Douglas A. Ducey, Governor Jami Snyder, Director

October 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 2023 Appropriation Status Report for the Period Ended August 31, 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 August 31, 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 July 15, 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.

AHCCCS submitted its Fiscal Year 2024 budget request, including an update of Fiscal Year 2023 for submission to the Governor’s Office of Strategic Planning and Budgeting pursuant to A.R.S. § 35-113. Therefore, for purposes of this report, projected annual expenditures equal the appropriations.

Enrollment Update – August 2022 enrollment is 2,434,071 members, a 12,550 member increase over the prior month. Enrollment for September 2022 increased to 2,452,743 members, a 18,672 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 573,783 members or 30.5%.

Major September 2022 changes by eligibility category include: 1931 for Families and

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

The Honorable Karen Fann
The Honorable Russell “Rusty” Bowers October 5, 2022
Page 2

Children/SOBRA – increase of 7,649; Supplemental Security Income – increase of 897; Prop 204 Restoration - increase of 8,062; Adult Expansion – decrease of 284; Medicare Cost Sharing – increase of 289; KidsCare – increase of 575; and Federal Emergency Services – increase of 1,247.

Tobacco Funds Revenue Update - Tobacco tax collections through August 2022 are $1.4 million less than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2023 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 2023
Through August 31, 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 2023…	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 2023 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 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	$	131,206,600	$	13,456,284	$	13,456,284	$		-	$	131,206,600	$	-	
AHCCCS Prop 204 Administration	15,367,300	3,024,579	3,024,579			-	15,367,300		-	
DES Eligibility	99,824,500	10,947,821	10,947,821			-	99,824,500		-	
DES Prop 204 Eligibility	44,358,700	3,421,188	3,421,188			-	44,358,700		-	
ADOA Data Center	19,325,800		-		-		-		19,325,800		-		
School District Suicide Prevention Coordinator	-		-		-		-		-		-		
TOTAL ADMINISTRATION		310,082,900 			30,849,872 			30,849,872 			-				310,082,900 			-			

Traditional Medicaid Services	7,203,608,100	1,218,641,751	1,218,641,751	-	7,203,608,100	-	
Proposition 204 Services	6,450,896,200	1,327,341,394	1,327,341,394	-	6,450,896,200	-	
ACA Adult Expansion	844,705,200	201,992,659	201,992,659	-	844,705,200	-	
KidsCare Services	152,682,100	31,349,676	31,349,676	-	152,682,100	-	
ALTCS Services	2,576,091,400	356,150,816	356,150,816	-	2,576,091,400	-	
Disproportionate Share Payments	5,087,100	-	-	-	5,087,100	-	
Rural Hospitals	28,612,400	-	-	-	28,612,400	-	
Voluntary Political Subdivision Programs	430,658,000	-	-	-	430,658,000	-	

DCS-CHP	244,906,300	37,548,387	37,548,387	-	244,906,300	-	
Behavioral Health Services - in Schools	17,891,200	2,185,893	2,185,893	-	17,891,200	-	
Targeted Investment Program	50,000,000	-	-	-	50,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900		10,593,366		10,593,366		-		77,646,900		-	
Supported Housing	65,324,800		2,334,350		2,334,350		-		65,324,800		-	
Crisis Services	16,391,300		375,033		375,033		-		16,391,300		-	
TOTAL PROGRAMMATIC		18,164,501,000 			3,188,513,326 			3,188,513,326 			-				18,164,501,000 			-		

TOTAL EXPENDITURES

 $  18,474,583,900 

 $	3,219,363,198 

 $	3,219,363,198 

 $	-	

 $  18,474,583,900 

 $	-	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2023 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 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	
$	
72,747,000	
$	8,571,217	
$	8,571,217	
-	$	72,747,000	
$	
-	
Proposition 204 - Administrative Expenditures		21,258,000	2,128,974	2,128,974	-	21,258,000		-	

