.00	0.00	0.00	0.03	
390G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.25	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F
4	0.10	0.67	0.79	0.06	0.00	0.03	0.80	0.85	1.64	2.36	2.67	0.00	
390J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	6.99	8.54	0.03	0.00	0.00	0.00	8.06	
3914	NEWLY ELIGIBLE MALE	6,329.74	6,150.41	5,993.22	5,824.81	5,663.45	5,537.36	5,432.82	5,191.95	5,148.40	5,061.51	4,946.82	4,809.37	
3915	NEWLY ELIGIBLE FEMA L	6,685.35	6,450.40	6,256.81	6,066.50	5,905.56	5,748.51	5,571.73	5,294.59	5,243.63	5,205.53	5,076.23	4,932.97	
3916	NEWLY ELIGIBLE MALE	34,840.80	35,024.17	35,323.57	35,321.36	35,256.68	35,247.11	35,203.80	35,251.92	35,189.39	35,163.06	35,183.63	35,232.85	
3917	NEWLY ELIGIBLE FEMA L	49,682.90	50,247.66	51,126.23	50,872.40	50,514.90	50,321.22	49,942.77	49,836.48	49,341.85	49,099.95	48,945.41	48,825.08	
3918	NEWLY ELIGIBLE M&F
4	41,600.09	41,624.86	41,789.27	41,720.32	41,457.18	41,286.55	41,199.36	41,185.89	40,905.45	40,776.44	40,755.23	40,618.85	
3919	NEWLY ELIGIBLE M&F 6	132.00	143.00	142.00	140.00	140.00	148.00	159.29	170.85	155.00	166.00	163.80	162.12	
391D	NEWLY ELIGIBLE MALE	19.27	12.52	13.19	18.50	17.91	18.89	15.41	15.90	22.84	15.73	23.48	17.56	
391E	NEWLY ELIGIBLE FEMA L	21.89	18.50	17.16	27.31	30.43	16.63	41.14	22.33	28.60	28.99	20.12	27.59	
391F	NEWLY ELIGIBLE MALE	245.69	151.61	211.70	275.09	228.32	253.75	267.45	214.87	262.44	206.36	189.29	228.13	
391G	NEWLY ELIGIBLE FEMA L	268.86	207.83	230.86	265.30	249.59	305.19	269.66	273.18	326.00	293.69	181.50	236.66	
391H	NEWLY ELIGIBLE M&F
4	249.31	241.12	270.30	266.10	268.42	403.68	345.48	303.47	293.26	277.67	225.10	217.98	
391J	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	1.00	1.00	1.00	1.00	1.00	1.00	6.00	6.00	5.00	5.00	5.00	5.00	
3927	NEWLY ELIGIBLE FEMA L	3.00	3.00	3.00	4.00	4.00	3.00	4.00	5.00	6.00	7.06	6.00	8.00	
3928	NEWLY ELIGIBLE M&F
4	20.00	20.74	25.00	22.00	20.00	21.00	22.00	23.21	33.32	28.60	23.00	26.00	
3929	NEWLY ELIGIBLE M&F 6	68.00	73.00	77.00	84.99	96.00	95.63	99.00	104.78	117.00	119.00	122.99	119.99	
392G	NEWLY ELIGIBLE FEMA
L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.93	0.00	0.00	
392H	NEWLY ELIGIBLE M&F 4	0.00	0.25	0.00	0.00	0.00	0.00	0.00	0.78	0.00	0.00	0.00	0.00	
SUBTOTAL:	143,363.84	143,695.92	144,982.32	144,583.73	143,694.73	143,391.56	142,758.22	142,254.86	141,607.65	140,750.95	140,243.65	140,041.65	

9.00	
14.00	
1,524.43	
984.91	
22,809.22	
22,452.63	
0.54	
0.28	
9.97	
23.62	
66,089.86	
68,437.81	
422,238.34	
598,756.85	
494,919.49	
1,822.06	
211.20	
300.69	
2,734.70	
3,108.32	
3,361.89	
1.00	
38.00	
56.06	
284.87	
1,177.38	
0.93	
1.03	
1,711,369.08	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
9939	BIRTH SUPP PAYMENT N	163.00	195.00	167.00	177.00	177.00	180.00	153.00	143.00	165.00	143.00	161.00	171.00		1,995.00		
SUBTOTAL:	163.00	195.00	167.00	177.00	177.00	180.00	153.00	143.00	165.00	143.00	161.00	171.00		1,995.00		

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	
4405	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	0.26	
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	1.00	
4412	SOBRA 100-133% M&F
1	2.00	1.00	2.00	1.00	1.00	1.00	1.00	1.00	0.00	2.00	1.00	2.00	
4413	SOBRA 100-133% M&F
6	44,116.21	44,077.31	42,532.90	44,094.38	43,400.52	43,010.76	42,611.34	42,352.71	42,079.88	41,867.34	41,954.52	41,775.29	
4414	SOBRA 100-133% MALE	14,078.65	14,479.94	14,271.99	14,658.41	14,579.96	14,668.90	14,749.88	14,986.24	14,895.63	14,829.31	15,005.12	15,156.53	
4415	SOBRA 100-133% FEMA L	13,664.39	14,102.03	13,566.78	14,138.29	14,054.05	14,163.87	14,256.98	14,446.11	14,421.12	14,445.86	14,560.78	14,634.62	
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	293.23	234.35	211.22	268.22	270.13	165.43	260.90	
441D	SOBRA 100-133% MALE	75.47	67.61	65.09	81.69	80.19	56.44	66.27	85.25	83.14	144.57	55.96	67.38	
441E	SOBRA 100-133% FEMA L	61.69	70.63	63.69	94.28	70.32	87.52	67.45	83.39	82.52	97.73	47.76	83.06	
4424	SOBRA 100-133% MALE	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	
SUBTOTAL:	72,272.31	73,018.71	70,771.98	73,389.54	72,432.93	72,282.72	71,988.27	72,167.92	71,832.51	71,658.94	71,792.57	71,983.04	

5.00	
0.26	
1.58	
15.00	
513,873.16	
176,360.56	
170,454.88	
0.41	
3,029.49	
929.06	
910.04	
12.00	
865,591.44	

9944

BIRTH SUPP PAYMENT S

104.00

104.00

6.00	2.00	13.00	11.00	7.00	10.00	7.00	12.00	14.00	7.00	8.00	7.00	
6.00	2.00	13.00	11.00	7.00	10.00	7.00	12.00	14.00	7.00	8.00	7.00	

SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	21.00	21.00	21.00	20.76	21.00	20.93	21.00	20.67	19.00	19.00	18.34	14.95	
4518	BC PATIENT FEMALE 4
5	130.82	133.94	138.27	140.12	138.70	143.38	143.61	136.76	130.12	127.67	127.83	128.99	
4519	BC PATIENT FEMALE 6 5	4.38	6.81	6.46	3.74	4.94	3.92	3.70	6.26	6.86	12.52	13.51	16.74	
451G	BC PATIENT FEMALE 2
1	1.00	0.00	0.00	0.00	0.00	1.06	0.00	0.00	0.00	0.00	0.15	0.09	
451H	BC PATIENT FEMALE 4 5	2.48	12.84	3.77	5.66	4.27	5.55	0.36	11.81	10.69	2.59	1.00	2.94	
451J	BC PATIENT FEMALE 6
5	1.78	0.88	5.31	0.24	0.85	0.06	4.97	9.70	75.63	4.49	4.39	0.37	
4617	CC PATIENT FEMALE 2 1	5.00	5.00	5.00	5.00	5.43	6.00	6.00	6.00	6.00	6.00	6.00	6.00	
4618	CC PATIENT FEMALE 4
5	4.00	4.00	4.00	4.00	4.00	4.00	4.00	3.00	4.00	4.00	5.15	6.00	
461G	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
461H	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	0.00	2.83	0.00	
SUBTOTAL:	170.46	184.47	183.81	179.52	179.75	184.90	183.64	194.20	257.30	176.27	179.20	176.08	

238.65	
1,620.21	
89.84	
2.30	
63.96	
108.67	
67.43	
50.15	
0.56	
7.83	
2,249.60	

8600	SSI BLIND FREEDOM/W O	4.00	4.00	7.00	7.00	7.00	9.00	10.00	12.21	13.00	14.00	13.00	16.00	
860Z	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.94	0.84	0.00	0.00	0.00	
8610	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	
8620	SSI BLIND FREEDOM/W
O	2.00	2.00	1.00	1.00	1.00	2.00	1.00	1.00	1.00	2.00	3.00	3.00	
8700	SSI DISABLED FREEDO M	2,310.09	2,327.98	2,342.21	2,320.57	2,347.36	2,351.56	2,375.53	2,392.40	2,401.67	2,391.58	2,392.22	2,419.41	
870Z	SSI DISABLED FREEDO
M	26.14	16.78	11.33	24.16	13.64	35.41	39.63	30.70	12.38	10.75	31.15	29.75	

116.21	
1.78	
12.00	
20.00	
28,372.58	
281.82	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8710	SSI DISABLED FREEDO M	354.90	367.24	366.79	365.90	372.87	387.06	380.55	376.11	393.13	406.91	432.65	439.20		4,643.31		
871Z	SSI DISABLED FREEDO
M	7.04	7.73	13.07	11.48	2.86	30.28	11.70	6.02	5.59	13.18	0.67	3.59		113.21		
8720	SSI DISABLED FREEDO M	581.16	591.19	596.75	609.32	634.35	639.57	653.79	661.88	676.32	707.94	746.03	768.19		7,866.49		
872Z	SSI DISABLED FREEDO
M	6.37	12.41	2.43	1.16	0.03	16.48	0.00	2.10	2.92	5.40	1.54	8.23		59.07		
SUBTOTAL:	3,292.70	3,330.33	3,341.58	3,341.59	3,380.11	3,472.36	3,473.20	3,484.36	3,507.85	3,552.76	3,621.26	3,688.37		41,486.47		

TOTAL:	1,827,814.88	1,836,310.28	1,843,212.89	1,865,813.86	1,872,832.06	1,890,207.53	1,894,792.42	1,907,817.10	1,924,149.92	1,930,343.92	1,937,200.89	1,950,994.49		22,681,490.24		

ACUTE CAPITATION - AMERICAN INDIAN A - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60		16.60		
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	16.60	33.20		49.80		
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	16.60	49.80		66.40		
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	16.60	16.60	16.60		49.80		
1015	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49.80	66.40	49.80		166.00		
	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	33.20	83.00	116.20		232.40		
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	16.60	16.60	16.60	199.20	398.40	464.80		1,112.20		
	O																
1018	TANF 45-64 M & F NON	15.87	15.87	15.87	15.87	15.87	15.87	16.60	16.60	0.00	83.00	199.20	215.80		626.42		
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	66.40	83.00		149.40		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.20	33.20	33.20		99.60		
	E																
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	83.00	132.80	265.60		481.40		
	D																
2220	SSI DISABLED WITH Q	15.87	15.87	15.87	15.87	15.87	15.87	16.60	16.60	16.60	33.20	66.40	99.60		344.22		
	M																
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	66.40	149.40	232.40		448.20		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	199.20	614.20	946.20		1,759.60		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	249.00	730.40	962.80		1,942.20		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.20	249.00	315.40		597.60		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	15.87	15.87	15.87	16.60	16.60	16.60	149.40	249.00	348.60		844.41		
5015	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	33.20		49.80		
	M																
5017	SOBRA PREG 21-44 FE	0.00	15.87	15.87	15.87	15.87	15.87	0.00	0.00	0.00	49.80	83.00	99.60		311.75		
	M																
SUBTOTAL:	31.74	47.61	47.61	63.48	63.48	63.48	66.40	66.40	49.80	1,278.20	3,187.20	4,382.40		9,347.80		

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	16.60	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	16.60	66.40	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	132.80	166.00	282.20	
1118	TANF EXPANDED 45-64	31.74	31.74	31.74	31.74	31.74	31.74	33.20	33.20	49.80	66.40	116.20	149.40	
2420	SSI AGED EXPANDED WI	47.61	47.61	47.61	47.61	47.61	47.61	49.80	49.80	49.80	116.20	132.80	166.00	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	49.80	49.80	
SUBTOTAL:	79.35	79.35	79.35	79.35	79.35	79.35	83.00	83.00	99.60	348.60	481.40	730.40	

16.60	
99.60	
581.00	
638.64	
850.06	
116.20	
2,302.10	

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	16.60	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	16.60	
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	16.60	16.60	
3516	ADULT 40-100% MALE 2	15.87	15.87	15.87	15.87	15.87	15.87	16.60	16.60	16.60	49.80	83.00	83.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	33.20	33.20	
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	49.80	99.60	149.40	
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	16.60	16.60	16.60	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	49.80	49.80	

16.60	
16.60	
33.20	
360.82	
83.00	
298.80	
49.80	
116.20	

ACUTE CAPITATION - AMERICAN INDIAN A - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	33.20		33.20		
3716	ADULT <40% EXP MALE	15.87	15.87	15.87	15.87	15.87	15.87	16.60	16.60	16.60	49.80	166.00	249.00		609.82		
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.20	83.00	215.80		332.00		
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	166.00	348.60	498.00		1,012.60		
SUBTOTAL:	31.74	31.74	31.74	31.74	31.74	31.74	33.20	33.20	33.20	398.40	913.00	1,361.20		2,962.64		

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	33.20	33.20	33.20	
3917	NEWLY ELIGIBLE FEMA L	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	66.40	49.80	
3918	NEWLY ELIGIBLE M&F
4	15.87	15.87	15.87	15.87	15.87	15.87	16.60	16.60	16.60	16.60	49.80	66.40	
SUBTOTAL:	31.74	15.87	15.87	15.87	15.87	15.87	16.60	16.60	16.60	66.40	149.40	149.40	

99.60	
148.67	
277.82	
526.09	

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	16.60	16.60	49.80	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	16.60	33.20	
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	49.80	66.40	
SUBTOTAL:	15.87	15.87	15.87	0.00	0.00	0.00	0.00	0.00	0.00	33.20	83.00	149.40	

83.00	
66.40	
163.81	
313.21	

49.80

49.80

15,501.64

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	16.60	16.60	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	16.60	16.60	16.60	

190.44	190.44	190.44	190.44	199.20	199.20	199.20	2,141.40	4,830.60	6,789.40	

TOTAL:

190.44

190.44

ACUTE CAPITATION - AMERICAN INDIAN A - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00		1.00		
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	1.00	2.00		3.00		
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	1.00	3.00		4.00		
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	1.00	1.00	1.00		3.00		
1015	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	4.00	3.00		10.00		
	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	2.00	5.00	7.00		14.00		
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	12.00	24.00	28.00		67.00		
	O																
1018	TANF 45-64 M & F NON	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	5.00	12.00	13.00		38.00		
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	4.00	5.00		9.00		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	2.00	2.00		6.00		
	E																
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5.00	8.00	16.00		29.00		
	D																
2220	SSI DISABLED WITH Q	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	4.00	6.00		21.00		
	M																
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	9.00	14.00		27.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12.00	37.00	57.00		106.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15.00	44.00	58.00		117.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	15.00	19.00		36.00		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	9.00	15.00	21.00		51.00		
5015	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00		3.00		
	M																
5017	SOBRA PREG 21-44 FE	0.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	3.00	5.00	6.00		19.00		
	M																
SUBTOTAL:	2.00	3.00	3.00	4.00	4.00	4.00	4.00	4.00	3.00	77.00	192.00	264.00		564.00		

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	1.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	4.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8.00	10.00	17.00	
1118	TANF EXPANDED 45-64	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	4.00	7.00	9.00	
2420	SSI AGED EXPANDED WI	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	7.00	8.00	10.00	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.00	3.00	
SUBTOTAL:	5.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00	6.00	21.00	29.00	44.00	

1.00	
6.00	
35.00	
39.00	
52.00	
7.00	
140.00	

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	1.00	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	1.00	
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	1.00	1.00	
3516	ADULT 40-100% MALE 2	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	3.00	5.00	5.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00	2.00	
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	3.00	6.00	9.00	
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	1.00	1.00	1.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.00	3.00	

1.00	
1.00	
2.00	
22.00	
5.00	
18.00	
3.00	
7.00	

ACUTE CAPITATION - AMERICAN INDIAN A - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	2.00		2.00		
3716	ADULT <40% EXP MALE	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	3.00	10.00	15.00		37.00		
3717	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	5.00	13.00		20.00		
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	10.00	21.00	30.00		61.00		
SUBTOTAL:	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	24.00	55.00	82.00		179.00		

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	2.00	2.00	
3917	NEWLY ELIGIBLE FEMA L	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	4.00	3.00	
3918	NEWLY ELIGIBLE M&F
4	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	3.00	4.00	
SUBTOTAL:	2.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	4.00	9.00	9.00	

6.00	
9.00	
17.00	
32.00	

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	1.00	1.00	3.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	2.00	
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	3.00	4.00	
SUBTOTAL:	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	5.00	9.00	

5.00	
4.00	
10.00	
19.00	

3.00

8710	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	

3.00

TOTAL:	12.00	12.00	12.00	12.00	12.00	12.00	12.00	12.00	12.00	129.00	291.00	409.00		937.00		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending June 30, 2022	
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	18.27	0.00	0.00	0.00	0.00	0.00	0.00		109.62		
1007	TANF 21-44 FEMALE WI	0.00	0.00	18.27	18.27	18.27	36.54	19.11	19.11	19.11	19.11	19.11	19.11		206.01		
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	109.62	133.77	133.77	133.77	133.77	95.55	95.55		1,146.39		
1011	TANF <1 M & F NON-ME	2,064.51	2,228.94	2,174.13	2,302.02	2,375.10	2,448.18	2,369.64	2,331.42	2,388.75	2,254.98	2,082.99	2,025.66		27,046.32		
1012	TANF 01-05 M & F NON	2,831.85	2,667.42	2,557.80	2,630.88	2,868.39	3,105.90	3,630.90	3,669.12	3,497.13	3,439.80	3,382.47	3,573.57		37,855.23		
1013	TANF 06-13 M & F NON	2,758.77	2,685.69	2,777.04	3,178.98	3,599.19	3,909.78	4,089.54	4,108.65	3,993.99	3,974.88	3,993.99	4,032.21		43,102.71		
1014	TANF 14-20 MALE NON-	895.23	913.50	1,059.66	1,205.82	1,297.17	1,479.87	1,605.24	1,643.46	1,643.46	1,624.35	1,567.02	1,528.80		16,463.58		
1015	TANF 14-20 FEMALE N	1,151.01	1,077.93	1,059.66	1,096.20	1,351.98	1,461.60	1,567.02	1,567.02	1,528.80	1,452.36	1,528.80	1,624.35		16,466.73		
	O																
1016	TANF 21-44 MALE NON-	3,800.16	3,854.97	3,928.05	3,964.59	4,092.48	4,202.10	4,643.73	4,739.28	4,624.62	4,567.29	4,643.73	4,624.62		51,685.62		
1017	TANF 21-44 FEMALE N	12,551.49	12,588.03	12,807.27	13,190.94	13,592.88	14,086.17	15,135.12	15,039.57	15,039.57	15,001.35	15,077.79	15,135.12		169,245.30		
	O																
1018	TANF 45-64 M & F NON	5,060.79	5,005.98	4,896.36	4,914.63	5,115.60	5,261.76	5,541.90	5,484.57	5,541.90	5,484.57	5,637.45	5,866.77		63,812.28		
1019	TANF 65+ M & F NON-M	18.27	18.27	36.54	36.54	54.81	36.54	38.22	76.44	76.44	76.44	76.44	76.44		621.39		
1026	TANF 21-44 MALE WITH	0.00	0.00	18.27	0.00	18.27	18.27	19.11	0.00	0.00	0.00	0.00	0.00		73.92		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	19.11	19.11	0.00	0.00	0.00	0.00		38.22		
1028	TANF 45-64 M & F WIT	36.54	36.54	36.54	36.54	18.27	18.27	38.22	38.22	38.22	38.22	38.22	38.22		412.02		
1029	TANF 65+ M & F WITH	91.35	91.35	73.08	73.08	54.81	54.81	57.33	57.33	57.33	57.33	38.22	38.22		744.24		
2100	SSI AGED WITH MEDIC	255.78	237.51	237.51	255.78	255.78	292.32	343.98	401.31	401.31	363.09	363.09	363.09		3,770.55		
	A																
2110	SSI AGED NON-MEDICA	310.59	310.59	365.40	401.94	383.67	365.40	363.09	363.09	382.20	382.20	439.53	477.75		4,545.45		
	R																
2120	SSI AGED WITH QMB	2,119.32	2,228.94	2,265.48	2,247.21	2,283.75	2,320.29	2,446.08	2,503.41	2,560.74	2,522.52	2,503.41	2,484.30		28,485.45		
2200	SSI DISABLED WITH M	712.53	694.26	694.26	712.53	657.72	694.26	783.51	745.29	783.51	745.29	707.07	726.18		8,656.41		
	E																
2210	SSI DISABLED NON-ME	10,596.60	10,523.52	10,870.65	10,943.73	10,870.65	10,907.19	11,179.35	11,236.68	11,198.46	11,198.46	11,274.90	11,179.35		131,979.54		
	D																
2220	SSI DISABLED WITH Q	4,074.21	4,110.75	4,147.29	4,147.29	4,202.10	4,238.64	4,471.74	4,529.07	4,490.85	4,490.85	4,548.18	4,509.96		51,960.93		
	M																
2300	SSI BLIND WITH MEDIC	18.27	18.27	18.27	18.27	18.27	18.27	19.11	19.11	19.11	19.11	19.11	19.11		224.28		
2310	SSI BLIND NON-MEDIC	127.89	127.89	146.16	146.16	146.16	146.16	152.88	152.88	171.99	191.10	191.10	191.10		1,891.47		
	A																
2320	SSI BLIND WITH QMB	18.27	18.27	18.27	18.27	18.27	36.54	38.22	38.22	38.22	38.22	38.22	38.22		357.21		
4311	SOBRA CHILD <1 M & F	4,348.26	4,275.18	3,946.32	3,873.24	3,654.00	3,544.38	3,286.92	3,306.03	3,650.01	3,630.90	4,070.43	4,089.54		45,675.21		
4312	SOBRA CHILD 01-05 M	28,720.44	29,085.84	29,542.59	29,707.02	29,469.51	29,506.05	30,595.11	30,461.34	30,499.56	30,136.47	30,671.55	30,747.99		359,143.47		
4313	SOBRA CHILD 06-13 M	27,039.60	27,806.94	28,336.77	28,245.42	27,953.10	27,806.94	29,047.20	29,200.08	29,868.93	29,868.93	30,404.01	30,690.66		346,268.58		
4314	SOBRA CHILD 14-20 MA	7,454.16	7,673.40	7,983.99	8,020.53	8,020.53	8,075.34	8,427.51	8,637.72	8,886.15	8,752.38	8,828.82	8,981.70		99,742.23		
4315	SOBRA CHILD 14-20 FE	7,070.49	7,472.43	7,819.56	7,910.91	7,929.18	7,947.45	8,274.63	8,446.62	8,503.95	8,752.38	8,924.37	9,115.47		98,167.44		
5013	SOBRA PREG 09-13 FE	0.00	0.00	0.00	0.00	0.00	0.00	19.11	19.11	19.11	19.11	19.11	19.11		114.66		
	M																
5015	SOBRA PREG 14-20 FE	54.81	73.08	54.81	91.35	127.89	127.89	57.33	152.88	171.99	152.88	133.77	133.77		1,332.45		
	M																
5017	SOBRA PREG 21-44 FE	1,151.01	1,114.47	1,187.55	1,187.55	1,096.20	1,278.90	1,146.60	1,261.26	1,223.04	1,031.94	1,108.38	1,242.15		14,029.05		
	M																
SUBTOTAL:	125,423.55	127,049.58	129,187.17	130,703.58	131,653.62	133,553.70	139,560.33	140,401.17	141,452.22	140,420.28	142,426.83	143,688.09		1,625,520.12		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		36.54		
1107	TANF EXPANDED 21-44	18.27	18.27	18.27	18.27	18.27	18.27	19.11	19.11	38.22	38.22	38.22	38.22		300.72		
1108	TANF EXPANDED 45-64	91.35	127.89	109.62	127.89	164.43	127.89	152.88	133.77	114.66	76.44	76.44	95.55		1,398.81		
1109	TANF EXPANDED 65+ M	164.43	164.43	200.97	200.97	146.16	146.16	171.99	191.10	210.21	229.32	286.65	286.65		2,399.04		
	&																
1114	TANF EXPANDED 14-20	18.27	18.27	18.27	36.54	36.54	36.54	19.11	19.11	19.11	19.11	38.22	19.11		298.20		
1115	TANF EXPANDED 14-20	127.89	164.43	146.16	127.89	109.62	91.35	95.55	114.66	95.55	133.77	95.55	76.44		1,378.86		
1116	TANF EXPANDED 21-44	2,247.21	2,247.21	2,320.29	2,283.75	2,192.40	2,119.32	2,082.99	2,063.88	2,197.65	2,178.54	2,178.54	2,140.32		26,252.10		
1117	TANF EXPANDED 21-44	6,211.80	6,339.69	6,394.50	6,175.26	5,882.94	5,718.51	5,866.77	5,733.00	5,790.33	6,210.75	6,363.63	6,325.41		73,012.59		
1118	TANF EXPANDED 45-64	2,868.39	2,996.28	3,087.63	3,124.17	3,032.82	3,032.82	3,134.04	3,172.26	3,286.92	3,306.03	3,344.25	3,286.92		37,672.53		
1119	TANF EXPANDED 65+ M	0.00	0.00	0.00	18.27	0.00	0.00	0.00	19.11	19.11	19.11	19.11	19.11		113.82		
	&																
1126	TANF EXPANDED 21-44	109.62	109.62	109.62	109.62	91.35	91.35	95.55	95.55	95.55	95.55	95.55	95.55		1,194.48		
1127	TANF EXPANDED 21-44	18.27	18.27	18.27	18.27	18.27	18.27	19.11	19.11	19.11	19.11	19.11	19.11		224.28		
1128	TANF EXPANDED 45-64	548.10	511.56	529.83	548.10	511.56	511.56	515.97	535.08	554.19	554.19	496.86	496.86		6,313.86		
1129	TANF EXPANDED 65+ M	493.29	493.29	493.29	584.64	657.72	694.26	707.07	707.07	707.07	726.18	726.18	726.18		7,716.24		
	&																
2400	SSI AGED EXPANDED	36.54	36.54	54.81	54.81	73.08	73.08	76.44	57.33	57.33	57.33	76.44	76.44		730.17		
	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	2,850.12	3,019.38	3,019.38	3,057.60	3,038.49	3,095.82	3,114.93		34,569.36		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	18.27	18.27	0.00	18.27	19.11	19.11	19.11	19.11	19.11	19.11		169.47		
	W																
2600	SSI DISABLED EXPAND	18.27	18.27	18.27	18.27	18.27	18.27	19.11	19.11	19.11	19.11	19.11	19.11		224.28		
	E																
2610	SSI DISABLED EXPAND	237.51	255.78	237.51	219.24	219.24	219.24	229.32	248.43	229.32	248.43	248.43	229.32		2,821.77		
	E																
2620	SSI DISABLED EXPAND	1,370.25	1,370.25	1,351.98	1,370.25	1,388.52	1,370.25	1,452.36	1,452.36	1,395.03	1,414.14	1,414.14	1,452.36		16,801.89		
	E																
SUBTOTAL:	17,155.53	17,484.39	17,831.52	17,794.98	17,411.31	17,155.53	17,695.86	17,638.53	17,925.18	18,402.93	18,651.36	18,536.70		213,683.82		

3506	ADULT 40-100% MALE 2	18.27	18.27	18.27	18.27	18.27	18.27	19.11	19.11	19.11	19.11	19.11	19.11	
3508	ADULT 40-100% M&F 45	36.54	36.54	36.54	36.54	18.27	36.54	19.11	57.33	19.11	19.11	57.33	19.11	
3509	ADULT 40-100% M&F 65	0.00	18.27	18.27	18.27	18.27	18.27	19.11	19.11	38.22	38.22	57.33	95.55	
3514	ADULT 40-100% MALE 1	383.67	401.94	401.94	438.48	456.75	493.29	515.97	515.97	477.75	477.75	477.75	573.30	
3515	ADULT 40-100% FEMAL E	365.40	347.13	383.67	401.94	401.94	365.40	363.09	363.09	420.42	420.42	401.31	535.08	
3516	ADULT 40-100% MALE 2	1,589.49	1,626.03	1,699.11	1,626.03	1,626.03	1,717.38	1,719.90	1,681.68	1,700.79	1,719.90	1,777.23	1,853.67	
3517	ADULT 40-100% FEMAL E	1,096.20	1,169.28	1,187.55	1,242.36	1,242.36	1,297.17	1,356.81	1,414.14	1,528.80	1,509.69	1,547.91	1,605.24	
3518	ADULT 40-100% M&F 45	3,343.41	3,361.68	3,453.03	3,379.95	3,434.76	3,526.11	3,592.68	3,573.57	3,554.46	3,650.01	3,669.12	3,726.45	
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	19.11	0.00	0.00	
3708	ADULT <40% EXP M&F 4	18.27	36.54	18.27	18.27	18.27	36.54	38.22	76.44	57.33	38.22	38.22	38.22	
3709	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	19.11	19.11	19.11	19.11	19.11	19.11	
3714	ADULT <40% EXP MALE	1,114.47	1,205.82	1,297.17	1,278.90	1,406.79	1,425.06	1,586.13	1,586.13	1,662.57	1,853.67	1,891.89	1,930.11	
3715	ADULT <40% EXP FEMA L	1,278.90	1,351.98	1,388.52	1,461.60	1,498.14	1,516.41	1,547.91	1,471.47	1,567.02	1,586.13	1,719.90	1,662.57	

224.28	
392.07	
358.89	
5,614.56	
4,768.89	
20,337.24	
16,197.51	
42,265.23	
19.11	
432.81	
114.66	
18,238.71	
18,050.55	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	12,533.22	13,008.24	13,264.02	13,519.80	13,702.50	13,976.55	15,039.57	15,135.12	15,345.33	15,517.32	15,651.09	15,918.63		172,611.39		
3717	ADULT <40% EXP FEMA	6,540.66	6,686.82	6,851.25	6,997.41	7,289.73	7,417.62	7,892.43	8,179.08	8,140.86	8,274.63	8,389.29	8,293.74		90,953.52		
	L																
3718	ADULT <40% EXP M&F	14,067.90	14,250.60	14,689.08	15,036.21	15,346.80	15,584.31	16,491.93	16,568.37	16,587.48	16,606.59	17,027.01	17,103.45		189,359.73		
	4																
3719	ADULT <40% EXP M&F	0.00	18.27	18.27	18.27	0.00	0.00	19.11	19.11	19.11	19.11	19.11	19.11		169.47		
	6																
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	18.27	19.11	19.11	19.11	38.22	38.22	38.22		190.26		
3728	ADULT <40% EXP M&F	18.27	18.27	18.27	18.27	36.54	18.27	19.11	19.11	19.11	19.11	19.11	19.11		242.55		
	4																
SUBTOTAL:	42,404.67	43,555.68	44,743.23	45,510.57	46,515.42	47,465.46	50,278.41	50,737.05	51,195.69	51,845.43	52,820.04	53,469.78		580,541.43		

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	18.27	19.11	19.11	19.11	19.11	19.11	19.11	
3908	NEWLY ELIGIBLE M&F
4	146.16	146.16	127.89	164.43	146.16	182.70	191.10	152.88	171.99	171.99	171.99	210.21	
3909	NEWLY ELIGIBLE M&F 6	127.89	127.89	109.62	109.62	146.16	182.70	191.10	210.21	210.21	191.10	191.10	210.21	
3914	NEWLY ELIGIBLE MALE	164.43	146.16	146.16	164.43	164.43	182.70	171.99	133.77	152.88	133.77	114.66	114.66	
3915	NEWLY ELIGIBLE FEMA L	347.13	365.40	401.94	365.40	347.13	383.67	401.31	382.20	363.09	382.20	401.31	382.20	
3916	NEWLY ELIGIBLE MALE	2,101.05	2,137.59	2,247.21	2,302.02	2,393.37	2,393.37	2,503.41	2,522.52	2,541.63	2,618.07	2,656.29	2,637.18	
3917	NEWLY ELIGIBLE FEMA L	3,416.49	3,599.19	3,654.00	3,727.08	3,654.00	3,544.38	3,611.79	3,669.12	3,688.23	3,573.57	3,592.68	3,650.01	
3918	NEWLY ELIGIBLE M&F
4	4,366.53	4,439.61	4,622.31	4,494.42	4,403.07	4,403.07	4,548.18	4,548.18	4,548.18	4,529.07	4,567.29	4,490.85	
3919	NEWLY ELIGIBLE M&F 6	0.00	18.27	18.27	18.27	18.27	18.27	19.11	0.00	0.00	0.00	0.00	19.11	
SUBTOTAL:	10,669.68	10,980.27	11,327.40	11,345.67	11,272.59	11,309.13	11,657.10	11,637.99	11,695.32	11,618.88	11,714.43	11,733.54	

132.93	
1,983.66	
2,007.81	
1,790.04	
4,522.98	
29,053.71	
43,380.54	
53,960.76	
129.57	
136,962.00	

4413	SOBRA 100-133% M&F
6	2,557.80	2,667.42	2,813.58	2,777.04	2,576.07	2,612.61	2,809.17	2,751.84	2,751.84	2,770.95	2,923.83	3,095.82	
4414	SOBRA 100-133% MALE	1,114.47	1,151.01	1,169.28	1,151.01	1,096.20	1,077.93	1,108.38	1,146.60	1,127.49	1,184.82	1,223.04	1,223.04	
4415	SOBRA 100-133% FEMA L	986.58	1,004.85	1,077.93	1,077.93	1,096.20	1,077.93	1,146.60	1,261.26	1,261.26	1,184.82	1,127.49	1,146.60	
SUBTOTAL:	4,658.85	4,823.28	5,060.79	5,005.98	4,768.47	4,768.47	5,064.15	5,159.70	5,140.59	5,140.59	5,274.36	5,465.46	

33,107.97	
13,773.27	
13,449.45	
60,330.69	

4518	BC PATIENT FEMALE 4 5	18.27	18.27	18.27	18.27	18.27	18.27	19.11	19.11	19.11	19.11	19.11	19.11	
SUBTOTAL:	18.27	18.27	18.27	18.27	18.27	18.27	19.11	19.11	19.11	19.11	19.11	19.11	

224.28

224.28

8700	SSI DISABLED FREEDO M	109.62	127.89	146.16	146.16	146.16	146.16	152.88	133.77	133.77	114.66	114.66	133.77	
8710	SSI DISABLED FREEDO
M	73.08	54.81	36.54	54.81	73.08	54.81	57.33	57.33	57.33	57.33	57.33	38.22	
8720	SSI DISABLED FREEDO M	36.54	36.54	36.54	36.54	36.54	36.54	19.11	19.11	19.11	0.00	0.00	0.00	
SUBTOTAL:	219.24	219.24	219.24	237.51	255.78	237.51	229.32	210.21	210.21	171.99	171.99	171.99	

1,605.66	
672.00	
276.57	
2,554.23	

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	19.11	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	19.11	0.00	0.00	

19.11

19.11

2,619,835.68

200,549.79	204,130.71	208,387.62	210,616.56	211,895.46	214,508.07	224,504.28	225,803.76	227,638.32	227,638.32	231,078.12	233,084.67	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending June 30, 2022	
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	1.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	1.00	1.00	1.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00		11.00		
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	6.00	7.00	7.00	7.00	7.00	5.00	5.00		61.00		
1011	TANF <1 M & F NON-ME	113.00	122.00	119.00	126.00	130.00	134.00	124.00	122.00	125.00	118.00	109.00	106.00		1,448.00		
1012	TANF 01-05 M & F NON	155.00	146.00	140.00	144.00	157.00	170.00	190.00	192.00	183.00	180.00	177.00	187.00		2,021.00		
1013	TANF 06-13 M & F NON	151.00	147.00	152.00	174.00	197.00	214.00	214.00	215.00	209.00	208.00	209.00	211.00		2,301.00		
1014	TANF 14-20 MALE NON-	49.00	50.00	58.00	66.00	71.00	81.00	84.00	86.00	86.00	85.00	82.00	80.00		878.00		
1015	TANF 14-20 FEMALE N	63.00	59.00	58.00	60.00	74.00	80.00	82.00	82.00	80.00	76.00	80.00	85.00		879.00		
	O																
1016	TANF 21-44 MALE NON-	208.00	211.00	215.00	217.00	224.00	230.00	243.00	248.00	242.00	239.00	243.00	242.00		2,762.00		
1017	TANF 21-44 FEMALE N	687.00	689.00	701.00	722.00	744.00	771.00	792.00	787.00	787.00	785.00	789.00	792.00		9,046.00		
	O																
1018	TANF 45-64 M & F NON	277.00	274.00	268.00	269.00	280.00	288.00	290.00	287.00	290.00	287.00	295.00	307.00		3,412.00		
1019	TANF 65+ M & F NON-M	1.00	1.00	2.00	2.00	3.00	2.00	2.00	4.00	4.00	4.00	4.00	4.00		33.00		
1026	TANF 21-44 MALE WITH	0.00	0.00	1.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		4.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00		2.00		
1028	TANF 45-64 M & F WIT	2.00	2.00	2.00	2.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	2.00		22.00		
1029	TANF 65+ M & F WITH	5.00	5.00	4.00	4.00	3.00	3.00	3.00	3.00	3.00	3.00	2.00	2.00		40.00		
2100	SSI AGED WITH MEDIC	14.00	13.00	13.00	14.00	14.00	16.00	18.00	21.00	21.00	19.00	19.00	19.00		201.00		
	A																
2110	SSI AGED NON-MEDICA	17.00	17.00	20.00	22.00	21.00	20.00	19.00	19.00	20.00	20.00	23.00	25.00		243.00		
	R																
2120	SSI AGED WITH QMB	116.00	122.00	124.00	123.00	125.00	127.00	128.00	131.00	134.00	132.00	131.00	130.00		1,523.00		
2200	SSI DISABLED WITH M	39.00	38.00	38.00	39.00	36.00	38.00	41.00	39.00	41.00	39.00	37.00	38.00		463.00		
	E																
2210	SSI DISABLED NON-ME	580.00	576.00	595.00	599.00	595.00	597.00	585.00	588.00	586.00	586.00	590.00	585.00		7,062.00		
	D																
2220	SSI DISABLED WITH Q	223.00	225.00	227.00	227.00	230.00	232.00	234.00	237.00	235.00	235.00	238.00	236.00		2,779.00		
	M																
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		12.00		
2310	SSI BLIND NON-MEDIC	7.00	7.00	8.00	8.00	8.00	8.00	8.00	8.00	9.00	10.00	10.00	10.00		101.00		
	A																
2320	SSI BLIND WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00		19.00		
4311	SOBRA CHILD <1 M & F	238.00	234.00	216.00	212.00	200.00	194.00	172.00	173.00	191.00	190.00	213.00	214.00		2,447.00		
4312	SOBRA CHILD 01-05 M	1,572.00	1,592.00	1,617.00	1,626.00	1,613.00	1,615.00	1,601.00	1,594.00	1,596.00	1,577.00	1,605.00	1,609.00		19,217.00		
4313	SOBRA CHILD 06-13 M	1,480.00	1,522.00	1,551.00	1,546.00	1,530.00	1,522.00	1,520.00	1,528.00	1,563.00	1,563.00	1,591.00	1,606.00		18,522.00		
4314	SOBRA CHILD 14-20 MA	408.00	420.00	437.00	439.00	439.00	442.00	441.00	452.00	465.00	458.00	462.00	470.00		5,333.00		
4315	SOBRA CHILD 14-20 FE	387.00	409.00	428.00	433.00	434.00	435.00	433.00	442.00	445.00	458.00	467.00	477.00		5,248.00		
5013	SOBRA PREG 09-13 FE	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00		6.00		
	M																
5015	SOBRA PREG 14-20 FE	3.00	4.00	3.00	5.00	7.00	7.00	3.00	8.00	9.00	8.00	7.00	7.00		71.00		
	M																
5017	SOBRA PREG 21-44 FE	63.00	61.00	65.00	65.00	60.00	70.00	60.00	66.00	64.00	54.00	58.00	65.00		751.00		
	M																
SUBTOTAL:	6,865.00	6,954.00	7,071.00	7,154.00	7,206.00	7,310.00	7,303.00	7,347.00	7,402.00	7,348.00	7,453.00	7,519.00		86,932.00		

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		2.00		
1107	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00		16.00		
1108	TANF EXPANDED 45-64	5.00	7.00	6.00	7.00	9.00	7.00	8.00	7.00	6.00	4.00	4.00	5.00		75.00		
1109	TANF EXPANDED 65+ M	9.00	9.00	11.00	11.00	8.00	8.00	9.00	10.00	11.00	12.00	15.00	15.00		128.00		
	&																
1114	TANF EXPANDED 14-20	1.00	1.00	1.00	2.00	2.00	2.00	1.00	1.00	1.00	1.00	2.00	1.00		16.00		
1115	TANF EXPANDED 14-20	7.00	9.00	8.00	7.00	6.00	5.00	5.00	6.00	5.00	7.00	5.00	4.00		74.00		
1116	TANF EXPANDED 21-44	123.00	123.00	127.00	125.00	120.00	116.00	109.00	108.00	115.00	114.00	114.00	112.00		1,406.00		
1117	TANF EXPANDED 21-44	340.00	347.00	350.00	338.00	322.00	313.00	307.00	300.00	303.00	325.00	333.00	331.00		3,909.00		
1118	TANF EXPANDED 45-64	157.00	164.00	169.00	171.00	166.00	166.00	164.00	166.00	172.00	173.00	175.00	172.00		2,015.00		
1119	TANF EXPANDED 65+ M	0.00	0.00	0.00	1.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00		6.00		
	&																
1126	TANF EXPANDED 21-44	6.00	6.00	6.00	6.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00	5.00		64.00		
1127	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		12.00		
1128	TANF EXPANDED 45-64	30.00	28.00	29.00	30.00	28.00	28.00	27.00	28.00	29.00	29.00	26.00	26.00		338.00		
1129	TANF EXPANDED 65+ M	27.00	27.00	27.00	32.00	36.00	38.00	37.00	37.00	37.00	38.00	38.00	38.00		412.00		
	&																
2400	SSI AGED EXPANDED	2.00	2.00	3.00	3.00	4.00	4.00	4.00	3.00	3.00	3.00	4.00	4.00		39.00		
	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	156.00	158.00	158.00	160.00	159.00	162.00	163.00		1,848.00		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	1.00	1.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		9.00		
	W																
2600	SSI DISABLED EXPAND	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		12.00		
	E																
2610	SSI DISABLED EXPAND	13.00	14.00	13.00	12.00	12.00	12.00	12.00	13.00	12.00	13.00	13.00	12.00		151.00		
	E																
2620	SSI DISABLED EXPAND	75.00	75.00	74.00	75.00	76.00	75.00	76.00	76.00	73.00	74.00	74.00	76.00		899.00		
	E																
SUBTOTAL:	939.00	957.00	976.00	974.00	953.00	939.00	926.00	923.00	938.00	963.00	976.00	970.00		11,434.00		

3506	ADULT 40-100% MALE 2	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	
3508	ADULT 40-100% M&F 45	2.00	2.00	2.00	2.00	1.00	2.00	1.00	3.00	1.00	1.00	3.00	1.00	
3509	ADULT 40-100% M&F 65	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	2.00	3.00	5.00	
3514	ADULT 40-100% MALE 1	21.00	22.00	22.00	24.00	25.00	27.00	27.00	27.00	25.00	25.00	25.00	30.00	
3515	ADULT 40-100% FEMAL E	20.00	19.00	21.00	22.00	22.00	20.00	19.00	19.00	22.00	22.00	21.00	28.00	
3516	ADULT 40-100% MALE 2	87.00	89.00	93.00	89.00	89.00	94.00	90.00	88.00	89.00	90.00	93.00	97.00	
3517	ADULT 40-100% FEMAL E	60.00	64.00	65.00	68.00	68.00	71.00	71.00	74.00	80.00	79.00	81.00	84.00	
3518	ADULT 40-100% M&F 45	183.00	184.00	189.00	185.00	188.00	193.00	188.00	187.00	186.00	191.00	192.00	195.00	
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	1.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	1.00	2.00	1.00	1.00	1.00	2.00	2.00	4.00	3.00	2.00	2.00	2.00	
3709	ADULT <40% EXP M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	
3714	ADULT <40% EXP MALE	61.00	66.00	71.00	70.00	77.00	78.00	83.00	83.00	87.00	97.00	99.00	101.00	
3715	ADULT <40% EXP FEMA L	70.00	74.00	76.00	80.00	82.00	83.00	81.00	77.00	82.00	83.00	90.00	87.00	