Programmatic Expenditures Traditional Medicaid Services		

1,421,653,500	

284,323,635	

284,323,635	

-	1,421,653,500		

-	
Proposition 204 Services	140,821,400	-	-	-	140,821,400	-	
ACA Adult Expansion	6,972,000	-	-	-	6,972,000	-	
KidsCare Services	29,518,300	10,735,179	10,735,179	-	29,518,300	-	
ALTCS Services	315,915,500	52,652,583	52,652,583	-	315,915,500	-	
DSH and Rural Hospitals	8,978,900	-	-	-	8,978,900	-	
DCS-CHP	69,062,500	10,065,907	10,065,907	-	69,062,500	-	
Behavior Health Services - in Schools	3,000,000	500,000	500,000	-	3,000,000	-	
Non Medicaid Seriously Mentally Ill Services	77,646,900	10,593,366	10,593,366	-	77,646,900	-	
Supported Housing	5,324,800	2,334,350	2,334,350	-	5,324,800	-	
Crisis Services	14,141,100	-	-	-	14,141,100	-	
Voluntary Political Subdivision Programs		9,000,000 		- 		- 		- 		9,000,000 		- 	
TOTAL GF EXPENDITURES	2,196,039,900	381,905,212	381,905,212	-	2,196,039,900	-	
	FEDERAL		
Administrative Expenditures	174,257,400	15,826,855	15,826,855	-	174,257,400	-	
Proposition 204 - Administrative Expenditures	34,104,000	4,316,793	4,316,793	-	34,104,000	-	
Programmatic Expenditures
Traditional Medicaid Services	
4,607,855,000	
757,233,338	
757,233,338	
-	
4,607,855,000	
-	
Proposition 204 Services	5,478,051,500	1,087,284,537	1,087,284,537	-	5,478,051,500	-	
ACA Adult Expansion	724,327,700	179,561,726	179,561,726	-	724,327,700	-	
KidsCare Services	107,682,500	20,457,871	20,457,871	-	107,682,500	-	
ALTCS Services and Nursing Facility Assessment	1,761,416,800	259,157,948	259,157,948	-	1,761,416,800	-	
DSH and Rural Hospitals	24,720,600	-	-	-	24,720,600	-	
DCS-CHP	171,145,000	26,970,000	26,970,000	-	171,145,000	-	
Behavior Health Services - in Schools	6,891,200	1,148,533	1,148,533	-	6,891,200	-	
Targeted Investment Program	34,504,800	-	-	-	34,504,800	-	
Supported Housing	60,000,000	-	-	-	60,000,000	-	
Voluntary Political Subdivision Programs		310,879,400 		- 		- 		- 		310,879,400 		- 	
TOTAL FEDERAL EXPENDITURES	13,495,835,900	2,351,957,601	2,351,957,601	-	13,495,835,900	-	
	COUNTY		
Administrative Expenditures Proposition 204 - BNCF	4,303,100	-	-	-	4,303,100	-	
Programmatic Expenditures
Traditional Medicaid Services Acute Care	
46,161,700	
7,486,250	
7,486,250	
-	
46,161,700	
-	
ALTCS Services		305,872,000 		30,946,096 		30,946,096 		- 		305,872,000 		- 	
TOTAL COUNTY EXPENDITURES	356,336,800	38,432,346	38,432,346
.	-	356,336,800	-	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2023 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 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	67,179,700	11,129,825	11,129,825	-	67,179,700	-	
Proposition 204 Services - Emergency Health Services	17,448,300	4,362,075	4,362,075	-	17,448,300	-	
Proposition 204 Services - Proposition 204 Protection	36,641,400	9,160,350	9,160,350	-	36,641,400	-	
Proposition 204 Services - ATLSF		102,000,000 		- 		- 		- 		102,000,000 		- 	
TOTAL TOBACCO EXPENDITURES	223,269,400	24,652,250	24,652,250	-	223,269,400	-	
	OTHER		
Administrative Expenditures							
Prescription Drug Rebate Program and SMI Housing Trust Fund	941,100	6,033	6,033	-	941,100	-	
Health Care Investment Fund	2,472,300	-	-	-	2,472,300	-	
Programmatic Expenditures							
Traditional Medicaid Services - IGA Fund	40,142,900	100,000	100,000	-	40,142,900	-	
Traditional Medicaid Services - Health Care Investment Fund	290,892,500	731,216	731,216	-	290,892,500	-	
Acute Care - Prescription Drug Rebate Program State Match	156,858,600	26,143,100	26,143,100	-	156,858,600	-	
Acute Care - Prescription Drug Rebate Program Federal Authority	572,638,300	131,120,834	131,120,834	-	572,638,300	-	
Long Term Care - Prescription Drug Rebate Program State Match	13,806,200	1,263,067	1,263,067	-	13,806,200	-	
Long Term Care - Prescription Drug Rebate Program Federal Authority	36,422,000	8,744,354	8,744,354	-	36,422,000	-	
Substance Abuse Disorder Services - Prescription Drug Rebate Program State Match	-	-	-	-	-	-	
Proposition 204 Services - Hospital Assessment	547,525,400	210,952,349	210,952,349	-	547,525,400	-	
Proposition 204 Services - IGA Fund	8,644,000	-	-	-	8,644,000	-	
Proposition 204 Services - Health Care Investment Fund	119,764,200	15,582,083	15,582,083	-	119,764,200	-	
ACA Adult Expansion - Hospital Assessment	101,385,100	20,773,416	20,773,416	-	101,385,100	-	
ACA Adult Expansion - IGA Fund	1,221,700	-	-	-	1,221,700	-	
ACA Adult Expansion - Health Care Investment Fund	10,798,700	1,657,518	1,657,518	-	10,798,700	-	
Traditional Medicaid Services - TPL	194,700	373,130	373,130	-	194,700	-	
ALTCS Services - TPL	-	578,908	578,908	-	-	-	
ALTCS Services - Nursing Facility Assessment	121,152,600	17,775	17,775	-	121,152,600	-	
ALTCS Services - Health Care Investment Fund	21,506,300	2,790,085	2,790,085	-	21,506,300	-	
DCS-CHP - Health Care Investment Fund	4,698,800	512,480	512,480	-	4,698,800	-	
Targeted Investment Program	15,495,200	-	-	-	15,495,200	-	
Children's Behavioral Health Services	8,000,000	537,359	537,359	-	8,000,000	-	
KidsCare Services - IGA Fund	358,400	(100,000)	(100,000)	-	358,400	-	
KidsCare Services -Health Care Investment Fund	2,971,600	253,752	253,752	-	2,971,600	-	
KidsCare Services Premiums	12,151,300	2,874	2,874	-	12,151,300	-	
Freedom to Work Premiums	31,200	425	425	-	31,200	-	
Crisis Services - Substance Abuse Services Fund	2,250,200	375,033	375,033	-	2,250,200	-	
Voluntary Political Subdivision Programs		110,778,600 		- 		- 		- 		110,778,600 		- 	
TOTAL OTHER EXPENDITURES	2,203,101,900	422,415,789	422,415,789	-	2,203,101,900	-	
	TOTAL		
Administrative Expenditures	310,082,900	30,849,872	30,849,872	-	310,082,900	-	
Acute Care	15,588,409,600	2,832,362,510	2,832,362,510	-	15,588,409,600	-	
Long Term Care		2,576,091,400 		356,150,816 		356,150,816 		- 		2,576,091,400 		- 	
TOTAL EXPENDITURES	 $	18,474,583,900 	 $	3,219,363,198 	 $	3,219,363,198 	 $	- 	 $	18,474,583,900 	 $	- 	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2023 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending August 31, 2022

GENERAL FUND:
Traditional Medicaid Services & Administrative	$	1,522,351,400	$	293,394,851	$	293,394,851	
Proposition 204 Services & Administrative	162,079,400	2,128,974	17,711,057	
KidsCare Services	29,518,300.00	10,735,179.26	10,735,179	
ALTCS Services	315,915,500	52,652,583	52,652,583	
Behavioral Health Traditional Medicaid Services		166,175,300 		22,993,624 		22,993,624 	
TOTAL	2,196,039,900	381,905,212	397,487,294	

FEDERAL:
Acute & Administrative	11,455,591,600	2,045,371,782	2,193,049,878	
KidsCare Services	107,682,500	20,457,871	26,795,294	
ALTCS Services	1,761,416,800	259,157,948	285,658,574	
Behavioral Health Traditional Medicaid Services		171,145,000 		26,970,000 		27,558,633 	
TOTAL	13,495,835,900	2,351,957,601	2,533,062,379	

COUNTY:				
Acute & Administrative	50,464,800		7,486,250		6,964,729	
ALTCS Services		305,872,000 			30,946,096 			58,782,950 	
TOTAL	356,336,800		38,432,346		65,747,679	

TOBACCO FUNDS:						
Traditional Medicaid Services	67,179,700		11,129,825		11,129,825	
Proposition 204 Services		156,089,700 			13,522,425 			13,522,425 	
TOTAL	223,269,400		24,652,250		24,652,250	

OTHER:

Administrative	3,413,400	6,033	6,033	
Traditional Medicaid Services - IGA Fund	40,142,900	100,000	100,000	
Acute Care - Prescription Drug Rebate Program	729,496,900	157,263,934	157,263,934	
Long Term Care - Prescription Drug Rebate Program	50,228,200	10,007,420	10,007,420	
Hospital Assessment	658,776,200	231,725,765	133,380,269	
Health Care Investment Fund	426,154,200	18,483,296	-	
Substance Abuse Disorder Services	-	-	-	
ALTCS	142,658,900	2,807,861	59,266	
Acute TPL - Note 1	194,700	373,130	373,130	
LTC TPL - Note 1	-	578,908	578,908	
KidsCare Services	3,330,000	253,752	-	
KidsCare TPL - Note 1	-	-	589.00	
Member Premiums - CHIP	12,151,300	2,874	2,874	
Member Premiums - Freedom to Work	31,200	425	425	
Targeted Investment Program	15,495,200	-	-	
Children's Behavioral Health Services	8,000,000	537,359	-	
Behavioral Health Traditional Medicaid Services	2,250,200	375,033	72,141	
Voluntary Political Subdivision - State Match		110,778,600 		-			-		
TOTAL	2,203,101,900	422,515,789	301,844,988	

TOTAL REVENUE

$	18,474,583,900

$	3,219,463,198

$	3,322,794,590

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 2023 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 2022

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

$	2,287,323	$

1,757,385	$

4,740,244	$

2,509,712

LTC	2,317,278	1,445,940	3,871,135	1,848,907
KidsCare	1,593	1,697	5,299	1,982

Total TPL Collections

 $	4,606,194 

 $	3,205,022 

 $	8,616,678 

 $	4,360,601 

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	166,889	$	148,717	$	373,130	$	217,598	
LTC		344,998	271,896		578,908	342,757	
KidsCare		166	123		589	134	
Total Expenditure Offsets	 $	512,053 		 $	420,736 		 $	952,627 		 $	560,489 	

August 2022

August 2021

July 1, 2022
August 31, 2022

July 1, 2021
August 31, 2021

Note 2:  Authorized Positions
Actual Positions as of August 31, 2022

`

FY 23 Total

1,163.5
1,128.0

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2023 APPROPRIATION STATUS REPORT
For the Period Ending August 31, 2022

Note 3:	Intergovernmental Service Agreement - State of Hawaii:		
	Beginning Balance July 1, 2022	$  2,861,808	
	Revenues	2,167,881	
	Transfers-In		112,722 	
	Total Revenues		2,280,604 	
	Expenditures	1,889,273	
	Transfers-out		300,000 	
	Total Expenditures		2,189,273 	
	Ending Balance August 31, 2022	 $  2,953,139 	

Of the $2,953,139 ending balance, $2,133,015 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through September 2022.