12.00	
21.00	
19.00	
300.00	
255.00	
1,088.00	
865.00	
2,261.00	
1.00	
23.00	
6.00	
973.00	
965.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	686.00	712.00	726.00	740.00	750.00	765.00	787.00	792.00	803.00	812.00	819.00	833.00		9,225.00		
3717	ADULT <40% EXP FEMA	358.00	366.00	375.00	383.00	399.00	406.00	413.00	428.00	426.00	433.00	439.00	434.00		4,860.00		
	L																
3718	ADULT <40% EXP M&F	770.00	780.00	804.00	823.00	840.00	853.00	863.00	867.00	868.00	869.00	891.00	895.00		10,123.00		
	4																
3719	ADULT <40% EXP M&F	0.00	1.00	1.00	1.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00		9.00		
	6																
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00		10.00		
3728	ADULT <40% EXP M&F	1.00	1.00	1.00	1.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		13.00		
	4																
SUBTOTAL:	2,321.00	2,384.00	2,449.00	2,491.00	2,546.00	2,598.00	2,631.00	2,655.00	2,679.00	2,713.00	2,764.00	2,798.00		31,029.00		

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	
3908	NEWLY ELIGIBLE M&F
4	8.00	8.00	7.00	9.00	8.00	10.00	10.00	8.00	9.00	9.00	9.00	11.00	
3909	NEWLY ELIGIBLE M&F 6	7.00	7.00	6.00	6.00	8.00	10.00	10.00	11.00	11.00	10.00	10.00	11.00	
3914	NEWLY ELIGIBLE MALE	9.00	8.00	8.00	9.00	9.00	10.00	9.00	7.00	8.00	7.00	6.00	6.00	
3915	NEWLY ELIGIBLE FEMA L	19.00	20.00	22.00	20.00	19.00	21.00	21.00	20.00	19.00	20.00	21.00	20.00	
3916	NEWLY ELIGIBLE MALE	115.00	117.00	123.00	126.00	131.00	131.00	131.00	132.00	133.00	137.00	139.00	138.00	
3917	NEWLY ELIGIBLE FEMA L	187.00	197.00	200.00	204.00	200.00	194.00	189.00	192.00	193.00	187.00	188.00	191.00	
3918	NEWLY ELIGIBLE M&F
4	239.00	243.00	253.00	246.00	241.00	241.00	238.00	238.00	238.00	237.00	239.00	235.00	
3919	NEWLY ELIGIBLE M&F 6	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	1.00	
SUBTOTAL:	584.00	601.00	620.00	621.00	617.00	619.00	610.00	609.00	612.00	608.00	613.00	614.00	

7.00	
106.00	
107.00	
96.00	
242.00	
1,553.00	
2,322.00	
2,888.00	
7.00	
7,328.00	

4413	SOBRA 100-133% M&F
6	140.00	146.00	154.00	152.00	141.00	143.00	147.00	144.00	144.00	145.00	153.00	162.00	
4414	SOBRA 100-133% MALE	61.00	63.00	64.00	63.00	60.00	59.00	58.00	60.00	59.00	62.00	64.00	64.00	
4415	SOBRA 100-133% FEMA L	54.00	55.00	59.00	59.00	60.00	59.00	60.00	66.00	66.00	62.00	59.00	60.00	
SUBTOTAL:	255.00	264.00	277.00	274.00	261.00	261.00	265.00	270.00	269.00	269.00	276.00	286.00	

1,771.00	
737.00	
719.00	
3,227.00	

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

12.00

12.00

8700	SSI DISABLED FREEDO M	6.00	7.00	8.00	8.00	8.00	8.00	8.00	7.00	7.00	6.00	6.00	7.00	
8710	SSI DISABLED FREEDO
M	4.00	3.00	2.00	3.00	4.00	3.00	3.00	3.00	3.00	3.00	3.00	2.00	
8720	SSI DISABLED FREEDO M	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	
SUBTOTAL:	12.00	12.00	12.00	13.00	14.00	13.00	12.00	11.00	11.00	9.00	9.00	9.00	

86.00	
36.00	
15.00	
137.00	

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	1.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	

1.00

1.00

TOTAL:	10,977.00	11,173.00	11,406.00	11,528.00	11,598.00	11,741.00	11,748.00	11,816.00	11,912.00	11,912.00	12,092.00	12,197.00		140,100.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending June 30, 2022	
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	54.50	85.50	85.50	57.00	85.50	114.00	142.50		924.25		
1009	TANF 65+ M & F WITH	54.50	81.75	81.75	109.00	109.00	190.75	256.50	228.00	199.50	199.50	171.00	171.00		1,852.25		
1011	TANF <1 M & F NON-ME	1,962.00	2,071.00	2,207.25	2,125.50	2,016.50	1,907.50	1,966.50	2,109.00	2,565.00	2,736.00	2,565.00	2,593.50		26,824.75		
1012	TANF 01-05 M & F NON	4,142.00	3,951.25	3,733.25	4,223.75	4,496.25	4,905.00	5,329.50	5,073.00	5,044.50	4,959.00	4,930.50	4,788.00		55,576.00		
1013	TANF 06-13 M & F NON	5,804.25	5,967.75	6,158.50	6,948.75	7,630.00	8,120.50	8,749.50	9,034.50	8,407.50	8,350.50	8,436.00	8,493.00		92,100.75		
1014	TANF 14-20 MALE NON-	1,798.50	1,880.25	1,907.50	2,071.00	2,152.75	2,316.25	2,593.50	2,650.50	2,679.00	2,764.50	2,793.00	2,707.50		28,314.25		
1015	TANF 14-20 FEMALE N	3,106.50	3,433.50	3,488.00	3,787.75	3,815.00	4,060.25	4,588.50	4,332.00	4,360.50	4,474.50	4,645.50	4,731.00		48,823.00		
	O																
1016	TANF 21-44 MALE NON-	11,881.00	12,344.25	12,916.50	13,161.75	13,788.50	14,088.25	15,133.50	15,105.00	15,333.00	15,219.00	15,133.50	15,076.50		169,180.75		
1017	TANF 21-44 FEMALE N	49,322.50	49,731.25	50,276.25	52,211.00	53,628.00	54,527.25	59,052.00	59,878.50	60,705.00	61,531.50	62,301.00	63,241.50		676,405.75		
	O																
1018	TANF 45-64 M & F NON	18,121.25	18,884.25	19,320.25	19,783.50	20,246.75	20,819.00	22,486.50	23,028.00	23,341.50	23,512.50	23,769.00	24,054.00		257,366.50		
1019	TANF 65+ M & F NON-M	136.25	109.00	109.00	109.00	54.50	81.75	85.50	57.00	114.00	142.50	142.50	142.50		1,283.50		
1028	TANF 45-64 M & F WIT	54.50	54.50	54.50	54.50	54.50	54.50	28.50	28.50	28.50	57.00	57.00	57.00		583.50		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	27.25	27.25	28.50	28.50	28.50	28.50	28.50	28.50		225.50		
2100	SSI AGED WITH MEDIC	2,697.75	2,697.75	2,697.75	2,725.00	2,861.25	2,970.25	3,220.50	3,249.00	3,334.50	3,334.50	3,306.00	3,306.00		36,400.25		
	A																
2110	SSI AGED NON-MEDICA	1,226.25	1,171.75	1,226.25	1,199.00	1,280.75	1,280.75	1,339.50	1,254.00	1,339.50	1,339.50	1,396.50	1,510.50		15,564.25		
	R																
2120	SSI AGED WITH QMB	13,325.25	13,597.75	14,006.50	14,170.00	14,388.00	14,497.00	15,390.00	15,390.00	15,532.50	15,703.50	15,931.50	16,131.00		178,063.00		
2200	SSI DISABLED WITH M	6,921.50	7,003.25	7,003.25	6,976.00	7,166.75	7,030.50	7,467.00	7,524.00	7,581.00	7,666.50	7,837.50	7,923.00		88,100.25		
	E																
2210	SSI DISABLED NON-ME	34,553.00	34,934.50	35,152.50	35,452.25	35,670.25	35,670.25	37,164.00	37,192.50	37,249.50	37,278.00	37,078.50	36,993.00		434,388.25		
	D																
2220	SSI DISABLED WITH Q	16,431.75	16,568.00	16,513.50	16,595.25	16,758.75	16,949.50	17,812.50	17,784.00	18,069.00	18,126.00	18,154.50	18,183.00		207,945.75		
	M																
2300	SSI BLIND WITH MEDIC	27.25	27.25	27.25	27.25	27.25	27.25	28.50	28.50	28.50	28.50	28.50	28.50		334.50		
2310	SSI BLIND NON-MEDIC	626.75	654.00	681.25	681.25	708.50	708.50	741.00	741.00	741.00	741.00	769.50	769.50		8,563.25		
	A																
2320	SSI BLIND WITH QMB	272.50	272.50	299.75	327.00	327.00	327.00	342.00	342.00	342.00	313.50	313.50	313.50		3,792.25		
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		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	28.50	28.50	28.50	0.00	0.00	0.00		85.50		
4311	SOBRA CHILD <1 M & F	2,997.50	3,024.75	3,351.75	3,133.75	3,460.75	3,242.75	3,391.50	3,106.50	3,648.00	4,503.00	4,788.00	5,016.00		43,664.25		
4312	SOBRA CHILD 01-05 M	54,282.00	54,908.75	55,399.25	54,936.00	54,500.00	54,200.25	56,031.00	56,059.50	56,287.50	57,256.50	57,883.50	58,311.00		670,055.25		
4313	SOBRA CHILD 06-13 M	79,379.25	80,469.25	81,123.25	81,477.50	81,259.50	81,177.75	85,528.50	85,870.50	86,925.00	88,264.50	88,863.00	89,889.00		1,010,227.00		
4314	SOBRA CHILD 14-20 MA	20,873.50	21,745.50	21,936.25	22,372.25	22,672.00	22,781.00	23,826.00	24,225.00	24,595.50	24,624.00	25,279.50	25,849.50		280,780.00		
4315	SOBRA CHILD 14-20 FE	22,999.00	23,598.50	24,388.75	24,361.50	24,279.75	24,279.75	25,365.00	26,049.00	26,020.50	26,163.00	26,619.00	26,790.00		300,913.75		
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.50	28.50	0.00	0.00		57.00		
	M																
5013	SOBRA PREG 09-13 FE	27.25	27.25	27.25	27.25	54.50	54.50	28.50	28.50	28.50	28.50	28.50	28.50		389.00		
	M																
5015	SOBRA PREG 14-20 FE	654.00	626.75	599.50	763.00	872.00	763.00	798.00	684.00	627.00	513.00	570.00	627.00		8,097.25		
	M																
5017	SOBRA PREG 21-44 FE	4,823.25	5,368.25	6,131.25	5,777.00	5,777.00	5,640.75	5,757.00	5,985.00	5,928.00	5,244.00	5,187.00	5,215.50		66,834.00		
	M																
SUBTOTAL:	358,582.75	365,313.50	370,899.75	375,641.25	380,164.75	382,753.50	404,643.00	407,179.50	411,198.00	415,216.50	419,121.00	423,111.00		4,713,824.50		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1106	TANF EXPANDED 21-44	54.50	54.50	54.50	81.75	81.75	81.75	85.50	85.50	85.50	85.50	85.50	85.50		921.75		
1107	TANF EXPANDED 21-44	54.50	54.50	54.50	54.50	54.50	54.50	57.00	57.00	57.00	57.00	85.50	85.50		726.00		
1108	TANF EXPANDED 45-64	436.00	436.00	436.00	436.00	436.00	436.00	456.00	427.50	399.00	427.50	427.50	484.50		5,238.00		
1109	TANF EXPANDED 65+ M	545.00	545.00	545.00	572.25	599.50	626.75	712.50	741.00	712.50	684.00	741.00	769.50		7,794.00		
	&																
1114	TANF EXPANDED 14-20	27.25	27.25	54.50	54.50	54.50	54.50	85.50	85.50	57.00	28.50	57.00	57.00		643.00		
1115	TANF EXPANDED 14-20	299.75	245.25	272.50	272.50	245.25	299.75	342.00	342.00	285.00	313.50	285.00	285.00		3,487.50		
1116	TANF EXPANDED 21-44	6,649.00	6,703.50	6,785.25	6,567.25	6,458.25	6,049.50	6,156.00	6,270.00	6,241.50	6,384.00	6,441.00	6,526.50		77,231.75		
1117	TANF EXPANDED 21-44	23,653.00	23,980.00	23,653.00	23,080.75	22,644.75	22,535.75	22,885.50	22,942.50	22,714.50	23,541.00	23,598.00	23,569.50		278,798.25		
1118	TANF EXPANDED 45-64	12,453.25	12,862.00	13,243.50	13,134.50	13,216.25	13,107.25	13,537.50	13,566.00	13,537.50	13,765.50	13,851.00	13,936.50		160,210.75		
1119	TANF EXPANDED 65+ M	54.50	81.75	81.75	81.75	81.75	109.00	57.00	85.50	85.50	114.00	85.50	85.50		1,003.50		
	&																
1126	TANF EXPANDED 21-44	245.25	218.00	218.00	218.00	218.00	218.00	228.00	228.00	228.00	199.50	171.00	142.50		2,532.25		
1127	TANF EXPANDED 21-44	272.50	272.50	272.50	272.50	218.00	218.00	228.00	228.00	228.00	228.00	256.50	256.50		2,951.00		
1128	TANF EXPANDED 45-64	1,280.75	1,335.25	1,308.00	1,335.25	1,444.25	1,498.75	1,510.50	1,539.00	1,567.50	1,567.50	1,567.50	1,567.50		17,521.75		
1129	TANF EXPANDED 65+ M	1,335.25	1,471.50	1,526.00	1,553.25	1,526.00	1,607.75	1,710.00	1,738.50	1,624.50	1,539.00	1,710.00	1,681.50		19,023.25		
	&																
2400	SSI AGED EXPANDED	190.75	190.75	218.00	218.00	245.25	245.25	228.00	228.00	285.00	285.00	228.00	256.50		2,818.50		
	WI																
2410	SSI AGED EXPANDED N	190.75	190.75	163.50	190.75	163.50	163.50	171.00	171.00	199.50	199.50	199.50	199.50		2,202.75		
	O																
2420	SSI AGED EXPANDED	8,638.25	8,829.00	8,938.00	9,156.00	9,292.25	9,428.50	9,889.50	10,032.00	10,060.50	10,174.50	10,374.00	10,402.50		115,215.00		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	0.00	27.25	27.25	27.25	28.50	57.00	57.00	85.50	114.00	114.00		537.75		
	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	28.50		28.50		
	E																
2610	SSI DISABLED EXPAND	463.25	463.25	463.25	545.00	517.75	463.25	456.00	456.00	399.00	399.00	427.50	342.00		5,395.25		
	E																
2620	SSI DISABLED EXPAND	3,624.25	3,651.50	3,678.75	3,624.25	3,488.00	3,488.00	3,505.50	3,505.50	3,534.00	3,591.00	3,534.00	3,619.50		42,844.25		
	E																
SUBTOTAL:	60,467.75	61,612.25	61,966.50	61,476.00	61,012.75	60,713.00	62,329.50	62,785.50	62,358.00	63,669.00	64,239.00	64,495.50		747,124.75		

3508	ADULT 40-100% M&F 45	54.50	27.25	109.00	27.25	54.50	81.75	114.00	85.50	85.50	57.00	57.00	57.00	
3509	ADULT 40-100% M&F 65	81.75	54.50	81.75	81.75	81.75	81.75	85.50	114.00	114.00	114.00	114.00	114.00	
3514	ADULT 40-100% MALE 1	1,144.50	1,062.75	1,144.50	1,144.50	1,062.75	1,062.75	1,054.50	1,111.50	1,140.00	1,311.00	1,225.50	1,225.50	
3515	ADULT 40-100% FEMAL E	1,580.50	1,389.75	1,308.00	1,471.50	1,635.00	1,607.75	1,710.00	1,482.00	1,482.00	1,567.50	1,510.50	1,396.50	
3516	ADULT 40-100% MALE 2	4,550.75	4,687.00	4,632.50	4,687.00	4,687.00	4,687.00	4,959.00	4,845.00	4,731.00	4,845.00	4,930.50	5,073.00	
3517	ADULT 40-100% FEMAL E	4,060.25	4,223.75	4,523.50	4,441.75	4,360.00	4,332.75	4,645.50	4,930.50	5,101.50	5,443.50	5,329.50	5,244.00	
3518	ADULT 40-100% M&F 45	9,782.75	9,946.25	10,218.75	10,218.75	9,946.25	10,082.50	10,288.50	10,146.00	10,003.50	10,203.00	10,431.00	10,573.50	
3519	ADULT 40-100% M&F 65	27.25	27.25	27.25	27.25	27.25	27.25	28.50	57.00	0.00	28.50	28.50	28.50	
3706	ADULT <40% EXP MALE	54.50	54.50	54.50	54.50	54.50	54.50	57.00	57.00	57.00	57.00	57.00	57.00	
3708	ADULT <40% EXP M&F 4	218.00	218.00	299.75	299.75	272.50	272.50	228.00	256.50	285.00	256.50	285.00	256.50	
3709	ADULT <40% EXP M&F
6	27.25	27.25	27.25	54.50	81.75	81.75	57.00	85.50	114.00	57.00	57.00	142.50	
3714	ADULT <40% EXP MALE	4,905.00	4,932.25	5,313.75	5,368.25	5,368.25	5,504.50	5,871.00	5,842.50	5,956.50	5,985.00	6,184.50	6,070.50	
3715	ADULT <40% EXP FEMA L	5,940.50	6,213.00	6,540.00	6,649.00	6,240.25	6,403.75	6,783.00	6,868.50	7,011.00	7,182.00	7,296.00	7,467.00	

810.25	
1,118.75	
13,689.75	
18,141.00	
57,314.75	
56,636.50	
121,840.75	
334.50	
669.00	
3,148.00	
812.75	
67,302.00	
80,594.00	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	42,101.25	43,818.00	45,126.00	46,107.00	46,543.00	47,088.00	49,989.00	50,787.00	51,556.50	52,611.00	53,409.00	54,064.50		583,200.25		
3717	ADULT <40% EXP FEMA	22,726.50	23,080.75	24,170.75	24,988.25	25,860.25	26,841.25	28,614.00	29,155.50	30,267.00	30,780.00	31,378.50	32,233.50		330,096.25		
	L																
3718	ADULT <40% EXP M&F	48,859.25	50,031.00	50,903.00	51,802.25	53,110.25	53,818.75	57,142.50	58,282.50	59,479.50	59,935.50	60,534.00	60,819.00		664,717.50		
	4																
3719	ADULT <40% EXP M&F	27.25	54.50	54.50	81.75	81.75	81.75	85.50	114.00	85.50	57.00	85.50	85.50		894.50		
	6																
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	28.50		28.50		
	L																
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	57.00	57.00	57.00	57.00	57.00	57.00		342.00		
	4																
SUBTOTAL:	146,141.75	149,847.75	154,534.75	157,505.00	159,467.00	162,110.25	171,769.50	174,277.50	177,526.50	180,547.50	182,970.00	184,993.50		2,001,691.00		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	27.25	27.25	27.25	28.50	28.50	28.50	28.50	28.50	28.50	
3908	NEWLY ELIGIBLE M&F 4	408.75	436.00	545.00	545.00	545.00	545.00	570.00	769.50	741.00	769.50	741.00	855.00	
3909	NEWLY ELIGIBLE M&F
6	408.75	436.00	381.50	517.75	545.00	572.25	655.50	684.00	798.00	769.50	826.50	912.00	
3914	NEWLY ELIGIBLE MALE	844.75	872.00	763.00	681.25	763.00	899.25	883.50	798.00	798.00	855.00	883.50	912.00	
3915	NEWLY ELIGIBLE FEMA L	1,226.25	1,199.00	1,253.50	1,226.25	1,199.00	1,144.50	1,282.50	1,225.50	1,254.00	1,197.00	1,140.00	1,197.00	
3916	NEWLY ELIGIBLE MALE	5,450.00	5,640.75	5,722.50	5,749.75	5,804.25	5,831.50	6,327.00	6,526.50	6,498.00	6,498.00	6,270.00	6,241.50	
3917	NEWLY ELIGIBLE FEMA L	9,864.50	10,355.00	10,709.25	10,818.25	10,627.50	10,600.25	11,001.00	11,086.50	10,887.00	10,887.00	10,830.00	10,972.50	
3918	NEWLY ELIGIBLE M&F
4	10,709.25	11,172.50	11,417.75	11,472.25	11,717.50	11,635.75	12,141.00	11,970.00	11,656.50	11,656.50	11,628.00	11,428.50	
3919	NEWLY ELIGIBLE M&F 6	27.25	27.25	27.25	54.50	54.50	54.50	85.50	114.00	85.50	142.50	85.50	142.50	
3928	NEWLY ELIGIBLE M&F
4	27.25	27.25	27.25	27.25	27.25	27.25	28.50	28.50	28.50	28.50	28.50	28.50	
3929	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28.50	28.50	28.50	
SUBTOTAL:	28,966.75	30,165.75	30,847.00	31,119.50	31,310.25	31,337.50	33,003.00	33,231.00	32,775.00	32,860.50	32,490.00	32,746.50	

252.75	
7,470.75	
7,506.75	
9,953.25	
14,544.50	
72,559.75	
128,638.75	
138,605.50	
900.75	
334.50	
85.50	
380,852.75	

4413	SOBRA 100-133% M&F
6	6,376.50	6,512.75	6,594.50	6,730.75	6,540.00	6,485.50	6,469.50	6,412.50	6,270.00	6,270.00	6,555.00	6,469.50	
4414	SOBRA 100-133% MALE	1,934.75	1,989.25	2,234.50	2,452.50	2,616.00	2,479.75	2,479.50	2,422.50	2,565.00	2,622.00	2,679.00	2,764.50	
4415	SOBRA 100-133% FEMA L	2,370.75	2,425.25	2,261.75	2,180.00	2,152.75	2,234.50	2,080.50	2,109.00	2,052.00	2,223.00	2,223.00	2,280.00	
SUBTOTAL:	10,682.00	10,927.25	11,090.75	11,363.25	11,308.75	11,199.75	11,029.50	10,944.00	10,887.00	11,115.00	11,457.00	11,514.00	

77,686.50	
29,239.25	
26,592.50	
133,518.25	

306.00

306.00

8700	SSI DISABLED FREEDO M	218.00	190.75	190.75	190.75	190.75	218.00	228.00	228.00	199.50	199.50	171.00	171.00	
8710	SSI DISABLED FREEDO
M	81.75	109.00	136.25	136.25	136.25	109.00	57.00	57.00	57.00	57.00	85.50	57.00	
8720	SSI DISABLED FREEDO M	0.00	27.25	27.25	27.25	27.25	27.25	28.50	28.50	28.50	28.50	0.00	28.50	
SUBTOTAL:	299.75	327.00	354.25	354.25	354.25	354.25	313.50	313.50	285.00	285.00	256.50	256.50	

2,396.00	
1,079.00	
278.75	
3,753.75	

7,981,071.00

4518	BC PATIENT FEMALE 4 5	27.25	27.25	27.25	27.25	27.25	27.25	28.50	28.50	28.50	28.50	28.50	0.00	
SUBTOTAL:	27.25	27.25	27.25	27.25	27.25	27.25	28.50	28.50	28.50	28.50	28.50	0.00	

605,168.00	618,220.75	629,720.25	637,486.50	643,645.00	648,495.50	683,116.50	688,759.50	695,058.00	703,722.00	710,562.00	717,117.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending June 30, 2022	
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	2.00	3.00	3.00	2.00	3.00	4.00	5.00		33.00		
1009	TANF 65+ M & F WITH	2.00	3.00	3.00	4.00	4.00	7.00	9.00	8.00	7.00	7.00	6.00	6.00		66.00		
1011	TANF <1 M & F NON-ME	72.00	76.00	81.00	78.00	74.00	70.00	69.00	74.00	90.00	96.00	90.00	91.00		961.00		
1012	TANF 01-05 M & F NON	152.00	145.00	137.00	155.00	165.00	180.00	187.00	178.00	177.00	174.00	173.00	168.00		1,991.00		
1013	TANF 06-13 M & F NON	213.00	219.00	226.00	255.00	280.00	298.00	307.00	317.00	295.00	293.00	296.00	298.00		3,297.00		
1014	TANF 14-20 MALE NON-	66.00	69.00	70.00	76.00	79.00	85.00	91.00	93.00	94.00	97.00	98.00	95.00		1,013.00		
1015	TANF 14-20 FEMALE N	114.00	126.00	128.00	139.00	140.00	149.00	161.00	152.00	153.00	157.00	163.00	166.00		1,748.00		
	O																
1016	TANF 21-44 MALE NON-	436.00	453.00	474.00	483.00	506.00	517.00	531.00	530.00	538.00	534.00	531.00	529.00		6,062.00		
1017	TANF 21-44 FEMALE N	1,810.00	1,825.00	1,845.00	1,916.00	1,968.00	2,001.00	2,072.00	2,101.00	2,130.00	2,159.00	2,186.00	2,219.00		24,232.00		
	O																
1018	TANF 45-64 M & F NON	665.00	693.00	709.00	726.00	743.00	764.00	789.00	808.00	819.00	825.00	834.00	844.00		9,219.00		
1019	TANF 65+ M & F NON-M	5.00	4.00	4.00	4.00	2.00	3.00	3.00	2.00	4.00	5.00	5.00	5.00		46.00		
1028	TANF 45-64 M & F WIT	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00	2.00	2.00	2.00		21.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		8.00		
2100	SSI AGED WITH MEDIC	99.00	99.00	99.00	100.00	105.00	109.00	113.00	114.00	117.00	117.00	116.00	116.00		1,304.00		
	A																
2110	SSI AGED NON-MEDICA	45.00	43.00	45.00	44.00	47.00	47.00	47.00	44.00	47.00	47.00	49.00	53.00		558.00		
	R																
2120	SSI AGED WITH QMB	489.00	499.00	514.00	520.00	528.00	532.00	540.00	540.00	545.00	551.00	559.00	566.00		6,383.00		
2200	SSI DISABLED WITH M	254.00	257.00	257.00	256.00	263.00	258.00	262.00	264.00	266.00	269.00	275.00	278.00		3,159.00		
	E																
2210	SSI DISABLED NON-ME	1,268.00	1,282.00	1,290.00	1,301.00	1,309.00	1,309.00	1,304.00	1,305.00	1,307.00	1,308.00	1,301.00	1,298.00		15,582.00		
	D																
2220	SSI DISABLED WITH Q	603.00	608.00	606.00	609.00	615.00	622.00	625.00	624.00	634.00	636.00	637.00	638.00		7,457.00		
	M																
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		12.00		
2310	SSI BLIND NON-MEDIC	23.00	24.00	25.00	25.00	26.00	26.00	26.00	26.00	26.00	26.00	27.00	27.00		307.00		
	A																
2320	SSI BLIND WITH QMB	10.00	10.00	11.00	12.00	12.00	12.00	12.00	12.00	12.00	11.00	11.00	11.00		136.00		
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		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00		3.00		
4311	SOBRA CHILD <1 M & F	110.00	111.00	123.00	115.00	127.00	119.00	119.00	109.00	128.00	158.00	168.00	176.00		1,563.00		
4312	SOBRA CHILD 01-05 M	1,992.00	2,015.00	2,033.00	2,016.00	2,000.00	1,989.00	1,966.00	1,967.00	1,975.00	2,009.00	2,031.00	2,046.00		24,039.00		
4313	SOBRA CHILD 06-13 M	2,913.00	2,953.00	2,977.00	2,990.00	2,982.00	2,979.00	3,001.00	3,013.00	3,050.00	3,097.00	3,118.00	3,154.00		36,227.00		
4314	SOBRA CHILD 14-20 MA	766.00	798.00	805.00	821.00	832.00	836.00	836.00	850.00	863.00	864.00	887.00	907.00		10,065.00		
4315	SOBRA CHILD 14-20 FE	844.00	866.00	895.00	894.00	891.00	891.00	890.00	914.00	913.00	918.00	934.00	940.00		10,790.00		
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00		2.00		
	M																
5013	SOBRA PREG 09-13 FE	1.00	1.00	1.00	1.00	2.00	2.00	1.00	1.00	1.00	1.00	1.00	1.00		14.00		
	M																
5015	SOBRA PREG 14-20 FE	24.00	23.00	22.00	28.00	32.00	28.00	28.00	24.00	22.00	18.00	20.00	22.00		291.00		
	M																
5017	SOBRA PREG 21-44 FE	177.00	197.00	225.00	212.00	212.00	207.00	202.00	210.00	208.00	184.00	182.00	183.00		2,399.00		
	M																
SUBTOTAL:	13,159.00	13,406.00	13,611.00	13,785.00	13,951.00	14,046.00	14,198.00	14,287.00	14,428.00	14,569.00	14,706.00	14,846.00		168,992.00		

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1106	TANF EXPANDED 21-44	2.00	2.00	2.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00		33.00		
1107	TANF EXPANDED 21-44	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	3.00	3.00		26.00		
1108	TANF EXPANDED 45-64	16.00	16.00	16.00	16.00	16.00	16.00	16.00	15.00	14.00	15.00	15.00	17.00		188.00		
1109	TANF EXPANDED 65+ M	20.00	20.00	20.00	21.00	22.00	23.00	25.00	26.00	25.00	24.00	26.00	27.00		279.00		
	&																
1114	TANF EXPANDED 14-20	1.00	1.00	2.00	2.00	2.00	2.00	3.00	3.00	2.00	1.00	2.00	2.00		23.00		
1115	TANF EXPANDED 14-20	11.00	9.00	10.00	10.00	9.00	11.00	12.00	12.00	10.00	11.00	10.00	10.00		125.00		
1116	TANF EXPANDED 21-44	244.00	246.00	249.00	241.00	237.00	222.00	216.00	220.00	219.00	224.00	226.00	229.00		2,773.00		
1117	TANF EXPANDED 21-44	868.00	880.00	868.00	847.00	831.00	827.00	803.00	805.00	797.00	826.00	828.00	827.00		10,007.00		
1118	TANF EXPANDED 45-64	457.00	472.00	486.00	482.00	485.00	481.00	475.00	476.00	475.00	483.00	486.00	489.00		5,747.00		
1119	TANF EXPANDED 65+ M	2.00	3.00	3.00	3.00	3.00	4.00	2.00	3.00	3.00	4.00	3.00	3.00		36.00		
	&																
1126	TANF EXPANDED 21-44	9.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00	7.00	6.00	5.00		91.00		
1127	TANF EXPANDED 21-44	10.00	10.00	10.00	10.00	8.00	8.00	8.00	8.00	8.00	8.00	9.00	9.00		106.00		
1128	TANF EXPANDED 45-64	47.00	49.00	48.00	49.00	53.00	55.00	53.00	54.00	55.00	55.00	55.00	55.00		628.00		
1129	TANF EXPANDED 65+ M	49.00	54.00	56.00	57.00	56.00	59.00	60.00	61.00	57.00	54.00	60.00	59.00		682.00		
	&																
2400	SSI AGED EXPANDED	7.00	7.00	8.00	8.00	9.00	9.00	8.00	8.00	10.00	10.00	8.00	9.00		101.00		
	WI																
2410	SSI AGED EXPANDED N	7.00	7.00	6.00	7.00	6.00	6.00	6.00	6.00	7.00	7.00	7.00	7.00		79.00		
	O																
2420	SSI AGED EXPANDED	317.00	324.00	328.00	336.00	341.00	346.00	347.00	352.00	353.00	357.00	364.00	365.00		4,130.00		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	1.00	1.00	1.00	2.00	2.00	3.00	4.00	4.00		19.00		
	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	1.00		1.00		
	E																
2610	SSI DISABLED EXPAND	17.00	17.00	17.00	20.00	19.00	17.00	16.00	16.00	14.00	14.00	15.00	12.00		194.00		
	E																
2620	SSI DISABLED EXPAND	133.00	134.00	135.00	133.00	128.00	128.00	123.00	123.00	124.00	126.00	124.00	127.00		1,538.00		
	E																
SUBTOTAL:	2,219.00	2,261.00	2,274.00	2,256.00	2,239.00	2,228.00	2,187.00	2,203.00	2,188.00	2,234.00	2,254.00	2,263.00		26,806.00		

3508	ADULT 40-100% M&F 45	2.00	1.00	4.00	1.00	2.00	3.00	4.00	3.00	3.00	2.00	2.00	2.00	
3509	ADULT 40-100% M&F 65	3.00	2.00	3.00	3.00	3.00	3.00	3.00	4.00	4.00	4.00	4.00	4.00	
3514	ADULT 40-100% MALE 1	42.00	39.00	42.00	42.00	39.00	39.00	37.00	39.00	40.00	46.00	43.00	43.00	
3515	ADULT 40-100% FEMAL E	58.00	51.00	48.00	54.00	60.00	59.00	60.00	52.00	52.00	55.00	53.00	49.00	
3516	ADULT 40-100% MALE 2	167.00	172.00	170.00	172.00	172.00	172.00	174.00	170.00	166.00	170.00	173.00	178.00	
3517	ADULT 40-100% FEMAL E	149.00	155.00	166.00	163.00	160.00	159.00	163.00	173.00	179.00	191.00	187.00	184.00	
3518	ADULT 40-100% M&F 45	359.00	365.00	375.00	375.00	365.00	370.00	361.00	356.00	351.00	358.00	366.00	371.00	
3519	ADULT 40-100% M&F 65	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	0.00	1.00	1.00	1.00	
3706	ADULT <40% EXP MALE	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	
3708	ADULT <40% EXP M&F 4	8.00	8.00	11.00	11.00	10.00	10.00	8.00	9.00	10.00	9.00	10.00	9.00	
3709	ADULT <40% EXP M&F
6	1.00	1.00	1.00	2.00	3.00	3.00	2.00	3.00	4.00	2.00	2.00	5.00	
3714	ADULT <40% EXP MALE	180.00	181.00	195.00	197.00	197.00	202.00	206.00	205.00	209.00	210.00	217.00	213.00	
3715	ADULT <40% EXP FEMA L	218.00	228.00	240.00	244.00	229.00	235.00	238.00	241.00	246.00	252.00	256.00	262.00	

29.00	
40.00	
491.00	
651.00	
2,056.00	
2,029.00	
4,372.00	
12.00	
24.00	
113.00	
29.00	
2,412.00	
2,889.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	1,545.00	1,608.00	1,656.00	1,692.00	1,708.00	1,728.00	1,754.00	1,782.00	1,809.00	1,846.00	1,874.00	1,897.00		20,899.00		
3717	ADULT <40% EXP FEMA	834.00	847.00	887.00	917.00	949.00	985.00	1,004.00	1,023.00	1,062.00	1,080.00	1,101.00	1,131.00		11,820.00		
	L																
3718	ADULT <40% EXP M&F	1,793.00	1,836.00	1,868.00	1,901.00	1,949.00	1,975.00	2,005.00	2,045.00	2,087.00	2,103.00	2,124.00	2,134.00		23,820.00		
	4																
3719	ADULT <40% EXP M&F	1.00	2.00	2.00	3.00	3.00	3.00	3.00	4.00	3.00	2.00	3.00	3.00		32.00		
	6																
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	1.00		1.00		
	L																
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	2.00	2.00	2.00	2.00	2.00	2.00		12.00		
	4																
SUBTOTAL:	5,363.00	5,499.00	5,671.00	5,780.00	5,852.00	5,949.00	6,027.00	6,115.00	6,229.00	6,335.00	6,420.00	6,491.00		71,731.00		

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	
3908	NEWLY ELIGIBLE M&F 4	15.00	16.00	20.00	20.00	20.00	20.00	20.00	27.00	26.00	27.00	26.00	30.00	
3909	NEWLY ELIGIBLE M&F
6	15.00	16.00	14.00	19.00	20.00	21.00	23.00	24.00	28.00	27.00	29.00	32.00	
3914	NEWLY ELIGIBLE MALE	31.00	32.00	28.00	25.00	28.00	33.00	31.00	28.00	28.00	30.00	31.00	32.00	
3915	NEWLY ELIGIBLE FEMA L	45.00	44.00	46.00	45.00	44.00	42.00	45.00	43.00	44.00	42.00	40.00	42.00	
3916	NEWLY ELIGIBLE MALE	200.00	207.00	210.00	211.00	213.00	214.00	222.00	229.00	228.00	228.00	220.00	219.00	
3917	NEWLY ELIGIBLE FEMA L	362.00	380.00	393.00	397.00	390.00	389.00	386.00	389.00	382.00	382.00	380.00	385.00	
3918	NEWLY ELIGIBLE M&F
4	393.00	410.00	419.00	421.00	430.00	427.00	426.00	420.00	409.00	409.00	408.00	401.00	
3919	NEWLY ELIGIBLE M&F 6	1.00	1.00	1.00	2.00	2.00	2.00	3.00	4.00	3.00	5.00	3.00	5.00	
3928	NEWLY ELIGIBLE M&F
4	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	
3929	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	1.00	
SUBTOTAL:	1,063.00	1,107.00	1,132.00	1,142.00	1,149.00	1,150.00	1,158.00	1,166.00	1,150.00	1,153.00	1,140.00	1,149.00	

9.00	
267.00	
268.00	
357.00	
522.00	
2,601.00	
4,615.00	
4,973.00	
32.00	
12.00	
3.00	
13,659.00	

4413	SOBRA 100-133% M&F
6	234.00	239.00	242.00	247.00	240.00	238.00	227.00	225.00	220.00	220.00	230.00	227.00	
4414	SOBRA 100-133% MALE	71.00	73.00	82.00	90.00	96.00	91.00	87.00	85.00	90.00	92.00	94.00	97.00	
4415	SOBRA 100-133% FEMA L	87.00	89.00	83.00	80.00	79.00	82.00	73.00	74.00	72.00	78.00	78.00	80.00	
SUBTOTAL:	392.00	401.00	407.00	417.00	415.00	411.00	387.00	384.00	382.00	390.00	402.00	404.00	

2,789.00	
1,048.00	
955.00	
4,792.00	

11.00

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

11.00

8700	SSI DISABLED FREEDO M	8.00	7.00	7.00	7.00	7.00	8.00	8.00	8.00	7.00	7.00	6.00	6.00	
8710	SSI DISABLED FREEDO
M	3.00	4.00	5.00	5.00	5.00	4.00	2.00	2.00	2.00	2.00	3.00	2.00	
8720	SSI DISABLED FREEDO M	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	1.00	
SUBTOTAL:	11.00	12.00	13.00	13.00	13.00	13.00	11.00	11.00	10.00	10.00	9.00	9.00	

86.00	
39.00	
10.00	
135.00	

TOTAL:	22,208.00	22,687.00	23,109.00	23,394.00	23,620.00	23,798.00	23,969.00	24,167.00	24,388.00	24,692.00	24,932.00	25,162.00		286,126.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending June 30, 2022	
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	3,694,396.00	3,741,891.06	3,727,457.88	3,746,637.22	3,777,183.95	3,793,296.46	3,856,732.41		44,384,560.24		
101Z	TANF ALTCS NON-MEDI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,023.13	6.74		5,029.87		
	C																
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	38,259,349.74	38,085,595.06	37,752,520.44	37,556,749.75	38,072,122.00	38,068,182.36	38,313,037.87		445,476,786.46		
	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	2,061,578.67	1,948,140.38	1,513,441.94	2,151,186.83	2,199,098.45	1,982,401.79	1,847,030.01		22,290,404.94		
	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	4,129,235.57	4,102,901.38	4,082,706.84	4,144,496.18	3,947,184.14	4,014,946.10	4,061,661.34		48,289,742.87		
	R																
211Z	SSI AGED NON-MEDICA	38,321.33	176,069.53	206,795.82	34,577.05	30,172.32	75,865.00	47,908.15	89,839.70	70,882.61	85,724.67	108,730.60	24,391.23		989,278.01		
	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	31,975,016.20	32,045,981.27	32,294,208.14	32,130,845.52	32,136,966.97	32,381,270.77	32,498,026.86		377,004,581.25		
212Z	SSI AGED WITH QMB P	38,684.17	36,279.73	88,506.41	93,118.91	55,521.09	45,863.14	57,679.90	48,736.11	77,015.91	29,626.03	48,164.99	47,559.29		666,755.68		
	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	19,229,431.63	19,234,892.16	18,677,652.05	18,680,317.40	18,744,988.22	18,819,646.43	19,024,253.79		224,503,612.30		
	E																
220Z	SSI DISABLED WITH M	198,326.27	167,396.77	129,934.00	188,619.07	245,045.00	130,651.52	173,007.95	188,611.51	231,298.18	158,397.33	186,406.85	173,189.17		2,170,883.62		
	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	190,110,868.20	191,128,097.91	191,359,093.41	192,288,516.65	193,247,587.79	194,091,685.20	196,361,692.32		2,277,468,142.87		
	D																
221Z	SSI DISABLED NON-ME	240,975.38	219,514.90	211,929.19	111,215.27	258,997.95	253,884.08	176,194.48	225,117.88	200,197.38	321,965.38	141,942.67	138,190.11		2,500,124.67		
	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	38,339,856.39	38,682,164.49	38,820,845.10	38,820,344.80	38,971,569.66	39,004,424.16	39,264,548.09		460,876,045.34		
	M																
222Z	SSI DISABLED WITH Q	9,979.18	995.74	8,005.85	7,703.47	8,159.63	11,658.76	9,307.82	6,749.38	6,110.97	8,764.02	15,781.35	17,390.79		110,606.96		
	M																
2300	SSI BLIND WITH MEDIC	25,162.19	39,639.50	64,488.62	69,433.44	80,929.89	86,300.40	173,520.82	198,696.95	203,115.55	202,396.87	197,697.92	192,392.50		1,533,774.65		
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	1.21		5,644.77		
2310	SSI BLIND NON-MEDIC	159,832.92	197,516.88	234,946.75	317,507.07	348,185.71	378,423.06	415,103.65	1,167,968.71	1,162,887.32	1,171,109.45	1,161,961.74	1,157,797.69		7,873,240.95		
	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	163,784.78	263,733.37	481,938.43	492,506.82	499,391.33	488,483.00	497,760.60		3,461,670.39		
SUBTOTAL:	310,908,213.77	312,173,691.39	312,301,519.73	328,107,070.41	328,752,523.88	328,946,163.14	330,286,119.85	330,635,584.47	331,963,109.09	333,574,076.26	334,510,045.52	337,475,662.02		3,919,633,779.53		

8700	SSI DISABLED FREEDO M	251,617.80	254,909.36	251,416.34	281,598.86	267,474.43	267,474.43	274,352.78	277,885.70	279,502.96	274,110.82	264,558.38	264,260.02	
870Z	SSI DISABLED FREEDO
M	7,216.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,505.61	0.00	1.70	
8710	SSI DISABLED FREEDO M	257,484.42	258,755.65	258,755.65	276,603.06	276,624.10	276,624.10	277,001.06	268,672.46	258,990.86	263,385.85	260,748.86	267,518.19	
871Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,477.96	0.00	0.00	28.47	
8720	SSI DISABLED FREEDO M	110,455.08	110,455.08	110,455.08	114,889.60	114,889.60	114,889.60	115,643.52	115,643.52	121,061.15	121,103.96	126,521.59	121,544.05	
SUBTOTAL:	626,773.41	624,120.09	620,627.07	673,091.52	658,988.13	658,988.13	666,997.36	662,201.68	673,032.93	662,106.24	651,828.83	653,352.43	

3,209,161.88	
10,723.42	
3,201,164.26	
13,506.43	
1,397,551.83	
7,832,107.82	

3,927,465,887.35

311,534,987.18	312,797,811.48	312,922,146.80	328,780,161.93	329,411,512.01	329,605,151.27	330,953,117.21	331,297,786.15	332,636,142.02	334,236,182.50	335,161,874.35	338,129,014.45	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending June 30, 2022	
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	682.40	685.35	682.67	686.55	691.54	694.64	703.56		8,185.13		
101Z	TANF ALTCS NON-MEDI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.64	0.00		0.64		
	C																
2100	SSI AGED WITH MEDIC	9,997.53	10,030.92	10,007.76	10,003.60	10,055.51	9,970.39	9,921.12	9,824.07	9,762.97	9,888.62	9,898.46	9,912.90		119,273.85		
	A																
210Z	SSI AGED WITH MEDIC	460.84	483.79	442.16	512.90	475.65	520.68	486.35	379.08	533.39	551.22	498.99	453.10		5,798.15		
	A																
2110	SSI AGED NON-MEDICA	496.50	506.10	501.65	494.14	492.10	497.13	494.38	492.34	502.25	479.47	484.96	480.20		5,921.22		
	R																
211Z	SSI AGED NON-MEDICA	5.24	23.69	27.08	4.17	3.40	9.67	5.21	11.26	8.04	9.69	13.35	3.26		124.06		
	R																
2120	SSI AGED WITH QMB	8,810.57	8,835.11	8,735.99	8,746.88	8,714.99	8,635.05	8,637.46	8,702.06	8,641.35	8,633.30	8,688.66	8,677.79		104,459.21		
212Z	SSI AGED WITH QMB P	11.92	9.74	24.26	25.48	14.40	11.26	13.89	12.05	18.67	7.17	11.80	12.50		173.14		
	P																
2200	SSI DISABLED WITH M	4,130.72	4,133.33	4,172.15	4,184.12	4,191.15	4,186.07	4,162.34	4,029.58	4,032.21	4,041.56	4,059.16	4,089.52		49,411.91		
	E																
220Z	SSI DISABLED WITH M	54.61	48.77	38.05	51.58	64.23	32.44	43.87	48.62	56.68	38.68	46.02	43.49		567.04		
	E																
2210	SSI DISABLED NON-ME	32,814.59	32,928.94	32,990.18	33,086.50	33,190.64	33,329.88	33,278.70	33,310.09	33,480.57	33,639.29	33,778.20	33,987.29		399,814.87		
	D																
221Z	SSI DISABLED NON-ME	29.71	28.33	27.06	13.55	30.95	28.35	21.80	26.08	24.21	37.20	16.03	15.70		298.97		
	D																
2220	SSI DISABLED WITH Q	8,067.13	8,065.26	8,060.21	8,030.02	8,021.69	7,951.24	7,977.07	7,993.25	7,996.80	8,034.03	8,036.57	8,068.25		96,301.52		
	M																
222Z	SSI DISABLED WITH Q	2.57	0.25	2.15	2.31	1.91	2.99	2.17	1.54	1.38	2.49	3.70	3.93		27.39		
	M																
2300	SSI BLIND WITH MEDIC	5.00	8.00	13.00	13.61	16.00	17.00	35.00	40.00	41.00	41.06	40.00	39.29		308.96		
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	62.00	67.00	200.81	201.01	202.99	202.06	200.32		1,345.45		
	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	34.26	57.00	98.00	100.44	102.00	99.83	101.36		718.61		
SUBTOTAL:	65,594.32	65,821.62	65,780.43	65,935.74	66,037.89	65,970.81	65,888.71	65,851.50	66,087.52	66,400.31	66,573.07	66,792.46		792,734.38		

8700	SSI DISABLED FREEDO M	56.16	57.00	56.00	58.99	56.00	56.00	57.00	57.98	59.00	58.00	56.29	56.00	
870Z	SSI DISABLED FREEDO
M	1.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	35.00	35.00	35.00	35.00	35.00	35.00	35.00	34.00	32.51	33.00	32.70	33.00	
871Z	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.48	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO M	24.00	24.00	24.00	24.00	24.00	24.00	24.00	24.00	25.00	25.00	26.00	25.00	
SUBTOTAL:	116.99	116.00	115.00	117.99	115.00	115.00	116.00	115.98	117.99	117.00	114.99	114.00	

684.42	
2.83	
410.21	
1.48	
293.00	
1,391.94	

TOTAL:	65,711.31	65,937.62	65,895.43	66,053.73	66,152.89	66,085.81	66,004.71	65,967.48	66,205.51	66,517.31	66,688.06	66,906.46		794,126.32		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending June 30, 2022	
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	-105.52	-47.60	-131.17	-64.19	0.00	-173.61	-925.02		-1,189.11		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	-57.78	-7.81	0.00	-40.08	0.00	-195.23	0.00	-316.87	-329.74		-947.51		
1013	TANF 06-13 M & F NON	0.00	122.25	0.00	-703.51	0.00	0.00	0.00	0.00	-279.49	0.00	-9.96	0.00		-870.71		
1014	TANF 14-20 MALE NON-	0.00	-136.32	-337.02	0.00	0.00	0.00	0.00	0.00	-1,102.49	0.00	-85.35	0.00		-1,661.18		
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	-50.94	0.00	-752.82		-1,252.11		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-82.64		-82.64		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-442.04		-442.04		
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	-1,068.20	-304.47	-7.04	0.00	0.00	0.00	-322.42		-1,537.16		
4312	SOBRA CHILD 01-05 M	0.00	-169.15	0.00	0.00	0.00	0.00	0.00	-14.08	-203.77	-1,973.96	0.00	453.15		-1,907.81		
4313	SOBRA CHILD 06-13 M	0.00	-1,119.97	0.00	0.00	-9.96	-8.36	0.00	-1,370.70	-915.86	915.86	-1,457.25	-915.86		-4,882.10		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	-3.32	0.00	0.00	0.00	-427.50	-928.28	0.00	0.00		-1,359.10		
4315	SOBRA CHILD 14-20 FE	0.00	-154.30	0.00	0.00	0.00	0.00	0.00	-14.92	-1,450.21	-374.29	0.00	-439.92		-2,433.64		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1.09		-1.09		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	-12.90	0.00	0.00	-25.51	0.00	1.84		-36.57		
SUBTOTAL:	0.00	-1,457.49	-785.37	-818.86	410.14	-1,182.08	-405.05	-1,537.91	-4,638.74	-2,437.12	-2,043.04	-3,756.56		-18,652.08		

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	

-21,381.12

0.00	-4,177.01	-794.89	-818.86	410.14	-1,182.08	-405.05	-1,537.91	-4,638.74	-2,437.12	-2,043.04	-3,756.56	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending June 30, 2022

431B

SOBRA CHILD 01-05 M

Current and

0.00

0.00

0.00

prior m

0.00

0.00

onth

0.00

data is

0.00

0.00

under re

0.00

0.00

visio

0.00

n.