Note 4:	Summary of Voluntary Political Subdivision Contribution Expenditures:

As of August 31, 2022 Expenditures

Appropriation	State Match	Federal	Total

DSH Voluntary	$	37,425,900		$	-	$	-	$	-	
GME Voluntary	393,232,100			-	-	-	
Total Voluntary Political Subdivision Program Expenditures	$	430,658,000		$	-	$	-	$	-	

Note 5:	Summary of ARPA HCBS Expenditures:

As of August 31, 2022
Appropriation	Expenditures

Traditional Medicaid Services	$	-	$	-
Proposition 204 Services	-	-
ACA Adult Expansion	-	-
DCS-CHP	-	-
LTC	237,200,000	-
Lump Sum	-	-

Total ARPA Expenditures	$	237,200,000	$	-

Appropriation Status Report
Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending August 31, 2022

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

TITLE XIX TRADITIONAL
CAPITATION - ACC	436,488,922	440,528,854	0	0	0	0	0	0	0	0	0	0	877,017,776	
CAPITATION - AIMHS	581,964	591,648	0	0	0	0	0	0	0	0	0	0	1,173,612	
CAPITATION - LTC	342,989,903	339,042,856	0	0	0	0	0	0	0	0	0	0	682,032,759	
MENTAL HEALTH - CHILD	-1,267	-1,876	0	0	0	0	0	0	0	0	0	0	-3,144	
MENTAL HEALTH - ADULT	402,823	382,548	0	0	0	0	0	0	0	0	0	0	785,371	
MENTAL HEALTH - GENERAL	1,963	-2,872	0	0	0	0	0	0	0	0	0	0	-908	
MENTAL HEALTH - DD	0	-26	0	0	0	0	0	0	0	0	0	0	-26	
MENTAL HEALTH - RBHA CRISIS	8,589,534	8,854,323	0	0	0	0	0	0	0	0	0	0	17,443,857	
FEE FOR SERVICE - ACUTE	78,535,266	106,685,236	0	0	0	0	0	0	0	0	0	0	185,220,502	
FFS - PRIOR QUARTER COVERAGE	212,618	290,908	0	0	0	0	0	0	0	0	0	0	503,526	
EMERGENCY SERVICES - FEDERAL	3,115,052	4,571,722	0	0	0	0	0	0	0	0	0	0	7,686,774	
FFS MEDICAID IN PUBLIC SCHOOLS	1,376,095	566,772	0	0	0	0	0	0	0	0	0	0	1,942,867	
STATE ONLY TRBHA FFS	100,489	174,050	0	0	0	0	0	0	0	0	0	0	274,539	
INPATIENT INMATES FFS	271,500	212,313	0	0	0	0	0	0	0	0	0	0	483,813	
FFS TRBHA FEE FOR SERVICE	20,430,959	28,245,816	0	0	0	0	0	0	0	0	0	0	48,676,775	
QMB - FEE FOR SERVICE	372,070	608,381	0	0	0	0	0	0	0	0	0	0	980,451	
MOHAVE COUNTY INMATES FFS	0	994	0	0	0	0	0	0	0	0	0	0	994	
MARICOPA CTY INMATES FFS	23,890	30,154	0	0	0	0	0	0	0	0	0	0	54,045	
PINAL COUNTY INMATES FFS	2,811	0	0	0	0	0	0	0	0	0	0	0	2,811	
PIMA COUNTY INMATES FFS	5,959	34,101	0	0	0	0	0	0	0	0	0	0	40,060	
FEE FOR SERVICE - LTC	13,316,137	15,118,972	0	0	0	0	0	0	0	0	0	0	28,435,109	
LFFS - PRIOR QUARTER COVERAGE	401	41	0	0	0	0	0	0	0	0	0	0	441	
INPATIENT INMATES LTC FFS	308	0	0	0	0	0	0	0	0	0	0	0	308	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,570,675	774,945	0	0	0	0	0	0	0	0	0	0	2,345,620	
REINSURANCE - ACC	19,336,199	15,397,746	0	0	0	0	0	0	0	0	0	0	34,733,946	
REINSURANCE - LTC	6,564,289	8,453,992	0	0	0	0	0	0	0	0	0	0	15,018,281	
SMIB - ACC	23,092,734	23,384,142	0	0	0	0	0	0	0	0	0	0	46,476,875	
HIB - ACC	1,292,333	1,344,125	0	0	0	0	0	0	0	0	0	0	2,636,458	
Q1	3,722,105	3,716,789	0	0	0	0	0	0	0	0	0	0	7,438,894	
SMIB - LTC	4,652,498	4,655,113	0	0	0	0	0	0	0	0	0	0	9,307,611	
HIB - LTC	393,889	402,921	0	0	0	0	0	0	0	0	0	0	796,809	
SUBTOTAL	967,442,120	1,004,064,687	0	0	0	0	0	0	0	0	0	0	1,971,506,807	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending August 31, 2022

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

TITLE XIX PROP 204
CAPITATION - ACC	425,765,838	431,964,180	0	0	0	0	0	0	0	0	0	0	857,730,017	
CAPITATION - AIMHS	327,295	331,386	0	0	0	0	0	0	0	0	0	0	658,681	
MENTAL HEALTH - ADULT	487,340	520,411	0	0	0	0	0	0	0	0	0	0	1,007,751	
MENTAL HEALTH - GENERAL	-156	0	0	0	0	0	0	0	0	0	0	0	-156	
MENTAL HEALTH - RBHA CRISIS	4,661,429	4,723,089	0	0	0	0	0	0	0	0	0	0	9,384,519	
FEE FOR SERVICE - ACUTE	92,476,405	129,084,882	0	0	0	0	0	0	0	0	0	0	221,561,286	
FFS - PRIOR QUARTER COVERAGE	-113	0	0	0	0	0	0	0	0	0	0	0	-113	
EMERGENCY SERVICES - FEDERAL	3,804,849	4,326,407	0	0	0	0	0	0	0	0	0	0	8,131,256	
FFS MEDICAID IN PUBLIC SCHOOLS	2,855	1,323	0	0	0	0	0	0	0	0	0	0	4,178	
INPATIENT INMATES FFS	456,967	506,721	0	0	0	0	0	0	0	0	0	0	963,687	
STATE ONLY TRBHA FFS	428,436	507,446	0	0	0	0	0	0	0	0	0	0	935,881	
FFS TRBHA FEE FOR SERVICE	26,098,534	40,277,267	0	0	0	0	0	0	0	0	0	0	66,375,801	
COCONINO COUNTY INMATES FFS	1,175	200	0	0	0	0	0	0	0	0	0	0	1,375	
PINAL COUNTY INMATES FFS	4,034	3,548	0	0	0	0	0	0	0	0	0	0	7,582	
PIMA COUNTY INMATES FFS	545	17,807	0	0	0	0	0	0	0	0	0	0	18,353	
MARICOPA CTY INMATES FFS	92,203	257,735	0	0	0	0	0	0	0	0	0	0	349,938	
MOHAVE COUNTY INMATES FFS	35	0	0	0	0	0	0	0	0	0	0	0	35	
REINSURANCE - ACC	8,192,688	6,194,253	0	0	0	0	0	0	0	0	0	0	14,386,941	
SMIB - ACC	10,484,754	10,564,495	0	0	0	0	0	0	0	0	0	0	21,049,249	
HIB - ACC	6,761	6,761	0	0	0	0	0	0	0	0	0	0	13,522	
SUBTOTAL	573,291,872	629,287,911	0	0	0	0	0	0	0	0	0	0	1,202,579,783	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending August 31, 2022