0.00

SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

101A	TANF 14-20 FEMALE N O
TANF < 1 M & F NON-M	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
101C	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

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	

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 June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
100H	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,255.05	0.00	0.00	0.00		1,255.05		
1010	TANF NON-MEDICARE	42,483.72	42,483.72	44,124.79	41,693.28	58,874.70	47,154.50	50,392.22	48,773.36	48,773.36	53,715.80	56,309.56	53,715.80		588,494.81		
1014	TANF 14-20 MALE NON-	0.00	0.00	345.64	0.00	0.00	0.00	0.00	353.03	0.00	0.00	510.24	0.00		1,208.91		
1015	TANF 14-20 FEMALE N	896.57	155.44	2,581.18	1,338.71	-332.35	167.34	52.22	0.00	2,844.77	-2,091.74	0.00	5,619.81		11,231.95		
	O																
1016	TANF 21-44 MALE NON-	0.00	0.00	2,344.25	920.36	2,334.38	2,008.07	0.00	0.00	0.00	0.00	0.00	53.96		7,661.02		
1017	TANF 21-44 FEMALE N	3,202.28	52.94	0.00	3,288.86	-1,729.18	1,023.07	3,479.20	-2,717.37	4,652.06	16,738.38	0.00	7,015.18		35,005.42		
	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	3,089.80	-1,729.17	0.00	0.00		2,364.67		
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		
2110	SSI AGED NON-MEDICA	0.00	0.00	0.00	0.00	0.00	340.26	0.00	-86.46	0.00	0.00	0.00	0.00		253.80		
	R																
211Z	SSI AGED NON-MEDICA	0.00	0.00	0.00	0.00	690.88	0.00	0.00	0.00	2,391.51	0.00	0.00	0.00		3,082.39		
	R																
2120	SSI AGED WITH QMB	3,247.31	138.46	1,641.07	1,618.86	1,618.86	1,618.86	1,618.86	1,618.86	1,618.86	1,618.86	1,618.86	1,618.86		19,596.58		
2200	SSI DISABLED WITH M	7,411.05	4,818.72	4,818.72	7,536.20	7,536.20	10,129.96	11,552.34	10,129.96	10,129.96	11,777.44	9,183.68	9,183.68		104,207.91		
	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	2,507.30	0.00	53.96		9,041.51		
	E																
2210	SSI DISABLED NON-ME	185,919.85	186,666.30	184,757.12	209,485.01	215,254.44	182,704.47	186,956.79	189,907.93	191,312.78	193,272.94	198,290.65	204,713.43		2,329,241.71		
	D																
221Z	SSI DISABLED NON-ME	3,652.70	0.00	52.94	3,303.85	-53.96	0.00	1,469.80	982.88	334.54	1,536.69	4,685.50	1,241.13		17,206.07		
	D																
2220	SSI DISABLED WITH Q	80,064.56	90,631.31	85,303.74	89,428.04	85,925.13	83,233.28	84,822.21	79,230.76	71,293.13	79,065.15	87,388.87	82,229.24		998,615.42		
	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	83.67	2,075.01		2,715.57		
	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	4,212.62	4,212.62	4,212.62	4,212.62	2,593.76	0.00	0.00		45,045.18		
	DI																
4314	SOBRA CHILD 14-20 MA	0.00	836.24	345.64	0.00	161.89	2,593.76	0.00	0.00	0.00	-5,187.52	0.00	0.00		-1,249.99		
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		
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	384.41	0.00	0.00		384.41		
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																
5010	SOBRA PREGNANT WO	0.00	0.00	0.00	0.00	0.00	1,647.48	1,647.48	1,647.48	1,647.48	1,647.48	1,647.48	1,647.48		11,532.36		
	MAN																
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	1,723.30	0.00	0.00	0.00	0.00	836.70	0.00	0.00	0.00		2,560.00		
	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	2,680.22	0.00	0.00		2,784.66		
	M																
SUBTOTAL:	349,006.13	332,398.73	334,819.23	372,558.94	376,568.62	336,833.67	346,203.74	334,053.05	344,392.62	358,530.00	359,718.51	369,167.54		4,214,250.78		

1100	TANF EXPANDED FPR FI	2,592.33	2,592.33	2,592.33	2,593.76	2,593.76	2,593.76	2,593.76	2,593.76	2,593.76	2,593.76	2,593.76	2,593.76	
110G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	1,586.37	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	20,903.88	16,662.64	19,256.40	21,850.16	22,796.44	17,608.92	17,608.92	

31,120.83	
1,586.37	
261,972.38	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	463.17	0.00	0.00	0.00	0.00		463.17		
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		2,843.48		
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		-1,923.34		
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		83.67		
111H	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,208.15		1,208.15		
1120	TANF EXPANDED FOR	4,888.38	6,529.45	6,529.45	6,504.06	6,504.06	6,504.06	9,097.82	6,504.06	6,504.06	6,504.06	6,504.06	6,532.68		79,106.20		
	FI																
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,726.78	0.00	0.00		-1,726.78		
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		2,319.95		
240Z	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	10,708.29	0.00	0.00	0.00	0.00	0.00		10,708.29		
	WI																
2420	SSI AGED EXPANDED	6,790.90	6,790.90	6,790.90	6,835.00	6,835.00	6,835.00	6,835.00	6,835.00	6,835.00	9,905.68	6,835.00	8,138.27		86,261.65		
	WI																
2600	SSI DISABLED EXPAND	2,592.33	2,592.33	2,592.33	2,593.76	2,593.76	2,593.76	2,593.76	2,593.76	4,212.62	2,593.76	4,212.62	2,593.76		34,358.55		
	E																
260Z	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	864.59	0.00	668.99	0.00	0.00	0.00	0.00	1,210.42		2,744.00		
	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	26,005.54	28,599.30	28,599.30	32,866.46	30,218.16	32,811.92	34,430.78		344,551.10		
	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	6,275.23	0.00		6,798.02		
	E																
SUBTOTAL:	61,954.00	68,528.86	64,989.34	75,910.24	82,658.57	67,022.37	77,759.56	66,845.45	74,862.06	72,885.08	76,841.51	74,316.74		864,573.78		

3510	ADULT 40-100% FOR FI	28,909.16	30,515.40	27,923.07	32,139.34	40,564.58	29,545.58	30,491.86	30,491.86	33,085.62	37,298.24	39,892.00	43,186.96	
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	5,605.86	1,087.71	0.00	0.00	2,334.38	4,145.28	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	92.63	1,757.31	0.00	1,689.46	
3518	ADULT 40-100% M&F 45	0.00	0.00	4,430.89	669.36	0.00	418.35	0.00	5,187.52	3,394.38	0.00	2,161.47	951.05	
351F	ADULT 40-100% MALE 2	0.00	83.62	0.00	167.34	0.00	0.00	83.67	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	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	0.00	0.00	0.00	2,593.76	2,593.76	2,593.76	2,593.76	2,593.76	2,593.76	
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	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	2,008.07	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	268,960.10	286,198.76	288,792.52	293,005.14	314,068.24	322,522.10	316,028.74	
3714	ADULT <40% EXP MALE	0.00	0.00	9,182.93	1,506.05	2,504.51	0.00	0.00	411.87	0.00	0.00	5,955.80	0.00	
3715	ADULT <40% EXP FEMA L	0.00	1,554.43	0.00	920.37	0.00	3,073.47	0.00	0.00	4,183.49	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	2,931.73	186.26	-11,089.35	2,442.07	12,831.69	14,384.07	16,212.34	
3717	ADULT <40% EXP FEMA L	-250.87	4,771.79	3,588.47	17,251.00	9,662.26	0.00	2,928.44	7,648.65	20,032.92	2,944.11	3,744.36	6,594.75	
3718	ADULT <40% EXP M&F
4	-1,003.48	9,699.48	11,814.16	18,910.94	6,194.43	-1,616.95	10,151.87	-407.29	9,336.52	12,529.02	5,192.21	-235.22	
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	83.67	0.00	

404,043.67	
1,987.45	
16,410.40	
11,322.11	
17,213.02	
334.63	
242.48	
15,562.56	
3,848.81	
2,008.07	
167.34	
3,360,535.48	
19,561.16	
9,731.76	
136,872.98	
78,915.88	
80,565.69	
170.13	
167.34	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371F	ADULT <40% EXP MALE	1,839.72	2,734.27	3,052.21	3,900.45	-318.51	0.00	265.72	8,885.12	4,610.79	2,716.70	3,060.78	5,290.14		36,037.39		
371G	ADULT <40% EXP FEMA L	1,449.43	0.00	1,382.58	2,517.88	172.92	0.00	469.99	185.27	83.67	3,307.74	6,958.53	0.00		16,528.01		
371H	ADULT <40% EXP M&F
4	2,293.90	0.00	0.00	658.68	864.59	418.35	8,317.40	1,574.78	0.00	2,031.48	1,798.62	5,597.15		23,554.95		
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		259.38		
SUBTOTAL:	262,318.02	272,391.34	309,499.54	384,521.12	441,240.52	311,344.56	342,775.44	334,274.71	372,860.99	394,412.67	412,492.65	397,909.13		4,236,040.69		

3900	NEWLY ELIGIBLE FOR F	2,592.33	2,592.33	2,592.33	2,593.76	5,187.52	5,187.52	5,187.52	5,187.52	5,187.52	5,187.52	5,187.52	5,187.52	
3910	NEWLY ELIGIBLE FOR
F	28,149.69	34,975.42	30,742.02	29,905.14	25,692.52	28,286.28	25,692.52	25,692.52	25,692.52	30,880.04	30,880.04	28,286.28	
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	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,757.06	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	2,247.93	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	1,647.48	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	33,473.80	32,527.52	30,880.04	32,637.10	38,315.49	36,067.56	33,473.80	

51,870.91	
344,874.99	
2,434.95	
7,612.87	
1,757.06	
3,251.97	
1,647.48	
413,450.23	

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	
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

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	2,593.76	0.00	0.00	0.00	0.00	0.00	2,507.30	
SUBTOTAL:	8,278.73	2,592.33	-2,116.41	2,593.76	20,742.93	2,593.76	0.00	0.00	0.00	0.00	0.00	2,507.30	

977.66	
2,420.84	
15,728.33	
18,065.57	
37,192.40	

S000	STATE-ONLY BHS	0.00	-1,606.24	0.00	-2,677.43	0.00	0.00	0.00	0.00	167.34	0.00	0.00	1,815.63	
SUBTOTAL:	0.00	-1,606.24	0.00	-2,677.43	0.00	0.00	0.00	0.00	167.34	0.00	0.00	1,815.63	

-2,300.70

-2,300.70

9,768,130.39

717,766.03	717,141.84	742,167.12	866,409.57	954,684.44	751,268.16	799,266.26	766,053.25	824,920.11	864,143.24	885,120.23	879,190.14	

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 June 30, 2022

RATE CODE	DESCRIPTION 100H	TANF 45-64 M & F WIT
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

2110	SSI AGED NON-MEDICA
R
211Z	SSI AGED NON-MEDICA
R
2120	SSI AGED WITH QMB

2200	SSI DISABLED WITH M
E

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

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

n. 0.00	0.00

2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
221Z	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
222Z	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
231Z	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4310	SOBRA CHILD NON-ME DI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
431E	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5000	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5007	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5010	SOBRA PREGNANT WO MAN	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5017	SOBRA PREG 21-44 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
501G	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
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	
																
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		0.00	
110G	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1110	TANF EXPANDED FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

220Z

SSI DISABLED WITH M E

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending June 30, 2022

RATE CODE	DESCRIPTION

1116

TANF EXPANDED 21-44

1117

TANF EXPANDED 21-44

1118

TANF EXPANDED 45-64

111G

111H

TANF EXPANDED 21-44

TANF EXPANDED 45-64

1120

1127

TANF EXPANDED FOR FI
TANF EXPANDED 21-44

112G

240Z

2420

2600

260Z

2610

2620

262Z

TANF EXPANDED 21-44

SSI AGED EXPANDED WI
SSI AGED EXPANDED
WI
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

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

E
SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

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

3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
3700	ADULT <40% EXP 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	
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	
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
371F	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

3900	NEWLY ELIGIBLE FOR F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3910	NEWLY ELIGIBLE FOR
F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391G	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
391H	NEWLY ELIGIBLE M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4410

SOBRA 100-133% FOR

Current and

0.00

0.00

0.00

prior m

0.00

0.00

0.00

onth

0.00

data is

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

under re

0.00

0.00

visio

0.00

F
SUBTOTAL:

0.00

0.00

0.00

0.00

n.

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		

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending June 30, 2022	
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	-163.20	0.00	0.00	-1,258.87	0.00		-1,422.07		
1015	TANF 14-20 FEMALE N	0.00	0.00	-70.53	0.00	0.00	0.00	0.00	-252.10	0.00	0.00	0.00	0.00		-322.63		
	O																
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	-1,309.57	0.00	0.00	0.00	-1,271.85	-428.06	0.00	0.00	0.00		-3,009.48		
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	0.00	-7.04	0.00	-28.16	-163.20	0.00	0.00	0.00		-198.40		
	O																
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	-13.60	0.00	0.00		-13.60		
101F	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-65.25	-50.49	0.00	0.00	0.00		-115.74		
2120	SSI AGED WITH QMB	0.00	0.00	-1,492.63	0.00	2,067.55	0.00	0.00	600.87	0.00	0.00	0.00	0.00		1,175.79		
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	103.82		245.74		
	E																
2210	SSI DISABLED NON-ME	-1,460.62	1,656.04	-141.06	0.00	0.00	0.00	-1,460.62	-1,693.00	0.00	0.00	1,818.12	-1,693.00		-2,974.14		
	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	79.72	0.00	0.00	0.00	0.00	0.00	1,002.09		1,646.05		
	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	-1,693.00	0.00		-1,693.00		
	A																
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	-50.70	0.00		-1,387.80		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	-564.24	0.00	0.00	0.00	0.00	-206.43	0.00	0.00	0.00	-14.92		-785.59		
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-7.04	0.00	0.00	0.00	0.00		-7.04		
	M																
SUBTOTAL:	-1,460.62	1,868.92	-3,605.56	-745.33	2,067.55	72.68	-1,460.62	-3,086.16	-641.75	-13.60	-1,184.45	-602.01		-8,790.95		

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	-55.36	0.00	-35.20	-1,693.00	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	-1,002.09	-1,460.62	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	-1,460.62	0.00	0.00	0.00	0.00	0.00	-28.16	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	1,002.09	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	1,002.09	-55.36	0.00	-35.20	-1,721.16	-1,002.09	-1,460.62	

1,309.57	
-1,942.07	
-2,462.71	
-1,488.78	
141.92	
1,854.45	
1,570.96	
-1,016.66	

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	-600.75	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	-276.17	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	-1,002.09	0.00	0.00	0.00	-7.46	
3716	ADULT <40% EXP MALE	-880.25	0.00	0.00	-9.40	-6.26	0.00	0.00	0.00	0.00	-56.02	0.00	-5.22	
3717	ADULT <40% EXP FEMA L	141.06	0.00	-336.72	0.00	0.00	-7.04	0.00	-27.20	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	-491.34	-5.68	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	-75.91	0.00	0.00	0.00	0.00	
SUBTOTAL:	-739.19	0.00	-2,044.37	-601.93	-6.26	-7.04	0.00	-2,473.46	-5.68	-56.02	0.00	-12.68	

-352.65	
-2,221.94	
-276.17	
-1,009.55	
-957.15	
-229.90	
-652.04	
-86.46	
-160.77	
-5,946.63	

3917

NEWLY ELIGIBLE FEMA L

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

-3,094.13

0.00

0.00

-3,094.13

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	799.82	-355.90	0.00	-21.12	0.00	0.00		422.80		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	799.82	-355.90	0.00	-3,115.25	0.00	0.00		-2,671.33		

-18,425.57

-2,199.81	2,010.84	-3,226.61	-2,966.39	3,370.86	1,067.73	-716.16	-5,915.52	-682.63	-4,906.03	-2,186.54	-2,075.31	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending June 30, 2022

RATE CODE	DESCRIPTION

1014

TANF 14-20 MALE NON-

1015

1016

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

1017

1018

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

101F

TANF 21-44 MALE NON-

2120

SSI AGED WITH QMB

2200

2210

221Z

2220

2310

4314

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

4315

SOBRA CHILD 14-20 FE

5017

SOBRA PREG 21-44 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

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	

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	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
0.00	

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
371G	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
371H	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3917	NEWLY ELIGIBLE 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															

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3918	NEWLY ELIGIBLE M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - DCS-CHP
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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	-1,762.76	0.00	0.00	0.00	0.00	0.00	0.00		-1,762.76		
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	7,343.28	0.00	0.00	0.00	0.00	0.00	0.00		-3,856.82		
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	4,171.87	0.00	0.00	0.00	0.00		4,927.34		
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	5,580.52	0.00	4,171.87	0.00	0.00	0.00	0.00		18,586.58		

18,586.58

3,105.29	-4,461.73	372.81	9,817.82	0.00	5,580.52	0.00	4,171.87	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - DCS-CHP
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431C	SOBRA CHILD 6-13 M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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 June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-2,769.12	0.00	0.00		-2,769.12		
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	-2,964.52	0.00	0.00	-6,121.81	0.00	0.00	0.00		-10,829.81		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	-581.16	0.00	0.00	0.00	0.00	0.00	0.00		-581.16		
SUBTOTAL:	1,740.54	0.00	-1,743.48	0.00	0.00	-3,545.68	0.00	0.00	-6,121.81	-2,769.12	0.00	0.00		-12,439.55		

-12,439.55

1,740.54	0.00	-1,743.48	0.00	0.00	-3,545.68	0.00	0.00	-6,121.81	-2,769.12	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2210	SSI DISABLED NON-ME
D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

Current and prior month data is under revision.

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	4.13	0.00	0.00	4.13	8.26	8.26		24.78		
1005	TANF 14-20 FEMALE WI	5.68	5.68	5.68	4.13	4.13	4.13	4.13	4.13	4.13	0.00	0.00	0.00		41.82		
1006	TANF 21-44 MALE WITH	1,074.23	1,074.23	1,105.56	657.65	634.84	672.90	698.10	712.98	723.73	679.01	659.16	636.35		9,328.74		
1007	TANF 21-44 FEMALE WI	1,394.71	1,311.57	1,345.26	856.88	824.59	881.70	807.18	812.99	825.38	916.13	938.89	979.06		11,894.34		
1008	TANF 45-64 M & F WIT	2,924.31	2,895.80	2,944.40	1,753.69	1,752.88	1,809.66	1,907.79	2,013.33	1,937.17	1,987.71	2,037.02	2,126.43		26,090.19		
1009	TANF 65+ M & F WITH	1,810.65	1,843.07	1,802.27	1,069.75	1,040.79	1,158.77	1,237.42	1,285.47	1,341.37	1,316.08	1,392.30	1,451.52		16,749.46		
1010	TANF NON-MEDICARE	1,295.76	1,291.31	1,290.84	4,608.98	4,637.14	4,647.51	4,701.38	4,685.66	4,711.33	4,732.87	4,758.54	4,816.92		46,178.24		
1011	TANF <1 M & F NON-ME	21,640.95	22,233.06	22,888.52	92,336.79	95,317.57	95,858.50	96,501.59	97,087.84	97,583.73	97,710.20	95,891.86	93,709.07		928,759.68		
1012	TANF 01-05 M & F NON	38,884.77	38,645.46	38,797.56	162,431.26	174,958.90	183,082.87	188,550.34	190,654.27	187,544.99	186,986.95	186,960.68	186,045.77		1,763,543.82		
1013	TANF 06-13 M & F NON	75,603.36	75,418.01	75,586.55	311,394.37	330,205.25	342,390.27	352,711.71	355,456.17	355,339.70	357,079.45	358,411.32	356,141.49		3,345,737.65		
1014	TANF 14-20 MALE NON-	71,039.41	73,009.06	75,999.09	106,616.03	113,066.25	117,087.61	121,153.90	123,247.42	124,259.24	126,374.64	127,177.80	127,637.93		1,306,668.38		
1015	TANF 14-20 FEMALE N	102,751.77	103,566.02	105,237.36	125,849.82	131,510.38	135,578.32	139,405.74	141,283.49	142,616.21	144,185.67	145,970.69	146,296.35		1,564,251.82		
	O																
1016	TANF 21-44 MALE NON-	407,163.72	408,211.05	410,905.98	242,517.02	253,710.54	259,910.03	268,056.79	272,992.39	276,441.51	279,757.64	283,237.93	285,228.71		3,648,133.31		
1017	TANF 21-44 FEMALE N	1,362,222.98	1,360,193.45	1,369,162.24	797,271.23	829,796.37	848,642.66	870,449.10	883,010.66	893,797.30	905,297.83	915,837.18	924,022.77		11,959,703.77		
	O																
1018	TANF 45-64 M & F NON	349,386.16	350,259.73	351,704.88	207,060.49	215,299.07	221,219.36	227,907.11	232,653.94	235,823.87	239,850.67	242,481.14	245,770.44		3,119,416.86		
1019	TANF 65+ M & F NON-M	1,777.08	1,794.12	1,832.33	1,093.35	1,104.52	1,148.45	1,139.35	1,234.61	1,207.29	1,239.58	1,197.76	1,231.31		15,999.75		
1023	TANF 06-13 M & F WIT	4.18	4.18	4.18	7.46	7.46	7.46	7.46	7.46	7.46	7.46	7.46	7.46		79.68		
1024	TANF 14-20 MALE WITH	14.43	14.43	14.43	14.08	14.08	14.08	14.08	18.21	18.21	11.17	11.17	11.17		169.54		
1025	TANF 14-20 FEMALE WI	25.19	25.19	25.19	14.50	14.50	14.50	14.50	14.50	14.50	7.46	7.46	7.46		184.95		
1026	TANF 21-44 MALE WITH	1,006.35	1,049.04	1,029.53	602.09	651.37	666.25	691.12	680.79	629.87	632.74	682.86	723.83		9,045.84		
1027	TANF 21-44 FEMALE WI	1,625.10	1,629.23	1,534.38	847.72	914.41	958.33	1,058.11	1,055.20	1,041.58	1,082.55	1,122.73	1,121.85		13,991.19		
1028	TANF 45-64 M & F WIT	2,169.62	2,123.26	2,192.46	1,221.67	1,275.92	1,315.67	1,321.48	1,287.97	1,340.57	1,408.10	1,451.18	1,421.30		18,529.20		
1029	TANF 65+ M & F WITH	1,218.05	1,216.16	1,296.10	826.66	848.62	888.83	898.78	895.07	902.53	941.48	939.42	916.19		11,787.89		
2100	SSI AGED WITH MEDIC	174,819.66	175,160.24	176,168.45	99,674.59	99,799.50	100,171.38	100,288.47	100,167.51	99,856.71	100,385.15	101,043.18	101,573.55		1,429,108.39		
	A																
2110	SSI AGED NON-MEDICA	116,703.65	117,582.26	118,537.53	66,438.53	67,571.27	68,205.69	68,999.70	69,084.28	70,509.14	71,453.98	72,273.73	72,669.84		980,029.60		
	R																
2120	SSI AGED WITH QMB	566,269.97	570,577.53	574,907.09	333,751.43	336,323.77	338,840.90	341,728.54	343,866.12	346,030.06	347,271.88	350,008.43	352,293.85		4,801,869.57		
2200	SSI DISABLED WITH M	105,597.57	105,433.82	106,658.15	61,258.77	61,503.54	61,933.83	62,779.32	62,406.51	62,854.28	63,252.13	63,474.93	64,439.52		881,592.37		
	E																
2210	SSI DISABLED NON-ME	771,094.17	771,630.83	772,149.44	616,715.54	617,648.93	617,887.12	618,592.27	617,717.48	617,472.23	617,936.53	619,742.73	620,665.42		7,879,252.69		
	D																
2220	SSI DISABLED WITH Q	435,771.54	436,494.18	437,429.48	252,167.32	251,978.91	252,012.66	252,067.13	251,878.55	251,542.78	250,784.29	250,842.88	251,120.39		3,574,090.11		
	M																
2300	SSI BLIND WITH MEDIC	530.20	530.20	595.84	359.42	385.09	414.09	552.78	588.40	614.87	593.33	625.24	646.36		6,435.82		
2310	SSI BLIND NON-MEDIC	6,462.40	6,569.99	6,645.44	4,598.17	4,592.78	4,650.77	4,688.84	5,623.53	5,580.45	5,599.08	5,639.25	5,669.51		66,320.21		
	A																
2320	SSI BLIND WITH QMB	3,204.68	3,361.73	3,487.45	2,125.48	2,151.15	2,200.85	2,370.26	2,636.99	2,665.61	2,668.52	2,661.06	2,638.68		32,172.46		
4301	SOBRA CHILD <1 M & F	0.00	0.83	0.00	7.04	7.04	7.04	7.04	7.04	7.04	7.04	7.04	14.08		71.23		
4302	SOBRA CHILD 01-05 M	5.01	5.01	0.00	0.00	0.00	0.00	0.00	0.00	7.04	7.04	7.04	7.04		38.18		
4303	SOBRA CHILD 06-13 M	10.02	10.02	8.36	14.92	14.92	7.46	19.05	19.05	33.97	29.84	29.84	29.42		226.87		
4305	SOBRA CHILD 14-20 FE	0.83	0.83	4.18	7.46	7.46	7.46	7.46	7.46	14.50	7.46	7.46	7.46		80.02		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4311	SOBRA CHILD <1 M & F	51,218.81	50,684.41	50,200.79	201,029.09	197,694.53	198,784.54	200,382.31	200,458.42	201,630.67	203,328.38	205,509.48	207,424.65		1,968,346.08		
4312	SOBRA CHILD 01-05 M	333,951.36	335,474.23	336,368.04	1,329,372.87	1,317,030.59	1,311,124.00	1,306,226.75	1,307,527.27	1,312,057.89	1,313,417.16	1,316,544.79	1,320,029.10		12,839,124.05		
4313	SOBRA CHILD 06-13 M	424,731.44	425,232.81	426,096.85	1,686,731.41	1,674,152.47	1,669,375.05	1,661,965.39	1,666,157.92	1,675,437.57	1,677,678.56	1,681,808.45	1,691,493.54		16,360,861.46		
4314	SOBRA CHILD 14-20 MA	275,794.71	279,860.47	280,370.15	513,828.77	513,776.95	514,979.32	515,669.05	522,561.39	523,505.89	522,962.37	525,333.15	530,177.54		5,518,819.76		
4315	SOBRA CHILD 14-20 FE	276,006.13	278,045.08	279,386.60	506,252.78	505,726.97	507,070.63	508,260.18	515,586.37	515,646.27	514,796.52	516,998.36	521,170.41		5,444,946.30		
4322	SOBRA CHILD 01-05 M	1.66	1.66	1.66	14.08	14.08	14.08	14.08	14.08	7.04	7.04	7.04	7.04		103.54		
4323	SOBRA CHILD 06-13 M	0.83	0.83	0.83	7.04	7.04	7.04	7.04	11.17	11.17	22.34	22.34	11.17		108.84		
4325	SOBRA CHILD 14-20 FE	21.45	21.45	29.69	18.63	26.09	18.63	18.63	14.50	14.50	14.50	14.50	14.50		227.07		
5005	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	7.04	7.04	0.00	0.00	0.00	0.00		14.08		
	M																
5007	SOBRA PREG 21-44 FE	260.91	265.16	298.04	203.30	206.21	217.42	202.50	206.63	232.30	202.46	201.66	220.29		2,716.88		
	M																
5008	SOBRA PREG 45-64 FE	13.60	13.60	13.60	7.04	7.46	7.46	7.46	7.46	7.46	7.46	0.00	11.59		104.19		
	M																
5013	SOBRA PREG 09-13 FE	13.25	10.73	8.92	36.84	62.93	44.30	54.67	54.25	51.34	44.30	61.29	39.75		482.57		
	M																
5015	SOBRA PREG 14-20 FE	23,441.55	23,870.48	23,958.23	14,853.60	14,731.45	14,588.96	14,288.58	14,683.29	14,517.55	13,695.37	13,452.36	14,061.20		200,142.62		
	M																
5017	SOBRA PREG 21-44 FE	184,904.86	192,300.97	199,397.98	114,243.08	113,569.98	115,993.68	112,834.44	116,292.43	115,598.77	112,029.12	112,109.43	116,839.44		1,606,114.18		
	M																
5018	SOBRA PREG 45-64 FE	753.59	795.36	821.13	443.91	436.87	449.30	403.74	419.88	425.24	371.45	394.21	431.05		6,145.73		
	M																
5025	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.04	0.00	0.00	0.00		7.04		
	M																
5027	SOBRA PREG 21-44 FE	352.78	348.53	342.62	197.94	211.60	232.30	240.60	199.63	217.42	188.84	205.83	215.36		2,953.45		
	M																
5028	SOBRA PREG 45-64 FE	71.67	44.47	44.47	33.13	18.63	25.67	32.71	36.84	32.71	25.67	32.71	36.84		435.52		
	M																
SUBTOTAL:	6,197,046.76	6,222,140.82	6,260,635.80	7,863,447.80	7,937,247.79	7,997,229.49	8,051,957.32	8,109,336.04	8,144,701.18	8,170,997.33	8,210,241.22	8,254,270.23		91,419,251.78		

3100	TRANSPLANT OPTION 1	5.68	5.68	5.68	4.13	4.13	4.13	4.13	4.13	4.13	4.13	4.13	4.13	
SUBTOTAL:	5.68	5.68	5.68	4.13	4.13	4.13	4.13	4.13	4.13	4.13	4.13	4.13	

54.21

54.21

1106	TANF EXPANDED 21-44	3,041.47	2,981.51	2,968.26	1,669.33	1,715.73	1,717.88	1,613.48	1,603.53	1,639.95	1,628.82	1,542.28	1,555.94	
1107	TANF EXPANDED 21-44	5,253.15	5,106.26	5,013.30	2,861.67	2,731.63	2,690.19	2,654.18	2,712.56	2,743.21	2,730.40	2,685.22	2,643.02	
1108	TANF EXPANDED 45-64	17,304.13	17,785.94	17,876.43	10,306.48	10,262.52	10,330.43	10,420.79	10,436.48	10,397.16	10,287.77	10,379.32	10,364.73	
1109	TANF EXPANDED 65+ M
&	10,852.64	11,123.12	11,515.42	6,865.80	6,946.53	6,981.68	6,930.66	7,069.42	7,143.44	7,216.66	7,243.97	7,358.59	
1112	TANF EXPANDED 01-05	1.66	0.83	0.83	14.08	7.04	7.04	7.04	14.08	7.04	7.04	7.04	0.00	
1113	TANF EXPANDED 06-13	5.01	5.01	5.84	7.46	18.63	18.63	18.63	22.76	22.76	19.05	26.51	14.92	
1114	TANF EXPANDED 14-20	2,572.90	2,482.30	2,412.29	1,318.63	1,285.93	1,292.97	1,215.12	1,117.33	1,052.28	1,035.29	1,052.61	1,099.44	
1115	TANF EXPANDED 14-20	16,030.03	15,323.12	14,530.75	7,671.14	7,401.16	7,236.60	6,990.12	6,771.89	6,757.82	6,713.89	6,640.94	6,548.66	
1116	TANF EXPANDED 21-44	335,614.45	337,335.76	335,668.81	188,394.74	181,317.67	178,992.51	175,241.44	174,199.44	174,472.03	174,133.07	174,016.92	174,428.19	
1117	TANF EXPANDED 21-44	950,610.58	956,423.69	950,212.59	527,295.40	506,040.59	497,812.76	490,231.72	487,288.13	490,588.20	490,735.58	491,294.73	490,514.12	
1118	TANF EXPANDED 45-64	328,959.81	333,039.48	333,462.10	187,342.37	182,804.20	181,256.82	178,468.58	179,422.43	180,056.24	179,590.52	180,001.79	181,499.39	
1119	TANF EXPANDED 65+ M
&	1,658.59	1,701.17	1,724.70	994.31	944.23	992.28	1,018.41	1,045.34	1,074.72	1,090.07	1,085.10	1,107.94	
1125	TANF EXPANDED 14-20	11.59	11.59	11.59	7.46	7.46	0.00	0.00	0.00	0.00	7.04	7.04	7.04	
1126	TANF EXPANDED 21-44	9,134.93	9,183.07	9,239.83	5,277.11	5,195.17	5,107.41	5,078.87	5,142.26	5,209.79	5,234.70	5,230.48	5,187.45	

23,678.18	
39,824.79	
146,152.18	
97,247.93	
73.72	
185.21	
17,937.09	
108,616.12	
2,603,815.03	
7,329,048.09	
2,625,903.73	
14,436.86	
70.81	
74,221.07	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1127	TANF EXPANDED 21-44	20,450.95	20,531.85	20,560.48	11,418.65	11,418.22	11,333.75	11,115.79	11,167.10	11,164.66	11,108.72	11,091.71	11,041.60		162,403.48		
1128	TANF EXPANDED 45-64	35,814.01	36,065.45	36,101.27	20,788.60	20,943.00	20,971.51	20,918.97	20,776.42	20,945.77	21,034.87	20,937.51	21,093.76		296,391.14		
1129	TANF EXPANDED 65+ M	25,237.97	25,250.65	25,421.77	15,098.13	15,178.20	15,289.13	15,431.69	15,600.68	15,794.19	16,043.41	16,111.98	16,407.80		216,865.60		
	&																
2400	SSI AGED EXPANDED	4,650.68	4,762.45	4,867.81	2,855.01	2,894.28	2,961.85	2,887.25	2,895.55	2,923.28	3,156.50	3,085.26	2,965.17		40,905.09		
	WI																
2410	SSI AGED EXPANDED N	1,727.09	1,706.03	1,810.81	1,026.58	992.99	1,026.96	998.00	926.34	1,001.20	953.57	985.49	1,004.96		14,160.02		
	O																
2420	SSI AGED EXPANDED	378,475.43	380,629.35	382,995.39	224,242.82	226,324.34	227,980.59	228,284.76	229,662.09	232,451.28	233,757.67	235,643.00	236,867.51		3,217,314.23		
	WI																
2500	SSI BLIND EXPANDED	13.60	13.60	13.60	7.04	7.04	14.08	7.04	7.04	7.04	7.04	0.00	0.00		97.12		
	W																
2510	SSI BLIND EXPANDED	11.59	11.59	25.19	29.00	36.04	21.96	37.26	51.34	44.30	48.43	41.39	33.93		392.02		
	N																
2520	SSI BLIND EXPANDED	203.30	284.55	406.37	350.74	413.29	427.37	528.41	539.58	598.38	660.93	690.31	683.27		5,786.50		
	W																
2600	SSI DISABLED EXPAND	4,406.88	4,524.91	4,328.73	2,401.19	2,361.02	2,507.20	2,589.94	2,720.57	2,483.21	2,528.35	2,428.53	2,578.42		35,858.95		
	E																
2610	SSI DISABLED EXPAND	18,026.56	17,441.23	17,294.92	9,922.11	9,908.51	9,602.79	9,451.73	9,353.09	9,190.84	9,109.63	9,068.99	8,745.95		137,116.35		
	E																
2620	SSI DISABLED EXPAND	206,887.26	207,251.76	207,656.43	119,127.98	118,915.43	119,303.57	118,569.01	118,102.42	118,015.16	118,024.18	117,933.31	117,990.91		1,687,777.42		
	E																
SUBTOTAL:	2,376,956.26	2,390,976.27	2,386,125.51	1,347,293.83	1,316,070.85	1,305,877.96	1,290,708.89	1,288,647.87	1,295,783.95	1,296,863.20	1,299,231.43	1,301,742.71		18,896,278.73		

3504	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	7.46	7.46	7.46	7.46	7.46	7.46	
3505	ADULT 40-100% FEMAL E	0.00	0.00	0.00	7.46	0.00	0.00	0.00	0.00	0.00	4.13	4.13	4.13	
3506	ADULT 40-100% MALE 2	334.93	305.72	317.31	208.35	215.81	208.35	178.93	200.05	182.64	167.72	164.01	181.80	
3507	ADULT 40-100% FEMAL E	290.46	242.09	206.97	149.93	170.63	200.05	152.00	152.00	144.96	139.14	120.51	135.81	
3508	ADULT 40-100% M&F 45	3,710.08	3,813.12	4,077.23	2,422.38	2,312.16	2,639.29	3,217.08	3,110.42	2,852.14	2,666.41	2,854.01	2,868.13	
3509	ADULT 40-100% M&F 65	3,217.04	3,757.86	4,551.44	2,655.27	2,856.11	3,074.78	3,316.63	4,087.77	3,962.13	3,949.29	4,015.09	4,329.32	
3514	ADULT 40-100% MALE 1	79,907.04	80,195.95	80,455.05	45,496.46	45,480.24	45,523.23	45,267.33	44,297.80	45,892.42	47,123.21	48,304.12	48,571.22	
3515	ADULT 40-100% FEMAL E	84,744.66	85,099.31	85,671.02	49,003.53	49,251.56	48,924.75	48,987.30	47,676.38	49,460.13	51,010.03	51,853.73	51,818.30	
3516	ADULT 40-100% MALE 2	346,020.47	349,705.40	353,175.36	197,238.69	193,148.43	193,632.70	191,781.74	192,745.30	192,122.41	192,445.16	192,814.03	194,256.11	
3517	ADULT 40-100% FEMAL E	282,437.16	285,893.74	289,079.52	162,718.13	160,345.44	161,166.82	160,438.91	161,808.18	163,093.51	164,517.33	166,491.58	168,147.84	
3518	ADULT 40-100% M&F 45	525,336.49	529,153.28	530,749.09	301,243.54	295,223.45	293,629.43	290,171.93	289,655.02	288,831.32	288,832.91	289,154.48	289,447.87	
3519	ADULT 40-100% M&F 65	357.88	423.64	458.18	347.83	381.80	343.70	347.03	499.41	298.60	373.13	289.08	315.97	
3524	ADULT 40-100% MALE 1	13.60	13.60	13.60	14.50	7.04	7.04	0.00	0.00	0.00	7.46	18.63	18.63	
3526	ADULT 40-100% MALE 2	25.19	38.79	38.79	21.54	29.00	29.00	72.92	70.01	73.72	81.18	81.18	81.18	
3527	ADULT 40-100% FEMAL E	40.80	40.80	54.40	21.12	35.62	28.58	69.17	69.17	69.17	68.75	54.25	54.25	
3528	ADULT 40-100% M&F 45	363.56	369.24	406.02	272.88	247.63	279.12	331.68	349.51	341.63	370.63	375.18	419.06	
3529	ADULT 40-100% M&F 65	166.52	180.12	189.70	116.38	130.04	130.04	130.46	156.55	181.84	171.89	193.43	207.51	
3705	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	7.04	7.04	7.04	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	1,046.53	1,057.89	1,135.47	652.65	680.81	674.19	624.07	671.70	676.67	593.04	622.84	562.39	
3707	ADULT <40% EXP FEMA L	604.46	579.27	610.14	340.38	323.81	337.89	332.11	342.06	356.94	360.23	384.68	379.75	
3708	ADULT <40% EXP M&F
4	6,819.51	7,282.98	7,675.01	4,658.90	4,891.68	5,203.55	5,496.00	5,669.87	5,912.60	5,790.02	6,150.67	6,549.42	
3709	ADULT <40% EXP M&F 6	1,283.94	1,401.98	1,665.36	1,082.40	1,212.81	1,393.77	1,592.18	1,870.04	1,863.00	1,785.99	1,858.07	2,118.10	