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

TITLE XIX ACA ADULT EXPANSION

CAPITATION - ACC	73,809,810	73,690,541	0	0	0	0	0	0	0	0	0	0	147,500,351	
CAPITATION - AIMHS	44,384	43,532	0	0	0	0	0	0	0	0	0	0	87,916	
MENTAL HEALTH - ADULT	36,068	39,363	0	0	0	0	0	0	0	0	0	0	75,430	
MENTAL HEALTH - RBHA CRISIS	974,919	977,520	0	0	0	0	0	0	0	0	0	0	1,952,439	
FEE FOR SERVICE - ACUTE	7,758,327	10,342,510	0	0	0	0	0	0	0	0	0	0	18,100,837	
FFS - PRIOR QUARTER COVERAGE	0	-29	0	0	0	0	0	0	0	0	0	0	-29	
EMERGENCY SERVICES - FEDERAL	5,758,867	6,799,743	0	0	0	0	0	0	0	0	0	0	12,558,610	
FFS MEDICAID IN PUBLIC SCHOOLS	46	28	0	0	0	0	0	0	0	0	0	0	74	
STATE ONLY TRBHA FFS	4,266	31,539	0	0	0	0	0	0	0	0	0	0	35,805	
INPATIENT INMATES FFS	28,041	91,716	0	0	0	0	0	0	0	0	0	0	119,757	
FFS TRBHA FEE FOR SERVICE	949,799	1,458,222	0	0	0	0	0	0	0	0	0	0	2,408,021	
MARICOPA CTY INMATES FFS	0	5,661	0	0	0	0	0	0	0	0	0	0	5,661	
REINSURANCE - ACC	1,450,557	1,126,345	0	0	0	0	0	0	0	0	0	0	2,576,903	
SMIB - ACC	25,005	30,596	0	0	0	0	0	0	0	0	0	0	55,601	
	90,840,087	94,637,287	0	0	0	0	0	0	0	0	0	0	185,477,375	
	1,631,574,079	1,727,989,885	0	0	0	0	0	0	0	0	0	0	3,359,563,964	

SUBTOTAL TOTAL TITLE XIX
TITLE XXI KIDSCARE
MENTAL HEALTH - RBHA CRISIS	29	44	0	0	0	0	0	0	0	0	0	0	73	
KidsCare - CAPITATION	13,685,225	13,840,794	0	0	0	0	0	0	0	0	0	0	27,526,018	
KidsCare - FEE FOR SERVICE	379,979	492,797	0	0	0	0	0	0	0	0	0	0	872,776	
KidsCare - MENTAL HEALTH	448,014	456,989	0	0	0	0	0	0	0	0	0	0	905,003	
KidsCare - REINSURANCE	515,131	70,396	0	0	0	0	0	0	0	0	0	0	585,526	

15,028,377	14,861,019	0	0	0	0	0	0	0	0	0	0	29,889,396	

TOTAL TITLE XXI

ACC CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	1,780.29	1,457.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,238.20		
1006	TANF 21-44 MALE WITH	32,816.83	29,202.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,019.30		
1007	TANF 21-44 FEMALE WI	63,662.35	60,584.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,247.01		
1008	TANF 45-64 M & F WIT	97,139.31	94,275.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,414.75		
1009	TANF 65+ M & F WITH	30,750.25	29,292.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,042.86		
100D	TANF 14-20 MALE WITH	0.00	-112.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-112.14		
100G	TANF 21-44 FEMALE WI	190.77	871.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,062.47		
100H	TANF 45-64 M & F WIT	0.00	400.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		400.82		
100J	TANF 65+ M & F WITH	249.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		249.17		
1011	TANF <1 M & F NON-ME	9,125,157.11	8,941,424.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,066,581.32		
1012	TANF 01-05 M & F NON	5,664,483.98	5,703,939.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,368,423.76		
1013	TANF 06-13 M & F NON	10,660,664.06	10,723,161.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,383,825.61		
1014	TANF 14-20 MALE NON-	4,145,191.65	4,191,331.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,336,522.96		
1015	TANF 14-20 FEMALE N	4,674,331.19	4,738,661.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,412,992.43		
	O																
1016	TANF 21-44 MALE NON-	17,149,298.83	17,352,270.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,501,569.30		
1017	TANF 21-44 FEMALE N	55,783,969.84	56,530,185.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		112,314,155.05		
	O																
1018	TANF 45-64 M & F NON	14,705,073.83	14,940,397.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,645,471.46		
1019	TANF 65+ M & F NON-M	69,879.13	70,527.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		140,406.98		
101A	TANF < 1 M & F NON-M	422,503.51	537,941.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		960,444.88		
101B	TANF 01-05 M & F NON	15,577.90	26,699.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,277.36		
101C	TANF 06-13 M & F NON	8,706.36	8,045.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,751.66		
101D	TANF 14-20 MALE NON-	2,437.01	11,342.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,779.57		
101E	TANF 14-20 FEMALE N	6,230.80	5,809.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,040.53		
	O																
101F	TANF 21-44 MALE NON-	166,457.55	153,588.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320,046.50		
101G	TANF 21-44 FEMALE N	293,505.28	334,444.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		627,950.06		
	O																
101H	TANF 44-64 M & F NON	91,452.39	81,366.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		172,819.24		
101J	TANF 65+ N & F NON-M	2,736.14	1,103.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,839.59		
1023	TANF 06-13 M & F WIT	143.85	143.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		287.70		
1024	TANF 14-20 MALE WITH	0.00	-1,177.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,177.41		
1025	TANF 14-20 FEMALE WI	149.53	72.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		221.88		
1026	TANF 21-44 MALE WITH	51,098.58	56,863.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		107,961.72		
1027	TANF 21-44 FEMALE WI	75,753.83	82,448.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		158,202.76		
1028	TANF 45-64 M & F WIT	67,654.56	76,272.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		143,926.92		
1029	TANF 65+ M & F WITH	20,554.49	20,878.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,433.18		
102F	TANF 21-44 MALE WITH	33.23	9,119.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,153.22		
102H	TANF 44-64 M & F WIT	365.54	266.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		631.99		

ACC CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC	915,511.77	928,107.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,843,618.85		
	A																
210Z	SSI AGED WITH MEDIC	34,531.94	47,312.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,844.13		
	A																
2110	SSI AGED NON-MEDICA	12,969,203.07	13,281,155.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,250,358.82		
	R																
211Z	SSI AGED NON-MEDICA	126,673.55	170,648.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		297,321.94		
	R																
2120	SSI AGED WITH QMB	7,628,842.22	7,684,205.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,313,048.21		
212Z	SSI AGED WITH QMB P	11,095.70	7,673.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,769.01		
	P																
2200	SSI DISABLED WITH M	2,527,711.39	2,539,705.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,067,416.64		
	E																
220Z	SSI DISABLED WITH M	53,780.28	35,068.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		88,848.76		
	E																
2210	SSI DISABLED NON-ME	78,349,021.95	78,099,288.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156,448,310.21		
	D																
221Z	SSI DISABLED NON-ME	748,350.73	866,300.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,614,651.33		
	D																
2220	SSI DISABLED WITH Q	16,216,280.81	16,216,098.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,432,379.59		
	M																
222Z	SSI DISABLED WITH Q	33,977.98	96,415.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,393.42		
	M																
2300	SSI BLIND WITH MEDIC	10,047.88	10,275.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,323.27		
230Z	SSI BLIND WITH MEDIC	1,520.18	37.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,557.79		
2310	SSI BLIND NON-MEDIC	733,452.07	732,615.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,466,068.05		
	A																
231Z	SSI BLIND NON-MEDIC	2,048.07	21,999.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,047.85		
	A																
2320	SSI BLIND WITH QMB	66,341.74	66,586.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,928.55		
232Z	SSI BLIND WITH QMB P	4.77	4.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.41		
4301	SOBRA CHILD <1 M & F	186.55	147.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		334.51		
4302	SOBRA CHILD 01-05 M	149.10	298.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		447.73		
4303	SOBRA CHILD 06-13 M	630.37	453.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,083.91		
4305	SOBRA CHILD 14-20 FE	299.32	299.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		598.64		
430A	SOBRA CHILD < 1 M &	9.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.65		
430B	SOBRA CHILD 01-05 M	0.00	43.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		43.41		
430C	SOBRA CHILD 06-13 M	37.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.97		
4311	SOBRA CHILD <1 M & F	20,486,020.43	20,828,123.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,314,144.08		
4312	SOBRA CHILD 01-05 M	43,401,888.47	43,443,440.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86,845,329.23		
4313	SOBRA CHILD 06-13 M	54,288,151.09	54,354,871.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108,643,022.61		
4314	SOBRA CHILD 14-20 MA	17,138,471.31	17,228,856.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,367,328.03		
4315	SOBRA CHILD 14-20 FE	16,858,765.80	17,012,303.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,871,069.71		
431A	SOBRA CHILD < 1 M &	194,688.52	263,370.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		458,058.89		
431B	SOBRA CHILD 01-05 M	236,658.85	308,033.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		544,692.14		
431C	SOBRA CHILD 6-13 M&F	313,680.20	347,904.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		661,584.60		
431D	SOBRA CHILD 14-20 MA	89,297.43	116,867.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		206,165.08		
431E	SOBRA CHILD 14-20 FE	86,785.94	121,988.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,774.02		
4322	SOBRA CHILD 01-05 M	299.32	299.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		598.64		

ACC CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4323	SOBRA CHILD 06-13 M	280.77	280.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		561.54		
4325	SOBRA CHILD 14-20 FE	123.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		123.42		
5007	SOBRA PREG 21-44 FE	9,270.64	8,835.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,106.63		
	M																
5008	SOBRA PREG 45-64 FE	238.55	145.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384.29		
	M																
500G	SOBRA PREG 21-44 FE	441.63	18,962.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,404.15		
	M																
500H	SOBRA PREG 45-64 FE	51.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.04		
	M																
5013	SOBRA PREG 09-13 FE	859.81	627.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,487.70		
	M																
5015	SOBRA PREG 14-20 FE	466,502.38	448,201.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		914,703.39		
	M																
5017	SOBRA PREG 21-44 FE	7,118,391.54	7,047,732.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,166,123.85		
	M																
5018	SOBRA PREG 45-64 FE	39,757.11	40,051.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,808.39		
	M																
501E	SOBRA PREG 14-20 FE	29,174.51	36,251.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,426.32		
	M																
501G	SOBRA PREG 21-44 FE	270,259.17	285,231.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		555,490.66		
	M																
501H	SOBRA PREG 45-64 FE	482.39	260.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		742.75		
	M																
5027	SOBRA PREG 21-44 FE	24,069.30	23,209.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,279.08		
	M																
5028	SOBRA PREG 45-64 FE	7,974.34	9,038.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,012.90		
	M																
502G	SOBRA PREG 21-44 FE	2,175.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,175.41		
	M																
SUBTOTAL:	404,924,467.57	407,562,735.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		812,487,202.86		

9910	TANF & SOBRA CHILDR E	3,453,057.50	3,771,273.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	52,573.81	19,328.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	110,322.51	72,020.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	9,672,727.16	10,798,862.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	13,288,680.98	14,661,484.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7,224,330.53	
71,902.09	
182,342.67	
20,471,589.83	
27,950,165.12	

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

33.00

33.00

1106	TANF EXPANDED 21-44	58,769.14	59,949.65	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	157,425.41	158,890.59	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	461,381.47	466,821.41	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
&	162,116.70	165,130.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	857.37	3,494.62	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	5,249.21	6,018.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	4,785.09	3,691.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	7,799.84	3,760.23	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	215.11	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	441.97	441.97	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	33,071.07	30,991.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

118,718.79	
316,316.00	
928,202.88	
327,247.30	
4,351.99	
11,267.99	
8,476.61	
11,560.07	
215.11	
883.94	
64,063.02	

ACC CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	189,562.64	178,961.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368,524.04		
1116	TANF EXPANDED 21-44	10,322,316.64	10,301,959.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,624,275.77		
1117	TANF EXPANDED 21-44	29,209,920.96	29,114,663.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58,324,584.89		
1118	TANF EXPANDED 45-64	10,781,337.34	10,815,314.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,596,652.19		
1119	TANF EXPANDED 65+ M	59,740.54	60,445.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,185.74		
	&																
111D	TANF EXPANDED 14-20	627.54	1,221.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,848.78		
111E	TANF EXPANDED 14-20	181.05	1,313.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,494.32		
111F	TANF EXPANDED 21-44	101,426.57	161,477.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		262,903.89		
111G	TANF EXPANDED 21-44	162,479.89	181,173.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		343,653.08		
111H	TANF EXPANDED 45-64	63,728.35	116,049.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		179,777.52		
1124	TANF EXPANDED 14-20	128.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128.87		
1125	TANF EXPANDED 14-20	153.30	153.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		306.60		
1126	TANF EXPANDED 21-44	320,332.88	321,565.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		641,898.06		
1127	TANF EXPANDED 21-44	783,302.61	765,462.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,548,765.34		
1128	TANF EXPANDED 45-64	1,113,746.03	1,110,138.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,223,884.31		
1129	TANF EXPANDED 65+ M	376,488.97	382,203.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		758,692.81		
	&																
112F	TANF EXPANDED 21-44	-4.36	164.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159.68		
112G	TANF EXPANDED 21-44	5,647.29	1,561.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,208.77		
112H	TANF EXPANDED 45-64	730.02	729.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,459.25		
112J	TANF EXPANDED 65+ M	119.60	575.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		695.16		
	&																
2400	SSI AGED EXPANDED	96,119.51	99,147.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		195,267.01		
	WI																
240Z	SSI AGED EXPANDED	20,337.38	27,845.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,182.79		
	WI																
2410	SSI AGED EXPANDED N	189,502.24	205,046.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394,548.90		
	O																
241Z	SSI AGED EXPANDED N	4,634.79	6,373.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,008.28		
	O																
2420	SSI AGED EXPANDED	7,487,646.63	7,592,876.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,080,523.00		
	WI																
242Z	SSI AGED EXPANDED	4,695.02	10,713.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,408.25		
	WI																
2500	SSI BLIND EXPANDED	211.15	223.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		434.50		
	W																
250Z	SSI BLIND EXPANDED	47.73	69.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		117.33		
	W																
2510	SSI BLIND EXPANDED	6,297.68	5,096.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,394.51		
	N																
2520	SSI BLIND EXPANDED	19,957.08	20,028.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,985.92		
	W																
2600	SSI DISABLED EXPAND	144,530.32	157,427.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		301,957.59		
	E																
260Z	SSI DISABLED EXPAND	20,469.28	27,513.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,982.55		
	E																
2610	SSI DISABLED EXPAND	1,683,006.05	1,662,384.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,345,390.76		
	E																
261Z	SSI DISABLED EXPAND	17,368.09	15,572.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,940.21		
	E																
2620	SSI DISABLED EXPAND	10,944,993.65	10,984,406.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,929,400.01		
	E																
262Z	SSI DISABLED EXPAND	3,456.76	7,636.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,093.43		
	E																