44.76	
19.85	
2,665.62	
2,104.55	
36,542.45	
43,772.73	
656,514.07	
703,500.70	
2,789,085.80	
2,326,138.16	
4,211,428.81	
4,436.25	
114.10	
642.50	
606.08	
4,126.14	
1,954.48	
21.12	
8,998.25	
4,951.72	
72,100.21	
19,127.64	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	174,259.45	176,966.61	181,513.76	105,254.05	107,361.45	109,108.27	110,496.45	108,948.41	113,398.31	116,457.58	117,704.67	118,912.40		1,540,381.41		
3715	ADULT <40% EXP FEMA	160,747.18	164,661.26	168,914.46	98,237.19	99,935.55	101,050.09	101,808.75	100,727.68	105,079.99	107,865.13	109,433.80	111,154.70		1,429,615.78		
	L																
3716	ADULT <40% EXP MALE	1,290,469.36	1,315,719.94	1,345,410.63	784,324.79	803,730.10	820,301.05	839,683.67	856,714.56	874,381.07	891,033.82	907,050.40	921,307.98		11,650,127.37		
3717	ADULT <40% EXP FEMA	742,977.91	757,598.87	774,866.09	450,302.30	462,140.37	472,083.33	483,312.95	493,573.85	503,250.84	512,439.68	521,923.47	530,655.57		6,705,125.23		
	L																
3718	ADULT <40% EXP M&F	1,302,549.14	1,316,979.72	1,336,071.24	779,147.63	796,503.31	809,376.08	824,526.86	836,514.42	849,482.40	860,558.39	871,178.98	880,323.99		11,463,212.16		
	4																
3719	ADULT <40% EXP M&F	506.67	651.44	839.36	444.35	481.61	545.43	569.03	1,184.41	573.20	563.68	539.23	551.67		7,450.08		
	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	131.26	247.22	258.39	319.26	308.51	314.75	333.38		2,800.42		
3727	ADULT <40% EXP FEMA	69.66	96.86	110.46	54.25	68.33	61.29	100.62	114.70	144.92	145.76	145.34	171.01		1,283.20		
	L																
3728	ADULT <40% EXP M&F	911.61	952.18	989.31	588.02	601.30	605.01	760.25	824.83	998.37	1,057.17	1,111.42	1,146.20		10,545.67		
	4																
3729	ADULT <40% EXP M&F	23.18	23.18	23.18	7.46	7.46	7.46	14.50	28.58	28.58	43.08	75.79	75.79		358.24		
	6																
SUBTOTAL:	5,009,451.38	5,083,408.14	5,169,485.05	2,987,166.95	3,027,893.64	3,070,695.55	3,114,042.27	3,152,335.57	3,203,987.27	3,250,937.91	3,295,289.01	3,335,106.94		43,699,799.68		

3904	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	4.13	4.13	4.13	4.13	4.13	4.13	4.13	4.13	4.13	
3905	NEWLY ELIGIBLE FEMA L	13.60	13.60	13.60	7.04	7.04	7.04	7.04	7.04	14.08	7.04	7.04	14.08	
3906	NEWLY ELIGIBLE MALE	1,448.07	1,405.26	1,449.73	849.73	875.02	872.11	872.49	913.08	926.74	871.65	874.52	910.98	
3907	NEWLY ELIGIBLE FEMA L	1,044.29	986.22	1,019.10	575.64	576.48	583.90	555.36	569.44	604.64	554.94	580.23	619.18	
3908	NEWLY ELIGIBLE M&F
4	19,804.68	20,393.25	20,943.48	12,592.05	12,994.09	13,355.26	13,589.05	14,059.75	14,571.26	14,051.52	14,150.91	14,859.84	
3909	NEWLY ELIGIBLE M&F 6	16,111.70	17,251.96	18,816.13	11,506.62	12,267.32	13,076.45	13,916.39	14,788.32	15,448.66	14,369.09	14,818.40	15,467.23	
3914	NEWLY ELIGIBLE MALE	80,467.12	78,188.05	76,444.18	41,564.92	40,481.41	39,518.78	38,732.22	36,962.98	36,622.30	36,066.49	35,355.81	34,316.90	
3915	NEWLY ELIGIBLE FEMA L	84,802.34	81,889.33	79,511.79	43,313.10	42,150.34	41,019.24	39,787.98	37,817.02	37,413.16	37,247.59	36,455.73	35,231.72	
3916	NEWLY ELIGIBLE MALE	438,158.33	440,631.19	443,860.55	251,858.40	251,353.00	251,125.12	250,940.84	251,506.02	250,471.42	251,118.66	251,053.92	250,927.32	
3917	NEWLY ELIGIBLE FEMA L	627,863.05	635,104.07	646,045.06	362,913.30	360,283.34	358,507.66	356,358.95	355,464.24	351,500.06	350,298.41	348,823.58	347,596.73	
3918	NEWLY ELIGIBLE M&F
4	510,704.17	511,244.98	513,862.23	293,785.60	291,526.78	290,064.89	290,304.55	289,891.80	287,868.99	287,009.45	286,919.25	285,548.13	
3919	NEWLY ELIGIBLE M&F 6	1,639.43	1,765.15	1,773.07	1,002.11	1,006.66	1,048.90	1,125.06	1,209.58	1,099.05	1,181.88	1,173.20	1,231.20	
3926	NEWLY ELIGIBLE MALE	25.19	25.19	25.19	14.50	14.50	7.46	43.08	43.08	35.62	35.62	35.62	35.62	
3927	NEWLY ELIGIBLE FEMA L	36.78	36.78	36.78	29.00	29.00	21.96	29.00	36.04	43.08	43.08	50.54	57.58	
3928	NEWLY ELIGIBLE M&F
4	239.51	259.02	301.48	154.82	137.03	136.99	144.45	158.15	236.85	198.32	158.57	177.20	
3929	NEWLY ELIGIBLE M&F 6	792.30	862.31	938.23	589.23	676.23	676.65	681.96	732.92	809.93	826.96	859.29	837.75	
SUBTOTAL:	1,783,150.56	1,790,056.36	1,805,040.60	1,020,760.19	1,014,382.37	1,010,026.54	1,007,092.55	1,004,163.59	997,669.97	993,884.83	991,320.74	987,835.59	

37.17	
118.24	
12,269.38	
8,269.42	
185,365.14	
177,838.27	
574,721.16	
596,639.34	
3,583,004.77	
5,100,758.45	
4,138,730.82	
15,255.29	
340.67	
449.62	
2,302.39	
9,283.76	
14,405,383.89	

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.04	7.04	7.04	7.04	7.04	
4405	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	7.04	
4412	SOBRA 100-133% M&F
1	8.36	4.18	5.01	7.46	7.04	7.04	7.04	7.04	0.00	14.50	7.04	14.08	
4413	SOBRA 100-133% M&F
6	77,864.70	78,493.49	79,008.12	312,161.39	306,679.13	303,460.28	301,419.17	299,453.54	297,484.74	296,182.92	297,285.97	295,332.94	
4414	SOBRA 100-133% MALE	59,246.96	61,682.51	62,682.69	104,270.69	103,663.75	104,308.11	104,909.22	106,486.19	105,910.81	105,357.60	106,692.69	107,646.43	
4415	SOBRA 100-133% FEMA L	58,389.54	60,234.07	61,959.93	100,601.96	100,001.46	100,717.92	101,508.59	102,814.70	102,884.59	102,891.96	103,923.44	104,096.06	

35.20	
7.04	
88.79	
2,944,826.39	
1,132,857.65	
1,100,024.22	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4424	SOBRA 100-133% MALE	0.83	0.83	0.83	7.04	7.04	7.04	7.04	7.04	7.04	7.04	7.04	7.04		65.85		
SUBTOTAL:	195,510.39	200,415.08	203,656.58	517,048.54	510,358.42	508,500.39	507,851.06	508,775.55	506,294.22	504,461.06	507,923.22	507,110.63		5,177,905.14		

4517	BC PATIENT FEMALE 2 1	257.82	271.42	269.41	154.45	147.83	140.79	148.25	148.25	133.75	133.75	112.63	105.59	
4518	BC PATIENT FEMALE 4
5	1,493.04	1,467.85	1,535.73	901.06	921.76	931.71	950.76	918.05	855.92	824.85	820.30	823.63	
4519	BC PATIENT FEMALE 6 5	25.19	25.19	25.19	14.50	14.50	14.50	14.50	14.50	14.50	21.96	26.09	21.54	
4617	CC PATIENT FEMALE 2
1	58.07	58.07	58.07	32.71	32.71	36.84	36.84	36.84	36.84	36.84	36.84	36.84	
4618	CC PATIENT FEMALE 4 5	50.38	50.38	50.38	29.00	29.00	29.00	29.00	21.54	21.54	29.00	29.00	43.08	
SUBTOTAL:	1,884.50	1,872.91	1,938.78	1,131.72	1,145.80	1,152.84	1,179.35	1,139.18	1,062.55	1,046.40	1,024.86	1,030.68	

2,023.94	
12,444.66	
232.16	
497.51	
411.30	
15,609.57	

8600	SSI BLIND FREEDOM/W O	54.40	54.40	95.20	49.28	49.28	63.36	70.40	84.48	91.52	98.98	91.94	113.06	
8610	SSI BLIND FREEDOM/W
O	13.60	13.60	13.60	7.04	7.04	7.04	7.04	7.04	7.04	7.04	7.04	7.04	
8620	SSI BLIND FREEDOM/W O	25.19	25.19	13.60	7.04	7.04	14.08	7.04	7.04	7.04	14.08	21.54	21.54	
8700	SSI DISABLED FREEDO
M	29,320.29	29,647.30	29,742.39	16,680.13	16,684.16	16,726.05	16,837.46	16,987.77	17,020.06	17,011.34	16,962.41	17,092.80	
8710	SSI DISABLED FREEDO M	4,978.17	5,094.31	5,059.07	2,793.23	2,855.39	2,899.65	2,911.66	2,871.49	2,981.30	3,073.23	3,235.09	3,311.72	
8720	SSI DISABLED FREEDO
M	7,425.33	7,572.57	7,632.53	4,377.38	4,535.62	4,584.90	4,694.62	4,763.00	4,833.80	5,056.58	5,351.07	5,476.89	
SUBTOTAL:	41,816.98	42,407.37	42,556.39	23,914.10	24,138.53	24,295.08	24,528.22	24,720.82	24,940.76	25,261.25	25,669.09	26,023.05	

916.30	
104.16	
170.42	
240,712.16	
42,064.31	
66,304.29	
350,271.64	

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7.04	0.00	0.00	0.00	0.00	
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	36.46	21.96	21.96	21.96	14.50	7.04	7.04	
6015	KIDS 14-19 FEMALE NO	27.20	27.20	40.80	21.12	21.12	21.12	28.58	28.58	28.58	43.08	28.58	36.04	
SUBTOTAL:	52.39	52.39	81.01	50.12	50.12	57.58	50.54	57.58	50.54	57.58	35.62	43.08	

7.04	
1.42	
278.09	
352.00	
638.55	

S000	STATE-ONLY BHS	0.00	0.00	0.00	0.00	0.00	0.00	7.46	7.46	0.00	7.04	0.00	7.46	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	7.46	7.46	0.00	7.04	0.00	7.46	

29.42

29.42

173,965,222.61

15,605,874.90	15,731,335.02	15,869,525.40	13,760,817.38	13,831,291.65	13,917,839.56	13,997,421.79	14,089,187.79	14,174,494.57	14,243,520.73	14,330,739.32	14,413,174.50	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending June 30, 2022

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE		TOTAL	
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1005	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1015

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

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00		0.00

0.00	
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

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

1023	TANF 06-13 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1024	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2100

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	

1018

1019

TANF 45-64 M & F NON

Cu0.00rren0.00t an0.0d0

pr0i.00or m0.00 ont0h.00

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

n. 0.00

0.00

0.00

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS

For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4312	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4313	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4322	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4323	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
4325	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5005	SOBRA PREG 14-20 FE	0.00
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	
5007	SOBRA PREG 21-44 FE	0.00
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	
5008	SOBRA PREG 45-64 FE	0.00
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	
5013	SOBRA PREG 09-13 FE	0.00
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	
5015	SOBRA PREG 14-20 FE	0.00
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	
5017	SOBRA PREG 21-44 FE	0.00
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	
5018	SOBRA PREG 45-64 FE	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
M
5025	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00
M	
5027	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
SUBTOTAL	:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
																
3100	TRANSPLANT OPTION 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	

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	

0.00	
0.00	
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 June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1129	TANF EXPANDED 65+ M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	&																
2400	SSI AGED EXPANDED	0.00	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		

3504	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	
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	
3705	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	
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3715	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																
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3717	ADULT <40% EXP FEMA	0.00	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																
3718	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																
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.

4403	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4405	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	
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4424	SOBRA 100-133% MALE	0.00	0.00	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		

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

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6013	KIDS 6-13 M & F NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6015	KIDS 14-19 FEMALE NO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	

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

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	

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		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
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	2,159.04	189.64	2,416.58	5,961.79	4,231.23	1,038.00	-227.18		50,725.20		
1007	TANF 21-44 FEMALE WI	2,344.68	3,883.48	1,715.06	2,619.31	4,268.63	3,232.63	1,882.11	2,287.11	2,839.36	1,193.23	4,082.77	5,083.73		35,432.10		
1008	TANF 45-64 M & F WIT	25,526.79	20,753.50	39,154.69	13,049.27	17,392.21	13,521.26	8,266.87	18,925.64	25,257.61	19,295.96	28,070.64	13,104.71		242,319.15		
1009	TANF 65+ M & F WITH	4,555.05	10,223.86	11,782.87	6,219.48	16,476.50	9,705.38	6,802.90	23,466.26	28,097.56	26,656.49	24,343.93	11,824.64		180,154.92		
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	1,479,185.81	747,250.93	1,366,491.77	1,789,666.70	1,056,448.78	1,535,438.52	1,231,513.14		15,559,278.82		
1012	TANF 01-05 M & F NON	218,987.02	387,489.81	458,317.96	301,286.82	354,252.34	414,673.20	274,045.43	515,766.26	639,628.59	342,763.74	654,529.71	540,617.74		5,102,358.62		
1013	TANF 06-13 M & F NON	430,508.15	675,349.59	791,204.52	559,058.37	707,850.71	863,689.19	579,469.18	939,463.33	1,207,474.39	577,951.64	1,116,876.20	898,202.68		9,347,097.95		
1014	TANF 14-20 MALE NON-	354,609.87	347,439.79	348,732.18	264,087.42	316,592.26	423,498.93	354,489.55	472,811.89	527,831.00	294,915.20	436,379.31	478,803.37		4,620,190.77		
1015	TANF 14-20 FEMALE N	508,656.09	544,497.32	719,924.16	453,905.29	652,069.79	628,110.63	452,471.53	672,381.65	887,296.73	648,636.14	801,019.16	728,619.80		7,697,588.29		
	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	3,514,257.50	2,784,314.13	3,507,260.45	5,359,980.43	3,146,503.96	4,387,490.95	4,270,632.25		42,080,861.02		
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	11,261,748.63	9,483,738.96	14,251,826.89	20,126,256.55	11,893,540.46	15,702,913.90	14,622,353.56		148,268,945.88		
	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	4,094,976.07	2,710,669.65	5,147,226.56	8,000,459.41	3,318,813.26	5,838,958.69	4,863,859.33		55,232,493.02		
1019	TANF 65+ M & F NON-M	35,671.33	20,810.34	17,660.93	7,553.66	11,173.92	10,966.59	3,203.52	17,439.78	22,439.54	6,322.86	28,578.23	12,851.64		194,672.34		
1026	TANF 21-44 MALE WITH	1,623.60	0.00	1,038.00	15.27	0.00	253.22	961.62	1,331.42	1,705.65	1,120.54	121.00	761.00		8,931.32		
1027	TANF 21-44 FEMALE WI	1,787.67	2,318.32	4,002.58	2,144.04	3,844.07	1,944.36	552.05	3,979.29	6,434.48	567.45	2,901.96	1,273.77		31,750.04		
1028	TANF 45-64 M & F WIT	8,927.86	16,761.17	7,626.87	25,079.50	21,525.37	12,358.95	9,402.64	9,025.14	19,074.64	6,128.78	9,383.76	10,127.26		155,421.94		
1029	TANF 65+ M & F WITH	7,346.06	7,001.81	7,403.77	1,887.58	6,086.56	2,821.24	946.81	6,279.74	13,891.47	2,521.82	4,311.61	2,549.96		63,048.43		
2100	SSI AGED WITH MEDIC	255,964.05	270,549.48	277,961.82	185,963.58	290,420.44	287,964.95	216,385.70	258,774.99	449,158.92	433,809.56	434,059.17	593,920.67		3,954,933.33		
	A																
2110	SSI AGED NON-MEDICA	310,045.67	446,886.05	463,985.83	330,759.15	434,445.69	446,191.72	456,147.10	524,620.05	655,454.69	330,874.23	511,701.50	592,348.91		5,503,460.59		
	R																
2120	SSI AGED WITH QMB	936,169.83	1,302,776.00	1,092,335.30	586,608.14	925,028.59	950,393.60	557,511.67	1,214,813.01	1,649,511.81	668,380.14	1,222,661.06	1,193,318.74		12,299,507.89		
2200	SSI DISABLED WITH M	778,233.51	827,764.83	968,299.73	486,365.08	658,002.75	567,318.85	460,978.86	722,190.08	1,018,099.54	557,861.11	721,003.48	836,826.36		8,602,944.18		
	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	10,270,455.97	6,867,473.02	12,537,854.76	18,193,584.19	8,474,543.75	13,543,292.65	12,947,412.52		136,213,412.19		
	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	1,952,614.62	1,199,948.09	1,847,347.34	2,899,674.68	1,387,354.63	2,080,628.08	2,406,710.37		23,976,622.29		
	M																
2300	SSI BLIND WITH MEDIC	8,661.85	7,051.30	4,343.76	573.84	11,995.16	2,395.85	447.92	5,841.58	9,170.51	968.83	7,698.17	970.63		60,119.40		
2310	SSI BLIND NON-MEDIC	158,293.34	160,526.18	138,716.55	91,767.90	224,334.40	210,694.25	97,887.72	263,224.12	368,044.31	190,093.84	322,834.26	187,867.38		2,414,284.25		
	A																
2320	SSI BLIND WITH QMB	21,995.35	14,885.83	21,077.82	11,613.11	24,863.73	28,260.64	27,587.28	32,978.43	46,702.82	31,913.62	43,179.19	51,569.68		356,627.50		
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	2,099,815.98	1,575,488.11	2,123,170.88	2,803,006.88	1,617,658.82	2,383,562.71	2,990,822.40		24,877,556.94		
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	4,478,083.96	2,906,978.69	4,917,084.16	7,356,247.23	4,002,730.68	6,047,375.62	5,389,163.68		55,921,247.27		
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	8,402,385.36	5,996,660.54	9,568,034.79	11,774,510.56	7,044,992.14	10,881,285.31	9,787,695.23		100,296,348.72		
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	2,581,506.69	1,989,664.78	2,859,806.32	6,573,134.77	2,253,758.83	3,137,921.49	3,144,834.73		36,270,649.79		
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	3,172,212.97	2,722,083.58	3,528,503.20	4,456,551.67	2,738,288.62	4,043,802.21	3,754,373.00		40,097,016.59		
5007	SOBRA PREG 21-44 FE	4,628.05	10,473.59	9,324.42	1,367.58	1,557.69	2,956.85	2,657.38	3,337.16	4,365.38	107.39	176.52	-422.43		40,529.58		
	M																
5008	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	95.92	0.00	0.00	898.04		993.96		
	M																
5013	SOBRA PREG 09-13 FE	519.00	0.00	0.00	0.00	1,895.02	14,946.72	1,524.24	1,222.19	519.00	1,159.00	-366.38	55.58		21,474.37		
	M																
5015	SOBRA PREG 14-20 FE	197,969.03	290,298.97	306,644.95	185,218.68	228,759.76	227,688.98	239,038.33	243,366.51	294,536.43	205,782.30	314,658.74	395,351.34		3,129,314.02		
	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	2,245,901.35	1,768,670.25	2,583,252.54	3,428,505.08	2,107,325.39	2,883,887.90	2,491,432.56		27,364,108.30		
	M																

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	-1,024.09	5,127.50	2,236.27	519.00	2,012.00	3,529.51	2,637.94	4,841.14	17,667.15	2,402.66	4,432.77	-3,270.00		41,111.85		
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109.30	0.00	0.00	778.11		887.41		
SUBTOTAL:	50,507,896.71	63,255,483.67	70,363,567.08	44,929,542.49	58,193,031.59	60,682,421.45	44,508,428.72	70,198,643.01	100,662,946.74	53,397,617.08	79,160,232.79	74,454,608.90		770,314,420.23		

1106	TANF EXPANDED 21-44	7,993.91	6,480.43	10,812.39	7,037.12	6,830.61	9,718.07	3,259.56	10,308.39	15,523.76	11,864.04	16,739.88	10,798.19	
1107	TANF EXPANDED 21-44	7,940.12	6,054.63	5,286.25	1,788.28	2,043.74	5,365.46	1,939.72	5,672.45	8,686.03	1,707.76	6,679.34	3,343.85	
1108	TANF EXPANDED 45-64	54,825.32	81,878.65	78,589.67	38,916.58	62,355.18	70,018.93	33,506.96	72,499.31	114,835.27	36,906.77	68,019.50	47,640.21	
1109	TANF EXPANDED 65+ M
&	63,425.03	89,100.40	87,116.63	60,440.82	66,686.90	105,087.51	57,084.08	108,351.33	148,570.93	60,800.93	99,931.22	100,294.25	
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	519.00	
1114	TANF EXPANDED 14-20	22,659.84	8,464.41	3,789.83	1,413.55	4,469.07	10,424.74	6,163.57	4,386.03	4,904.37	2,370.89	2,413.97	1,248.89	
1115	TANF EXPANDED 14-20	52,208.78	59,020.80	56,244.99	37,861.65	49,238.73	45,922.83	32,572.49	43,247.75	61,447.90	67,122.57	58,089.20	66,177.87	
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	1,372,507.68	1,470,422.92	1,328,281.16	1,583,982.48	974,016.01	1,445,209.15	1,083,615.85	
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	3,733,796.82	2,942,999.50	4,752,184.89	6,346,781.55	3,422,692.74	5,366,101.34	4,491,240.23	
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	2,056,771.39	1,265,327.35	3,051,563.73	3,904,261.04	1,488,133.45	2,772,662.01	2,243,489.64	
1119	TANF EXPANDED 65+ M
&	12,852.80	19,798.86	18,154.87	12,690.29	34,603.30	13,393.92	-1,338.78	17,215.22	34,931.42	9,412.12	29,835.16	30,015.12	
1126	TANF EXPANDED 21-44	22,671.29	25,880.87	21,112.21	15,140.14	17,223.80	16,443.09	15,605.20	15,773.62	32,884.72	9,915.46	17,874.50	22,906.90	
1127	TANF EXPANDED 21-44	52,545.51	60,653.01	64,030.77	60,670.45	79,525.63	87,318.39	53,044.72	62,804.17	93,174.36	59,567.17	57,148.33	75,311.11	
1128	TANF EXPANDED 45-64	155,261.45	188,912.72	214,732.29	113,956.10	157,023.18	162,783.89	117,052.22	173,587.33	298,475.70	122,902.03	167,259.81	192,109.08	
1129	TANF EXPANDED 65+ M
&	137,416.27	189,820.40	161,415.67	108,438.17	204,353.83	174,562.66	97,580.45	177,887.26	289,510.47	94,547.01	185,464.22	194,101.98	
2400	SSI AGED EXPANDED WI	11,541.53	14,383.97	13,622.09	10,367.73	28,334.03	24,541.02	36,816.10	30,895.88	46,839.55	26,214.57	28,535.49	10,883.76	
2410	SSI AGED EXPANDED N
O	38,873.31	86,611.80	41,342.92	12,252.65	28,403.93	20,292.53	3,395.02	27,810.28	47,992.66	6,010.78	23,848.03	14,071.53	
2420	SSI AGED EXPANDED WI	729,630.08	1,112,499.01	1,083,835.62	530,415.04	844,758.70	736,370.01	406,203.74	988,593.75	1,467,404.54	554,561.01	1,051,881.76	975,053.27	
2500	SSI BLIND EXPANDED
W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,163.85	1,013.58	19.74	89.95	
2510	SSI BLIND EXPANDED N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	150.99	640.00	
2520	SSI BLIND EXPANDED
W	103.61	773.52	4,598.34	6,047.77	1,499.44	20,858.62	28,486.39	24,400.10	36,558.93	18,750.58	20,796.56	21,166.94	
2600	SSI DISABLED EXPAND E	8,250.79	11,161.38	20,293.90	26,336.77	45,474.79	32,425.42	8,929.75	12,851.84	13,167.42	10,684.16	25,029.42	18,739.42	
2610	SSI DISABLED EXPAND
E	145,351.78	224,911.14	162,087.04	104,221.58	166,005.67	132,179.23	73,154.55	157,006.96	320,148.16	134,914.62	199,327.20	202,134.86	
2620	SSI DISABLED EXPAND E	668,815.93	657,308.64	673,128.64	349,712.39	588,354.95	530,437.25	420,483.13	628,056.24	817,679.07	447,372.83	580,970.51	586,834.15	
SUBTOTAL:	9,848,542.57	12,036,402.40	12,921,723.87	7,202,532.34	9,732,874.44	9,361,219.46	7,072,688.64	11,693,377.69	15,693,924.18	7,561,481.08	12,223,987.33	10,392,426.05	

117,366.35	
56,507.63	
759,992.35	
1,046,890.03	
1,038.00	
72,709.16	
629,155.56	
16,047,462.72	
52,380,478.34	
28,768,487.82	
231,564.30	
233,431.80	
805,793.62	
2,064,055.80	
2,015,098.39	
282,975.72	
350,905.44	
10,481,206.53	
7,287.12	
790.99	
184,040.80	
233,345.06	
2,021,442.79	
6,949,153.73	
125,741,180.05	

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	5,572.82	5,235.17	5,987.72	10,053.70	4,903.95	6,751.54	8,580.36	
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	7,292.07	7,567.19	13,817.53	14,073.68	10,216.45	19,517.67	16,311.25	
3509	ADULT 40-100% M&F 65	6,297.74	8,786.24	15,772.24	3,299.33	8,388.19	6,499.20	2,845.89	12,087.98	23,366.98	10,687.28	13,295.03	17,339.46	

79,610.92	
1,038.00	
158,337.69	
128,665.56	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	128,903.50	116,959.21	159,757.94	137,842.69	101,289.47	148,905.20	116,495.11	164,328.29	207,282.45	154,095.14	200,789.51	245,395.00		1,882,043.51		
3515	ADULT 40-100% FEMAL	129,870.25	126,253.51	145,831.83	93,574.42	123,011.34	155,571.90	82,753.55	152,209.47	210,102.33	114,068.03	224,572.65	202,186.09		1,760,005.37		
	E																
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	1,785,209.78	1,313,666.77	1,787,546.35	2,364,231.73	1,258,601.92	2,039,235.47	1,917,430.36		23,285,330.96		
3517	ADULT 40-100% FEMAL	1,041,959.06	1,237,700.17	1,507,192.95	914,412.88	1,332,456.43	1,434,727.17	971,745.35	1,648,968.12	2,321,952.59	1,036,170.14	1,645,507.22	1,642,196.23		16,734,988.31		
	E																
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	3,024,469.89	1,864,114.16	3,699,168.65	5,017,730.59	1,877,847.90	3,404,280.91	2,787,542.52		38,745,765.71		
3519	ADULT 40-100% M&F 65	2,221.47	3,092.85	13,217.96	10,002.73	38,268.92	8,370.02	6,445.15	24,093.53	11,241.67	2,370.35	705.68	-1,592.00		118,438.33		
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	2,071.20	346.14	2,414.04	2,272.46	194.15	4,630.07	5,598.60		25,182.97		
3706	ADULT <40% EXP MALE	10,633.94	23,984.56	4,669.80	750.93	505.10	5,801.59	7,699.52	10,316.07	5,252.92	3,444.88	5,477.28	2,453.78		80,990.37		
3707	ADULT <40% EXP FEMA	1.99	2,403.00	0.00	18.37	42.23	0.00	0.00	2,595.00	4,639.86	6,782.99	429.43	-578.83		16,334.04		
	L																
3708	ADULT <40% EXP M&F	45,125.52	49,384.54	32,831.93	19,112.06	30,772.98	28,492.76	14,169.14	43,741.18	64,041.10	23,505.27	25,118.98	59,712.18		436,007.64		
	4																
3709	ADULT <40% EXP M&F	2,803.98	28,164.39	6,431.16	4,981.90	7,160.70	10,434.82	19,682.03	16,589.37	28,273.37	11,379.01	19,384.08	2,826.21		158,111.02		
	6																
3714	ADULT <40% EXP MALE	621,360.59	554,889.29	876,545.69	493,194.81	454,993.26	576,571.09	576,907.44	783,705.21	1,164,355.29	724,291.99	952,590.40	1,031,356.65		8,810,761.71		
3715	ADULT <40% EXP FEMA	643,610.77	820,674.39	951,536.69	609,655.14	751,093.14	864,916.83	639,113.37	927,440.68	1,364,694.66	836,045.68	1,259,495.14	983,466.59		10,651,743.08		
	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	21,466,511.82	18,252,232.02	23,104,880.09	32,304,017.28	22,639,809.17	28,638,112.22	31,661,441.48		270,264,394.86		
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	10,065,821.72	8,248,777.12	11,141,395.39	16,110,574.28	9,824,554.39	13,660,701.88	15,367,878.44		128,186,260.99		
	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	19,894,721.70	14,826,290.25	21,729,404.12	30,949,243.73	17,401,390.46	27,394,412.19	25,144,294.93		254,859,616.46		
	4																
3719	ADULT <40% EXP M&F	5,868.72	10,073.43	7,031.23	3,378.82	15,282.09	6,512.87	20,244.78	15,999.88	19,822.87	3,179.50	19,006.35	8,589.02		134,989.56		
	6																
3726	ADULT <40% EXP MALE	0.00	89.78	26.64	0.00	0.00	0.00	785.68	3,450.54	17,474.28	5,577.63	10,915.37	12,935.36		51,255.28		
3727	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,474.12	519.00	1,472.78	1,752.24		5,218.14		
	L																
3728	ADULT <40% EXP M&F	43,757.41	19,537.11	20,036.99	14,127.59	15,443.59	9,166.70	43,499.96	16,457.42	20,513.12	11,047.05	18,281.74	32,471.17		264,339.85		
	4																
SUBTOTAL:	50,900,877.25	59,087,898.23	66,599,245.35	44,713,893.81	54,791,048.37	59,507,641.15	47,020,615.79	65,306,596.63	92,236,685.06	55,960,682.33	79,564,683.59	81,149,587.09		756,839,454.65		

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	5,113.50	542.98	5,277.67	2,811.17	8,220.11	828.05	5,048.86	
3907	NEWLY ELIGIBLE FEMA L	1,667.42	2,453.02	0.00	0.00	0.00	0.00	0.00	0.00	1,557.00	348.12	33,268.73	1,364.39	
3908	NEWLY ELIGIBLE M&F
4	45,188.51	85,144.19	54,253.45	38,548.85	41,052.01	74,602.53	54,857.91	71,388.89	133,457.09	64,381.05	84,183.39	72,639.74	
3909	NEWLY ELIGIBLE M&F 6	36,961.32	36,807.33	39,166.58	20,667.00	41,510.01	37,781.81	22,849.52	52,150.17	88,932.67	35,380.16	60,986.08	42,584.10	
3914	NEWLY ELIGIBLE MALE	110,275.43	85,315.24	77,577.86	56,747.93	60,614.11	81,485.18	61,444.20	78,784.89	96,044.06	77,614.59	117,046.30	189,434.81	
3915	NEWLY ELIGIBLE FEMA L	101,112.74	154,557.83	144,259.07	94,182.08	115,249.39	114,987.81	82,956.90	131,703.25	164,018.69	107,656.35	178,145.99	134,453.12	
3916	NEWLY ELIGIBLE MALE	1,095,766.22	1,219,994.12	1,574,243.01	1,026,197.50	1,389,497.45	1,069,620.49	919,614.30	1,565,974.76	1,790,898.74	1,097,584.11	1,653,684.81	1,520,156.01	
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	1,916,319.76	1,172,183.83	2,106,960.82	2,783,258.53	1,188,026.54	2,151,985.55	1,603,522.48	
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	2,722,990.92	1,558,121.76	3,673,033.28	5,140,072.99	1,905,771.09	3,652,316.29	2,879,691.09	
3919	NEWLY ELIGIBLE M&F 6	8,020.21	6,386.64	6,052.30	5,611.34	8,474.31	6,834.72	3,653.23	8,814.91	17,096.95	5,328.87	5,616.97	20,074.80	
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	860.20	206.26	703.02	393.13	70.75	589.75	74.75	

519.00	
36,446.93	
40,658.68	
819,697.61	
515,776.75	
1,092,384.60	
1,523,283.22	
15,923,231.52	
22,142,753.48	
37,186,369.50	
101,965.25	
6,190.92	
8,888.77	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3929	NEWLY ELIGIBLE M&F 6	755.41	792.88	1,329.98	204.89	1,441.45	712.63	511.27	2,476.92	2,821.76	1,142.72	1,041.85	-617.13		12,614.63		
SUBTOTAL:	5,825,472.83	7,828,428.13	7,645,677.69	4,831,000.96	6,553,672.94	6,031,309.55	3,876,942.16	7,697,268.58	10,221,362.78	4,491,524.46	7,939,693.76	6,468,427.02		79,410,780.86		

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	640.00	0.00	
4413	SOBRA 100-133% M&F
6	468,186.79	696,749.93	871,033.75	548,623.98	620,691.52	831,561.21	496,157.36	872,570.69	1,009,758.50	571,663.05	989,166.12	880,781.05	
4414	SOBRA 100-133% MALE	193,865.89	275,272.41	332,214.72	241,936.40	293,437.88	253,566.78	235,429.73	268,797.48	362,975.70	167,343.60	302,286.18	260,976.15	
4415	SOBRA 100-133% FEMA L	257,007.26	345,910.41	485,010.88	251,057.77	295,204.08	297,863.25	237,878.39	378,727.10	487,520.78	244,364.20	395,807.00	281,321.67	
SUBTOTAL:	919,059.94	1,317,932.75	1,688,259.35	1,041,618.15	1,209,333.48	1,382,991.24	969,465.48	1,520,095.27	1,860,254.98	983,370.85	1,687,899.30	1,423,078.87	

640.00	
8,856,943.95	
3,188,102.92	
3,957,672.79	
16,003,359.66	

4517	BC PATIENT FEMALE 2 1	9,490.94	1,210.35	479.00	0.00	0.00	637.92	0.00	0.00	519.00	0.00	0.00	640.00	
4518	BC PATIENT FEMALE 4
5	2,886.76	4,235.11	3,896.43	2,032.08	3,593.00	223.21	2,595.00	10,264.00	8,873.91	1,733.22	4,967.14	1,446.63	
SUBTOTAL:	12,377.70	5,445.46	4,375.43	2,032.08	3,593.00	861.13	2,595.00	10,264.00	9,392.91	1,733.22	4,967.14	2,086.63	

12,977.21	
46,746.49	
59,723.70	

8700	SSI DISABLED FREEDO M	29,292.48	37,923.07	38,553.81	17,731.06	31,293.09	33,649.30	29,431.21	45,622.03	80,761.78	40,783.70	43,949.97	29,553.21	
8710	SSI DISABLED FREEDO
M	25,450.96	47,158.52	28,356.43	13,454.75	34,091.97	21,653.07	44,535.55	70,638.83	155,161.22	23,858.98	65,659.85	54,983.96	
8720	SSI DISABLED FREEDO M	7,369.22	1,805.95	7,047.13	788.29	3,873.38	1,476.74	1,260.89	6,049.08	5,270.58	1,379.86	1,425.95	2,587.22	
SUBTOTAL:	62,112.66	86,887.54	73,957.37	31,974.10	69,258.44	56,779.11	75,227.65	122,309.94	241,193.58	66,022.54	111,035.77	87,124.39	

458,544.71	
585,004.09	
40,334.29	
1,083,883.09	

S000	STATE-ONLY BHS	1,742.57	48,951.66	-6,474.77	0.00	0.00	0.00	0.00	33.85	15,064.12	0.00	0.00	0.00	
SUBTOTAL:	1,742.57	48,951.66	-6,474.77	0.00	0.00	0.00	0.00	33.85	15,064.12	0.00	0.00	0.00	

59,317.43

59,317.43

1,749,511,081.11

118,078,082.23	143,666,391.28	159,290,331.37	102,752,593.93	130,552,812.26	137,023,223.09	103,525,963.44	156,548,588.97	220,940,824.35	122,462,431.56	180,692,499.68	173,977,338.95	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending June 30, 2022	
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	3,700.59	2,501.25	1,317.39	10,602.39	1,003.43	879.15	4,795.02		34,006.95		
1012	TANF 01-05 M & F NON	0.00	584.30	1,551.41	319.12	156.41	7,148.25	65.87	2,069.22	10.41	90.18	118.52	3,872.56		15,986.25		
1013	TANF 06-13 M & F NON	0.00	108.81	0.00	616.91	199.91	0.00	2,180.81	0.00	228.50	17.62	8.81	268.13		3,629.50		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	185.98	0.00	292.83	0.00	0.00	0.00	0.00	0.00	964.55		1,443.36		
1015	TANF 14-20 FEMALE N	0.00	34.56	0.00	156.41	0.00	4,796.86	5,003.50	107.62	5,784.77	0.00	1,075.85	169.69		17,129.26		
	O																
1017	TANF 21-44 FEMALE N	8,697.66	1,003.09	7,548.27	18,217.45	14,156.83	3,799.25	16,009.66	7,741.79	19,642.88	18,247.38	17,289.75	22,279.59		154,633.60		
	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	86,434.46	18,403.52	33,476.13	31,968.38	46,787.98	43,466.17	28,385.08		375,620.42		
4312	SOBRA CHILD 01-05 M	5,456.38	16,221.91	24,716.50	10,659.31	33,768.67	18,945.66	18,473.56	12,736.94	13,055.95	14,611.74	11,224.95	7,028.45		186,900.02		
4313	SOBRA CHILD 06-13 M	37,828.14	30,961.06	14,000.54	4,399.19	9,601.62	6,363.69	3,307.81	25,678.22	34,890.79	17,117.69	6,491.14	5,350.32		195,990.21		
4314	SOBRA CHILD 14-20 MA	15,311.62	14,097.42	16,295.62	6,937.85	2,334.15	12,736.88	12,189.58	16,801.10	8,177.32	11,721.97	5,967.48	14,546.58		137,117.57		
4315	SOBRA CHILD 14-20 FE	16,279.08	21,793.44	5,675.13	964.19	2,456.39	10,754.42	7,766.76	39,884.15	58,226.61	6,839.90	73,207.37	16,348.07		260,195.51		
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	11.02	0.00	0.00	0.00	519.41	65.01	0.00	1,437.50	0.00		2,032.94		
	M																
5015	SOBRA PREG 14-20 FE	15,222.45	17,478.11	14,911.24	8,978.69	16,140.73	4,181.69	8,350.80	6,409.59	23,238.38	16,002.56	12,904.49	10,518.32		154,337.05		
	M																
5017	SOBRA PREG 21-44 FE	39,336.78	65,516.68	74,710.59	84,873.11	72,645.36	104,213.77	79,014.22	102,715.69	127,670.81	57,327.06	103,527.05	81,719.79		993,270.91		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	6,140.07	0.00	40.60	1,267.88	39.37	491.94	160.99	0.00		8,140.85		
	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	263,368.35	173,307.94	250,725.13	333,601.57	190,259.45	277,759.22	196,246.15		2,544,866.43		

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	
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	-276.26	-6,644.75	0.00	0.00	0.00	-74.28	0.00	0.00	0.00	0.00	-143.05	
SUBTOTAL:	0.00	-308.89	-6,644.75	1,844.56	0.00	0.00	-74.28	0.00	0.00	0.00	0.00	-143.05	

1,844.56	
-41.07	
8.44	
0.00	
-7,138.34	
-5,326.41	

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	1,749.54	2,667.13	526.96	42,999.92	2,225.45	549.48	5,466.78	
4414	SOBRA 100-133% MALE	753.65	0.00	311.12	0.00	708.48	259.83	0.00	0.00	615.85	1,365.90	771.41	547.39	
4415	SOBRA 100-133% FEMA L	2,565.94	386.03	1,053.61	5,117.91	0.00	318.33	-111.38	847.08	373.36	84.45	1,311.75	1,131.88	

107,235.19	
5,333.63	
13,078.96	

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	22,438.56	8,136.81	4,046.11	5,883.17	21,442.02	2,327.70	2,555.75	1,374.04	43,989.13	3,675.80	2,632.64	7,146.05		125,647.78		

TOTAL:	191,240.19	190,343.72	180,316.90	150,069.81	203,121.41	265,696.05	175,789.41	252,099.17	377,590.70	193,935.25	280,391.86	203,249.15		2,663,843.62		

FEDERAL EMERGENCY SERVICES
For The Period Ending June 30, 2022	
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	28,678.22	6,983.75	14,181.80	64,852.98	44,981.48	9,832.16	51,845.34		312,727.21		
1012	TANF 01-05 M & F NON	15,297.23	9,075.54	7,755.84	4,105.07	15,206.33	26,135.58	8,654.91	34,876.76	37,341.50	27,309.91	49,739.12	21,257.71		256,755.50		
1013	TANF 06-13 M & F NON	59,826.19	66,110.48	47,837.56	239,651.05	31,614.14	35,159.16	60,100.15	46,664.90	88,289.15	107,972.82	91,142.43	284,321.77		1,158,689.80		
1014	TANF 14-20 MALE NON-	278,180.05	31,321.08	34,537.75	82,949.79	179,349.33	120,804.99	47,574.75	23,516.09	38,708.96	27,189.64	63,239.69	42,674.47		970,046.59		
1015	TANF 14-20 FEMALE N	189,513.40	152,543.86	194,485.94	129,570.88	145,796.62	440,614.35	108,208.34	374,800.38	180,929.78	129,670.72	146,078.34	208,330.86		2,400,543.47		
	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	1,600,112.94	1,481,804.19	1,611,477.11	1,509,616.66	1,288,952.61	1,405,948.61	1,274,577.96		17,519,822.55		
	O																
1018	TANF 45-64 M & F NON	2,748.27	2,056.06	7,502.32	16,638.26	6,606.25	11,930.82	5,824.85	189.50	10,590.54	2,476.65	9,585.12	6,587.64		82,736.28		
2100	SSI AGED WITH MEDIC	31,697.85	19,353.33	35,356.56	18,752.05	8,835.36	49,222.80	25,904.17	41,657.93	21,885.24	43,438.63	22,454.73	36,975.93		355,534.58		
	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	1,785,329.64	1,709,551.36	2,119,948.01	2,230,027.62	1,603,359.38	1,700,290.50	1,902,778.57		20,564,408.87		
	R																
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	405.03	508.56	398.75	1,864.15	0.00	0.00	6.58		3,183.07		
2200	SSI DISABLED WITH M	3,601.48	1.02	1,981.67	105.29	734.51	715.03	105.29	889.19	766.85	1,138.10	371.09	821.14		11,230.66		
	E																
2210	SSI DISABLED NON-ME	9,746.22	21,117.57	5,696.80	8,816.00	9,691.71	16,728.83	10,341.15	12,458.45	17,872.38	7,914.08	14,105.66	18,032.21		152,521.06		
	D																
2220	SSI DISABLED WITH Q	34.30	0.00	0.00	16.86	817.11	0.00	798.10	0.00	884.04	2,425.41	549.47	877.32		6,402.61		
	M																
SUBTOTAL:	3,795,664.25	2,999,893.65	3,845,462.67	3,282,559.63	3,155,336.24	4,115,837.39	3,466,359.57	4,281,058.87	4,203,629.85	3,286,829.43	3,513,336.92	3,849,087.50		43,795,055.97		