ACC CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	75,027,137.36	75,236,900.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		150,264,037.81		

9911	SB PAYMENT FOR TAN F	1,430,957.38	1,579,479.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	6,730.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,437,687.59	1,579,479.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,010,437.00	
6,730.21	
3,017,167.21	

3504	ADULT 40-100% MALE 1	711.68	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	1,311.34	611.85	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	21,654.42	26,568.13	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	24,357.30	24,108.50	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	341,059.00	353,320.48	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	456,823.83	482,478.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	1,595.49	83.67	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	4,828,199.00	4,879,934.54	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	5,123,981.15	5,156,882.67	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	19,704,046.35	19,794,453.17	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	17,131,914.30	17,347,714.28	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	29,304,281.42	29,364,798.42	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	32,960.60	30,755.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	24,010.00	23,291.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	26,010.92	26,624.01	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	164,889.99	181,214.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	137,250.55	149,839.68	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	280,355.41	290,378.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	0.00	711.68	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	1,463.66	2,175.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3525	ADULT 40-100% FEMAL E	0.00	699.49	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	10,642.75	10,642.75	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	12,037.20	13,165.60	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	48,236.52	50,095.49	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	19,647.12	20,279.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	3,988.91	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	68,462.35	87,626.21	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	68,096.70	69,947.83	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	785,998.61	827,873.23	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	228,743.77	248,557.15	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	-170.08	540.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

711.68	
1,923.19	
48,222.55	
48,465.80	
694,379.48	
939,301.84	
1,679.16	
9,708,133.54	
10,280,863.82	
39,498,499.52	
34,479,628.58	
58,669,079.84	
63,716.01	
47,301.79	
52,634.93	
346,104.78	
287,090.23	
570,734.27	
711.68	
3,639.00	
699.49	
21,285.50	
25,202.80	
98,332.01	
39,926.69	
3,988.91	
156,088.56	
138,044.53	
1,613,871.84	
477,300.92	
370.46	

ACC CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
370G	ADULT <40% EXP FEMA	598.41	3,263.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,861.53		
	L																
370H	ADULT <40% EXP M&F	2,394.90	1,802.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,197.82		
	4																
3714	ADULT <40% EXP MALE	11,532,347.36	11,705,574.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,237,922.20		
3715	ADULT <40% EXP FEMA	10,855,982.45	11,080,957.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,936,940.10		
	L																
3716	ADULT <40% EXP MALE	95,185,189.34	96,993,211.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192,178,400.56		
3717	ADULT <40% EXP FEMA	55,957,688.06	57,061,172.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		113,018,860.46		
	L																
3718	ADULT <40% EXP M&F	92,300,079.57	93,481,786.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185,781,866.32		
	4																
3719	ADULT <40% EXP M&F	53,341.37	65,142.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		118,484.23		
	6																
371D	ADULT <40% EXP MALE	96,742.09	96,758.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		193,500.82		
371E	ADULT <40% EXP FEMA	94,589.71	99,984.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		194,574.27		
	L																
371F	ADULT <40% EXP MALE	1,133,492.02	1,197,208.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,330,700.86		
371G	ADULT <40% EXP FEMA	588,590.93	726,629.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,315,220.53		
	L																
371H	ADULT <40% EXP M&F	978,569.28	1,045,274.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,023,843.65		
	4																
371J	ADULT <40% EXP M&F	615.24	3,091.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,707.04		
	6																
3724	ADULT <40% EXP MALE	0.00	622.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		622.82		
3726	ADULT <40% EXP MALE	39,850.65	45,419.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85,270.25		
3727	ADULT <40% EXP FEMA	29,435.94	29,602.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,038.38		
	L																
3728	ADULT <40% EXP M&F	136,675.13	141,226.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277,902.04		
	4																
3729	ADULT <40% EXP M&F	9,905.13	11,328.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,233.25		
	6																
372F	ADULT <40% EXP MALE	0.00	873.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		873.27		
372H	ADULT <40% EXP M&F	2,315.35	1,371.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,686.71		
	4																
SUBTOTAL:	347,850,963.19	353,257,677.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		701,108,640.51		

9935	BIRTH SUPP PAYMENT A	430,719.57	451,079.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	1,019,329.95	1,439,042.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,450,049.52	1,890,122.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

881,799.15	
2,458,372.58	
3,340,171.73	

3904	NEWLY ELIGIBLE MALE	509.30	509.30	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	1,039.14	1,039.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	120,702.42	122,483.75	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	76,498.85	81,779.69	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	1,304,952.22	1,315,654.40	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	1,221,831.72	1,272,553.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA
L	83.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	16.13	405.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	2,343,709.45	2,279,267.31	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	2,438,363.16	2,356,230.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,018.60	
2,078.28	
243,186.17	
158,278.54	
2,620,606.62	
2,494,385.18	
83.67	
421.55	
4,622,976.76	
4,794,593.32	

ACC CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	18,346,919.61	18,323,571.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,670,491.40		
3917	NEWLY ELIGIBLE FEMA	25,171,969.90	25,090,484.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,262,454.88		
	L																
3918	NEWLY ELIGIBLE M&F	21,084,527.97	21,027,455.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,111,983.38		
	4																
3919	NEWLY ELIGIBLE M&F	90,435.69	101,068.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191,504.00		
	6																
391D	NEWLY ELIGIBLE MALE	10,105.94	21,311.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,417.09		
391E	NEWLY ELIGIBLE FEMA	16,507.07	16,217.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,724.17		
	L																
391F	NEWLY ELIGIBLE MALE	110,053.40	134,672.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		244,725.42		
391G	NEWLY ELIGIBLE FEMA	121,595.91	153,467.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		275,063.73		
	L																
391H	NEWLY ELIGIBLE M&F	178,121.35	176,993.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		355,115.31		
	4																
391J	NEWLY ELIGIBLE M&F	0.00	757.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		757.89		
	6																
3926	NEWLY ELIGIBLE MALE	2,559.59	2,057.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,617.53		
3927	NEWLY ELIGIBLE FEMA	8,156.26	9,775.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,931.38		
	L																
3928	NEWLY ELIGIBLE M&F	18,078.76	17,008.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,086.94		
	4																
3929	NEWLY ELIGIBLE M&F	58,488.18	63,922.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,410.41		
	6																
SUBTOTAL:	72,725,225.69	72,568,686.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,293,912.22		

9939	BIRTH SUPP PAYMENT N	1,084,584.04	1,121,854.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,084,584.04	1,121,854.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,206,438.70

2,206,438.70

4403	SOBRA 100-133% M&F
6	153.30	153.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	565.04	673.70	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	423.62	211.81	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	8,814,726.63	8,765,459.47	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	3,220,832.14	3,242,385.23	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	3,134,044.38	3,135,164.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441A	SOBRA 100-133% M&F
<	108.66	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	48,615.71	66,574.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	12,268.74	19,909.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	16,821.39	22,224.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	152.17	152.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	15,248,711.78	15,252,908.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

306.60	
1,238.74	
635.43	
17,580,186.10	
6,463,217.37	
6,269,209.29	
108.66	
115,190.45	
32,178.13	
39,045.52	
304.34	
30,501,620.63	

9944	BIRTH SUPP PAYMENT S	39,231.46	52,116.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	39,231.46	52,116.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

91,348.44

91,348.44

4517	BC PATIENT FEMALE 2 1	5,749.24	5,419.06	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	55,164.97	56,985.81	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	6,359.23	7,087.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

11,168.30	
112,150.78	
13,446.36	

ACC CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
451G	BC PATIENT FEMALE 2	72.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		72.60		
	1																
451H	BC PATIENT FEMALE 4	1,949.36	1,272.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,221.90		
	5																
451J	BC PATIENT FEMALE 6	1,169.60	71.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,240.87		
	5																
4617	CC PATIENT FEMALE 2	4,578.63	4,578.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,157.26		
	1																
4618	CC PATIENT FEMALE 4	2,527.24	2,527.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,054.48		
	5																
SUBTOTAL:	77,570.87	77,941.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		155,512.55		

8600	SSI BLIND FREEDOM/W O	7,137.58	7,281.43	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	1,336.38	1,336.38	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	439.87	439.87	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	1,696,772.78	1,699,664.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	9,454.15	35,712.11	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	622,171.32	609,857.36	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	11,632.51	4,520.06	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	559,919.66	562,424.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	1,379.01	413.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,910,243.26	2,921,650.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14,419.01	
2,672.76	
879.74	
3,396,437.10	
45,166.26	
1,232,028.68	
16,152.57	
1,122,344.57	
1,792.63	
5,831,893.32	

1,882,248,144.10

936,064,569.81	946,183,574.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	2.00	-0.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.78		
1006	TANF 21-44 MALE WITH	89.72	81.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.42		
1007	TANF 21-44 FEMALE WI	135.07	139.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274.47		
1008	TANF 45-64 M & F WIT	295.00	312.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		607.61		
1009	TANF 65+ M & F WITH	198.29	199.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		397.29		
100D	TANF 14-20 MALE WITH	0.00	-0.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-0.76		
100G	TANF 21-44 FEMALE WI	0.83	1.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.92		
100H	TANF 45-64 M & F WIT	0.00	2.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.73		
100J	TANF 65+ M & F WITH	1.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.70		
1011	TANF <1 M & F NON-ME	13,259.95	13,001.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,261.78		
1012	TANF 01-05 M & F NON	26,071.93	26,203.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52,275.91		
1013	TANF 06-13 M & F NON	50,103.17	50,371.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,474.33		
1014	TANF 14-20 MALE NON-	18,035.40	18,267.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,303.03		
1015	TANF 14-20 FEMALE N	20,547.03	20,758.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,305.45		
	O																
1016	TANF 21-44 MALE NON-	39,803.36	40,236.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,039.79		
1017	TANF 21-44 FEMALE N	127,453.35	129,273.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256,726.43		
	O																
1018	TANF 45-64 M & F NON	33,766.54	34,219.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,985.64		
1019	TANF 65+ M & F NON-M	160.53	162.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322.54		
101A	TANF < 1 M & F NON-M	628.63	801.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,429.83		
101B	TANF 01-05 M & F NON	74.67	128.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203.24		
101C	TANF 06-13 M & F NON	41.39	38.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.39		
101D	TANF 14-20 MALE NON-	11.42	53.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64.64		
101E	TANF 14-20 FEMALE N	28.45	26.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.61		
	O																
101F	TANF 21-44 MALE NON-	350.26	370.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		720.85		
101G	TANF 21-44 FEMALE N	685.70	791.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,477.13		
	O																
101H	TANF 44-64 M & F NON	215.07	194.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		409.61		
101J	TANF 65+ N & F NON-M	6.35	2.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.78		
1023	TANF 06-13 M & F WIT	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		
1024	TANF 14-20 MALE WITH	0.00	-8.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-8.11		
1025	TANF 14-20 FEMALE WI	1.00	0.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.48		
1026	TANF 21-44 MALE WITH	110.59	115.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		225.61		
1027	TANF 21-44 FEMALE WI	155.12	147.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302.38		
1028	TANF 45-64 M & F WIT	190.96	195.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		386.12		
1029	TANF 65+ M & F WITH	128.96	131.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		259.96		
102F	TANF 21-44 MALE WITH	0.22	3.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.73		
102H	TANF 44-64 M & F WIT	2.45	1.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.25		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC	4,989.15	5,084.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,073.64		
	A																
210Z	SSI AGED WITH MEDIC	190.15	226.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		416.23		
	A																
2110	SSI AGED NON-MEDICA	9,717.37	9,952.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,670.17		
	R																
211Z	SSI AGED NON-MEDICA	97.55	131.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228.62		
	R																
2120	SSI AGED WITH QMB	41,798.86	42,132.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83,931.19		
212Z	SSI AGED WITH QMB P	23.14	34.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.08		
	P																
2200	SSI DISABLED WITH M	4,887.48	4,942.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,829.85		
	E																
220Z	SSI DISABLED WITH M	120.14	95.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215.39		
	E																
2210	SSI DISABLED NON-ME	53,423.42	53,258.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,681.84		
	D																
221Z	SSI DISABLED NON-ME	569.19	648.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,217.97		
	D																
2220	SSI DISABLED WITH Q	27,228.09	27,287.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,515.36		
	M																
222Z	SSI DISABLED WITH Q	43.59	73.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.94		
	M																
2300	SSI BLIND WITH MEDIC	47.79	49.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97.53		
230Z	SSI BLIND WITH MEDIC	10.19	0.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.44		
2310	SSI BLIND NON-MEDIC	537.89	537.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,075.41		
	A																
231Z	SSI BLIND NON-MEDIC	1.41	17.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.70		
	A																
2320	SSI BLIND WITH QMB	261.28	253.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		514.36		
232Z	SSI BLIND WITH QMB P	0.03	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.06		
4301	SOBRA CHILD <1 M & F	1.25	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.25		
4302	SOBRA CHILD 01-05 M	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4303	SOBRA CHILD 06-13 M	4.19	3.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.22		
4305	SOBRA CHILD 14-20 FE	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
430A	SOBRA CHILD < 1 M &	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.06		
430B	SOBRA CHILD 01-05 M	0.00	0.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.29		
430C	SOBRA CHILD 06-13 M	0.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.25		
4311	SOBRA CHILD <1 M & F	29,831.26	30,342.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,173.91		
4312	SOBRA CHILD 01-05 M	182,182.34	182,424.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		364,606.92		
4313	SOBRA CHILD 06-13 M	233,502.97	233,897.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		467,400.60		
4314	SOBRA CHILD 14-20 MA	73,339.40	73,890.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,230.19		
4315	SOBRA CHILD 14-20 FE	72,093.27	72,731.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		144,824.50		
431A	SOBRA CHILD < 1 M &	287.53	383.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		671.41		
431B	SOBRA CHILD 01-05 M	1,056.46	1,345.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,402.45		
431C	SOBRA CHILD 6-13 M&F	1,359.63	1,597.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,957.30		
431D	SOBRA CHILD 14-20 MA	394.66	519.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		913.71		
431E	SOBRA CHILD 14-20 FE	389.24	552.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		941.54		
4322	SOBRA CHILD 01-05 M	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		