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	372.53	303.57	2,522.25	909.93	1,157.76	0.00	
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	32.06	3,557.76	
1108	TANF EXPANDED 45-64	3,654.82	1,512.44	0.00	802.54	61.68	0.00	0.00	871.16	427.73	2,834.33	1,421.66	728.00	
1109	TANF EXPANDED 65+ M
&	0.00	294.36	19.89	0.00	430.62	712.14	0.00	35.02	0.00	9.14	0.00	2,047.21	
1114	TANF EXPANDED 14-20	156.41	0.00	0.00	0.00	358.42	304.61	0.00	132.02	0.00	293.04	0.00	0.00	
1115	TANF EXPANDED 14-20	21,962.65	8,746.94	7,951.94	8,397.53	15,921.31	35,304.89	16,672.20	34,440.33	34,740.93	16,392.79	18,214.00	18,179.29	
1116	TANF EXPANDED 21-44	1,048,326.70	533,095.41	836,204.67	534,727.26	809,351.05	1,412,791.78	880,945.31	680,388.70	718,471.65	790,865.16	523,554.37	686,479.00	
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	2,142,130.31	1,693,628.44	1,675,678.26	1,826,129.97	1,496,490.31	1,615,867.40	1,667,526.98	
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	1,820,529.63	1,636,789.26	1,542,502.21	1,469,840.36	2,101,156.19	1,167,822.77	1,604,581.95	
1119	TANF EXPANDED 65+ M
&	6,248.58	98,287.60	3,205.64	5,835.12	20,772.36	25,450.76	41,639.41	82,772.32	50,750.74	30,288.96	19,309.65	37,028.41	
2400	SSI AGED EXPANDED WI	0.00	750.24	0.00	0.00	6,642.67	0.00	115.85	46.32	174.80	1,948.61	2.04	-789.44	
2410	SSI AGED EXPANDED N
O	23,075.05	47,015.76	9,193.87	9,065.70	23,191.15	33,750.71	35,666.23	26,771.77	56,113.61	16,811.12	14,510.40	10,337.03	
2420	SSI AGED EXPANDED WI	2,672.63	2,821.03	3,103.16	1,986.63	672.00	6,545.72	7,086.22	2,476.25	2,077.94	2,572.22	4,204.75	6,588.42	
2600	SSI DISABLED EXPAND
E	0.00	0.00	25.52	0.00	25.52	21.69	25.52	71.71	97.74	4,166.27	4,518.93	2,784.96	
SUBTOTAL:	3,942,636.11	3,125,659.78	4,376,209.45	3,269,109.07	3,488,601.65	5,477,542.24	4,312,940.97	4,046,489.64	4,161,347.72	4,464,738.07	3,370,615.79	4,039,049.57	

5,266.04	
5,314.17	
12,314.36	
3,548.38	
1,244.50	
236,924.80	
9,455,201.06	
20,103,499.80	
17,461,099.08	
421,589.55	
8,891.09	
305,502.40	
42,806.97	
11,737.86	
48,074,940.06	

3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	39.36	0.00	2,080.04	705.46	0.00	215.70	86.31	0.00	25.26	260.38	
3908	NEWLY ELIGIBLE M&F
4	5,103.28	11,405.62	3,222.06	13,888.28	13,299.87	45,323.05	13,686.77	13,367.40	23,420.25	34,800.25	23,251.21	26,732.60	
3914	NEWLY ELIGIBLE MALE	57,585.65	38,174.24	165,495.15	36,091.71	46,227.65	43,001.56	45,662.38	27,743.93	47,828.79	115,486.51	23,380.68	73,638.39	
3915	NEWLY ELIGIBLE FEMA L	115,785.62	25,600.25	56,584.36	47,504.16	34,340.55	50,060.68	52,249.93	43,375.55	108,321.71	29,975.04	51,434.90	41,559.73	
3916	NEWLY ELIGIBLE MALE	1,618,808.94	1,156,470.36	2,006,997.01	1,533,863.67	1,013,151.30	1,908,617.15	1,602,598.42	1,605,628.84	1,684,866.95	1,217,354.38	1,788,547.71	2,362,410.34	

3,412.51	
227,500.64	
720,316.64	
656,792.48	
19,499,315.07	

FEDERAL EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3917	NEWLY ELIGIBLE FEMA L	724,167.62	367,395.52	849,627.24	505,272.52	493,415.89	684,554.67	662,932.33	752,378.37	773,835.64	636,118.27	625,789.27	641,673.62		7,717,160.96		
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	5,068,545.03	4,206,181.32	4,850,926.07	4,617,166.29	4,022,203.43	3,884,028.28	4,658,783.54		49,932,139.41		
3919	NEWLY ELIGIBLE M&F 6	3,916.65	3,165.63	1,799.11	1,462.01	627.47	4,742.58	1,411.64	1,926.30	4,968.91	7,969.31	5,767.40	644.74		38,401.75		
SUBTOTAL:	6,513,412.40	5,298,522.39	7,706,741.27	5,483,395.35	4,574,802.83	7,805,550.18	6,584,722.79	7,295,562.16	7,260,494.85	6,063,907.19	6,402,224.71	7,805,703.34		78,795,039.46		

12,035,064.05

15,625,472.42

15,693,840.41

13,286,177.42

TOTAL:

14,251,712.76

11,424,075.82

15,928,413.39

11,218,740.72

17,398,929.81

14,364,023.33

15,623,110.67

13,815,474.69

170,665,035.49

QMB - FEE FOR SERVICE
For The Period Ending June 30, 2022	
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	527,433.83	-63,326.02	471,302.25	625,552.98	408,498.03	460,234.72	606,845.60		5,992,197.41		
8040	SLMB	10,591.96	13,331.67	16,872.58	3,135.34	517.37	2,996.36	2,149.45	2,987.42	4,769.27	1,723.26	-645.66	3,125.23		61,554.25		
8050	QI1	1,075.12	95.19	0.00	511.57	0.00	60.16	0.00	111.76	792.98	155.98	0.00	0.00		2,802.76		
SUBTOTAL:	435,180.28	487,099.08	843,662.08	376,844.91	859,000.47	530,490.35	-61,176.57	474,401.43	631,115.23	410,377.27	459,589.06	609,970.83		6,056,554.42		

TOTAL:	435,180.28	487,099.08	843,662.08	376,844.91	859,000.47	530,490.35	-61,176.57	474,401.43	631,115.23	410,377.27	459,589.06	609,970.83		6,056,554.42		

FFS TRBHA FEE FOR SERVICE
For The Period Ending June 30, 2022	
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	11.32	12.04	188.24	0.00	0.00	0.00	0.00		314.08		
1008	TANF 45-64 M & F WIT	0.00	0.00	22,210.23	0.00	0.00	0.00	0.00	328.96	664.04	807.54	0.00	0.00		24,010.77		
1009	TANF 65+ M & F WITH	0.00	0.00	4,215.20	6,322.80	6,531.00	0.00	345.17	0.00	269.20	519.00	138.88	17.88		18,359.13		
1011	TANF <1 M & F NON-ME	4,905.00	10,954.40	8,750.19	13,943.22	26,824.28	6,747.00	906.76	5,230.22	5,451.00	3,522.60	8,203.79	3,612.17		99,050.63		
1012	TANF 01-05 M & F NON	5,626.25	2,786.30	1,277.85	1,562.27	3,970.40	3,694.91	4,374.43	5,342.89	6,042.43	8,547.85	9,867.68	10,948.26		64,041.52		
1013	TANF 06-13 M & F NON	81,451.13	58,519.56	118,487.21	90,405.60	87,630.65	151,552.71	137,656.50	146,694.27	231,743.88	159,728.62	212,319.79	193,195.20		1,669,385.12		
1014	TANF 14-20 MALE NON-	42,132.88	29,288.97	33,590.99	38,137.38	30,326.66	39,253.44	30,434.92	31,056.52	28,251.28	42,736.66	26,576.95	38,702.23		410,488.88		
1015	TANF 14-20 FEMALE N	64,001.10	120,115.95	102,020.64	100,057.47	69,999.33	100,741.78	91,999.53	82,520.07	200,175.50	68,956.98	83,378.27	163,864.88		1,247,831.50		
	O																
1016	TANF 21-44 MALE NON-	561,748.49	571,592.94	961,699.66	604,489.67	977,875.64	998,059.31	988,306.97	1,070,525.99	1,709,937.94	1,349,678.11	1,662,351.01	1,956,314.42		13,412,580.15		
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	2,791,039.25	2,831,872.43	3,251,691.86	4,905,195.12	4,511,031.16	5,586,559.56	6,303,030.42		43,538,008.94		
	O																
1018	TANF 45-64 M & F NON	545,048.85	491,200.28	994,927.74	702,988.29	936,687.78	703,208.99	566,771.41	658,171.65	1,239,046.24	957,640.38	1,113,850.41	1,192,175.18		10,101,717.20		
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	2,560.00	0.00		2,560.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	667.10	493.44	1,151.36	2,302.72		4,614.62		
2100	SSI AGED WITH MEDIC	10,326.36	9,475.12	24,032.04	15,449.54	20,149.40	13,884.08	53,617.49	78,574.13	90,006.69	36,142.02	38,897.28	84,110.96		474,665.11		
	A																
2110	SSI AGED NON-MEDICA	5,557.30	5,133.50	16,103.90	11,521.38	3,181.07	3,611.46	3,229.60	5,772.23	22,945.27	29,147.58	21,699.89	25,123.29		153,026.47		
	R																
2120	SSI AGED WITH QMB	89,006.32	31,344.36	35,253.28	75,170.03	87,339.13	112,726.67	102,992.58	101,465.31	124,834.56	182,276.36	275,603.91	250,429.52		1,468,442.03		
2200	SSI DISABLED WITH M	83,719.93	59,115.36	60,831.81	46,621.41	71,228.16	83,499.51	151,588.48	63,062.19	105,811.33	65,602.79	118,983.58	195,312.93		1,105,377.48		
	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	2,323,995.03	1,965,565.83	2,886,093.27	3,227,058.54	2,609,155.33	3,707,474.85	3,876,923.82		30,650,585.33		
	D																
2220	SSI DISABLED WITH Q	339,374.02	322,783.65	373,624.51	324,036.72	528,720.43	387,751.14	315,256.98	351,378.95	471,686.23	604,052.30	619,646.14	612,691.64		5,251,002.71		
	M																
2310	SSI BLIND NON-MEDIC	18,109.19	36,079.45	24,510.44	35,785.32	70,438.73	117,438.60	43,817.16	59,641.94	144,966.21	93,785.81	121,400.15	143,938.60		909,911.60		
	A																
2320	SSI BLIND WITH QMB	337.66	8,098.45	511.59	32,128.21	41,322.57	165.79	0.00	21.48	0.00	0.00	0.00	715.90		83,301.65		
4311	SOBRA CHILD <1 M & F	9,013.41	6,950.60	7,985.24	9,734.34	6,480.86	4,651.50	5,840.68	3,811.69	10,983.60	3,214.88	3,545.66	5,845.66		78,058.12		
4312	SOBRA CHILD 01-05 M	298,186.88	150,684.59	277,660.34	162,264.21	166,010.85	192,878.08	222,321.45	244,373.36	511,822.04	572,794.95	346,676.34	314,108.12		3,459,781.21		
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	2,636,311.39	1,756,662.71	2,350,598.30	2,734,517.97	2,684,481.08	3,164,819.65	3,432,547.13		31,696,869.11		
4314	SOBRA CHILD 14-20 MA	743,015.80	820,032.78	973,546.02	673,453.34	880,837.74	889,422.76	742,178.50	907,421.68	881,522.09	894,128.73	1,108,306.73	1,101,913.25		10,615,779.42		
4315	SOBRA CHILD 14-20 FE	845,608.70	867,812.66	1,009,568.80	729,754.98	834,451.23	968,864.83	999,095.62	1,048,681.47	1,215,248.12	1,105,797.89	1,348,044.11	1,681,991.41		12,654,919.82		
5007	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	82.80	82.80	0.00	82.80	0.00	0.00	0.00		248.40		
	M																
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	7,855.84	5,310.40	16,703.00	6,510.23	33,762.45	27,318.07	44,934.59		156,942.20		
	M																
5017	SOBRA PREG 21-44 FE	147,608.78	173,502.35	242,786.68	115,235.44	146,821.37	235,418.31	187,886.92	267,461.19	380,301.58	318,952.31	510,170.95	442,062.26		3,168,208.14		
	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	640.00	0.00		640.00		
	M																
SUBTOTAL:	11,342,980.91	10,117,749.38	13,654,796.62	10,487,756.57	12,510,456.88	12,772,866.50	11,208,127.36	13,636,810.86	18,255,740.99	16,336,956.82	20,120,185.01	22,076,812.44		172,521,240.34		

1,699.64

17.97

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	28.56	224.57	564.61	519.00	242.00	0.00	
1108	TANF EXPANDED 45-64	13.62	0.00	1,946.05	0.00	583.33	405.69	483.50	669.75	3,281.10	301.71	6,018.93	371.66	

14,075.34

FFS TRBHA FEE FOR SERVICE
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1109	TANF EXPANDED 65+ M	230.94	5.59	9,013.27	5,695.54	7,992.97	4,895.84	624.27	103.46	0.00	675.39	5,787.40	5,251.20		40,275.87		
	&																
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,417.76	5,688.72	2,555.16		10,661.64		
1115	TANF EXPANDED 14-20	1,142.07	611.90	1,586.16	1,627.42	559.84	1,404.32	2,173.68	3,787.47	3,565.32	1,557.44	2,149.12	2,816.00		22,980.74		
1116	TANF EXPANDED 21-44	272,049.59	175,061.87	281,363.54	263,129.24	366,265.16	279,166.91	355,531.29	297,721.30	393,345.16	289,221.14	419,561.04	429,679.85		3,822,096.09		
1117	TANF EXPANDED 21-44	458,809.63	514,553.07	935,673.82	568,045.27	749,898.87	645,566.58	454,301.54	542,959.56	684,709.26	674,123.30	1,055,635.86	997,757.92		8,282,034.68		
1118	TANF EXPANDED 45-64	253,873.87	194,394.89	330,740.11	181,849.54	233,985.45	178,310.10	92,740.50	188,381.77	304,371.68	158,379.35	292,531.50	440,874.12		2,850,432.88		
1119	TANF EXPANDED 65+ M	0.00	0.00	0.00	335.08	0.00	0.00	0.00	167.54	513.33	493.44	328.96	1,480.32		3,318.67		
	&																
1126	TANF EXPANDED 21-44	1,710.63	1,166.27	2,317.05	739.10	1,880.26	10,610.73	743.50	675.57	1,438.00	1,886.16	9,078.58	62.74		32,308.59		
1127	TANF EXPANDED 21-44	15.12	15.12	0.00	327.86	0.00	3,297.00	3,801.38	4,061.68	7,252.92	7,138.47	11,212.24	12,889.99		50,011.78		
1128	TANF EXPANDED 45-64	18,358.18	11,238.13	25,467.96	20,429.52	11,286.34	7,739.18	14,367.54	16,449.13	32,340.98	13,289.58	30,710.18	85,737.33		287,414.05		
1129	TANF EXPANDED 65+ M	102.28	104.18	61,907.98	17,801.67	26,597.96	8,357.12	18,288.39	1,155.07	24,826.41	22,738.85	44,478.38	38,158.49		264,516.78		
	&																
2400	SSI AGED EXPANDED	0.00	0.00	0.00	7.82	9,801.07	82.80	82.54	13.32	0.00	0.00	0.00	0.00		9,987.55		
	WI																
2410	SSI AGED EXPANDED N	0.00	0.00	1,038.00	0.00	0.00	0.00	963.61	0.00	519.00	519.00	242.00	0.00		3,281.61		
	O																
2420	SSI AGED EXPANDED	69,367.06	45,800.06	32,700.12	29,715.01	164,642.96	63,412.19	88,276.87	112,527.78	66,140.65	44,619.88	63,674.60	88,936.93		869,814.11		
	WI																
2520	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	163.62	7,329.60		7,493.22		
	W																
2600	SSI DISABLED EXPAND	1,109.28	995.10	2,610.51	718.96	1,629.26	8,398.38	6,608.30	10,754.58	14,596.55	0.00	23,504.00	24,626.40		95,551.32		
	E																
2610	SSI DISABLED EXPAND	41,283.35	1,714.54	1,431.35	2,916.07	14,757.05	14,128.56	8,283.11	10,186.01	12,209.29	13,422.46	9,495.77	32,171.48		161,999.04		
	E																
2620	SSI DISABLED EXPAND	87,019.81	87,596.69	66,251.65	75,767.10	96,182.58	152,169.88	150,807.23	162,920.05	143,717.32	163,701.47	238,681.41	298,807.48		1,723,622.67		
	E																
SUBTOTAL:	1,205,085.43	1,033,322.48	1,754,121.37	1,169,105.20	1,686,063.10	1,377,945.28	1,198,105.81	1,352,758.61	1,693,391.58	1,395,004.40	2,219,184.31	2,469,506.67		18,553,594.24		

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	328.96	822.40	1,644.80	
3514	ADULT 40-100% MALE 1	6,635.93	16,975.08	116,931.15	32,841.66	42,097.99	74,814.12	34,474.70	14,789.41	18,725.45	12,817.56	20,487.19	1,073.17	
3515	ADULT 40-100% FEMAL E	6,426.89	9,649.17	11,116.51	7,844.51	13,198.80	20,564.93	5,720.89	7,028.90	28,555.16	13,677.11	32,576.37	60,001.78	
3516	ADULT 40-100% MALE 2	278,067.16	207,478.03	321,849.35	357,881.54	208,556.02	143,218.79	145,909.03	246,665.78	246,020.87	231,052.18	227,586.39	267,176.77	
3517	ADULT 40-100% FEMAL E	101,424.52	124,454.19	138,604.14	94,824.36	126,473.69	164,180.18	145,464.59	102,203.87	217,419.86	125,748.08	174,888.32	218,595.35	
3518	ADULT 40-100% M&F 45	181,723.59	98,013.88	90,702.39	98,653.37	147,608.85	124,281.55	147,146.64	196,180.59	226,092.36	168,876.69	240,091.44	304,766.27	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	519.00	0.00	0.00	0.00	0.00	1,280.00	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	517.10	516.88	14.26	2,085.83	790.88	534.90	4,096.76	
3714	ADULT <40% EXP MALE	189,769.08	209,305.38	248,578.51	326,550.88	302,417.85	264,280.23	259,391.31	339,479.16	586,653.23	313,294.62	318,367.23	474,590.22	
3715	ADULT <40% EXP FEMA L	76,578.54	74,351.22	138,343.70	69,099.80	82,258.02	195,312.23	124,577.30	242,856.39	260,141.10	352,188.00	318,790.33	399,659.55	
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	6,046,749.54	6,239,730.11	7,142,940.05	9,955,718.43	8,293,706.06	10,554,955.16	11,976,845.27	
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	2,800,938.10	2,818,074.14	3,077,706.16	4,633,600.98	4,162,533.48	5,043,522.02	5,806,549.82	
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	3,096,958.81	2,832,040.95	3,600,060.46	5,216,294.58	4,264,669.33	5,817,025.01	6,426,545.57	
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	31.37	0.00	4,084.64	7,658.70	
SUBTOTAL:	9,505,500.10	9,153,942.06	12,037,408.70	10,538,745.88	10,861,293.18	12,932,334.58	12,753,046.54	14,969,925.03	21,391,339.22	17,939,682.95	22,755,011.40	25,949,204.03	

2,796.16	
392,663.41	
216,361.02	
2,881,461.91	
1,734,281.15	
2,024,137.62	
1,799.00	
759.66	
15,809.21	
3,832,677.70	
2,334,156.18	
84,275,753.90	
39,786,318.04	
43,276,684.00	
11,774.71	
180,787,433.67	

FFS TRBHA FEE FOR SERVICE
For The Period Ending June 30, 2022

RATE CODE	DESCRIPTION

3906

NEWLY ELIGIBLE MALE

3908

3909

3914

3915

3916

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

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

3917

3918

3919

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

6
SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
310.70	37.04	23,722.10	8,716.90	8,935.15	5,361.09	3,574.06	12,253.92	11,247.64	9,407.64	3,814.95	7,336.34	
94,717.53	
84.18	33.70	798.93	38.32	171.05	56.29	18.61	822.40	8,456.44	52.74	8,591.21	5,405.76	24,529.63	
765.78	345.34	0.00	0.00	0.00	335.08	335.08	335.08	2,726.72	1,154.42	436.67	30,028.85	36,463.02	
7,811.01	4,785.44	9,403.64	4,692.17	5,192.34	11,710.76	12,396.02	14,048.18	10,781.23	14,949.33	11,725.81	7,425.58	114,921.51	
23,987.07	21,740.20	31,576.35	18,918.93	22,995.16	16,625.95	5,688.45	17,111.10	12,679.10	7,280.75	21,767.93	44,058.98	244,429.97	
91,395.28	145,417.00	191,831.99	114,272.65	150,023.11	177,215.39	119,220.29	67,639.06	162,514.91	178,461.22	204,630.84	355,600.77	1,958,222.51	
120,692.21	124,826.77	241,826.52	206,654.66	293,178.70	128,298.13	152,698.90	91,178.46	146,838.95	219,030.76	308,756.25	339,963.89	2,373,944.20	
139,993.60	173,373.25	254,348.02	135,038.08	207,465.03	106,528.03	84,357.53	163,005.78	94,977.03	102,374.03	150,158.36	260,395.29	1,872,014.03	
1,762.97	1,442.43	1,282.16	2,243.78	1,923.24	2,083.51	2,404.05	1,762.97	3,281.78	1,923.24	2,004.97	2,404.05	24,519.15	
386,802.80	472,001.17	754,789.71	490,575.49	689,883.78	448,214.23	380,692.99	368,156.95	453,503.80	534,634.13	711,886.99	1,052,619.51	6,743,761.55	

4413	SOBRA 100-133% M&F
6	122,467.39	68,119.05	89,856.83	57,358.28	65,309.11	76,619.12	56,186.72	56,165.73	60,174.94	42,877.54	63,221.84	66,719.43	
4414	SOBRA 100-133% MALE	50,573.74	62,321.59	67,965.08	59,381.36	52,822.39	41,861.42	17,449.49	26,876.38	32,468.96	52,701.52	52,422.84	39,424.94	
4415	SOBRA 100-133% FEMA L	33,189.36	38,442.32	32,477.64	17,271.82	10,983.86	54,807.88	24,803.01	38,242.86	66,157.06	62,914.44	60,114.59	55,378.66	
SUBTOTAL:	206,230.49	168,882.96	190,299.55	134,011.46	129,115.36	173,288.42	98,439.22	121,284.97	158,800.96	158,493.50	175,759.27	161,523.03	

825,075.98	
556,269.71	
494,783.50	
1,876,129.19	

4518	BC PATIENT FEMALE 4 5	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:	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

519.00

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	811.78	1,350.86	1,227.02	1,524.24	689.28	1,025.44	244.21	387.32	1,685.86	
8710	SSI DISABLED FREEDO
M	581.74	519.00	2,348.74	581.74	1,100.74	1,038.00	1,526.77	519.00	561.80	1,012.44	1,065.74	1,920.00	
8720	SSI DISABLED FREEDO M	672.96	1,064.35	1,574.30	25,279.06	12,907.58	4,135.98	3,178.76	18,296.99	9,701.77	977.16	4,022.35	3,280.25	
SUBTOTAL:	1,254.70	1,583.35	3,923.04	26,672.58	15,359.18	6,401.00	6,229.77	19,505.27	11,289.01	2,233.81	5,475.41	6,886.11	

8,946.01	
12,775.71	
85,091.51	
106,813.23	

380,589,491.22

22,648,373.43	20,947,481.40	28,395,338.99	22,846,867.18	25,892,171.48	27,711,050.01	25,644,641.69	30,468,441.69	41,964,065.56	36,367,005.61	45,987,502.39	51,716,551.79	

TOTAL:

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending June 30, 2022		
RATE COD	E	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	18,343.69	17,989.91	19,508.97	6,185.28	15,477.69	27,723.64	25,736.66	278,266.24		
1017	TANF 21-44 FEMALE N O	70,091.96	48,521.90	37,027.06	81,355.38	18,856.97	93,688.61	25,740.69	42,489.49	49,639.51	43,990.92	31,891.01	56,691.37	599,984.87		
1018	TANF 45-64 M & F NON	0.00	9,671.26	19,755.39	16,022.99	0.00	3,379.84	8,449.60	9,784.52	9,163.99	773.16	11,018.88	5,971.91	93,991.54		
2200	SSI DISABLED WITH M E	0.00	0.00	2,559.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,339.00	0.00	4,898.39		
2210	SSI DISABLED NON-ME
D	42,656.50	40,852.26	98,085.86	109,265.89	109,987.31	64,457.25	41,056.29	70,936.29	43,282.12	38,325.49	96,815.71	59,728.77	815,449.74		
2220	SSI DISABLED WITH Q M	1,484.00	6,798.00	1,868.00	1,524.00	1,300.00	0.00	0.00	1,484.00	3,347.20	1,556.00	1,556.00	0.00	20,917.20		
2310	SSI BLIND NON-MEDIC
A	0.00	0.00	0.00	0.00	0.00	5,118.78	0.00	0.00	0.00	0.00	0.00	0.00	5,118.78		
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	1,556.00	0.00	1,556.00		
5017	SOBRA PREG 21-44 FE M	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		
SUBTOTAL	:	126,689.87	136,683.55	166,565.71	246,419.31	197,157.38	184,988.17	93,236.49	144,203.27	111,618.10	100,123.26	172,900.24	148,128.71	1,828,714.06		

1116	TANF EXPANDED 21-44	6,825.04	6,665.10	9,677.77	8,904.61	1,706.26	9,277.92	0.00	5,971.91	4,718.93	27,193.65	7,604.64	30,328.89	
1117	TANF EXPANDED 21-44	23,247.88	13,863.45	44,365.52	23,208.08	36,839.04	16,209.47	13,609.23	16,115.34	3,852.39	23,554.33	8,465.98	18,089.30	
1118	TANF EXPANDED 45-64	2,559.39	0.00	5,118.78	10,237.56	0.00	0.00	0.00	0.00	15,948.16	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	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,062.60	
2620	SSI DISABLED EXPAND
E	0.00	1,484.00	1,484.00	3,325.38	0.00	0.00	1,484.00	1,556.00	1,556.00	0.00	0.00	0.00	
SUBTOTAL:	32,632.31	22,012.55	60,646.07	47,159.63	38,545.30	25,487.39	15,093.23	23,643.25	26,075.48	50,747.98	16,070.62	65,480.79	

118,874.72	
241,420.01	
33,863.89	
1,484.00	
17,062.60	
10,889.38	
423,594.60	

3516	ADULT 40-100% MALE 2	23,516.51	31,405.87	14,810.18	36,129.44	42,461.51	11,055.30	26,917.38	2,297.31	0.00	6,825.04	12,343.09	12,570.43	
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	8,904.61	0.00	0.00	25,593.90	10,267.23	
3518	ADULT 40-100% M&F 45	6,825.04	4,265.65	5,118.78	3,412.52	0.00	11,044.25	0.00	1,706.26	10,115.10	9,159.92	5,971.91	7,398.70	
3716	ADULT <40% EXP MALE	226,799.33	204,742.58	369,743.69	238,148.77	333,401.13	304,783.98	212,797.64	266,393.08	271,959.96	245,358.09	372,281.46	286,108.02	
3717	ADULT <40% EXP FEMA L	92,837.14	67,136.59	138,731.06	88,240.02	115,392.13	69,980.98	80,582.01	71,238.54	120,769.83	80,560.54	92,953.97	102,782.46	
3718	ADULT <40% EXP M&F
4	101,663.69	78,648.25	98,364.05	100,195.45	131,559.23	97,537.60	65,463.59	123,400.45	121,482.31	56,325.90	69,895.57	92,048.38	
SUBTOTAL:	455,054.23	389,158.42	640,631.21	477,297.10	630,262.16	494,402.11	385,760.62	473,940.25	524,327.20	398,229.49	579,039.90	511,175.22	

220,332.06	
83,620.25	
65,018.13	
3,332,517.73	
1,121,205.27	
1,136,584.47	
5,959,277.91	

3916	NEWLY ELIGIBLE MALE	31,043.50	11,943.82	39,990.60	38,070.97	57,193.24	25,294.16	3,412.52	26,304.16	14,282.77	32,922.63	45,158.70	16,471.84	
3917	NEWLY ELIGIBLE FEMA L	36,684.59	19,755.39	5,971.91	6,505.16	0.00	5,118.78	2,559.39	19,197.23	11,090.69	11,033.50	10,450.93	10,237.56	
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	34,978.33	6,825.04	37,537.72	4,081.95	5,118.78	
SUBTOTAL:	83,084.43	61,257.97	70,300.07	46,282.39	62,605.36	30,412.94	5,971.91	80,479.72	32,198.50	81,493.85	59,691.58	31,828.18	

342,088.91	
138,605.13	
164,912.86	
645,606.90	

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,556.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO
M	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:	0.00	0.00	4,265.65	0.00	0.00	0.00	0.00	0.00	1,556.00	0.00	0.00	0.00	

1,556.00	
4,265.65	
5,821.65	

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

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	697,460.84	609,112.49	942,408.71	822,277.21	928,570.20	735,290.61	500,062.25	722,266.49	695,775.28	630,594.58	827,702.34	756,612.90		8,868,133.90		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022

RATE CODE	DESCRIPTION

1016

TANF 21-44 MALE NON-

1017

1028

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

2100

2110

2120

SSI AGED WITH MEDIC A
SSI AGED NON-MEDICA
R
SSI AGED WITH QMB

2200

2210

2220

5017

SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SOBRA PREG 21-44 FE

M
SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3,498.18	46,815.64	3,826.51	342.84	0.00	0.00	0.00	0.00	8,432.86	8,488.56	1,108.29	32,292.56	
104,805.44	
0.00	0.00	0.00	0.00	6,063.67	0.00	0.00	8,039.22	0.00	0.00	1,882.09	0.00	15,984.98	
1,926.51	4,854.96	3,906.23	972.15	0.00	0.00	3,783.40	0.00	0.00	0.00	0.00	0.00	15,443.25	
98,739.64	75,979.38	112,867.92	120,745.26	52,836.19	143,105.85	79,192.43	130,290.73	93,460.24	28,306.48	5,894.56	35,957.29	977,375.97	
221,793.66	73,454.17	58,967.17	66,735.86	118,878.87	117,053.55	35,846.12	59,897.71	178,208.81	53,061.77	146,779.78	324,921.40	1,455,598.87	
10,933.93	9,243.06	1,175.56	0.00	11,593.30	92.82	14,585.86	2,168.49	8.83	183.65	0.00	314.22	50,299.72	
54,393.61	73,203.41	70,926.99	71,537.79	95,895.86	40,135.40	42,079.33	126,958.07	18,825.60	82,119.77	20,599.06	80,932.82	777,607.71	
-875.99	4,285.35	35,665.98	2,509.47	692.39	69,470.31	23,542.58	18,677.96	13,300.59	3,381.13	2,613.50	591.28	173,854.55	
4,617.92	3,125.93	779.17	4,199.49	20,180.45	1,120.11	581.82	0.00	21,593.71	639.00	3,295.19	18,769.85	78,902.64	
3,896.89	8,213.49	18,462.64	5,253.80	66.21	40.19	8,941.88	10,071.50	1,158.50	1,459.95	73.70	5,141.33	62,780.08	
398,924.35	299,175.39	306,578.17	272,296.66	306,206.94	371,018.23	208,553.42	356,103.68	334,989.14	177,640.31	182,246.17	498,920.75	3,712,653.21	

1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,832.67	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	2,814.22	
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	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	7,122.90	
SUBTOTAL:	6,482.67	512.06	59.64	96.05	0.00	0.00	0.00	0.00	3,832.67	0.00	0.00	9,937.12	

3,832.67	
2,814.22	
7,150.42	
7,122.90	
20,920.21	

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	234.11	0.00	849.06	461.91	17,554.34	0.00	31,256.89	791.37	513.92	
3517	ADULT 40-100% FEMAL E	4,774.47	437.85	3,513.11	190.77	0.00	69.12	0.00	0.00	0.00	42.80	5,825.65	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	
3708	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,845.09	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	248,828.95	223,273.42	357,069.79	382,181.48	123,231.13	310,402.33	320,932.23	
3717	ADULT <40% EXP FEMA L	50,748.03	8,892.95	17,517.66	6,055.17	6,652.59	30,603.90	9,410.94	51,570.16	30,306.11	26,961.94	62,613.36	10,110.27	
3718	ADULT <40% EXP M&F
4	479,876.78	414,766.29	693,911.97	370,041.52	355,927.96	359,531.93	390,089.80	391,354.33	314,529.44	251,229.40	162,809.30	390,323.85	
3719	ADULT <40% EXP M&F 6	0.00	250.83	0.00	0.00	0.00	6,412.21	0.00	378.50	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	646,295.17	623,236.07	824,772.21	727,017.03	432,722.16	542,442.01	721,880.27	

51,661.60	
14,853.77	
3,929.50	
6,845.09	
1,775.39	
3,416,975.19	
311,443.08	
4,574,392.57	
7,041.54	
8,388,917.73	

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	10,892.39	862.40	34,788.99	38,610.68	648.28	17,843.30	28,798.53	
3917	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	543.48	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	18,496.96	14,043.15	15,236.74	15,197.77	423.36	424.53	28,008.02	
SUBTOTAL:	28,391.26	46,766.66	36,606.48	18,325.39	26,398.73	29,932.83	14,905.55	50,025.73	53,808.45	1,071.64	18,267.83	56,806.55	

75.48	
221,291.12	
543.48	
159,397.02	
381,307.10	

4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,612.60	160.60	0.00	20,702.32	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,612.60	160.60	0.00	20,702.32	

33,475.52

33,475.52

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
TOTAL:	1,237,327.63	1,202,740.94	1,490,817.22	859,260.91	827,226.56	1,047,246.23	846,695.04	1,230,901.62	1,132,259.89	611,594.71	742,956.01	1,308,247.01		12,537,273.77		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022	
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	472.36	0.00	0.00	0.00	0.00	0.00	0.00		6,356.01		
SUBTOTAL:	0.00	0.00	0.00	0.00	5,883.65	472.36	0.00	0.00	0.00	0.00	0.00	0.00		6,356.01		

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	3,262.41	0.00	0.00	0.00	64.65	1,194.37	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	3,262.41	0.00	0.00	0.00	64.65	1,194.37	0.00	

4,521.43

4,521.43

3716	ADULT <40% EXP MALE	0.00	466.52	0.00	1,574.95	0.00	-990.00	0.00	0.00	0.00	0.00	0.00	8.70	
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	-990.00	0.00	0.00	0.00	0.00	0.00	8.70	

1,060.17	
5,135.85	
6,196.02	

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	200.57	5,347.05	0.00	0.00	0.00	9.14	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	200.57	5,347.05	0.00	0.00	0.00	9.14	0.00	

5,556.76

5,556.76

TOTAL:	0.00	466.52	0.00	1,574.95	11,019.50	2,945.34	5,347.05	0.00	0.00	64.65	1,203.51	8.70		22,630.22		

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022	
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	14,088.04	0.00	0.00	0.00	330.28	8,896.00		27,218.73		
1015	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	0.00	8,053.65	0.00	0.00	0.00	0.00	0.00	0.00		8,053.65		
	O																
1016	TANF 21-44 MALE NON-	3,461.80	40,823.31	4,974.07	0.00	151.81	1,125.35	692.03	1,838.00	13,044.52	10,435.18	0.00	2,872.08		79,418.15		
1017	TANF 21-44 FEMALE N	3,964.82	4,869.30	6,565.76	4,423.65	10,190.80	38,200.40	698.60	9,694.06	3,543.20	10,439.67	0.00	6,162.71		98,752.97		
	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	15,879.23	0.00	2,029.33	5,351.36	0.00	0.00	28,034.84		76,778.49		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	3,693.27	0.00	42.80	404.65	6,754.76	0.00	0.00		10,895.48		
	M																
4314	SOBRA CHILD 14-20 MA	25,668.80	1,615.86	0.00	0.00	0.00	6,652.31	0.00	0.00	0.00	0.00	0.00	0.00		33,936.97		
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	14,725.77	1,215.97	407.76	0.00	9,924.90	0.00	12,250.74		38,525.14		
	M																
SUBTOTAL:	44,023.81	47,762.43	24,961.73	5,377.04	23,743.68	88,329.98	16,694.64	14,011.95	22,343.73	37,554.51	330.28	58,216.37		383,350.15		

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	38,718.28	0.00	0.00	0.00	35.37	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	2,686.58	0.00	0.00	0.00	0.00	0.00	2,103.17	42.80	0.00	3,465.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.73	0.00	0.00	0.00	
SUBTOTAL:	1,673.02	29,150.19	2,993.60	0.00	0.00	0.00	38,718.28	0.00	2,112.90	42.80	35.37	3,465.00	

1,747.59	
68,136.29	
8,297.55	
9.73	
78,191.16	

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	21,889.34	38,764.13	0.00	1,094.24	6,616.56	6,086.00	1,729.59	
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	2,885.33	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	43,536.73	13,101.30	1,287.30	3,331.74	153.73	0.00	0.00	
3716	ADULT <40% EXP MALE	33,660.99	53,727.97	67,680.64	79,535.70	47,551.23	91,510.59	68,084.56	14,783.35	78,812.93	82,609.44	60,506.35	108,994.98	
3717	ADULT <40% EXP FEMA L	739.50	3,504.90	17,526.29	21,065.42	5,648.82	27,181.61	14,765.12	8,578.39	25,258.63	5,839.54	23,999.63	25,235.07	
3718	ADULT <40% EXP M&F
4	14,476.50	22,588.30	37,018.74	6,461.28	38,360.27	53,197.04	45,679.98	27,686.00	161,571.97	13,224.35	96,243.57	77,070.94	
SUBTOTAL:	48,934.35	89,465.08	138,739.03	120,681.12	116,912.25	240,200.64	180,395.09	52,335.04	270,069.51	108,443.62	186,835.55	213,030.58	

11,814.17	
99,345.47	
23.32	
16,471.45	
27.06	
77,979.80	
787,458.73	
179,342.92	
593,578.94	
1,766,041.86	

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	65.55	0.00	0.00	1,221.21	9,500.58	146.08	348.43	
3918	NEWLY ELIGIBLE M&F 4	0.00	15,700.83	31,078.02	62.53	661.83	7,944.09	48,124.35	467.53	1,161.60	0.00	0.00	0.00	
SUBTOTAL:	6,339.89	16,109.82	39,601.42	62.53	661.83	8,009.64	48,124.35	467.53	2,382.81	9,500.58	146.08	348.43	

254.05	
26,300.08	
105,200.78	
131,754.91	

2,359,338.08

100,971.07	182,487.52	206,295.78	126,120.69	141,317.76	336,540.26	283,932.36	66,814.52	296,908.95	155,541.51	187,347.28	275,060.38	

TOTAL:

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	898.09	3,560.23	0.00	1,893.14	3,030.79	0.00		9,382.25		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	898.09	3,560.23	0.00	1,893.14	3,030.79	0.00		9,382.25		

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	
3716	ADULT <40% EXP MALE	0.00	0.00	638.13	12,903.51	0.00	65.55	0.00	0.00	15,729.58	0.00	435.93	0.00	
3717	ADULT <40% EXP FEMA L	0.00	945.71	0.00	0.00	0.00	0.00	0.00	2,088.97	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,474.45	9,365.26	638.13	12,903.51	0.00	65.55	0.00	2,088.97	15,729.58	0.00	435.93	0.00	

14,894.00	
29,772.70	
3,034.68	
47,701.38	

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	168.51	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F 4	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:	0.00	123.63	0.00	0.00	0.00	0.00	168.51	0.00	0.00	0.00	0.00	0.00	

168.51	
123.63	
292.14	

TOTAL:	6,474.45	9,488.89	638.13	12,903.51	0.00	65.55	1,066.60	5,649.20	15,729.58	1,893.14	3,466.72	0.00		57,375.77		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022	
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	465.51	15,358.75	0.00	310.47	4,456.41	0.00	48.95		32,978.48		
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,499.49	223.23	0.00	5,376.85	4,393.47		14,493.04		
	O																
2210	SSI DISABLED NON-ME	0.00	28,815.66	4,084.32	0.00	16,809.06	9.11	2,920.89	0.00	4,116.36	1,043.11	0.00	19,904.50		77,703.01		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	4,331.73	381.60	2,038.92	10,582.57	317.83	94.72	111.37	31.20		17,889.94		
	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	256.06	5,846.46	204.99	1,721.30	0.00	0.00		17,261.99		
	M																
SUBTOTAL:	1,349.76	36,188.67	20,024.89	1,797.44	21,140.79	856.22	20,574.62	20,928.52	5,172.88	7,315.54	5,488.22	24,378.12		165,215.67		

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	4,327.35	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	12,630.77	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	4,327.35	0.00	0.00	0.00	0.00	0.00	12,630.77	

4,327.35	
12,630.77	
16,958.12	

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	5,870.84	
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	4,423.27	36,791.71	11,118.91	77,755.84	-22,780.62	24,729.96	51,251.94	
3717	ADULT <40% EXP FEMA L	397.62	369.92	0.00	0.00	15,358.75	1,209.94	0.00	1,246.59	94.44	1,801.70	6,117.20	0.00	
3718	ADULT <40% EXP M&F
4	1,917.96	46,698.86	24,287.91	64.90	15,988.36	8,632.29	394.66	21,666.95	13,976.06	592.71	9,937.78	8,648.28	
SUBTOTAL:	65,554.80	57,923.37	36,816.91	21,455.74	50,546.63	14,265.50	37,186.37	34,032.45	91,826.34	-20,386.21	40,784.94	65,771.06	

5,870.84	
-69.28	
310,573.46	
26,596.16	
152,806.72	
495,777.90	

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	

708,277.45

80,789.13	96,348.41	57,309.84	36,989.96	71,687.42	19,449.07	57,760.99	54,960.97	96,999.22	-13,070.67	46,273.16	102,779.95	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	208.38	0.00	0.00	0.00		208.38		
2100	SSI AGED WITH MEDIC
A	0.00	1,845.57	25,876.66	313.14	117.04	2,650.15	0.00	0.00	0.00	0.00	28.42	0.00		30,830.98		
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	8,383.69	0.00	0.00	0.00	0.00	0.00	0.00		8,383.69		
2220	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,085.67	0.00		5,085.67		
SUBTOTAL:	0.00	1,845.57	25,876.66	313.14	117.04	11,033.84	0.00	0.00	208.38	0.00	5,114.09	0.00		44,508.72		

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	3,986.42	288.34	0.00	-25.99	3,001.11	11,408.29	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	10,506.42	0.00	289.08	
3718	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	13,963.36	975.23	178.10	390.42	23,774.80	0.00	426.79	
SUBTOTAL:	19,831.24	1,120.32	5,558.70	6,344.57	3,757.65	17,949.78	1,263.57	178.10	364.43	37,282.33	11,408.29	715.87	

11,827.35	
4,969.24	
38,474.06	
10,795.50	
39,708.70	
105,774.85	

TOTAL:	19,831.24	2,965.89	31,435.36	11,824.11	3,874.69	28,983.62	1,263.57	178.10	572.81	37,282.33	16,522.38	715.87		155,449.97		

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022	
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	77.77	0.00	0.00	0.00	0.00	0.00	0.00		3,087.89		
SUBTOTAL:	0.00	3,010.12	0.00	0.00	0.00	77.77	0.00	0.00	0.00	0.00	0.00	0.00		3,087.89		

3718	ADULT <40% EXP M&F 4	30,896.08	5,314.53	0.00	0.00	0.00	2,286.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	30,896.08	5,314.53	0.00	0.00	0.00	2,286.00	0.00	0.00	0.00	0.00	0.00	0.00	

38,496.61

38,496.61

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	
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

2,161.80

43,746.30

30,896.08	8,324.65	495.83	9.11	1,656.86	2,363.77	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

YUMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2022	
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 June 30, 2022	
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	1,557.00	1,129.17	2,076.00	3,230.68	1,074.63	4,850.17	5,482.14		20,437.79		
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	3,189,912.36	2,441,921.25	2,649,394.19	3,280,509.05	2,606,945.16	3,245,867.96	3,122,915.21		34,037,504.15		
	A																
2110	SSI AGED NON-MEDICA	178,092.13	183,838.11	146,870.10	124,194.15	108,431.39	134,931.42	140,827.31	146,223.05	183,178.87	159,097.13	250,305.25	160,971.07		1,916,959.98		
	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	4,932,087.93	4,015,531.98	4,308,805.27	5,084,288.51	3,886,673.47	4,582,303.37	4,963,995.61		52,746,245.04		
2200	SSI DISABLED WITH M	399,573.10	455,641.98	525,687.24	388,274.54	432,642.92	540,568.41	457,731.39	452,311.78	471,077.61	389,838.13	520,622.22	476,522.25		5,510,491.57		
	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	4,363,384.41	2,894,192.36	4,146,768.79	5,043,305.83	3,220,511.30	3,667,687.50	4,349,664.91		46,841,755.97		
	D																
2220	SSI DISABLED WITH Q	1,026,312.95	1,007,788.62	1,183,265.75	952,334.50	867,333.01	1,294,708.86	915,779.41	1,104,654.83	1,317,306.76	1,055,474.22	1,062,095.46	1,434,205.77		13,221,260.14		
	M																
2310	SSI BLIND NON-MEDIC	0.00	1,820.00	1,415.68	479.00	479.00	479.00	519.00	4,148.12	34,860.12	19,692.61	42,772.16	49,665.61		156,330.30		
	A																
2320	SSI BLIND WITH QMB	731.80	10,880.62	5,798.46	1,777.74	1,906.22	2,157.47	2,708.16	2,343.11	7,094.79	8,707.38	7,584.02	7,840.18		59,529.95		
SUBTOTAL:	11,935,741.18	13,184,875.25	14,068,020.19	10,956,341.43	11,490,467.70	14,459,786.86	10,870,340.03	12,816,725.14	15,424,852.22	11,348,014.03	13,384,088.11	14,571,262.75		154,510,514.89		

8720	SSI DISABLED FREEDO M	3,521.28	3,521.28	3,521.28	4,401.60	3,082.08	4,720.80	3,822.74	3,855.75	4,820.55	3,856.44	3,856.44	4,820.55	
SUBTOTAL:	3,521.28	3,521.28	3,521.28	4,401.60	3,082.08	4,720.80	3,822.74	3,855.75	4,820.55	3,856.44	3,856.44	4,820.55	

47,800.79

47,800.79

154,558,315.68

11,939,262.46	13,188,396.53	14,071,541.47	10,960,743.03	11,493,549.78	14,464,507.66	10,874,162.77	12,820,580.89	15,429,672.77	11,351,870.47	13,387,944.55	14,576,083.30	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending June 30, 2022	
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	320.45	0.00	1,513.78	3,424.55	21.25	0.00	1,894.20		12,306.78		
SUBTOTAL:	127.43	3,517.92	777.05	0.00	68.42	320.45	0.00	1,513.78	3,424.55	21.25	0.00	1,894.20		11,665.05		

TOTAL:	127.43	3,517.92	777.05	0.00	68.42	320.45	0.00	1,513.78	3,424.55	21.25	0.00	1,894.20		11,665.05		

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	324.67	19,296.76	0.00	0.00	0.00		19,621.43		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	18.04	0.00	9.73	0.00	0.00	0.00	0.00	0.00	16,700.09		16,727.86		
2220	SSI DISABLED WITH Q
M	0.00	0.00	0.00	0.00	0.00	0.00	10,341.42	0.00	0.00	0.00	0.00	0.00		10,341.42		
SUBTOTAL:	0.00	0.00	0.00	18.04	0.00	9.73	10,341.42	324.67	19,296.76	0.00	0.00	16,700.09		46,690.71		

18.04

19,296.76

16,700.09

0.00

TOTAL:

0.00

0.00

0.00

0.00

9.73

10,341.42

324.67

0.00

46,690.71

MARICOPA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending June 30, 2022	
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	1,429.64	0.00	0.00	0.00	0.00		11,421.19		
SUBTOTAL:	0.00	0.00	0.00	9,991.55	0.00	0.00	0.00	1,429.64	0.00	0.00	0.00	0.00		11,421.19		

TOTAL:	0.00	0.00	0.00	9,991.55	0.00	0.00	0.00	1,429.64	0.00	0.00	0.00	0.00		11,421.19		

PIMA COUNTY INMATES LTC FEE FOR SERVICE
For The Period Ending June 30, 2022	
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 June 30, 2022	
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 June 30, 2022	
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	74,185.44	37,635.40	50,384.14	52,096.71	63,001.81	57,493.41	105,370.19		589,924.24		
1013	TANF 06-13 M & F NON	91,066.17	51,026.88	47,818.32	94,962.32	136,044.10	192,386.37	96,745.41	130,863.20	112,156.97	168,131.83	157,237.65	305,731.8		1,584,171.08		
1014	TANF 14-20 MALE NON-	5,228.32	4,431.35	4,752.40	8,855.55	11,088.59	17,053.84	9,006.98	12,127.75	13,096.53	22,266.68	15,850.67	32,187.34		155,946.00		
1015	TANF 14-20 FEMALE N	5,475.16	5,342.85	4,993.58	5,683.72	8,746.28	13,162.20	6,304.37	7,746.43	7,232.85	7,858.83	7,956.75	15,315.99		95,819.01		
	O																
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	7.25	64.13	0.00	0.00	0.00	0.00	0.00	0.00		71.38		
	O																
2210	SSI DISABLED NON-ME	173,115.72	125,794.88	133,327.71	252,867.20	329,879.22	447,447.05	229,580.48	303,529.57	339,131.21	357,386.35	332,123.50	589,865.0		3,614,047.97		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	512.35	0.00	195.18	897.97	518.38	154.11	318.47	506.94	488.60		3,592.00		
	M																
2310	SSI BLIND NON-MEDIC	4,120.81	1,176.86	473.50	3,427.34	3,422.63	6,711.13	3,888.47	4,304.29	4,303.10	4,005.13	3,108.81	6,873.06		45,815.13		
	A																
4305	SOBRA CHILD 14-20 FE	0.00	30.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.08		
4312	SOBRA CHILD 01-05 M	157,326.02	111,327.12	99,245.24	177,308.85	212,878.67	363,040.08	185,439.61	240,092.59	238,102.96	294,108.24	279,580.76	514,419.8		2,872,869.98		
4313	SOBRA CHILD 06-13 M	399,774.67	177,621.98	205,347.01	398,372.60	524,772.66	786,572.96	391,898.60	489,255.87	440,914.42	584,257.79	558,444.50	1,102,701.77		6,059,934.83		
4314	SOBRA CHILD 14-20 MA	25,904.55	13,026.73	18,187.11	30,810.36	42,121.88	63,719.23	32,651.51	38,987.08	40,994.69	50,869.37	41,030.29	96,223.78		494,526.58		
4315	SOBRA CHILD 14-20 FE	14,245.41	6,872.40	9,131.42	12,461.72	18,855.29	32,881.14	14,291.24	15,485.26	19,278.37	29,644.92	21,476.21	45,583.15		240,206.53		
4325	SOBRA CHILD 14-20 FE	60.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.16		
5015	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	41.55	72.77	0.00	0.00	0.00	0.00	0.00	0.00		114.32		
	M																
SUBTOTAL:	905,470.26	517,738.42	545,133.20	1,022,388.65	1,328,391.15	1,997,491.52	1,008,340.04	1,293,294.56	1,267,461.92	1,581,849.42	1,474,809.49	2,814,760.66		15,757,129.29		

1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	14.64	0.00	9.75	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	163.66	0.00	441.98	0.00	36.62	57.48	35.12	28.74	0.00	157.86	43.11	133.86	
SUBTOTAL:	163.66	0.00	441.98	0.00	36.62	57.48	49.76	28.74	9.75	157.86	43.11	133.86	

24.39	
1,098.43	
1,122.82	

3514	ADULT 40-100% MALE 1	140.34	0.00	77.55	276.03	181.37	239.17	18.42	72.19	0.00	220.38	114.33	251.13	
3515	ADULT 40-100% FEMAL E	106.33	104.74	0.00	68.47	48.81	114.87	107.21	157.29	76.65	106.74	147.11	252.52	
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	556.44	579.19	820.37	924.43	782.99	972.78	1,326.92	
3715	ADULT <40% EXP FEMA L	313.22	69.69	90.71	77.02	378.67	884.76	210.11	149.71	550.94	791.05	537.10	829.22	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	38.78	77.55	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,371.21	1,161.58	529.97	809.01	988.53	1,795.24	953.71	1,277.11	1,552.02	1,901.16	1,771.32	2,659.79	

1,590.91	
1,290.74	
79.56	
8,810.91	
4,882.20	
116.33	
16,770.65	

3914	NEWLY ELIGIBLE MALE	42.18	0.00	11.41	0.00	0.00	0.00	0.00	23.04	0.00	34.56	0.00	0.00	
3915	NEWLY ELIGIBLE FEMA L	34.23	0.00	0.00	22.82	105.70	101.31	23.04	46.08	34.56	46.08	23.04	103.68	
SUBTOTAL:	76.41	0.00	11.41	22.82	105.70	101.31	23.04	69.12	34.56	80.64	23.04	103.68	

111.19	
540.54	
651.73	

4413	SOBRA 100-133% M&F
6	82,220.16	38,167.34	38,948.73	72,538.71	101,128.63	152,692.52	72,936.56	91,405.56	92,045.28	103,688.99	100,092.15	199,273.76	
4414	SOBRA 100-133% MALE	5,272.95	3,158.75	4,123.25	5,942.35	8,374.65	11,855.45	7,057.22	6,980.96	7,088.95	11,689.60	9,082.90	23,709.91	
4415	SOBRA 100-133% FEMA L	1,573.92	856.33	2,411.40	2,051.96	3,511.60	3,737.57	1,823.71	3,240.35	2,693.20	4,056.24	4,295.47	8,571.76	
SUBTOTAL:	89,067.03	42,182.42	45,483.38	80,533.02	113,014.88	168,285.54	81,817.49	101,626.87	101,827.43	119,434.83	113,470.52	231,555.43	

1,145,138.39	
104,336.94	
38,823.51	
1,288,298.84	

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
TOTAL:	996,148.57	561,082.42	591,599.94	1,103,753.50	1,442,536.88	2,167,731.09	1,091,184.04	1,396,296.40	1,370,885.68	1,703,423.91	1,590,117.48	3,049,213.42		17,063,973.33		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending June 30, 2022	
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	66,198.56	37,172.64	40,878.56	36,194.88	46,015.14	40,838.46	81,959.47		499,779.84		
2200	SSI DISABLED WITH M	2,547.47	1,921.95	942.37	1,659.83	2,202.58	2,752.62	1,618.03	1,899.62	1,978.07	1,486.90	2,279.82	3,650.12		24,939.38		
	E																
2210	SSI DISABLED NON-ME	966,696.62	654,574.85	724,198.91	1,296,862.59	1,753,486.22	2,258,867.05	1,127,121.40	1,576,756.15	1,618,805.44	1,893,649.59	1,630,741.98	3,106,604.67		18,608,365.47		
	D																
2220	SSI DISABLED WITH Q	3,663.92	3,004.47	2,057.76	797.68	1,645.71	1,746.87	500.44	302.18	871.33	497.22	575.08	7,657.59		23,320.25		
	M																
2310	SSI BLIND NON-MEDIC	187.21	145.89	944.52	1,539.66	3,660.37	4,357.42	1,856.22	5,781.67	7,473.96	7,896.18	9,606.75	19,460.20		62,910.05		
	A																
SUBTOTAL:	998,151.51	680,777.47	746,634.49	1,338,274.44	1,810,614.00	2,333,922.52	1,168,268.73	1,625,618.18	1,665,323.68	1,949,545.03	1,684,042.09	3,219,332.05		19,220,504.19		

TOTAL:	998,151.51	680,777.47	746,634.49	1,338,274.44	1,810,614.00	2,333,922.52	1,168,268.73	1,625,618.18	1,665,323.68	1,949,545.03	1,684,042.09	3,219,332.05		19,220,504.19		

ACC REINSURANCE
For The Period Ending June 30, 2022	
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	5,791.10	42,120.06	-5,791.10		34,738.14		
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	2,443,011.54	960,473.36	1,247,232.82	368,524.72	1,611,100.97	970,815.53	938,210.88		12,738,686.87		
1012	TANF 01-05 M & F NON	219,605.16	48,868.07	87,834.76	-24,221.41	564,671.57	46,575.33	109,161.80	417,296.49	82,697.29	118,867.58	115,404.20	189,563.53		1,976,324.37		
1013	TANF 06-13 M & F NON	143,739.01	225,159.36	342,722.34	286,015.36	357,865.91	105,976.60	158,588.64	245,365.07	542,603.71	155,829.52	154,482.71	182,838.10		2,901,186.33		
1014	TANF 14-20 MALE NON-	79,170.51	522,389.71	204,866.45	241,961.66	132,744.13	127,033.74	162,046.29	160,801.26	219,346.73	178,111.71	245,833.03	173,266.96		2,447,572.18		
1015	TANF 14-20 FEMALE N	-530,028.71	592,137.54	358,417.57	153,705.39	480,314.77	1,029,323.12	-75,843.93	501,629.93	249,883.23	214,009.47	350,556.65	306,641.95		3,630,746.98		
	O																
1016	TANF 21-44 MALE NON-	299,099.48	449,500.21	468,492.48	288,542.51	64,928.90	372,985.46	591,020.35	689,926.85	143,333.76	225,726.76	324,983.69	101,385.71		4,019,926.16		
1017	TANF 21-44 FEMALE N	263,457.21	511,045.35	184,348.08	884,786.44	172,730.44	768,860.47	491,489.76	235,548.60	311,399.24	300,299.30	1,144,403.81	604,854.64		5,873,223.34		
	O																
1018	TANF 45-64 M & F NON	1,651.63	401,313.63	153,928.36	266,957.26	301,898.84	482,276.35	399,875.58	139,739.79	224,535.15	600,793.34	133,846.69	369,545.89		3,476,362.51		
1019	TANF 65+ M & F NON-M	37,390.48	0.00	0.00	16,144.18	0.00	0.00	4,030.62	0.00	0.00	0.00	0.00	0.00		57,565.28		
2100	SSI AGED WITH MEDIC	24,312.30	16,698.38	22,574.32	239,444.83	52,168.21	-8,138.52	72,722.75	-18,312.24	28,308.45	111,889.98	8,171.60	171,858.88		721,698.94		
	A																
2110	SSI AGED NON-MEDICA	202,250.07	225,724.82	194,027.46	240,847.48	49,115.17	337,541.34	8,180.40	169,456.77	135,527.89	182,041.53	175.90	4,091.93		1,748,980.76		
	R																
2200	SSI DISABLED WITH M	53,510.85	95,381.23	97,192.30	49,047.40	7,039.73	33,038.47	90,831.99	86,643.43	69,529.66	41,237.48	94,459.54	13,441.23		731,353.31		
	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	8,493,064.05	4,003,697.14	4,579,123.92	3,209,213.60	3,637,461.91	7,438,313.19	3,834,834.73		65,674,216.02		
	D																
2310	SSI BLIND NON-MEDIC	19,560.32	29,509.77	26,853.29	28,824.76	25,349.99	111,977.11	-16,737.18	65,412.34	0.00	41,654.47	600,062.58	6,681.71		939,149.16		
	A																
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	8,221.93	7,067.97	0.00	0.00	0.00	-7,067.97	7,067.97	0.00		15,289.90		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,903.55	0.00	0.00	0.00	0.00		8,903.55		
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	5,207,010.84	1,805,379.95	1,382,024.38	1,636,438.24	1,461,874.04	1,615,774.99	1,410,600.22		25,139,625.97		
4312	SOBRA CHILD 01-05 M	779,395.01	1,066,279.07	-129,925.64	3,691,086.51	450,542.56	1,184,986.73	1,344,028.96	455,225.46	-70,601.95	433,736.30	633,179.39	341,634.23		10,179,566.63		
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	1,986,340.04	897,888.06	471,403.57	1,716,544.64	1,542,817.57	1,748,891.88	1,554,669.08		19,237,289.99		
4314	SOBRA CHILD 14-20 MA	859,529.87	1,127,354.33	886,840.97	1,195,205.19	1,234,020.69	687,536.25	1,217,972.60	644,961.62	554,718.42	692,341.17	1,139,510.18	512,756.10		10,752,747.39		
4315	SOBRA CHILD 14-20 FE	443,365.60	402,560.90	279,339.42	391,832.75	445,325.30	339,099.31	442,607.73	244,131.62	379,726.80	290,530.17	506,398.23	342,551.71		4,507,469.54		
5015	SOBRA PREG 14-20 FE	97,527.92	-28.98	-2,902.18	5.23	4,278.51	48,109.53	0.00	2,855.95	0.00	691.40	0.00	0.00		150,537.38		
	M																
5017	SOBRA PREG 21-44 FE	39,140.95	-482.98	171,036.30	4,144.65	73,802.15	315,905.59	32,503.76	-28,786.98	80,055.93	39,913.43	29,924.83	33,194.82		790,352.45		
	M																
8020	QMB ONLY	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,065.48	1,029.36	7,686.97	0.00	0.00		10,781.81		
SUBTOTAL:	16,203,523.77	16,598,884.89	14,321,242.42	18,544,137.05	13,420,404.05	24,119,581.32	12,699,918.63	11,702,649.68	9,882,814.87	11,887,338.20	17,304,376.65	11,086,831.20		177,771,702.73		

3100	TRANSPLANT OPTION 1	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:	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

52,502.80

1106	TANF EXPANDED 21-44	0.00	12.88	0.00	0.00	87.14	84.13	9,067.46	0.00	21,271.01	0.00	0.00	-2,142.45	
1107	TANF EXPANDED 21-44	0.00	36.86	71.15	37.56	12.10	143,282.82	37.20	52.81	0.00	0.05	245.16	18.96	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	19.43	0.00	0.00	3.81	848.97	31.04	-831.00	29,659.73	-28,732.02	
1115	TANF EXPANDED 14-20	105.76	623.96	358.97	0.00	0.01	104.59	0.05	0.00	0.00	7.62	0.00	0.00	
1116	TANF EXPANDED 21-44	145,844.18	274,112.45	117,332.35	447,863.20	165,737.42	369,233.68	310,770.37	237,016.39	622,346.44	303,898.26	-19,096.90	1,127,203.10	

28,380.17	
143,794.67	
999.96	
1,200.96	
4,102,260.94	

ACC REINSURANCE
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	261,613.22	227,437.15	209,902.26	283,627.40	333,655.35	321,891.94	340,924.09	302,701.92	383,256.88	540,252.91	675,476.42	309,235.26		4,189,974.80		
1118	TANF EXPANDED 45-64	294,930.77	449,226.15	203,686.40	253,376.86	120,044.37	528,629.19	53,100.80	635,550.28	80,387.32	-6,238.40	175,121.14	412,472.28		3,200,287.16		
2400	SSI AGED EXPANDED	-72,844.44	86,521.49	-42,799.09	202.11	11.18	14.92	104.05	0.00	0.00	0.00	-26.06	19.79		-28,796.05		
	WI																
2410	SSI AGED EXPANDED N	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		
	O																
2510	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	21,599.29	0.00	0.00	-7,575.36	4,011.07	0.00		18,035.00		
	N																
2600	SSI DISABLED EXPAND	774.39	19,691.00	89,494.48	4,054.69	-42,816.41	16,659.37	-4.13	169.72	17,816.73	2,723.36	300.81	2,010.94		110,874.95		
	E																
2610	SSI DISABLED EXPAND	5,792.60	377,120.15	18,303.26	113,137.66	80,068.48	211,638.31	76,360.45	90,521.65	200,764.13	-12,104.85	134,579.53	-24,182.71		1,271,998.66		
	E																
SUBTOTAL:	636,216.48	1,440,198.69	677,812.04	1,102,318.91	656,799.64	1,591,538.95	811,963.44	1,266,861.74	1,325,873.55	820,132.59	1,000,270.90	1,795,903.15		13,125,890.08		

3507	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,307.04	19,990.45	0.00	
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	-2,454.60	
3514	ADULT 40-100% MALE 1	77,957.72	100,633.40	191,656.52	67,711.66	58,079.18	17,808.01	183,919.21	-45,434.63	67,533.36	345,221.05	47,424.40	48,242.92	
3515	ADULT 40-100% FEMAL E	25,736.61	20,014.15	77.43	20,051.19	31,648.13	1,246.92	19,997.83	19,897.17	9,121.14	11,842.88	41,744.23	21,815.32	
3516	ADULT 40-100% MALE 2	348,938.56	289,328.58	604,804.85	454,102.58	235,666.79	597,800.82	388,554.80	52,678.73	418,786.37	564,930.49	148,702.47	281,594.57	
3517	ADULT 40-100% FEMAL E	101,009.97	226,175.55	37,660.57	117,370.16	81,347.58	118,837.41	106,403.17	155,430.90	47,468.52	7,817.71	110,789.23	117,695.14	
3518	ADULT 40-100% M&F 45	975,205.30	1,273,861.24	486,674.85	938,264.03	701,095.37	1,385,869.76	546,582.52	838,393.69	531,922.80	503,513.94	673,341.92	309,825.02	
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	1,689.90	0.00	-1,689.90	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	9,953.56	0.00	-9,828.67	-9,953.56	0.00	
3707	ADULT <40% EXP FEMA L	-1,770.62	10,391.20	0.00	1,135.71	-1,135.71	1,842.52	58,381.17	-1,135.71	1,135.71	0.00	17,472.84	1,135.71	
3708	ADULT <40% EXP M&F
4	17,983.99	0.00	-17,210.32	77,139.37	-72,677.17	3,637.95	12,145.42	38,798.30	0.00	518.71	5,322.12	1,686.66	
3714	ADULT <40% EXP MALE	95,231.87	116,706.62	138,464.69	109,107.32	-19,413.50	312,611.45	120,103.24	141,942.68	29,181.16	-7,878.92	227,313.82	159,899.08	
3715	ADULT <40% EXP FEMA L	7,172.81	5,208.09	65,079.84	36,674.55	359,586.54	101,978.63	31,139.79	25,416.86	21,960.75	22,780.37	26,936.58	20,872.12	
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	4,019,131.81	1,180,751.22	1,926,615.52	1,151,918.88	1,664,326.90	2,259,586.96	2,045,803.48	
3717	ADULT <40% EXP FEMA L	310,370.74	947,673.73	413,033.48	903,648.55	646,530.40	539,735.31	765,535.09	360,700.33	384,546.03	749,497.51	467,743.34	381,804.77	
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	4,345,816.19	2,043,332.14	1,130,410.15	2,398,274.93	2,797,769.19	1,917,881.42	2,012,973.00	
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	23,076.37	0.00	0.00	0.00	0.00	-221.02	174.53	
SUBTOTAL:	6,611,729.12	9,638,492.38	6,231,801.04	9,541,426.61	7,604,099.08	11,471,083.05	5,456,845.60	4,651,977.65	5,061,849.65	6,665,818.20	5,954,075.20	5,401,067.72	

35,297.49	
111.28	
1,160,752.80	
223,193.00	
4,385,889.61	
1,228,005.91	
9,164,550.44	
0.00	
2,613.15	
87,452.82	
67,345.03	
1,423,269.51	
724,806.93	
26,620,297.75	
6,870,819.28	
32,272,830.42	
23,029.88	
84,290,265.30	

3906	NEWLY ELIGIBLE MALE	-752.29	757.99	0.00	0.00	0.00	0.00	144.76	0.00	0.00	0.00	0.00	-144.76	
3907	NEWLY ELIGIBLE FEMA L	475.99	0.00	0.00	0.00	0.00	3,327.57	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	732.80	926.01	394.17	632.49	22.54	147.97	449.72	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	2,043.02	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	152,808.63	120,325.69	34,738.65	71,071.56	105,871.24	104,051.94	73,713.15	
3915	NEWLY ELIGIBLE FEMA L	0.00	113,111.60	96,419.13	30,309.85	147,839.91	22,764.03	21,124.65	0.00	21,942.27	21,942.28	1,217.26	9.44	
3916	NEWLY ELIGIBLE MALE	212,173.30	186,229.89	592,799.98	305,378.93	110,585.10	1,084,109.39	538,934.28	466,335.12	241,054.58	234,551.10	623,792.32	228,622.87	
3917	NEWLY ELIGIBLE FEMA L	-71,941.78	724,590.55	299,249.50	367,089.84	270,007.22	318,342.88	240,951.99	213,979.61	4,261.40	45,805.56	86,560.01	245,563.20	
3918	NEWLY ELIGIBLE M&F
4	268,129.98	767,859.53	517,519.66	665,960.60	344,337.69	1,334,150.72	858,085.68	193,498.30	492,159.91	783,912.69	461,001.67	580,181.84	

5.70	
3,803.56	
997.38	
2,043.02	
591,777.72	
476,680.42	
4,824,566.86	
2,744,459.98	
7,266,798.27	

ACC REINSURANCE
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	402,888.42	1,794,647.35	1,513,941.22	1,393,892.65	769,651.07	2,916,236.02	1,782,536.08	908,945.85	831,122.21	1,192,105.41	1,276,771.17	1,128,395.46		15,911,132.91		

4413	SOBRA 100-133% M&F
6	1,081,973.95	316,533.84	164,632.00	500,536.04	926,834.67	452,844.30	232,771.84	419,112.88	229,073.54	91,627.25	79,196.53	436,476.44		
4414	SOBRA 100-133% MALE	275,120.22	349,953.71	236,665.37	118,963.50	101,287.01	132,891.30	269,639.24	281,495.43	141,563.82	297,174.34	177,788.98	146,871.24		
4415	SOBRA 100-133% FEMA L	90,194.19	35,082.85	16,267.47	72,860.77	184,220.38	321,118.19	15,822.72	-41,993.93	44,664.29	230,862.13	113,944.40	100,755.69		
SUBTOTAL:	1,447,288.36	701,570.40	417,564.84	692,360.31	1,212,342.06	906,853.79	518,233.80	658,614.38	415,301.65	619,663.72	370,929.91	684,103.37		

4,931,613.28	
2,529,414.16	
1,183,799.15	
8,644,826.59	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	33,195.52	1,365.87	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4
5	0.00	10,200.21	0.00	10,570.78	0.00	-7,167.42	20,555.16	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	10,200.21	0.00	10,570.78	33,195.52	-5,801.55	20,555.16	0.00	0.00	0.00	0.00	0.00	

34,561.39	
34,158.73	
68,720.12	

8700	SSI DISABLED FREEDO M	10.08	11.93	25.88	170.47	787.24	34.91	38.33	367.13	144.23	12.28	0.00	756.94	
8710	SSI DISABLED FREEDO
M	20,406.89	0.00	7,834.36	27,039.03	0.00	0.00	5,461.64	7,877.26	-1,469.16	1,510.41	0.00	0.00	
SUBTOTAL:	20,416.97	11.93	7,860.24	27,209.50	787.24	34.91	5,499.97	8,244.39	-1,324.93	1,522.69	0.00	756.94	

2,359.42	
68,660.43	
71,019.85	

299,936,060.38

25,374,565.92	30,184,005.85	23,170,221.80	31,311,915.81	23,697,278.66	40,999,526.49	21,295,552.68	19,197,293.69	17,515,637.00	21,186,580.81	25,906,423.83	20,097,057.84	

TOTAL:

LONG TERM CARE REINSURANCE
For The Period Ending June 30, 2022	
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	185,725.28	156,755.02	4,913.20	176,426.20	55,442.08	139,133.90	85,452.32		1,250,857.96		
2100	SSI AGED WITH MEDIC	84,134.87	290,782.74	147,944.75	381,822.47	56,672.65	139,628.81	237,933.00	166,400.34	114,692.80	227,103.82	55,235.19	58,121.14		1,960,472.58		
	A																
2110	SSI AGED NON-MEDICA	56,842.01	-26,366.84	78,327.52	832.41	-26,593.54	130,213.94	8,511.02	52,197.84	39,112.74	14,507.38	129,615.01	-12,357.37		444,842.12		
	R																
2200	SSI DISABLED WITH M	455,169.54	338,840.81	137,969.98	840,107.26	426,955.04	296,772.14	488,547.44	334,107.59	233,264.09	400,918.11	172,820.23	216,638.80		4,342,111.03		
	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	5,264,295.42	3,743,641.39	5,283,829.09	3,525,641.35	5,576,041.65	6,568,760.99	1,843,555.07		64,405,836.76		
	D																
2310	SSI BLIND NON-MEDIC	0.00	0.00	0.00	0.00	0.00	12,031.33	0.00	0.00	0.00	0.00	0.00	0.00		12,031.33		
	A																
SUBTOTAL:	6,395,905.64	6,277,663.48	4,730,970.80	8,061,064.99	10,824,918.52	6,028,666.92	4,635,387.87	5,841,448.06	4,089,137.18	6,274,013.04	7,065,565.32	2,191,409.96		72,416,151.78		

8710	SSI DISABLED FREEDO M	127,089.85	41,854.60	137,042.44	24,227.16	19,008.96	19,008.96	106,162.55	116,115.14	0.00	106,162.55	0.00	116,115.14	
SUBTOTAL:	127,089.85	41,854.60	137,042.44	24,227.16	19,008.96	19,008.96	106,162.55	116,115.14	0.00	106,162.55	0.00	116,115.14	

812,787.35

812,787.35

TOTAL:	6,522,995.49	6,319,518.08	4,868,013.24	8,085,292.15	10,843,927.48	6,047,675.88	4,741,550.42	5,957,563.20	4,089,137.18	6,380,175.59	7,065,565.32	2,307,525.10		73,228,939.13		

ACC SMIB
For The Period Ending June 30, 2022	
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	39,039.90	46,148.40	47,174.40	51,696.50	46,753.20	51,502.70	50,538.60		526,252.70		
1010	TANF NON-MEDICARE	445.50	594.00	594.00	594.00	594.00	742.50	850.50	1,020.60	1,020.60	1,190.70	1,020.60	850.50		9,517.50		
1020	TANF WITH QMB	51,959.40	48,407.10	44,272.50	48,708.00	51,388.80	50,017.20	59,247.90	57,299.40	54,009.90	55,152.90	58,768.20	53,270.70		632,502.00		
2100	SSI AGED WITH MEDIC	92,265.00	95,363.60	93,915.60	93,204.50	97,225.70	93,184.00	118,711.60	108,311.50	115,272.60	118,903.30	124,311.10	115,775.30		1,266,443.80		
	A																
2110	SSI AGED NON-MEDICA	584,071.10	596,524.30	575,977.90	592,815.90	576,492.60	581,756.70	675,358.80	676,435.00	664,312.50	666,721.80	686,422.20	673,149.60		7,550,038.40		
	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	5,881,178.90	6,843,603.30	6,865,712.00	6,889,093.40	6,981,510.20	7,028,177.20	7,073,475.80		76,380,360.40		
2200	SSI DISABLED WITH M	99,770.80	98,655.00	92,255.60	97,400.50	103,660.80	102,152.50	121,271.20	132,115.30	121,679.70	126,324.60	117,984.20	119,726.20		1,332,996.40		
	E																
2210	SSI DISABLED NON-ME	503,769.90	509,549.70	506,306.10	524,841.60	494,707.20	499,564.80	572,913.60	571,135.80	570,086.10	572,343.90	571,301.10	567,388.80		6,463,908.60		
	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	4,350,887.10	4,934,878.40	4,947,263.60	4,927,532.50	4,907,648.40	4,875,302.50	4,917,669.30		55,508,539.50		
	M																
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	594.00	148.50	-148.50	170.10	764.10	510.30	0.00	170.10	170.10		2,378.70		
2310	SSI BLIND NON-MEDIC	4,455.00	2,177.80	4,603.50	4,752.00	4,603.50	4,603.50	5,103.00	4,592.70	4,932.90	4,762.80	4,762.80	4,592.70		53,942.20		
	A																
2320	SSI BLIND WITH QMB	38,910.90	39,352.50	41,134.50	41,283.00	43,061.10	41,580.00	49,285.80	53,132.10	48,500.10	53,173.80	48,818.70	52,685.10		550,917.60		
4320	SOBRA CHILD WITH Q	1,039.50	891.00	594.00	1,782.00	891.00	891.00	1,020.60	1,020.60	1,020.60	850.50	850.50	850.50		11,701.80		
	MB																
5000	SOBRA PREGNANT WO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-340.20	0.00	0.00		-340.20		
	MAN																
5020	SOBRA PREGNANT WO	3,861.00	4,888.80	4,900.50	3,861.00	3,118.50	5,346.00	5,907.60	4,422.60	3,763.80	4,932.90	4,932.90	5,103.00		55,038.60		
	MAN																
8020	QMB ONLY	1,050,878.90	1,054,919.70	1,043,080.30	1,042,820.20	1,045,476.00	1,040,794.50	1,235,035.60	1,259,473.20	1,251,680.90	1,236,302.20	1,249,102.90	1,254,250.30		13,763,814.70		
8040	SLMB	6,483,083.80	6,541,858.20	6,524,451.00	6,541,455.10	6,580,667.80	6,581,413.60	7,602,982.30	7,588,435.40	7,647,039.30	7,693,484.60	7,653,561.10	7,716,554.80		85,154,987.00		
8888	SMIB ONLY NOT ELIGIB	-17,559.20	-14,668.20	-20,626.30	-14,115.00	-30,842.50	-14,407.50	-17,734.90	-15,615.40	-37,363.70	-20,753.60	-17,919.40	-19,664.00		-241,269.70		
9999	SMIB ONLY NOT ELIGIB	120,096.40	308,510.70	248,682.00	286,289.40	218,558.00	365,542.50	276,428.00	384,045.40	281,251.20	382,962.10	518,768.50	545,073.90		3,936,208.10		
SUBTOTAL:	19,021,143.50	19,396,454.10	19,273,559.70	19,463,575.70	19,423,883.90	19,624,138.70	22,531,181.80	22,686,738.30	22,596,039.20	22,831,924.10	22,977,837.90	23,131,461.20		252,957,938.10		

1100	TANF EXPANDED FPR FI	259,941.30	264,920.70	266,025.50	262,408.00	270,836.00	261,278.40	304,942.90	301,387.90	301,427.50	304,721.30	296,195.60	306,289.50	
1110	TANF EXPANDED FOR
FI	148.50	148.50	148.50	445.50	297.00	297.00	340.20	1,104.30	340.20	170.10	340.20	340.20	
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	1,114,060.80	1,268,610.10	1,252,435.90	1,273,408.10	1,278,003.10	1,283,152.70	1,288,046.10	
2400	SSI AGED EXPANDED
WI	34,517.10	35,398.60	29,822.00	33,056.10	30,813.00	32,595.00	37,725.00	34,440.80	39,405.20	39,088.00	37,185.80	37,619.50	
2410	SSI AGED EXPANDED N O	594.00	594.00	742.50	1,188.00	594.00	594.00	680.40	680.40	680.40	680.40	1,871.10	1,530.90	
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	4,896,564.00	5,644,330.20	5,612,179.60	5,649,822.60	5,768,268.60	5,762,371.10	5,824,740.20	
2500	SSI BLIND EXPANDED W	0.00	148.50	148.50	148.50	148.50	148.50	488.70	170.10	170.10	170.10	170.10	170.10	
2520	SSI BLIND EXPANDED
W	1,633.50	3,118.50	4,455.00	6,979.50	7,682.00	8,870.00	10,549.40	11,949.70	14,458.50	16,329.60	15,819.30	16,669.80	
2600	SSI DISABLED EXPAND E	27,007.50	25,987.50	26,433.00	25,096.50	22,275.00	21,532.50	26,146.80	35,019.10	34,454.80	26,182.50	28,233.90	23,835.60	
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	2,542,048.40	2,912,343.40	2,905,383.90	2,869,339.70	2,883,398.50	2,879,171.60	2,898,134.60	
SUBTOTAL:	8,715,229.40	8,802,736.90	8,769,283.60	8,824,244.50	8,867,038.50	8,877,988.60	10,206,157.10	10,154,751.70	10,183,507.10	10,317,012.20	10,304,511.40	10,397,376.50	

3,400,374.60	
4,120.20	
14,330,583.20	
421,666.10	
10,430.10	
63,084,349.30	
2,081.70	
118,514.80	
322,204.70	
32,725,512.80	
114,419,837.50	

3500	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	-445.50	0.00	0.00	0.00	0.00	0.00	
3520	ADULT 40-100% FOR FI	7,385.00	7,682.00	7,682.00	8,573.00	9,315.50	9,464.00	9,698.90	14,585.90	14,396.90	13,206.20	14,248.40	12,485.90	
3700	ADULT <40% EXP FOR F	0.00	0.00	0.00	0.00	0.00	445.50	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	17,902.90	19,273.90	24,126.90	28,531.40	30,896.60	30,748.10	33,958.40	

-445.50	
128,723.70	
445.50	
259,249.70	

ACC SMIB
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	20,413.00	23,816.80	21,909.70	22,789.00	25,520.50	27,812.40	28,527.30	38,712.80	42,928.30	44,102.80	44,996.50	46,444.30		387,973.40		

3920	NEWLY ELIGIBLE FOR F	14,107.50	14,701.50	15,147.00	15,741.00	19,378.50	18,267.00	22,342.50	23,860.90	24,720.60	28,716.60	28,536.80	26,495.60		
SUBTOTAL:	14,107.50	14,701.50	15,147.00	15,741.00	19,378.50	18,267.00	22,342.50	23,860.90	24,720.60	28,716.60	28,536.80	26,495.60		

252,015.50

252,015.50

8620	SSI BLIND FREEDOM/W O	148.50	594.00	297.00	148.50	148.50	148.50	170.10	170.10	170.10	340.20	340.20	510.30	
8720	SSI DISABLED FREEDO
M	82,920.90	83,972.10	85,312.50	84,273.00	87,540.00	89,766.00	103,778.40	108,367.40	112,169.20	110,358.10	116,098.30	124,368.40	
SUBTOTAL:	83,069.40	84,566.10	85,609.50	84,421.50	87,688.50	89,914.50	103,948.50	108,537.50	112,339.30	110,698.30	116,438.50	124,878.70	

3,186.00	
1,188,924.30	
1,192,110.30	

369,209,874.80

27,853,962.80	28,322,275.40	28,165,509.50	28,410,771.70	28,423,509.90	28,638,121.20	32,892,157.20	33,012,601.20	32,959,534.50	33,332,454.00	33,472,321.10	33,726,656.30	

TOTAL:

ACC HIB
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	499.00		499.00		
1020	TANF WITH QMB	1,931.10	1,931.10	1,413.00	423.90	3,297.00	2,355.00	2,495.00	2,769.00	2,495.00	1,996.00	1,996.00	2,495.00		25,597.10		
2100	SSI AGED WITH MEDIC	-471.00	3,768.00	2,355.00	471.00	2,355.00	3,297.00	7,554.00	-2,720.00	1,771.00	-274.00	0.00	2,094.00		20,200.00		
	A																
2110	SSI AGED NON-MEDICA	1,413.00	0.00	0.00	0.00	0.00	0.00	0.00	1,469.00	0.00	1,497.00	6,487.00	0.00		10,866.00		
	R																
2120	SSI AGED WITH QMB	749,466.20	786,766.40	796,893.00	787,737.60	769,868.40	770,196.90	855,123.20	860,220.30	844,932.30	861,391.60	836,383.40	849,470.30		9,768,449.60		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	471.00	0.00	518.10	-518.10	0.00	0.00	705.10	0.00	-998.00		178.10		
	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	1,771.00	0.00		3,184.00		
	D																
2220	SSI DISABLED WITH Q	340,500.60	353,217.20	366,650.00	374,218.80	367,848.30	381,295.20	415,506.40	411,848.40	404,001.10	425,575.20	406,889.80	399,442.00		4,646,993.00		
	M																
2320	SSI BLIND WITH QMB	3,085.00	3,085.00	3,085.00	3,085.00	3,085.00	3,085.00	3,268.00	3,268.00	4,266.00	3,767.00	3,767.00	3,767.00		40,613.00		
8020	QMB ONLY	7,559.20	6,570.20	7,512.20	7,041.20	6,570.20	7,041.20	8,249.80	7,731.80	7,731.80	7,731.80	7,731.80	7,232.80		88,704.00		
9999	SMIB ONLY NOT ELIGIB	-9,496.40	-7,488.90	-3,132.00	-70.70	-13,588.30	-11,445.30	-2,239.20	3,812.20	-18,241.10	-12,598.50	-4,589.00	-2,944.10		-82,021.30		
SUBTOTAL:	1,093,987.70	1,149,262.00	1,174,776.20	1,173,377.80	1,139,435.60	1,156,343.10	1,289,439.10	1,288,398.70	1,246,956.10	1,289,791.20	1,260,437.00	1,261,058.00		14,523,262.50		

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	499.00	499.00	
1120	TANF EXPANDED FOR
FI	942.00	942.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	499.00	499.00	0.00	
2420	SSI AGED EXPANDED WI	4,498.00	4,498.00	4,498.00	4,498.00	5,440.00	3,556.00	5,264.00	5,264.00	5,763.00	6,262.00	6,262.00	6,262.00	
SUBTOTAL:	5,440.00	5,440.00	5,487.10	4,498.00	5,440.00	3,556.00	5,264.00	5,264.00	5,763.00	6,761.00	7,260.00	6,761.00	

1,987.10	
2,882.00	
62,065.00	
66,934.10	

TOTAL:	1,099,427.70	1,154,702.00	1,180,263.30	1,177,875.80	1,144,875.60	1,159,899.10	1,294,703.10	1,293,662.70	1,252,719.10	1,296,552.20	1,267,697.00	1,267,819.00		14,590,196.60		

Q1
For The Period Ending June 30, 2022	
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	3,148,186.00	3,492,158.50	3,457,873.40	3,494,106.90	3,519,277.20	4,003,398.20	3,638,828.10		40,359,467.00		
9999	SMIB ONLY NOT ELIGIB	86,723.80	87,154.30	82,169.50	78,505.90	71,671.00	79,268.00	173,927.10	121,534.50	83,274.20	85,608.40	93,597.50	81,682.50		1,125,116.70		
SUBTOTAL:	3,186,885.30	3,196,653.70	3,204,188.20	3,218,204.20	3,205,931.80	3,227,454.00	3,666,085.60	3,579,407.90	3,577,381.10	3,604,885.60	4,096,995.70	3,720,510.60		41,484,583.70		

41,484,583.70

3,186,885.30	3,196,653.70	3,204,188.20	3,218,204.20	3,205,931.80	3,227,454.00	3,666,085.60	3,579,407.90	3,577,381.10	3,604,885.60	4,096,995.70	3,720,510.60	

TOTAL:

LTC SMIB
For The Period Ending June 30, 2022	
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	1,001,354.20	1,152,666.50	1,125,756.80	1,111,150.40	1,115,663.80	1,105,054.80	1,126,743.80		12,740,979.80		
	A																
2110	SSI AGED NON-MEDICA	225,559.80	224,680.50	216,938.10	227,947.50	228,096.00	226,904.10	261,948.60	257,742.00	260,766.60	261,249.30	264,670.20	261,443.70		2,917,946.40		
	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	1,272,622.80	1,462,985.90	1,451,689.00	1,458,597.10	1,444,464.60	1,440,068.90	1,451,843.20		16,400,076.10		
2200	SSI DISABLED WITH M	379,137.50	380,173.10	379,796.00	385,058.00	388,409.00	386,775.50	447,300.00	438,471.30	421,987.70	425,211.40	417,330.40	422,838.80		4,872,488.70		
	E																
2210	SSI DISABLED NON-ME	5,197.50	6,979.50	15,163.50	7,425.00	7,128.00	6,979.50	7,697.70	8,823.60	6,293.70	6,633.90	5,273.10	6,463.80		90,058.80		
	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	1,168,126.80	1,340,134.30	1,339,892.40	1,336,593.40	1,351,209.60	1,350,768.30	1,347,267.20		15,129,389.90		
	M																
2300	SSI BLIND WITH MEDIC	445.50	742.50	891.00	1,485.00	1,633.50	1,485.00	2,891.70	3,231.90	3,402.00	3,402.00	3,552.10	3,572.10		26,734.30		
2310	SSI BLIND NON-MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	170.10	170.10	340.20		680.40		
	A																
2320	SSI BLIND WITH QMB	891.00	1,930.50	3,118.50	3,861.00	4,603.50	5,049.00	7,824.60	9,355.50	16,499.70	16,819.90	17,010.00	16,499.70		103,462.90		
SUBTOTAL:	4,081,476.30	4,084,851.70	4,074,483.00	4,094,275.40	4,077,996.60	4,069,296.90	4,683,449.30	4,634,962.50	4,615,290.60	4,624,824.60	4,603,897.90	4,637,012.50		52,281,817.30		

8720	SSI DISABLED FREEDO M	2,970.00	3,267.00	2,970.00	2,970.00	2,970.00	2,970.00	3,402.00	3,231.90	3,061.80	2,891.70	2,721.60	2,381.40	
SUBTOTAL:	2,970.00	3,267.00	2,970.00	2,970.00	2,970.00	2,970.00	3,402.00	3,231.90	3,061.80	2,891.70	2,721.60	2,381.40	

35,807.40

35,807.40

TOTAL:	4,084,446.30	4,088,118.70	4,077,453.00	4,097,245.40	4,080,966.60	4,072,266.90	4,686,851.30	4,638,194.40	4,618,352.40	4,627,716.30	4,606,619.50	4,639,393.90		52,317,624.70		

LTC HIB
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC	-989.10	1,413.00	942.00	235.50	-47.10	0.00	-471.00	0.00	998.00	499.00	-499.00	-499.00		1,582.30		
	A																
2110	SSI AGED NON-MEDICA	0.00	0.00	0.00	0.00	0.00	942.00	0.00	0.00	0.00	0.00	8,483.00	0.00		9,425.00		
	R																
2120	SSI AGED WITH QMB	369,762.40	362,538.00	369,943.90	361,282.30	362,859.80	364,649.90	389,911.00	393,749.20	377,842.30	407,291.40	373,279.10	392,537.90		4,525,647.20		
2200	SSI DISABLED WITH M	471.00	-471.00	942.00	730.00	-259.00	0.00	-471.00	0.00	0.00	-4,794.00	274.00	225.00		-3,353.00		
	E																
2220	SSI DISABLED WITH Q	3,297.00	5,440.00	5,016.10	4,545.10	7,324.00	4,757.00	4,266.00	4,266.00	5,066.40	7,084.90	7,485.00	5,988.00		64,535.50		
	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	499.00	0.00		499.00		
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	499.00	0.00	0.00		499.00		
SUBTOTAL:	372,541.30	368,920.00	376,844.00	366,792.90	369,877.70	370,348.90	393,235.00	398,015.20	383,906.70	410,580.30	389,521.10	398,251.90		4,598,835.00		

4,598,835.00

372,541.30	368,920.00	376,844.00	366,792.90	369,877.70	370,348.90	393,235.00	398,015.20	383,906.70	410,580.30	389,521.10	398,251.90	

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
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	11.80	0.00	50.47	1,484.00	178.34	1,038.00	82.80		15,990.16		
1007	TANF 21-44 FEMALE WI	1,061.40	2,994.24	1,644.07	2,050.98	4,089.19	3,142.59	1,700.46	2,044.66	2,528.07	1,081.38	3,912.95	4,833.67		31,083.66		
1008	TANF 45-64 M & F WIT	11,881.80	9,793.67	31,205.96	5,027.02	9,501.42	5,929.33	1,928.08	4,395.12	13,300.79	6,343.70	12,559.98	4,622.42		116,489.29		
1009	TANF 65+ M & F WITH	4,333.46	9,212.25	10,094.10	3,648.79	14,627.64	8,195.27	5,204.58	21,483.88	26,818.24	12,699.57	10,607.18	388.91		127,313.87		
1011	TANF <1 M & F NON-ME	525,201.59	613,922.09	736,678.46	481,331.69	515,193.34	674,757.72	486,661.55	757,600.13	934,429.39	530,210.20	979,363.35	634,147.18		7,869,496.69		
1012	TANF 01-05 M & F NON	169,929.14	310,833.38	332,843.42	204,676.49	250,955.14	305,365.28	217,502.64	412,189.41	545,076.55	281,002.17	550,755.49	420,557.92		4,001,687.03		
1013	TANF 06-13 M & F NON	296,826.59	526,741.64	614,784.21	397,757.29	512,384.74	629,945.06	437,761.83	722,526.44	895,480.49	415,706.85	907,560.77	583,269.31		6,940,745.22		
1014	TANF 14-20 MALE NON-	154,040.74	222,795.34	215,330.97	124,809.64	161,560.04	190,687.54	138,271.21	267,900.43	269,610.06	114,989.21	266,094.44	162,745.67		2,288,835.29		
1015	TANF 14-20 FEMALE N	197,282.57	308,878.29	423,150.58	220,744.15	318,551.99	284,445.24	219,345.68	381,896.70	527,920.67	275,922.04	483,943.89	363,980.93		4,006,062.73		
	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	1,433,490.44	937,378.24	1,705,303.78	2,543,660.44	889,534.65	2,062,032.70	1,366,693.74		17,690,230.78		
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	5,284,486.41	3,521,953.64	7,203,992.10	10,135,802.16	3,751,239.73	7,740,262.97	5,132,421.34		69,807,819.05		
	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	2,405,853.92	1,298,232.78	3,459,546.07	5,093,591.52	1,507,787.85	3,634,654.32	2,410,859.54		32,271,184.60		
1019	TANF 65+ M & F NON-M	29,568.92	16,943.08	13,494.00	4,222.41	9,744.78	9,342.00	3,114.00	16,618.66	21,295.39	6,322.86	26,535.40	12,389.94		169,591.44		
1026	TANF 21-44 MALE WITH	1,038.00	0.00	1,038.00	0.00	0.00	0.00	0.00	0.00	519.00	1,120.54	121.00	761.00		4,597.54		
1027	TANF 21-44 FEMALE WI	1,787.67	2,277.92	2,096.76	208.10	3,984.05	846.68	298.43	3,782.13	5,977.16	176.45	2,100.32	-585.99		22,949.68		
1028	TANF 45-64 M & F WIT	4,427.76	12,707.27	4,195.62	2,276.68	3,496.41	1,799.47	1,768.89	4,086.11	5,593.63	1,580.74	2,443.01	897.98		45,273.57		
1029	TANF 65+ M & F WITH	3,849.95	3,316.13	4,884.13	356.92	6,053.90	2,615.15	577.01	6,046.34	7,483.63	2,136.92	3,921.74	1,933.38		43,175.20		
2100	SSI AGED WITH MEDIC	91,253.04	127,115.47	160,678.72	34,338.80	154,505.47	144,755.45	96,638.79	127,996.76	254,177.34	83,336.04	149,562.55	224,562.99		1,648,921.42		
	A																
2110	SSI AGED NON-MEDICA	162,099.48	234,117.25	266,337.32	96,438.97	209,759.40	160,155.91	234,325.63	293,414.18	353,876.56	95,331.14	280,953.49	218,813.16		2,605,622.49		
	R																
2120	SSI AGED WITH QMB	494,968.66	813,541.23	625,538.14	179,336.10	532,240.39	363,076.42	163,970.71	687,832.34	1,052,960.24	200,561.40	644,319.50	518,735.87		6,277,081.00		
2200	SSI DISABLED WITH M	355,126.49	407,617.53	349,163.59	110,709.42	253,368.52	184,348.65	140,595.66	376,792.08	529,857.54	149,647.15	311,622.33	262,990.18		3,431,839.14		
	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	5,037,750.08	2,651,654.08	6,322,147.26	9,305,117.63	3,488,028.54	6,945,751.93	4,671,861.29		64,194,322.98		
	D																
2220	SSI DISABLED WITH Q	676,032.85	1,109,381.07	824,558.41	263,321.80	726,470.29	463,090.76	207,707.85	802,692.74	1,371,429.82	280,749.05	796,018.69	615,519.15		8,136,972.48		
	M																
2300	SSI BLIND WITH MEDIC	807.30	6,282.05	3,343.23	93.82	5,776.39	1,554.36	197.17	5,076.23	8,399.86	229.05	7,021.16	-630.24		38,150.38		
2310	SSI BLIND NON-MEDIC	80,164.12	120,088.45	90,468.26	47,831.64	133,124.12	101,797.18	33,502.39	144,069.80	203,129.66	77,114.63	220,816.84	62,911.48		1,315,018.57		
	A																
2320	SSI BLIND WITH QMB	10,927.99	9,036.92	7,520.25	4,341.44	15,326.99	3,706.99	1,637.80	8,662.56	15,158.79	3,860.25	9,507.65	11,954.26		101,641.89		
4311	SOBRA CHILD <1 M & F	958,167.28	1,020,153.99	1,232,627.59	811,668.78	934,721.68	1,098,633.17	784,424.30	1,300,333.03	1,744,155.17	944,961.11	1,678,214.98	1,487,980.70		13,996,041.78		
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	3,128,375.92	2,000,369.97	3,728,938.31	4,874,797.16	2,445,161.87	4,707,785.70	3,726,678.10		39,389,101.79		
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	5,733,486.52	3,891,568.08	6,290,363.57	7,987,856.99	4,073,705.70	7,597,645.15	5,324,479.20		65,392,939.40		
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	1,604,126.89	1,164,758.76	1,810,811.40	2,207,078.87	1,002,784.77	2,008,510.30	1,719,168.42		19,925,402.45		
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	1,820,949.91	1,393,309.46	2,421,573.85	3,031,145.62	1,550,169.81	2,855,689.56	2,058,212.05		25,143,981.55		
5007	SOBRA PREG 21-44 FE	132.57	1,038.00	804.40	11.02	1,159.43	433.87	409.13	2,010.00	730.89	33.39	176.52	-519.00		6,420.22		
	M																
5008	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	95.92	0.00	0.00	0.00		95.92		
	M																
5013	SOBRA PREG 09-13 FE	519.00	0.00	0.00	0.00	1,895.02	11,931.00	519.00	1,122.19	519.00	1,159.00	-519.00	-519.00		16,626.21		
	M																
5015	SOBRA PREG 14-20 FE	127,286.50	223,424.67	217,271.20	99,516.91	147,840.88	150,234.03	169,726.20	162,391.14	176,048.67	143,701.34	225,252.75	192,937.03		2,035,631.32		
	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	1,214,766.22	862,721.89	1,337,801.08	1,770,089.72	1,041,564.10	1,597,234.32	1,144,751.56		14,242,903.75		
	M																

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	-1,789.32	4,839.32	2,076.00	519.00	2,012.00	2,076.00	2,637.94	4,671.00	12,975.00	640.00	3,961.00	-3,270.00		31,347.94		
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	109.30	0.00	0.00	0.00		109.30		
SUBTOTAL:	26,360,676.51	38,200,049.19	41,406,648.77	22,342,776.41	31,360,745.54	32,466,163.23	21,072,373.83	40,798,161.95	55,930,280.94	23,380,771.54	46,727,432.93	33,336,616.94		413,382,697.78		

1106	TANF EXPANDED 21-44	2,141.13	6,248.87	4,831.25	1,996.36	3,484.92	3,178.72	722.90	5,033.86	4,377.29	1,117.88	4,054.61	1,110.21	
1107	TANF EXPANDED 21-44	3,768.06	4,757.95	2,979.96	959.55	1,778.16	1,604.82	1,256.75	2,980.87	4,335.98	298.91	2,948.17	963.00	
1108	TANF EXPANDED 45-64	19,652.04	43,930.14	31,828.78	10,887.09	27,668.72	22,355.55	9,841.92	46,215.87	54,480.71	11,414.40	29,513.26	9,013.08	
1109	TANF EXPANDED 65+ M
&	27,288.27	51,442.24	33,629.57	7,856.53	26,255.47	20,393.97	10,058.77	40,580.37	86,299.50	15,313.88	49,686.49	32,347.18	
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	519.00	
1114	TANF EXPANDED 14-20	1,981.86	1,555.74	2,735.97	0.00	519.00	2,076.00	2,595.00	3,114.00	4,671.00	2,197.00	2,404.00	1,764.00	
1115	TANF EXPANDED 14-20	26,621.95	30,863.61	30,613.19	20,366.02	31,445.85	22,121.99	17,724.43	33,884.71	35,650.67	16,672.46	23,447.16	11,830.54	
1116	TANF EXPANDED 21-44	604,674.80	971,127.14	1,076,231.31	497,025.15	628,958.11	716,087.42	401,817.07	901,547.21	1,032,002.29	444,046.69	875,155.92	530,808.38	
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	2,274,028.39	1,460,735.24	3,192,225.43	4,058,379.18	1,593,884.50	3,339,637.04	2,261,500.78	
1118	TANF EXPANDED 45-64	1,569,030.92	2,269,021.84	2,258,563.91	847,565.83	1,622,696.79	1,411,088.63	804,665.21	2,243,455.56	3,026,523.31	886,532.64	2,089,504.53	1,362,283.87	
1119	TANF EXPANDED 65+ M
&	11,937.00	19,658.75	16,480.00	7,785.00	22,087.08	8,277.58	7,920.02	16,089.00	29,242.51	8,301.28	25,559.67	18,017.43	
1126	TANF EXPANDED 21-44	7,561.31	14,386.47	7,040.11	5,495.26	9,450.33	6,721.51	5,030.03	7,767.24	17,803.91	3,837.77	9,126.84	10,663.67	
1127	TANF EXPANDED 21-44	17,413.86	24,887.45	14,916.40	6,891.09	10,952.16	8,381.34	4,741.06	13,550.97	19,817.99	6,186.35	11,018.52	8,602.42	
1128	TANF EXPANDED 45-64	70,166.43	115,595.00	80,480.48	24,417.72	62,582.19	46,229.69	20,714.29	65,833.11	142,504.67	32,870.08	73,071.35	59,924.77	
1129	TANF EXPANDED 65+ M
&	76,465.14	123,669.50	83,597.78	26,889.21	79,724.02	49,357.98	24,688.79	99,301.72	184,372.87	34,251.10	94,186.24	77,100.67	
2400	SSI AGED EXPANDED WI	5,874.59	11,160.02	11,556.25	6,265.35	15,633.34	11,257.76	6,089.87	18,262.65	29,209.98	12,578.71	17,517.76	6,006.30	
2410	SSI AGED EXPANDED N
O	27,794.17	46,691.46	22,387.57	11,930.85	23,538.70	15,068.13	3,326.88	27,182.19	47,341.14	4,811.03	23,026.00	11,836.99	
2420	SSI AGED EXPANDED WI	398,264.41	708,169.48	488,600.44	159,454.96	469,469.64	304,197.54	100,954.68	621,513.47	948,364.23	175,038.48	559,528.09	428,928.70	
2500	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	89.95	
2510	SSI BLIND EXPANDED N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	640.00	
2520	SSI BLIND EXPANDED
W	0.00	317.98	1,260.60	433.24	768.95	1,216.66	271.42	1,229.83	3,740.60	555.85	1,829.49	1,586.99	
2600	SSI DISABLED EXPAND E	5,884.00	7,018.57	12,600.34	9,963.07	24,018.21	16,564.41	4,975.73	7,772.36	10,700.45	3,528.62	12,497.34	16,821.83	
2610	SSI DISABLED EXPAND
E	89,695.00	133,083.14	104,157.90	31,228.81	72,078.64	56,531.84	21,650.30	99,505.38	170,323.63	61,917.93	119,747.61	95,401.61	
2620	SSI DISABLED EXPAND E	196,173.58	317,376.45	223,308.00	66,762.96	204,896.18	119,853.91	57,246.57	241,874.86	367,908.39	81,033.70	214,793.56	165,841.90	
SUBTOTAL:	5,434,174.49	8,092,381.96	7,933,816.27	3,502,166.92	5,936,809.09	5,116,593.84	2,967,026.93	7,688,920.66	10,278,050.30	3,396,389.26	7,578,253.65	5,113,603.27	

38,298.00	
28,632.18	
316,801.56	
401,152.24	
1,038.00	
25,613.57	
301,242.58	
8,679,481.49	
31,425,889.65	
20,390,933.04	
191,355.32	
104,884.45	
147,359.61	
794,389.78	
953,605.02	
151,412.58	
264,935.11	
5,362,484.12	
89.95	
640.00	
13,211.61	
132,344.93	
1,055,321.79	
2,257,070.06	
73,038,186.64	

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	202.13	211.59	289.66	2,241.60	274.39	1,298.53	-386.77	
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	2,517.73	1,434.39	5,850.22	7,060.61	2,122.42	10,649.53	6,935.55	
3509	ADULT 40-100% M&F 65	4,057.01	3,872.90	4,959.57	1,838.72	5,282.53	4,640.94	1,089.69	9,076.49	17,730.89	2,887.20	11,008.22	5,319.21	

7,686.66	
1,038.00	
57,682.94	
71,763.37	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	69,387.94	79,951.30	95,542.99	59,276.59	55,194.98	57,819.04	37,155.80	95,436.13	119,208.00	56,645.16	96,277.85	51,893.88		873,789.66		
3515	ADULT 40-100% FEMAL	102,402.53	94,821.55	112,513.09	56,549.09	101,620.15	129,022.85	67,011.15	130,589.63	183,283.74	84,473.05	151,608.17	108,465.45		1,322,360.45		
	E																
3516	ADULT 40-100% MALE 2	701,144.58	981,566.21	1,025,560.17	523,661.69	798,362.64	600,135.15	336,245.51	780,470.67	1,123,476.17	290,115.40	816,173.59	521,173.09		8,498,084.87		
3517	ADULT 40-100% FEMAL	538,146.16	761,032.73	891,240.94	378,639.16	647,516.79	608,001.87	353,283.20	804,657.11	1,148,370.64	329,928.62	883,610.07	542,570.78		7,886,998.07		
	E																
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	1,679,433.70	946,942.90	2,391,768.84	3,669,771.98	879,899.16	2,485,874.80	1,438,783.41		23,630,392.29		
3519	ADULT 40-100% M&F 65	1,631.66	2,076.00	7,381.21	2,076.00	3,633.00	3,633.00	1,557.00	5,190.00	12,975.00	2,297.53	2,732.00	-1,592.00		43,590.40		
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	362.09	194.32	99.23	411.79	0.00	3,433.48	3,873.18		11,155.23		
3706	ADULT <40% EXP MALE	1,369.20	5,371.87	1,948.80	750.93	497.68	2,155.91	3,022.15	3,901.39	2,453.41	619.02	288.37	379.85		22,758.58		
3707	ADULT <40% EXP FEMA	1.99	2,403.00	0.00	0.00	0.00	0.00	0.00	2,595.00	3,633.00	0.00	121.00	-917.00		7,836.99		
	L																
3708	ADULT <40% EXP M&F	8,384.38	27,515.76	20,025.60	8,894.22	17,830.21	8,846.99	6,403.04	31,086.49	33,745.44	10,903.80	14,438.43	21,436.70		209,511.06		
	4																
3709	ADULT <40% EXP M&F	1,175.38	1,838.48	1,804.43	1,801.09	1,168.72	646.70	2,404.33	3,615.08	17,309.97	2,340.79	6,288.14	862.17		41,255.28		
	6																
3714	ADULT <40% EXP MALE	235,096.31	292,525.63	448,953.34	195,179.59	234,271.95	252,743.11	214,971.94	345,956.28	466,655.22	196,966.27	373,719.20	250,011.76		3,507,050.60		
3715	ADULT <40% EXP FEMA	335,188.89	489,997.28	592,804.11	289,302.05	402,079.87	423,637.72	303,235.83	543,625.31	695,985.22	309,121.60	590,936.37	405,050.47		5,380,964.72		
	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	5,192,530.12	3,928,499.05	7,118,750.96	9,379,915.11	3,849,038.06	7,438,402.16	5,858,394.63		68,830,875.49		
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	3,079,828.75	2,207,396.25	4,375,763.54	5,868,348.71	2,173,135.96	4,679,414.79	3,578,384.21		41,207,547.28		
	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	7,458,754.57	4,998,296.33	10,772,393.96	15,612,860.39	5,085,462.78	12,081,712.46	8,074,876.33		104,861,843.16		
	4																
3719	ADULT <40% EXP M&F	4,267.21	9,570.80	6,247.52	612.85	10,917.28	5,709.00	3,633.00	11,937.00	9,925.13	1,928.81	10,157.00	7,005.00		81,910.60		
	6																
3726	ADULT <40% EXP MALE	0.00	89.78	0.00	0.00	0.00	0.00	0.00	0.00	1,430.76	82.80	1,873.22	771.24		4,247.80		
3727	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	519.00	519.00	640.00	761.00		2,439.00		
	L																
3728	ADULT <40% EXP M&F	1,701.99	1,864.92	2,257.08	2,731.12	3,593.95	4,091.56	5,212.29	6,848.89	13,948.55	4,525.80	10,460.16	14,650.32		71,886.63		
	4																
SUBTOTAL:	17,808,431.03	26,788,688.62	26,308,132.79	13,413,418.02	19,708,816.15	19,514,712.93	13,418,199.76	27,439,901.88	38,391,260.33	13,283,287.62	29,671,117.54	20,888,702.46		266,634,669.13		

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	1,598.29	329.85	325.16	2,819.66	192.12	769.40	1,664.48	
3907	NEWLY ELIGIBLE FEMA L	737.72	455.00	0.00	0.00	0.00	0.00	0.00	0.00	1,557.00	0.00	392.64	-519.00	
3908	NEWLY ELIGIBLE M&F
4	16,070.55	27,952.59	22,844.56	15,286.33	29,377.87	17,918.76	8,667.15	30,821.42	66,594.88	14,468.73	40,414.93	21,125.52	
3909	NEWLY ELIGIBLE M&F 6	21,413.98	28,515.33	30,231.74	13,869.40	24,853.38	22,395.82	12,125.64	36,416.48	64,600.77	20,931.44	43,376.22	24,280.25	
3914	NEWLY ELIGIBLE MALE	40,125.82	44,615.64	50,062.71	36,082.00	47,758.57	44,002.03	27,197.42	60,301.18	56,532.72	25,663.57	54,832.28	29,433.39	
3915	NEWLY ELIGIBLE FEMA L	64,491.39	71,696.34	106,084.49	54,459.47	74,157.40	81,494.48	59,693.34	104,134.81	114,783.21	47,931.44	104,855.37	84,486.03	
3916	NEWLY ELIGIBLE MALE	535,939.67	754,062.16	908,490.15	443,663.90	599,677.31	540,434.83	430,938.17	841,562.91	1,096,805.00	359,680.13	844,765.88	608,263.16	
3917	NEWLY ELIGIBLE FEMA L	997,769.63	1,507,925.27	1,519,017.72	831,472.02	1,339,770.59	1,164,873.25	800,806.20	1,615,567.21	2,147,645.14	790,546.02	1,588,180.15	1,029,580.38	
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	1,745,453.83	858,729.22	2,484,543.23	3,667,842.34	998,594.45	2,532,346.32	1,610,787.56	
3919	NEWLY ELIGIBLE M&F 6	5,797.52	3,114.00	3,633.00	3,633.00	3,713.00	3,775.17	2,076.00	6,789.90	15,209.31	2,716.00	3,891.63	17,104.01	
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	24.27	126.25	632.03	0.00	0.00	519.00	0.00	

519.00	
10,718.07	
2,623.36	
311,543.29	
343,010.45	
516,607.33	
968,267.77	
7,964,283.27	
15,333,153.58	
23,948,169.22	
71,452.54	
519.00	
3,075.22	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3929	NEWLY ELIGIBLE M&F 6	755.41	775.26	373.04	204.89	747.47	618.53	178.86	2,102.06	1,639.80	644.86	679.99	-735.33		7,984.84		
SUBTOTAL:	3,494,593.15	5,155,339.36	5,030,525.92	2,577,448.07	4,079,473.84	3,622,589.26	2,200,868.10	5,183,196.39	7,236,029.83	2,261,368.76	5,215,023.81	3,425,470.45		49,481,926.94		

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	640.00	0.00	
4413	SOBRA 100-133% M&F
6	329,247.64	475,397.11	668,840.08	432,812.49	458,840.57	570,237.36	371,696.77	615,026.88	656,676.51	378,312.47	686,416.47	506,475.35	
4414	SOBRA 100-133% MALE	109,006.07	210,348.00	261,621.65	162,138.67	216,638.22	203,253.23	135,934.30	208,142.14	262,646.78	109,088.23	243,817.64	184,047.45	
4415	SOBRA 100-133% FEMA L	171,230.65	249,819.01	301,954.69	187,754.46	215,470.22	213,563.72	163,603.26	309,872.59	365,255.88	170,360.77	326,623.62	218,546.40	
SUBTOTAL:	609,484.36	935,564.12	1,232,416.42	782,705.62	890,949.01	987,054.31	671,234.33	1,133,041.61	1,284,579.17	657,761.47	1,257,497.73	909,069.20	

640.00	
6,149,979.70	
2,306,682.38	
2,894,055.27	
11,351,357.35	

4517	BC PATIENT FEMALE 2 1	0.00	0.00	479.00	0.00	0.00	637.92	0.00	0.00	519.00	0.00	0.00	640.00	
4518	BC PATIENT FEMALE 4
5	1,557.00	3,401.00	3,896.43	1,477.00	3,593.00	0.00	2,595.00	3,114.00	8,304.00	640.00	3,442.00	-121.23	
SUBTOTAL:	1,557.00	3,401.00	4,375.43	1,477.00	3,593.00	637.92	2,595.00	3,114.00	8,823.00	640.00	3,442.00	518.77	

2,275.92	
31,898.20	
34,174.12	

8700	SSI DISABLED FREEDO M	14,610.46	23,510.46	16,676.32	4,767.20	14,279.04	13,752.94	5,378.46	18,260.41	32,330.67	6,968.14	24,854.81	12,342.41	
8710	SSI DISABLED FREEDO
M	11,418.00	29,128.18	16,568.00	8,304.00	14,093.00	10,861.00	5,800.40	17,646.00	29,773.61	7,126.27	12,498.00	12,488.02	
8720	SSI DISABLED FREEDO M	1,971.00	1,805.95	5,663.21	459.24	2,313.26	572.28	207.57	4,255.70	3,548.80	635.72	1,170.19	1,494.77	
SUBTOTAL:	27,999.46	54,444.59	38,907.53	13,530.44	30,685.30	25,186.22	11,386.43	40,162.11	65,653.08	14,730.13	38,523.00	26,325.20	

187,731.32	
175,704.48	
24,097.69	
387,533.49	

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	61,732,937.71	40,343,684.38	82,286,498.60	113,194,676.65	42,994,948.78	90,491,290.66	63,700,306.29		814,310,545.45		

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
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	39,483.77	29,819.70	29,727.92	46,454.14	38,461.98	35,969.65	44,506.80		443,474.46		
8040	SLMB	438.70	305.87	1,035.48	610.39	246.00	178.66	25.72	425.48	1,474.00	463.62	0.00	4.14		5,208.06		
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	39,662.43	29,845.42	30,153.40	47,928.14	38,925.60	35,969.65	44,510.94		448,691.42		

32,613.60

47,928.14

44,510.94

35,969.65

TOTAL:

26,495.51

40,114.80

45,573.10

36,898.83

39,662.43

29,845.42

30,153.40

38,925.60

448,691.42

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
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	10,309.14	107.73	1,858.45	0.00	39.26	3,221.72	440.88		156,735.41		
1012	TANF 01-05 M & F NON	99.89	860.92	630.84	0.00	150.67	295.15	0.00	0.00	542.61	673.11	0.00	422.53		3,675.72		
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	192.12		381.59		
1014	TANF 14-20 MALE NON-	0.00	0.00	87.21	0.00	151.93	186.36	1,026.17	201.51	0.00	0.00	68.76	0.00		1,721.94		
1015	TANF 14-20 FEMALE N	2,590.30	141.65	0.00	0.00	70.14	0.00	0.00	357.24	114.08	0.00	0.00	0.00		3,273.41		
	O																
1016	TANF 21-44 MALE NON-	1,114.79	8,635.85	15,957.91	9,395.62	5,385.09	1,911.38	1,131.20	11,188.37	0.00	7,382.04	5,922.40	2,082.04		70,106.69		
1017	TANF 21-44 FEMALE N	2,043.82	4,803.99	3,331.64	949.05	3,808.86	2,214.29	13,286.05	4,483.30	1,840.26	1,711.75	9,881.67	23,651.97		72,006.65		
	O																
1018	TANF 45-64 M & F NON	13,225.63	12,087.26	1,374.68	6,354.16	4,507.68	6,570.70	4,529.15	18,686.61	5,059.34	292.42	5,628.31	2,352.56		80,668.50		
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	1,001.03	744.22	2,737.17	331.14	3,386.77	633.71	588.84		14,741.52		
	A																
2110	SSI AGED NON-MEDICA	1,794.27	46,370.20	18,360.68	5,170.30	9,861.25	21,321.79	23,276.94	25,307.22	-10,264.60	7,533.58	36,332.14	11,196.01		196,259.78		
	R																
2120	SSI AGED WITH QMB	1,010.93	1,323.05	34.20	736.78	146.50	721.12	0.00	0.00	429.24	0.00	0.00	-893.34		3,508.48		
2200	SSI DISABLED WITH M	552.93	1,456.66	2,901.31	1,763.21	550.20	1,351.27	9.71	114.71	4,428.60	320.34	737.16	1,706.26		15,892.36		
	E																
2210	SSI DISABLED NON-ME	110,466.44	17,889.57	115,151.37	20,746.04	23,705.03	6,106.91	31,799.22	16,070.21	150,055.91	115,249.44	156,368.68	205,415.11		969,023.93		
	D																
2220	SSI DISABLED WITH Q	359.19	2,141.94	85.85	536.32	2,072.16	2,242.85	360.90	0.00	169.42	175.56	0.00	568.05		8,712.24		
	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	84,207.89	23,668.69	31,923.54	27,190.18	8,599.27	6,892.70	50,608.89		316,645.62		
4312	SOBRA CHILD 01-05 M	6,391.81	3,280.49	2,289.08	6,096.28	744.74	1,727.72	590.94	54,009.46	655,531.42	19,879.40	16,017.38	128.98		766,687.70		
4313	SOBRA CHILD 06-13 M	1,479.36	975.86	1,898.94	643.56	13,021.16	1,666.14	1,532.27	529,424.82	788.07	1,122.33	1,215.67	132.08		553,900.26		
4314	SOBRA CHILD 14-20 MA	2,684.63	1,094.83	1,922.69	2,268.08	4,609.23	549.31	741.80	341.93	175.04	1,230.57	27.22	1,125.88		16,771.21		
4315	SOBRA CHILD 14-20 FE	4,356.84	6,216.94	4,306.22	841.43	1,689.94	8,994.64	0.00	339.00	629.57	197.80	3,387.90	1,374.47		32,334.75		
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																
5008	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																
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	164.91	44.11	1,897.34	378.16	639.22	0.00	5,846.46		15,521.27		
	M																
5017	SOBRA PREG 21-44 FE	14,845.21	10,086.86	18,930.46	41,196.05	28,992.23	13,621.73	13,904.99	13,161.12	8,303.88	14,662.91	17,440.30	10,017.68		205,163.42		
	M																

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	204,226.07	130,469.68	313,068.63	110,831.12	141,585.25	165,164.33	116,754.09	712,102.00	845,702.32	183,095.77	263,775.72	316,957.47		3,503,732.45		

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	4,344.00	0.00	0.00	0.00	0.00	-4,344.00	8.90	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	1,469.16	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	2,707.51	313.58	1,181.27	2,045.24	1,272.33	1,840.24	2,634.21	
1117	TANF EXPANDED 21-44	4,674.57	2,883.06	7,326.39	2,161.95	4,043.67	6,381.87	9,477.82	2,116.76	2,767.70	984.89	9,042.17	441.12	
1118	TANF EXPANDED 45-64	15,302.75	5,437.66	6,034.25	55,775.56	0.00	746.32	4,365.78	13,319.76	1,000.58	-699.20	63.57	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	87.30	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	20.51	3,343.65	1,712.18	2,134.90	61.15	
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	-786.62	60.33	0.00	1,319.42	74.30	
2500	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	
2510	SSI BLIND 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	
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	13.21	86.03	
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	101.03	1,754.25	186.76	182.06	348.81	
SUBTOTAL:	36,127.40	10,279.88	17,949.74	63,623.50	19,770.68	9,835.70	14,157.18	15,952.71	6,715.05	3,465.86	16,064.73	3,645.62	

8.90	
0.00	
0.00	
1,784.96	
0.00	
0.00	
0.00	
48,441.40	
52,301.97	
101,347.03	
87.30	
0.00	
0.00	
0.00	
0.00	
9,985.39	
0.00	
700.32	
0.00	
0.00	
0.00	
99.24	
60.30	
2,771.24	
217,588.05	

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	-1,508.39	0.00	

0.00	
0.00	
0.00	
363.71	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	322.42	0.00	0.00	0.00	0.00		322.42		
3515	ADULT 40-100% FEMAL	644.13	239.80	574.55	0.00	0.00	0.00	0.00	0.00	0.00	999.51	0.00	0.00		2,457.99		
	E																
3516	ADULT 40-100% MALE 2	3,500.98	6,370.35	4,687.74	4,818.70	34,252.34	11,298.42	3,239.30	2,691.41	11,185.20	20,718.50	10,101.44	2,265.93		115,130.31		
3517	ADULT 40-100% FEMAL	-2,278.80	32,841.17	7,813.39	7,533.48	5,901.86	-3,041.54	158.29	111.38	1,149.29	0.00	28,115.39	3,540.57		81,844.48		
	E																
3518	ADULT 40-100% M&F 45	6,321.70	5,284.26	34,872.18	22,804.70	22,411.68	26,142.04	21,784.60	44,149.98	34,771.39	33,882.70	2,144.79	16,507.44		271,077.46		
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	140.77	0.00	0.00	118.33	0.00	0.00		2,035.69		
	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	64.96		64.96		
	6																
3714	ADULT <40% EXP MALE	395.81	755.00	911.53	2,628.63	0.00	382.24	181.74	9,424.71	1,894.34	0.00	720.26	5,492.87		22,787.13		
3715	ADULT <40% EXP FEMA	493.24	0.00	127.16	0.00	421.63	102.14	420.02	695.67	10,916.07	2,693.23	2,067.75	1,698.45		19,635.36		
	L																
3716	ADULT <40% EXP MALE	84,556.81	61,039.82	105,345.67	41,671.02	46,561.29	30,049.79	11,475.24	38,676.87	97,899.17	42,558.52	82,350.17	15,171.85		657,356.22		
3717	ADULT <40% EXP FEMA	13,093.01	17,172.28	35,388.38	55,457.34	11,515.76	28,753.75	16,922.79	48,474.48	9,966.10	9,237.12	193,919.47	12,152.97		452,053.45		
	L																
3718	ADULT <40% EXP M&F	142,483.33	-59,507.68	259,783.72	258,119.00	101,385.22	107,981.00	128,907.83	70,303.35	55,316.44	21,867.31	57,999.34	107,103.30		1,251,742.16		
	4																
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	15,495.09	3,030.13	1,519.01	0.00	368.23	0.00		20,412.46		
	6																
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	L																
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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	201,667.84	198,725.67	217,880.40	224,617.01	132,075.22	376,278.45	163,998.34		2,897,349.81		

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	51.94	
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	2,370.38	
3914	NEWLY ELIGIBLE MALE	1,917.24	165.43	935.11	0.00	0.00	0.00	0.00	0.00	56.48	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	1,679.18	865.71	315.46	34.72	
3916	NEWLY ELIGIBLE MALE	19,779.02	2,691.49	4,306.23	26,703.95	2,373.72	760.69	2.24	2,511.02	8,342.49	8,336.51	1,122.64	11,328.55	
3917	NEWLY ELIGIBLE FEMA L	18,827.19	4,429.18	7,108.49	7,318.00	224.48	8,473.30	1,387.84	2,409.55	390.00	1,504.32	1,518.55	4,423.44	
3918	NEWLY ELIGIBLE M&F
4	13,670.08	42,060.22	54,084.19	4,527.02	12,281.95	5,297.21	2,095.57	44,291.07	45,297.62	6,961.99	26,141.94	20,340.92	
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	

0.00	
0.00	
0.00	
51.94	
2,370.38	
3,074.26	
3,555.16	
88,258.55	
58,014.34	
277,049.78	
0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
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		0.00		
SUBTOTAL:	54,569.10	49,346.32	66,530.98	38,736.53	14,880.15	14,531.20	3,485.65	49,211.64	55,765.77	17,668.53	29,098.59	38,549.95		432,374.41		

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	1,362.28	51.82	1,691.84	200.00	80.00	100.00	0.00	0.00	121.40	602.50	340.31	175.63	
4414	SOBRA 100-133% MALE	264.60	-136.89	0.00	0.00	83.00	83.00	0.00	0.00	0.00	13.69	0.00	97.23	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	186.58	0.00	0.00	826.49	83.83	188.12	0.00	0.00	0.00	
SUBTOTAL:	1,626.88	-85.07	1,691.84	386.58	163.00	183.00	826.49	83.83	309.52	616.19	340.31	272.86	

0.00	
4,725.78	
404.63	
1,285.02	
6,415.43	

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	8.97	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	8.97	0.00	0.00	

0.00	
85.40	
0.00	
85.40	

S000	STATE-ONLY BHS	1,742.57	5,676.45	-6,474.77	0.00	0.00	0.00	0.00	33.85	15,064.12	0.00	0.00	0.00	
SUBTOTAL:	1,742.57	5,676.45	-6,474.77	0.00	0.00	0.00	0.00	33.85	15,064.12	0.00	0.00	0.00	

16,042.22

16,042.22

TOTAL:	548,433.83	262,396.47	842,288.38	606,913.96	398,873.18	391,382.07	333,949.08	995,264.43	1,148,173.79	336,930.54	685,557.80	523,424.24		7,073,587.77		

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
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	487,950.06	-93,145.72	441,574.33	579,098.84	370,036.05	424,265.07	562,338.80		5,547,832.51		
8040	SLMB	10,153.26	13,025.80	15,154.86	2,524.95	271.37	2,817.70	2,123.73	2,561.94	3,295.27	1,259.64	-645.66	3,121.09		55,663.95		
8050	QI1	1,066.22	95.19	0.00	511.57	0.00	60.16	0.00	111.76	792.98	155.98	0.00	0.00		2,793.86		
SUBTOTAL:	408,658.24	446,984.28	797,406.74	344,231.31	821,237.73	490,827.92	-91,021.99	444,248.03	583,187.09	371,451.67	423,619.41	565,459.89		5,606,290.32		

344,231.31

583,187.09

565,459.89

423,619.41

TOTAL:

408,658.24

446,984.28

797,406.74

821,237.73

490,827.92

-91,021.99

444,248.03

371,451.67

5,606,290.32

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending June 30, 2022	
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	1,557.00	1,038.00	2,076.00	3,139.51	1,074.63	4,850.17	5,176.33		19,949.64		
2100	SSI AGED WITH MEDIC	477,605.14	638,635.22	522,769.41	356,422.86	457,100.96	365,195.94	249,660.43	569,754.27	649,785.33	441,208.09	1,103,607.81	558,486.60		6,390,232.06		
	A																
2110	SSI AGED NON-MEDICA	69,557.92	78,739.29	82,660.80	53,230.67	63,035.35	55,907.97	64,662.70	74,213.60	90,418.39	69,337.30	181,732.61	79,417.17		962,913.77		
	R																
2120	SSI AGED WITH QMB	665,719.14	919,902.30	757,555.35	426,766.51	654,577.41	490,446.62	258,071.46	837,375.56	818,149.77	439,266.11	1,137,993.76	705,129.91		8,110,953.90		
2200	SSI DISABLED WITH M	115,099.39	121,216.11	126,077.60	93,414.56	139,833.91	98,121.54	71,327.59	115,195.17	111,138.65	75,271.36	214,245.98	121,884.63		1,402,826.49		
	E																
2210	SSI DISABLED NON-ME	847,990.95	1,285,024.65	1,357,146.54	709,874.82	966,892.41	1,206,866.74	544,379.74	1,432,915.06	1,746,508.43	655,760.11	1,412,404.45	1,280,825.09		13,446,588.99		
	D																
2220	SSI DISABLED WITH Q	161,448.52	204,127.73	194,978.26	70,038.18	129,989.73	102,250.13	34,191.86	179,657.86	232,542.85	87,866.85	210,113.86	146,083.94		1,753,289.77		
	M																
2310	SSI BLIND NON-MEDIC	0.00	1,820.00	1,415.68	479.00	479.00	479.00	519.00	2,595.00	18,912.80	5,890.17	27,836.30	31,536.03		91,961.98		
	A																
2320	SSI BLIND WITH QMB	0.00	2,954.00	0.00	0.00	0.00	0.00	0.00	269.20	1,307.20	0.00	1,048.40	-398.00		5,180.80		
SUBTOTAL:	2,337,421.06	3,252,419.30	3,042,603.64	1,710,226.60	2,412,946.77	2,320,824.94	1,223,850.78	3,214,051.72	3,671,902.93	1,775,674.62	4,293,833.34	2,928,141.70		32,183,897.40		

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	2,320,824.94	1,223,850.78	3,214,051.72	3,671,902.93	1,775,674.62	4,293,833.34	2,928,141.70		32,183,897.40		

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2022	
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	91.17	0.00	91.17	0.00	0.00	305.81		488.15		
2100	SSI AGED WITH MEDIC	7,532.14	17,384.41	14,691.56	3,303.91	9,400.29	15,871.70	607.06	7,654.64	25,779.81	3,179.13	8,127.97	3,709.84		117,242.46		
	A																
2110	SSI AGED NON-MEDICA	1,733.06	-260.82	668.08	0.00	1,175.23	-113.47	0.00	920.00	0.00	76.64	1,135.06	0.00		5,333.78		
	R																
2120	SSI AGED WITH QMB	5,137.41	-38.81	2.81	4,981.35	2,082.41	398.12	4,660.60	2,046.12	830.68	0.00	3,770.99	536.26		24,407.94		
2200	SSI DISABLED WITH M	1,075.79	2,104.59	5,774.65	4,172.76	253.37	214.64	51.97	70.99	11,569.42	0.00	321.46	99.24		25,708.88		
	E																
2210	SSI DISABLED NON-ME	25,090.04	26,946.78	77,216.01	43,008.85	122,140.53	86,496.55	52,252.73	123,566.30	60,236.68	69,019.70	35,853.57	19,052.05		740,879.79		
	D																
2220	SSI DISABLED WITH Q	1,733.99	264.51	1,488.43	2,589.83	2,998.66	7,163.80	9,923.60	8,933.57	15,795.92	2,660.22	2,485.60	2,727.05		58,765.18		
	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	519.00	1,159.00		1,678.00		
	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	110,031.34	67,587.13	143,191.62	114,303.68	74,935.69	52,213.65	27,589.25		974,504.18		

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

974,504.18

42,302.43	46,400.66	99,841.54	58,056.70	138,050.49	110,031.34	67,587.13	143,191.62	114,303.68	74,935.69	52,213.65	27,589.25	

TOTAL:

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending June 30, 2022	
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	2,147.24	189.64	2,366.11	4,477.79	4,052.89	0.00	-309.98		34,735.04		
1007	TANF 21-44 FEMALE WI	1,283.28	889.24	70.99	568.33	179.44	90.04	181.65	242.45	311.29	111.85	169.82	250.06		4,348.44		
1008	TANF 45-64 M & F WIT	13,644.99	10,959.83	7,948.73	8,022.25	7,890.79	7,591.93	6,338.79	14,530.52	11,956.82	12,952.26	15,510.66	8,482.29		125,829.86		
1009	TANF 65+ M & F WITH	221.59	1,011.61	1,688.77	2,570.69	1,848.86	1,510.11	1,598.32	1,982.38	1,279.32	13,956.92	13,736.75	11,435.73		52,841.05		
1011	TANF <1 M & F NON-ME	576,302.62	596,270.52	863,942.40	777,362.05	526,320.18	794,118.95	260,481.65	607,033.19	855,237.31	526,199.32	552,853.45	596,880.21		7,533,001.85		
1012	TANF 01-05 M & F NON	48,957.99	75,795.51	124,843.70	96,610.33	103,146.53	109,012.77	56,542.79	103,576.85	94,009.43	61,088.46	103,774.22	119,637.29		1,096,995.87		
1013	TANF 06-13 M & F NON	133,681.56	148,607.95	176,330.84	161,201.08	195,465.97	233,744.13	141,707.35	216,936.89	311,952.48	162,244.79	209,315.43	314,562.83		2,405,751.30		
1014	TANF 14-20 MALE NON-	200,569.13	124,644.45	133,314.00	139,277.78	154,880.29	232,625.03	215,192.17	204,709.95	258,220.94	179,925.99	170,216.11	316,057.70		2,329,633.54		
1015	TANF 14-20 FEMALE N	308,783.22	235,477.38	296,773.58	233,161.14	333,447.66	343,665.39	233,125.85	290,127.71	359,261.98	372,714.10	317,075.27	364,638.87		3,688,252.15		
	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	2,078,855.68	1,845,804.69	1,790,768.30	2,816,319.99	2,249,587.27	2,314,239.08	2,901,856.47		24,315,226.78		
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	5,975,047.93	5,948,499.27	7,043,351.49	9,984,136.87	8,140,588.98	7,952,769.26	9,466,280.25		78,384,642.92		
	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	1,682,551.45	1,407,907.72	1,668,993.88	2,901,808.55	1,810,732.99	2,198,676.06	2,450,647.23		22,880,639.92		
1019	TANF 65+ M & F NON-M	6,102.41	3,867.26	4,166.93	3,331.25	1,429.14	1,624.59	89.52	821.12	1,144.15	0.00	2,042.83	461.70		25,080.90		
1026	TANF 21-44 MALE WITH	585.60	0.00	0.00	15.27	0.00	253.22	961.62	1,331.42	1,186.65	0.00	0.00	0.00		4,333.78		
1027	TANF 21-44 FEMALE WI	0.00	40.40	1,905.82	1,935.94	-139.98	1,097.68	253.62	197.16	457.32	391.00	801.64	1,859.76		8,800.36		
1028	TANF 45-64 M & F WIT	4,500.10	4,053.90	3,431.25	22,802.82	18,028.96	10,559.48	7,633.75	4,939.03	13,481.01	4,548.04	6,940.75	9,229.28		110,148.37		
1029	TANF 65+ M & F WITH	3,496.11	3,685.68	2,519.64	1,530.66	32.66	206.09	369.80	233.40	6,407.84	384.90	389.87	616.58		19,873.23		
2100	SSI AGED WITH MEDIC	164,035.71	141,989.22	116,514.72	149,916.82	135,192.76	142,208.47	119,002.69	128,041.06	194,650.44	347,086.75	283,862.91	368,768.84		2,291,270.39		
	A																
2110	SSI AGED NON-MEDICA	146,151.92	166,398.60	179,287.83	229,149.88	214,825.04	264,714.02	198,544.53	205,898.65	311,842.73	228,009.51	194,415.87	362,339.74		2,701,578.32		
	R																
2120	SSI AGED WITH QMB	440,190.24	487,911.72	466,762.96	406,535.26	392,641.70	586,596.06	393,540.96	526,980.67	596,122.33	467,818.74	578,341.56	675,476.21		6,018,918.41		
2200	SSI DISABLED WITH M	422,554.09	418,690.64	616,234.83	373,892.45	404,084.03	381,618.93	320,373.49	345,283.29	483,813.40	407,893.62	408,643.99	572,129.92		5,155,212.68		
	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	5,226,598.98	4,184,019.72	6,199,637.29	8,738,368.11	4,871,220.90	6,441,172.04	8,070,136.12		71,049,977.87		
	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	1,487,281.01	991,879.34	1,044,654.60	1,528,075.44	1,106,430.02	1,284,609.39	1,790,623.17		15,830,937.57		
	M																
2300	SSI BLIND WITH MEDIC	7,854.55	769.25	1,000.53	480.02	6,218.77	841.49	250.75	765.35	770.65	739.78	677.01	1,600.87		21,969.02		
2310	SSI BLIND NON-MEDIC	78,129.22	40,437.73	48,248.29	43,936.26	91,210.28	108,897.07	64,385.33	119,154.32	164,914.65	112,979.21	102,017.42	124,955.90		1,099,265.68		
	A																
2320	SSI BLIND WITH QMB	11,067.36	5,848.91	13,557.57	7,271.67	9,536.74	24,553.65	25,949.48	24,315.87	31,544.03	28,053.37	33,671.54	39,615.42		254,985.61		
4311	SOBRA CHILD <1 M & F	1,076,008.21	772,705.68	1,205,488.30	549,565.60	639,369.59	916,974.92	767,395.12	790,914.31	1,029,725.71	664,061.20	698,413.61	1,451,317.35		10,561,939.60		
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	1,347,980.32	906,017.78	1,134,136.39	1,810,117.35	1,537,689.41	1,323,501.87	1,661,837.34		15,749,066.55		
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	2,667,232.70	2,103,560.19	2,748,246.40	3,780,800.24	2,970,164.11	3,276,173.09	4,462,791.75		34,337,900.20		
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	976,830.49	824,164.22	1,048,652.99	4,365,345.74	1,249,743.49	1,129,351.76	1,424,540.43		16,327,908.80		
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	1,342,268.42	1,328,774.12	1,106,590.35	1,424,776.48	1,187,921.01	1,184,695.50	1,694,786.48		14,920,671.04		
5007	SOBRA PREG 21-44 FE	4,495.48	9,435.59	8,520.02	1,356.56	398.26	2,522.98	2,248.25	1,327.16	3,634.49	74.00	0.00	96.57		34,109.36		
	M																
5008	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	898.04		898.04		
	M																
5013	SOBRA PREG 09-13 FE	0.00	0.00	0.00	0.00	0.00	3,015.72	1,005.24	100.00	0.00	0.00	152.62	574.58		4,848.16		
	M																
5015	SOBRA PREG 14-20 FE	66,671.21	64,519.43	89,373.75	85,701.77	80,734.00	77,290.04	69,268.02	79,078.03	118,109.60	61,441.74	89,405.99	196,567.85		1,078,161.43		
	M																
5017	SOBRA PREG 21-44 FE	830,096.74	820,031.04	1,026,189.67	862,715.74	928,074.37	1,017,513.40	892,043.37	1,232,290.34	1,650,111.48	1,051,098.38	1,269,213.28	1,336,663.32		12,916,041.13		
	M																

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5018	SOBRA PREG 45-64 FE M	765.23	288.18	160.27	0.00	0.00	1,453.51	0.00	170.14	4,692.15	1,762.66	471.77	0.00		9,763.91		
5028	SOBRA PREG 45-64 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	778.11		778.11		
SUBTOTAL:	23,942,994.13	24,924,964.80	28,643,849.68	22,475,934.96	26,690,700.80	28,051,093.89	23,319,300.80	28,688,379.06	43,859,064.76	29,833,667.66	32,157,302.42	40,799,084.28		353,386,337.24		

1106	TANF EXPANDED 21-44	5,852.78	231.56	5,981.14	696.76	3,345.69	6,539.35	2,536.66	5,274.53	15,490.47	10,737.26	12,685.27	9,687.98	
1107	TANF EXPANDED 21-44	4,172.06	1,296.68	2,306.29	828.73	265.58	3,760.64	682.97	2,691.58	4,350.05	1,408.85	3,731.17	2,380.85	
1108	TANF EXPANDED 45-64	35,173.28	37,948.51	46,760.89	28,029.49	34,686.46	47,663.38	23,665.04	26,283.44	60,354.56	25,492.37	38,506.24	38,627.13	
1109	TANF EXPANDED 65+ M
&	36,136.76	37,658.16	53,487.06	52,584.29	40,115.63	84,693.54	47,025.31	67,770.96	62,271.43	45,487.05	48,775.57	67,947.07	
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	8,348.74	3,568.57	1,272.03	233.37	173.89	9.97	-515.11	
1115	TANF EXPANDED 14-20	25,586.83	28,157.19	25,631.80	17,495.63	17,792.88	23,800.84	14,848.06	9,363.04	25,797.23	50,450.11	34,642.04	54,347.33	
1116	TANF EXPANDED 21-44	686,488.60	561,120.76	774,717.43	536,741.76	415,895.39	653,712.75	1,068,292.27	425,552.68	549,934.95	528,696.99	568,212.99	550,173.26	
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	1,453,386.56	1,472,786.44	1,557,842.70	2,285,634.67	1,827,823.35	2,017,422.13	2,229,298.33	
1118	TANF EXPANDED 45-64	694,910.36	730,558.86	724,708.91	556,651.82	630,019.75	644,936.44	456,296.36	794,788.41	876,737.15	602,300.01	679,565.07	881,205.77	
1119	TANF EXPANDED 65+ M
&	915.80	140.11	1,674.87	4,905.29	12,516.22	5,116.34	-9,258.80	1,126.22	5,601.61	1,110.84	4,275.49	11,997.69	
1126	TANF EXPANDED 21-44	15,109.98	11,494.40	14,072.10	9,644.88	7,773.47	9,721.58	10,575.17	8,006.38	15,080.81	6,077.69	8,747.66	12,243.23	
1127	TANF EXPANDED 21-44	35,131.65	35,765.56	49,114.37	53,779.36	68,573.47	78,937.05	48,303.66	49,253.20	73,356.37	53,380.82	46,129.81	66,708.69	
1128	TANF EXPANDED 45-64	85,095.02	73,317.72	134,251.81	89,538.38	94,440.99	116,554.20	96,337.93	107,754.22	155,971.03	90,031.95	94,188.46	132,184.31	
1129	TANF EXPANDED 65+ M
&	60,951.13	66,150.90	77,817.89	81,548.96	124,629.81	125,204.68	72,891.66	78,585.54	105,137.60	60,295.91	91,277.98	117,001.31	
2400	SSI AGED EXPANDED WI	5,058.46	3,223.95	2,065.84	4,102.38	10,596.17	13,283.26	30,726.23	12,612.72	14,285.92	11,923.68	8,882.83	4,816.31	
2410	SSI AGED EXPANDED N
O	11,079.14	39,920.34	18,955.35	321.80	4,865.23	5,224.40	68.14	628.09	651.52	1,199.75	822.03	2,234.54	
2420	SSI AGED EXPANDED WI	331,233.83	404,329.53	595,334.13	370,960.08	375,289.06	432,172.47	305,249.06	367,866.90	518,979.98	379,522.53	491,034.25	546,050.27	
2500	SSI BLIND EXPANDED
W	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,163.85	1,013.58	19.74	0.00	
2510	SSI BLIND EXPANDED N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	150.99	0.00	
2520	SSI BLIND EXPANDED
W	103.61	455.54	3,337.74	5,614.53	730.49	19,641.96	28,214.97	23,170.27	32,818.33	18,194.73	18,967.07	19,579.95	
2600	SSI DISABLED EXPAND E	2,366.79	4,142.81	7,693.56	16,373.70	21,456.58	15,861.01	3,954.02	5,079.48	2,466.97	7,155.54	12,518.87	1,831.56	
2610	SSI DISABLED EXPAND
E	55,596.48	91,828.00	57,929.14	72,992.77	93,927.03	75,647.39	51,504.25	57,501.58	149,824.53	72,996.69	79,579.59	106,733.25	
2620	SSI DISABLED EXPAND E	472,597.75	339,931.91	449,820.64	282,795.98	383,458.77	410,583.34	363,236.56	386,080.35	448,016.43	366,152.37	365,994.89	420,643.44	
SUBTOTAL:	4,378,240.68	3,933,740.56	4,969,957.86	3,636,741.92	3,776,294.67	4,234,789.92	4,091,504.53	3,988,504.32	5,409,158.83	4,161,625.96	4,626,140.11	5,275,177.16	

79,059.45	
27,875.45	
443,190.79	
643,952.83	
0.00	
47,095.59	
327,912.98	
7,319,539.83	
20,902,286.72	
8,272,678.91	
40,121.68	
128,547.35	
658,434.01	
1,269,666.02	
1,061,493.37	
121,577.75	
85,970.33	
5,118,022.09	
7,197.17	
150.99	
170,829.19	
100,900.89	
966,060.70	
4,689,312.43	
52,481,876.52	

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	5,370.69	5,023.58	5,698.06	7,812.10	4,629.56	5,453.01	8,967.13	
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	4,774.34	6,132.80	7,967.31	7,013.07	8,094.03	8,868.14	9,375.70	
3509	ADULT 40-100% M&F 65	2,215.66	3,387.31	10,795.03	1,157.25	3,105.66	1,858.26	1,756.20	3,011.49	5,636.09	7,800.08	3,795.20	12,020.25	

71,924.26	
0.00	
100,654.75	
56,538.48	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3514	ADULT 40-100% MALE 1	59,515.56	37,007.91	64,214.95	78,566.10	46,094.49	91,086.16	79,339.31	68,569.74	88,074.45	97,449.98	104,511.66	193,501.12		1,007,931.43		
3515	ADULT 40-100% FEMAL	26,823.59	31,192.16	32,744.19	37,025.33	21,391.19	26,549.05	15,742.40	21,619.84	26,818.59	28,595.47	72,964.48	93,720.64		435,186.93		
	E																
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	1,173,776.21	974,181.96	1,004,384.27	1,229,570.36	947,768.02	1,212,960.44	1,393,991.34		14,672,115.78		
3517	ADULT 40-100% FEMAL	506,091.70	443,826.27	608,138.62	528,240.24	679,037.78	829,766.84	618,303.86	844,199.63	1,172,432.66	706,241.52	733,781.76	1,096,084.88		8,766,145.76		
	E																
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	1,318,894.15	895,386.66	1,263,249.83	1,313,187.22	964,066.04	916,261.32	1,332,251.67		14,844,295.96		
3519	ADULT 40-100% M&F 65	589.81	1,016.85	5,836.75	7,926.73	34,635.92	4,737.02	4,888.15	18,903.53	-1,733.33	72.82	-2,026.32	0.00		74,847.93		
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	1,709.11	151.82	2,314.81	1,860.67	194.15	1,196.59	1,725.42		14,027.74		
3706	ADULT <40% EXP MALE	9,223.05	18,612.69	2,721.00	0.00	7.42	3,645.68	4,677.37	6,414.68	2,799.51	2,825.86	5,188.91	2,073.93		58,190.10		
3707	ADULT <40% EXP FEMA	0.00	0.00	0.00	18.37	42.23	0.00	0.00	0.00	1,006.86	6,782.99	308.43	338.17		8,497.05		
	L																
3708	ADULT <40% EXP M&F	35,952.73	20,880.60	12,806.33	10,217.84	12,942.77	19,645.77	7,625.33	12,654.69	30,295.66	12,483.14	10,680.55	38,275.48		224,460.89		
	4																
3709	ADULT <40% EXP M&F	1,628.60	26,325.91	4,626.73	3,180.81	5,991.98	9,788.12	17,277.70	12,974.29	10,963.40	9,038.22	13,095.94	1,899.08		116,790.78		
	6																
3714	ADULT <40% EXP MALE	385,868.47	261,608.66	426,680.82	295,386.59	220,721.31	323,445.74	361,753.76	428,324.22	695,805.73	527,325.72	578,150.94	775,852.02		5,280,923.98		
3715	ADULT <40% EXP FEMA	307,928.64	330,677.11	358,605.42	320,353.09	348,591.64	441,176.97	335,457.52	383,119.70	657,793.37	524,230.85	666,491.02	576,717.67		5,251,143.00		
	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	16,243,931.91	14,312,257.73	15,941,965.24	22,821,675.34	18,735,863.27	21,117,359.89	25,774,348.34		200,740,272.49		
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	6,957,239.22	6,024,458.08	6,717,157.37	10,232,259.47	7,642,181.31	8,783,201.43	11,770,835.12		86,515,987.93		
	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	12,327,986.13	9,699,086.09	10,886,706.81	15,281,066.90	12,294,060.37	15,248,738.09	16,951,069.50		148,728,823.04		
	4																
3719	ADULT <40% EXP M&F	1,601.51	502.63	783.71	2,765.97	4,364.81	803.87	1,116.69	1,032.75	8,378.73	1,250.69	8,481.12	1,584.02		32,666.50		
	6																
3726	ADULT <40% EXP MALE	0.00	0.00	26.64	0.00	0.00	0.00	785.68	3,450.54	16,043.52	5,494.83	9,042.15	12,164.12		47,007.48		
3727	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	955.12	0.00	832.78	991.24		2,779.14		
	L																
3728	ADULT <40% EXP M&F	42,055.42	17,672.19	17,779.91	11,396.47	11,849.64	5,075.14	38,287.67	9,608.53	6,564.57	6,521.25	7,821.58	17,820.85		192,453.22		
	4																
SUBTOTAL:	32,842,380.84	32,232,500.40	39,841,590.60	30,907,139.56	34,859,758.12	39,791,260.38	33,403,690.36	37,643,327.33	53,616,280.06	42,532,970.17	49,507,159.11	60,065,607.69		487,243,664.62		

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	3,515.21	213.13	4,952.51	-8.49	8,027.99	58.65	3,384.38	
3907	NEWLY ELIGIBLE FEMA L	929.70	1,998.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	348.12	32,876.09	1,883.39	
3908	NEWLY ELIGIBLE M&F
4	29,117.96	57,191.60	31,408.89	23,262.52	11,674.14	56,683.77	46,190.76	40,567.47	66,862.21	49,912.32	43,768.46	51,462.28	
3909	NEWLY ELIGIBLE M&F 6	15,547.34	8,292.00	8,934.84	6,797.60	16,656.63	15,385.99	10,723.88	15,733.69	24,331.90	14,448.72	17,609.86	15,933.47	
3914	NEWLY ELIGIBLE MALE	68,232.37	40,534.17	26,580.04	20,665.93	12,855.54	37,483.15	34,246.78	18,483.71	39,454.86	51,951.02	62,214.02	160,001.42	
3915	NEWLY ELIGIBLE FEMA L	36,245.78	82,861.49	38,077.62	39,535.05	41,091.99	33,493.33	23,263.56	27,568.44	47,556.30	58,859.20	72,975.16	49,932.37	
3916	NEWLY ELIGIBLE MALE	540,047.53	463,240.47	661,446.63	555,829.65	787,446.42	528,424.97	488,673.89	721,900.83	685,751.25	729,567.47	807,796.29	900,564.30	
3917	NEWLY ELIGIBLE FEMA L	503,815.27	689,089.90	561,199.26	663,550.85	568,978.12	742,973.21	369,989.79	488,984.06	635,223.39	395,976.20	562,286.85	569,518.66	
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	972,239.88	697,296.97	1,144,198.98	1,426,933.03	900,214.65	1,093,828.03	1,248,562.61	
3919	NEWLY ELIGIBLE M&F 6	2,222.69	3,272.64	2,419.30	1,978.34	4,761.31	3,059.55	1,577.23	2,025.01	1,887.64	2,612.87	1,725.34	2,970.79	
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	835.93	80.01	70.99	393.13	70.75	70.75	74.75	

0.00	
25,728.86	
38,035.32	
508,102.38	
170,395.92	
572,703.01	
551,460.29	
7,870,689.70	
6,751,585.56	
12,961,150.50	
30,512.71	
5,671.92	
5,813.55	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending June 30, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3929	NEWLY ELIGIBLE M&F 6	0.00	17.62	956.94	0.00	693.98	94.10	332.41	374.86	1,181.96	497.86	361.86	118.20		4,629.79		
SUBTOTAL:	2,276,310.58	2,623,742.45	2,548,620.79	2,214,816.36	2,459,318.95	2,394,189.09	1,672,588.41	2,464,860.55	2,929,567.18	2,212,487.17	2,695,571.36	3,004,406.62		29,496,479.51		

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	137,576.87	221,301.00	200,501.83	115,611.49	161,770.95	261,223.85	124,460.59	257,543.81	352,960.59	192,748.08	302,409.34	374,130.07	
4414	SOBRA 100-133% MALE	84,595.22	65,061.30	70,593.07	79,797.73	76,716.66	50,230.55	99,495.43	60,655.34	100,276.60	57,987.35	58,362.09	76,831.47	
4415	SOBRA 100-133% FEMA L	85,776.61	96,091.40	183,056.19	63,116.73	79,733.86	84,299.53	73,448.64	68,770.68	122,076.78	74,003.43	69,183.38	62,775.27	
SUBTOTAL:	307,948.70	382,453.70	454,151.09	258,525.95	318,221.47	395,753.93	297,404.66	386,969.83	575,313.97	324,738.86	429,954.81	513,736.81	

0.00	
2,702,238.47	
880,602.81	
1,062,332.50	
4,645,173.78	

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	223.21	0.00	7,150.00	569.91	1,093.22	1,525.14	1,567.86	
SUBTOTAL:	10,820.70	2,044.46	0.00	555.08	0.00	223.21	0.00	7,150.00	569.91	1,093.22	1,525.14	1,567.86	

10,701.29	
14,848.29	
25,549.58	

8700	SSI DISABLED FREEDO M	14,682.02	14,412.61	21,877.49	12,963.86	17,014.05	19,896.36	24,052.75	27,361.62	48,431.11	33,815.56	19,095.16	17,210.80	
8710	SSI DISABLED FREEDO
M	13,956.53	18,030.34	11,788.43	5,150.75	19,998.97	10,792.07	38,735.15	52,992.83	125,387.61	16,723.74	53,161.85	42,495.94	
8720	SSI DISABLED FREEDO M	5,398.22	0.00	1,383.92	329.05	1,560.12	904.46	1,053.32	1,793.38	1,721.78	744.14	255.76	1,092.45	
SUBTOTAL:	34,036.77	32,442.95	35,049.84	18,443.66	38,573.14	31,592.89	63,841.22	82,147.83	175,540.50	51,283.44	72,512.77	60,799.19	

270,813.39	
409,214.21	
16,236.60	
696,264.20	

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	74,898,903.31	62,848,329.98	73,261,338.92	106,565,495.21	79,117,866.48	89,490,165.72	109,720,379.61		928,017,582.10		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending June 30, 2022	
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	2,808,844.72	2,191,653.76	2,071,985.28	2,604,943.91	2,162,557.94	2,134,132.18	2,560,718.77		27,530,029.63		
	A																
2110	SSI AGED NON-MEDICA	106,801.15	105,359.64	63,541.22	70,963.48	44,220.81	79,136.92	76,164.61	71,089.45	92,760.48	89,683.19	67,437.58	81,553.90		948,712.43		
	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	4,441,243.19	3,752,799.92	3,469,383.59	4,265,308.06	3,447,407.36	3,440,538.62	4,258,329.44		44,610,883.20		
2200	SSI DISABLED WITH M	283,397.92	332,321.28	393,834.99	290,687.22	292,555.64	442,232.23	386,351.83	337,045.62	348,369.54	314,566.77	306,054.78	354,538.38		4,081,956.20		
	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	3,070,021.12	2,297,559.89	2,590,287.43	3,218,228.59	2,481,618.08	2,219,429.48	3,049,787.77		32,621,841.65		
	D																
2220	SSI DISABLED WITH Q	863,130.44	803,396.38	986,799.06	879,706.49	734,344.62	1,185,294.93	871,663.95	916,063.40	1,068,967.99	964,947.15	849,496.00	1,285,394.78		11,409,205.19		
	M																
2310	SSI BLIND NON-MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,553.12	15,947.32	13,802.44	14,416.86	16,970.58		62,690.32		
	A																
2320	SSI BLIND WITH QMB	731.80	7,926.62	5,798.46	1,777.74	1,906.22	2,157.47	2,708.16	2,073.91	5,787.59	8,707.38	6,535.62	8,238.18		54,349.15		
SUBTOTAL:	9,556,017.69	9,886,055.29	10,925,575.01	9,188,058.13	8,939,470.44	12,028,930.58	9,578,902.12	9,459,481.80	11,620,313.48	9,483,290.31	9,038,041.12	11,615,531.80		121,319,667.77		

8720	SSI DISABLED FREEDO M	3,521.28	3,521.28	3,521.28	4,401.60	3,082.08	4,720.80	3,822.74	3,855.75	4,820.55	3,856.44	3,856.44	4,820.55	
SUBTOTAL:	3,521.28	3,521.28	3,521.28	4,401.60	3,082.08	4,720.80	3,822.74	3,855.75	4,820.55	3,856.44	3,856.44	4,820.55	

47,800.79

47,800.79

121,367,468.56

9,559,538.97	9,889,576.57	10,929,096.29	9,192,459.73	8,942,552.52	12,033,651.38	9,582,724.86	9,463,337.55	11,625,134.03	9,487,146.75	9,041,897.56	11,620,352.35	

TOTAL:

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending June 30, 2022	
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 June 30, 2022	
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	219,566.31	212,177.49	200,872.97	206,933.97	218,858.33	216,457.35	228,605.32		2,511,066.89		
	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	2,938,770.76	2,972,991.38	2,991,749.81	3,005,354.25	3,009,264.57	3,018,209.77	3,023,914.01		35,138,614.12		
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	5,950,738.75	6,071,813.55	6,179,345.49	6,218,303.56	6,306,018.51	6,355,899.97	6,389,513.42		71,577,987.52		
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	1,794,305.01	1,835,498.48	1,867,715.06	1,897,201.82	1,924,044.17	1,959,613.90	1,978,066.81		21,592,831.96		
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	1,760,214.23	1,802,108.30	1,848,409.84	1,863,654.07	1,898,180.42	1,919,543.90	1,942,914.12		21,235,776.98		
9960	KIDSCARE KICK PAYME	31,989.83	0.00	25,594.40	38,656.56	19,328.28	46,012.98	6,442.76	25,771.04	12,885.52	32,213.80	19,497.66	52,455.74		310,848.57		
	N																
SUBTOTAL:	11,005,329.06	11,301,371.21	13,129,471.24	12,114,309.92	12,394,535.44	12,709,608.04	12,901,031.96	13,113,864.21	13,204,333.19	13,388,579.80	13,489,222.55	13,615,469.42		152,367,126.04		

152,367,126.04

11,005,329.06	11,301,371.21	13,129,471.24	12,114,309.92	12,394,535.44	12,709,608.04	12,901,031.96	13,113,864.21	13,204,333.19	13,388,579.80	13,489,222.55	13,615,469.42	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending June 30, 2022	
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	328.60	317.58	300.52	309.64	327.34	323.92	341.90		3,830.42		
	C																
6012	KIDS 1-5 M & F NON-M	12,930.55	13,128.32	15,819.65	13,281.87	13,569.01	13,835.95	14,003.37	14,089.64	14,152.72	14,169.74	14,213.68	14,239.41		167,433.91		
6013	KIDS 6-13 M & F NON-	25,317.92	26,183.49	30,599.47	26,712.00	27,366.79	28,019.46	28,590.78	29,096.44	29,281.72	29,699.73	29,918.68	30,080.37		340,866.85		
6014	KIDS 14-19 MALE NON-	7,478.10	7,815.20	8,723.08	7,981.22	8,214.41	8,401.92	8,615.71	8,764.91	8,904.09	9,038.26	9,207.31	9,294.27		102,438.48		
6015	KIDS 14-19 FEMALE NO	7,298.96	7,675.06	8,725.21	7,821.96	8,036.99	8,256.87	8,442.18	8,659.39	8,723.99	8,882.00	8,993.71	9,097.77		100,614.09		
9960	KIDSCARE KICK PAYME	5.00	0.00	4.00	6.00	3.00	7.00	1.00	4.00	2.00	5.00	3.00	8.00		48.00		
	N																
SUBTOTAL:	53,368.23	55,108.33	64,171.04	56,118.48	57,512.10	58,849.80	59,970.62	60,914.90	61,374.16	62,122.07	62,660.30	63,061.72		715,231.75		

TOTAL:	53,368.23	55,108.33	64,171.04	56,118.48	57,512.10	58,849.80	59,970.62	60,914.90	61,374.16	62,122.07	62,660.30	63,061.72		715,231.75		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending June 30, 2022	
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	2,311.53	2,253.99	2,116.14	2,178.70	2,315.02	2,290.14	2,378.35		21,922.40		
	C																
6012	KIDS 1-5 M & F NON-M	21,775.23	21,787.37	22,029.86	94,016.18	96,003.90	97,857.15	99,060.48	99,826.14	100,229.67	100,678.38	101,186.11	101,544.69		955,995.16		
6013	KIDS 6-13 M & F NON-	43,242.68	43,788.47	44,422.82	189,798.78	194,517.25	199,142.90	202,976.80	206,682.33	207,740.13	211,028.97	212,639.45	213,863.88		1,969,844.46		
6014	KIDS 14-19 MALE NON-	29,087.98	29,653.90	30,313.07	57,137.98	58,819.85	60,242.87	61,823.76	62,755.30	63,760.75	64,842.13	66,026.60	66,649.52		651,113.71		
6015	KIDS 14-19 FEMALE NO	28,581.97	28,438.89	29,511.89	56,269.83	57,593.96	59,211.95	60,533.83	62,074.73	62,593.97	63,604.93	65,425.33	65,112.21		638,953.49		
SUBTOTAL:	123,237.06	124,202.03	126,786.67	399,445.69	409,198.94	418,766.40	426,648.86	433,454.64	436,503.22	442,469.43	447,567.63	449,548.65		4,237,829.22		

4,237,829.22

126,786.67	399,445.69	409,198.94	418,766.40	426,648.86	433,454.64	436,503.22	442,469.43	447,567.63	449,548.65	

TOTAL:

123,237.06

124,202.03

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending June 30, 2022	
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	342.00	333.00	312.00	320.00	338.00	336.00	350.00		3,990.00		
	C																
6012	KIDS 1-5 M & F NON-M	13,353.00	13,377.00	13,460.00	13,738.00	14,025.00	14,295.00	14,469.00	14,586.00	14,652.00	14,715.00	14,798.00	14,832.00		170,300.00		
6013	KIDS 6-13 M & F NON-	26,266.00	26,507.00	26,872.00	27,726.00	28,400.00	29,080.00	29,633.00	30,177.00	30,368.00	30,807.00	31,051.00	31,230.00		348,117.00		
6014	KIDS 14-19 MALE NON-	7,806.00	7,919.00	8,112.00	8,351.00	8,593.00	8,797.00	9,021.00	9,155.00	9,302.00	9,458.00	9,634.00	9,724.00		105,872.00		
6015	KIDS 14-19 FEMALE NO	7,661.00	7,750.00	7,951.00	8,238.00	8,440.00	8,677.00	8,861.00	9,091.00	9,169.00	9,317.00	9,441.61	9,543.00		104,139.61		
SUBTOTAL:	55,430.00	55,882.00	56,719.00	58,382.00	59,791.00	61,191.00	62,317.00	63,321.00	63,811.00	64,635.00	65,260.61	65,679.00		732,418.61		

TOTAL:	55,430.00	55,882.00	56,719.00	58,382.00	59,791.00	61,191.00	62,317.00	63,321.00	63,811.00	64,635.00	65,260.61	65,679.00		732,418.61		

KidsCare - FEE FOR SERVICE
For The Period Ending June 30, 2022	
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	3,230.20	1,662.52	2,271.54	6,655.48	13,500.86	26,228.28	2,672.34		81,574.46		
	C																
6012	KIDS 1-5 M & F NON-M	22,373.20	31,277.24	36,527.43	32,544.80	29,729.54	42,223.98	19,938.10	37,921.06	49,856.62	47,076.34	46,891.85	95,630.86		491,991.02		
6013	KIDS 6-13 M & F NON-	63,485.29	87,613.42	106,116.78	74,257.91	109,919.60	160,351.75	119,393.22	163,269.02	199,209.14	145,011.27	315,040.28	131,804.24		1,675,471.92		
6014	KIDS 14-19 MALE NON-	18,415.53	39,190.11	67,120.33	33,745.67	46,409.74	101,969.83	84,017.76	107,567.23	153,277.59	124,240.63	88,712.19	133,341.73		998,008.34		
6015	KIDS 14-19 FEMALE NO	84,488.19	106,377.93	90,904.13	35,455.49	73,309.23	99,313.87	112,655.91	65,003.06	129,717.75	116,342.52	90,826.23	171,254.49		1,175,648.80		
SUBTOTAL:	202,286.30	268,869.92	303,460.12	177,991.59	262,006.87	407,089.63	337,667.51	376,031.91	538,716.58	446,171.62	567,698.83	534,703.66		4,422,694.54		

4,422,694.54

303,460.12	177,991.59	262,006.87	407,089.63	337,667.51	376,031.91	538,716.58	446,171.62	567,698.83	534,703.66	

TOTAL:

202,286.30

268,869.92

KidsCare - REINSURANCE
For The Period Ending June 30, 2022	
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	2,415.93	4,607.61	34,516.52	39,782.23	45,449.01	111,630.63	45,717.82		415,073.46		
6013	KIDS 6-13 M & F NON-	150,067.69	196,176.95	226,795.86	117,268.47	118,331.77	68,887.46	188,314.80	140,851.72	217,303.14	155,161.87	162,043.84	210,725.86		1,951,929.43		
6014	KIDS 14-19 MALE NON-	117,438.31	48,871.56	231,096.19	376,007.17	-132,514.06	202,620.73	47,870.44	108,170.05	89,335.49	50,485.34	87,938.73	-175,952.09		1,051,367.86		
6015	KIDS 14-19 FEMALE NO	28,381.76	1,171,474.89	-699,044.59	4,353.61	384,174.75	33,292.15	57,294.33	24,891.06	1,596.48	29.21	22,600.43	64,148.95		1,093,193.03		
SUBTOTAL:	344,676.15	1,468,999.54	-200,584.42	497,696.58	359,046.19	307,216.27	298,087.18	308,429.35	348,017.34	251,125.43	384,213.63	144,640.54		4,511,563.78		

TOTAL:	344,676.15	1,468,999.54	-200,584.42	497,696.58	359,046.19	307,216.27	298,087.18	308,429.35	348,017.34	251,125.43	384,213.63	144,640.54		4,511,563.78		

KidsCare - TRANSPLANT REINSURANCE
For The Period Ending June 30, 2022	
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	42,273.28	306,790.10	0.00	0.00	0.00	0.00	0.00		497,020.31		
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	55,949.50	8,425.34	12,095.06	257,585.24		334,055.14		
6015	KIDS 14-19 FEMALE NO	43,579.50	0.00	973,347.89	142,540.39	0.00	105,936.57	0.00	0.00	0.00	0.00	0.00	0.00		1,265,404.35		
SUBTOTAL:	43,579.50	0.00	973,347.89	142,540.39	147,956.93	148,209.85	306,790.10	0.00	55,949.50	8,425.34	12,095.06	257,585.24		2,096,479.80		

142,540.39

55,949.50

257,585.24

12,095.06

TOTAL:

43,579.50

0.00

973,347.89

147,956.93

148,209.85

306,790.10

0.00

8,425.34

2,096,479.80

28

9

9

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending June 30, 2022

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	673.40	676.35	673.67	678.55	681.54	685.29	693.56		8,075.78	
2100	SSI AGED WITH MEDICA	289.35	289.16	291.12	294.54	293.42	295.06	295.87	295.10	292.50	293.98	293.78	296.33		3,520.21	
210Z	SSI AGED WITH MEDICA	0.00	0.00	0.00	0.00	0.00	1.93	-1.93	0.00	0.00	0.00	0.00	0.00		0.00	
2110	SSI AGED NON-MEDICAR	11.00	11.00	10.00	10.00	12.00	10.93	11.70	11.00	9.25	10.00	7.00	7.00		120.88	
2120	SSI AGED WITH QMB	462.87	465.26	463.71	462.68	461.42	457.28	461.27	467.81	471.82	462.71	458.15	457.10		5,552.08	
2200	SSI DISABLED WITH ME	1,944.80	1,953.08	1,990.06	1,994.79	1,998.71	2,016.38	2,020.61	1,957.62	1,963.07	1,972.14	1,980.25	1,986.31		23,777.82	
2210	SSI DISABLED NON-MED	28,375.96	28,475.39	28,524.03	28,633.86	28,746.75	28,861.80	28,822.35	28,842.53	29,008.66	29,128.93	29,255.73	29,454.11		346,130.10	
221Z	SSI DISABLED NON-MED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00	
2220	SSI DISABLED WITH QM	5,245.82	5,253.18	5,244.37	5,234.92	5,229.60	5,212.01	5,219.31	5,263.74	5,259.83	5,269.19	5,274.24	5,285.92		62,992.13	
2300	SSI BLIND WITH MEDIC	4.00	6.00	10.00	10.32	12.00	13.00	24.00	28.00	28.00	27.00	27.00	26.00		215.32	
2310	SSI BLIND NON-MEDICA	23.00	26.93	31.36	38.41	40.83	48.00	51.00	169.46	170.69	173.00	173.80	172.32		1,118.80	
2320	SSI BLIND WITH QMB	6.00	11.00	16.00	18.00	18.00	19.00	32.00	65.00	65.00	65.00	64.00	65.00		444.00	
8700	SSI DISABLED FREEDOM	30.00	30.00	30.00	32.99	31.00	31.00	32.00	31.99	31.00	30.00	28.00	28.00		365.98	
8710	SSI DISABLED FREEDOM	8.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00	8.00		96.00	
8720	SSI DISABLED FREEDOM	16.00	16.00	16.00	16.00	16.00	16.00	16.00	16.00	17.00	17.00	18.00	17.00		197.00	
SUBTOTAL:	37,074.26	37,202.43	37,295.00	37,425.28	37,535.14	37,663.79	37,668.53	37,829.92	38,003.3	7	38,138.49	38,273.24	38,496.65		452,606.10	
TOTAL:	37,074.26	37,202.43	37,295.00	37,425.	37,535.14	37,663.7	37,668.53	37,829.92	38,003.3	7	38,138.4	38,273.24	38,496.65		452,606.10	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending June 30, 2022

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	377,473.86	378,065.68	371,945.70	369,340.99	430,116.70	430,437.20	428,941.59	4,691,683.79	
EPD	114,298,940.29	114,887,545.38	114,523,533.95	127,410,250.77	127,450,037.30	126,946,334.59	126,500,307.80	125,975,149.58	126,374,548.19	127,182,159.69	127,375,293.84	128,448,392.52	1,487,372,493.90	
TOTAL AHCCCS LTC	114,684,215.66	115,269,945.25	114,903,064.48	127,789,778.91	127,828,665.46	127,323,808.45	126,878,373.48	126,347,095.28	126,743,889.18	127,612,276.39	127,805,731.04	128,877,334.11	1,492,064,177.69	
DES/DD	196,850,771.52	197,527,866.23	198,019,082.32	200,990,383.02	201,582,846.55	202,281,342.82	204,074,743.73	204,950,690.87	205,892,252.84	206,623,906.11	207,356,143.31	209,251,680.34	2,435,401,709.66	
TOTAL DES LTC	196,850,771.52	197,527,866.23	198,019,082.32	200,990,383.02	201,582,846.55	202,281,342.82	204,074,743.73	204,950,690.87	205,892,252.84	206,623,906.11	207,356,143.31	209,251,680.34	2,435,401,709.66	
TOTAL LTC - CAP	311,534,987.18	312,797,811.48	312,922,146.80	328,780,161.93	329,411,512.01	329,605,151.27	330,953,117.21	331,297,786.15	332,636,142.02	334,236,182.50	335,161,874.35	338,129,014.45	3,927,465,887.35	

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	14,464,507.66	10,874,162.77	12,820,580.89	15,429,672.77	11,351,870.47	13,387,944.55	14,576,083.30	154,558,315.68	
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	14,464,507.66	10,874,162.77	12,820,580.89	15,429,672.77	11,351,870.47	13,387,944.55	14,576,083.30	154,558,315.68	

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	3,495,603.36	3,437,110.64	3,619,102.45	2,526,282.35	3,123,512.72	2,295,494.36	1,374,906.17	38,742,574.92	
DES/DD	2,785,169.38	2,352,274.55	2,263,940.31	2,639,762.53	7,728,036.80	2,552,072.52	1,304,439.78	2,338,460.75	1,562,854.83	3,256,662.87	4,770,070.96	932,618.93	34,486,364.21	
TOTAL DES LTC	2,785,169.38	2,352,274.55	2,263,940.31	2,639,762.53	7,728,036.80	2,552,072.52	1,304,439.78	2,338,460.75	1,562,854.83	3,256,662.87	4,770,070.96	932,618.93	34,486,364.21	
TOTAL LTC - REIN	6,522,995.49	6,319,518.08	4,868,013.24	8,085,292.15	10,843,927.48	6,047,675.88	4,741,550.42	5,957,563.20	4,089,137.18	6,380,175.59	7,065,565.32	2,307,525.10	73,228,939.13	

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	4,442,615.80	5,080,086.30	5,036,209.60	5,002,259.10	5,038,296.60	4,996,140.60	5,037,645.80	56,916,459.70	

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

BEHAVIORAL HEALTH EXPENDITURES BY RBHA - CAPITATION AMOUNTS
For the Period Ending June 30, 2022

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	8,388,835.84	8,438,657.92	8,497,209.60	8,549,418.24	8,591,580.80	8,646,168.96	8,696,103.68	105,188,087.08	

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	4,380,467.24	4,404,697.32	4,431,724.90	4,458,834.54	4,480,998.20	4,507,578.18	4,535,023.52	55,092,866.68	

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	1,148,536.48	1,154,066.55	1,160,253.29	1,166,241.79	1,170,941.73	1,176,992.18	1,182,047.30	13,684,268.85	

00010705	HEALTH CHOICE RBHA - CAP AMOUNTS	0.00	903.40	-1,640.66	0.00	0.00	0.00	190.60	-496.72	-1,450.21	0.00	-1,450.21	-4.17	-3,947.97	

00010730	CENPATICO RBHA - CAP AMOUNTS	860.29	1,060.00	-723.96	-239.16	505.55	79.72	596.32	-5,618.70	-1,645.09	-3,713.22	-431.49	-4,266.26	-13,536.00	

00010789	MERCY MARICOPA RBHA - CAP AMOUNTS	-1,319.56	-4,332.55	-1,647.36	-3,471.87	3,377.12	-705.99	-1,765.09	-930.28	-2,767.44	-3,460.09	-2,525.56	-1,325.10	-20,873.77	
			
Subtotal		
	15,605,415.63	15,728,965.87	15,865,513.42	13,757,106.35	13,835,174.32	13,917,213.29	13,996,443.62	14,082,142.09	14,168,631.83	14,236,347.42	14,326,332.06	14,407,578.97	173,926,864.87	

15,605,415.63	15,728,965.87	15,865,513.42	13,757,106.35	13,835,174.32	13,917,213.29	13,996,443.62	14,082,142.09	14,168,631.83	14,236,347.42	14,326,332.06	14,407,578.97	173,926,864.87	

GRAND TOTAL

BEHAVIORAL HEALTH EXPENDITURES BY RBHA - MEMBER MONTHS
For the Period Ending June 30, 2022

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	1,191,596.00	1,198,673.00	1,206,990.00	1,214,406.00	1,220,395.00	1,228,149.00	1,235,242.00	14,342,961.00	
			
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	587,194.00	590,442.00	594,065.00	597,699.00	600,670.00	604,233.00	607,912.00	7,065,799.00	
			
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	278,096.00	279,435.00	280,933.00	282,383.00	283,521.00	284,986.00	286,210.00	3,346,856.00	
			
00010705	HEALTH CHOICE RBHA - CAP MEMBER MONTHS	0.00	16.51	-27.74	0.00	0.00	0.00	4.77	-6.99	-24.00	0.00	-24.00	-0.06	-61.51	
			
00010730	CENPATICO RBHA - CAP MEMBER MONTHS	0.97	17.04	-8.26	-2.99	9.19	1.00	9.78	-82.98	-45.76	-54.03	-3.00	-69.68	-228.72	
			
00010789	MERCY MARICOPA RBHA - CAP MEMBER MONTHS	-22.00	-129.14	-31.99	-69.13	57.00	-22.31	-33.00	-13.67	-20.96	-86.99	-50.00	-38.44	-460.63	
			
Subtotal	1,995,297.97	2,007,512.41	2,021,232.01	2,033,916.88	2,044,236.19	2,056,864.69	2,068,531.55	2,081,884.36	2,094,397.28	2,104,444.98	2,117,291.00	2,129,255.82	24,754,865.14	

1,995,297.97	2,007,512.41	2,021,232.01	2,033,916.88	2,044,236.19	2,056,864.69	2,068,531.55	2,081,884.36	2,094,397.28	2,104,444.98	2,117,291.00	2,129,255.82	24,754,865.14	

GRAND TOTAL