ACC CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4323	SOBRA CHILD 06-13 M	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
4325	SOBRA CHILD 14-20 FE	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.83		
5007	SOBRA PREG 21-44 FE	36.17	35.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.25		
	M																
5008	SOBRA PREG 45-64 FE	1.64	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.64		
	M																
500G	SOBRA PREG 21-44 FE	2.92	7.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.20		
	M																
500H	SOBRA PREG 45-64 FE	0.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.35		
	M																
5013	SOBRA PREG 09-13 FE	4.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
	M																
5015	SOBRA PREG 14-20 FE	2,036.92	1,961.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,998.67		
	M																
5017	SOBRA PREG 21-44 FE	16,661.15	16,515.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,176.76		
	M																
5018	SOBRA PREG 45-64 FE	74.31	75.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149.63		
	M																
501E	SOBRA PREG 14-20 FE	134.12	159.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		293.56		
	M																
501G	SOBRA PREG 21-44 FE	648.27	668.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,317.01		
	M																
501H	SOBRA PREG 45-64 FE	1.08	0.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.74		
	M																
5027	SOBRA PREG 21-44 FE	34.16	29.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.71		
	M																
5028	SOBRA PREG 45-64 FE	6.64	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.64		
	M																
502G	SOBRA PREG 21-44 FE	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.83		
	M																
SUBTOTAL:	1,090,595.73	1,098,111.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,188,706.76		

9910	TANF & SOBRA CHILDR E	530.00	579.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9920	SSI W/MEDICARE KICK	8.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9921	SSI W/O MEDICARE KIC	17.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9950	S.O.B.R.A. KICK PAYM	1,482.00	1,654.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,037.00	2,247.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,109.00	
11.00	
28.00	
3,136.00	
4,284.00	

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

2.00

1106	TANF EXPANDED 21-44	215.64	215.00	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	376.46	370.20	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	1,467.34	1,481.87	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
&	1,006.56	1,020.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110F	TANF EXPANDED 21-44	5.82	5.43	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	5.51	10.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110H	TANF EXPANDED 45-64	12.54	24.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
110J	TANF EXPANDED 65+ M
&	29.64	25.53	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	1.00	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	2.00	2.00	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	156.00	146.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

430.64	
746.66	
2,949.21	
2,027.30	
11.25	
15.66	
37.23	
55.17	
1.00	
4.00	
302.13	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	879.41	830.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,709.51		
1116	TANF EXPANDED 21-44	24,611.45	24,597.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		49,208.99		
1117	TANF EXPANDED 21-44	68,420.19	68,170.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		136,590.23		
1118	TANF EXPANDED 45-64	25,214.53	25,316.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,530.64		
1119	TANF EXPANDED 65+ M	141.00	142.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		283.00		
	&																
111D	TANF EXPANDED 14-20	2.95	5.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.74		
111E	TANF EXPANDED 14-20	0.83	6.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.95		
111F	TANF EXPANDED 21-44	248.55	378.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		627.07		
111G	TANF EXPANDED 21-44	388.73	435.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		824.25		
111H	TANF EXPANDED 45-64	152.87	286.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		439.70		
1124	TANF EXPANDED 14-20	0.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.87		
1125	TANF EXPANDED 14-20	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1126	TANF EXPANDED 21-44	732.80	750.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,483.25		
1127	TANF EXPANDED 21-44	1,572.19	1,545.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,117.53		
1128	TANF EXPANDED 45-64	2,936.85	2,953.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,890.04		
1129	TANF EXPANDED 65+ M	2,154.04	2,184.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,338.64		
	&																
112F	TANF EXPANDED 21-44	-0.03	0.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.63		
112G	TANF EXPANDED 21-44	4.22	1.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.36		
112H	TANF EXPANDED 45-64	5.05	4.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.03		
112J	TANF EXPANDED 65+ M	0.79	3.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.59		
	&																
2400	SSI AGED EXPANDED	493.34	514.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,008.14		
	WI																
240Z	SSI AGED EXPANDED	134.07	180.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315.04		
	WI																
2410	SSI AGED EXPANDED N	143.78	155.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299.66		
	O																
241Z	SSI AGED EXPANDED N	3.62	5.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.71		
	O																
2420	SSI AGED EXPANDED	33,924.56	34,331.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,255.70		
	WI																
242Z	SSI AGED EXPANDED	19.82	47.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67.76		
	WI																
2500	SSI BLIND EXPANDED	1.41	1.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.92		
	W																
250Z	SSI BLIND EXPANDED	0.32	0.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.80		
	W																
2510	SSI BLIND EXPANDED	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
	N																
2520	SSI BLIND EXPANDED	92.49	93.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		185.49		
	W																
2600	SSI DISABLED EXPAND	398.70	406.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		805.31		
	E																
260Z	SSI DISABLED EXPAND	47.79	60.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		108.02		
	E																
2610	SSI DISABLED EXPAND	1,232.07	1,213.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,445.71		
	E																
261Z	SSI DISABLED EXPAND	13.23	12.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.33		
	E																
2620	SSI DISABLED EXPAND	16,721.92	16,798.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,520.62		
	E																
262Z	SSI DISABLED EXPAND	5.31	32.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.27		
	E																

ACC CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	183,983.23	184,775.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		368,758.75		

9911	SB PAYMENT FOR TAN F	219.00	242.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9922	SB PAYMENT FOR SSI
E	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	220.00	242.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

461.00	
1.00	
462.00	

3504	ADULT 40-100% MALE 1	1.00	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	2.00	1.00	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	26.00	29.00	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	23.00	21.00	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	455.99	472.33	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	649.88	686.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
350H	ADULT 40-100% M&F 45	0.97	0.03	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	6,849.39	6,924.53	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	7,297.20	7,331.89	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	27,196.55	27,302.54	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	23,652.00	23,987.14	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	41,302.85	41,412.50	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	48.00	44.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351D	ADULT 40-100% MALE 1	35.04	33.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351E	ADULT 40-100% FEMAL E	38.24	38.71	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	229.60	257.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351G	ADULT 40-100% FEMAL E	191.30	207.60	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	409.03	419.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
351J	ADULT 40-100% M&F 65	0.00	1.00	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	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3525	ADULT 40-100% FEMAL E	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3526	ADULT 40-100% MALE 2	13.00	13.00	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	8.00	9.83	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	65.92	69.00	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	29.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
352H	ADULT 40-100% M&F 45	2.48	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	74.48	83.19	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	60.22	61.25	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	973.77	1,010.91	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	323.19	352.00	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	-0.06	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.00	
3.00	
55.00	
44.00	
928.32	
1,336.04	
1.00	
13,773.92	
14,629.09	
54,499.09	
47,639.14	
82,715.35	
92.00	
68.60	
76.95	
486.99	
398.90	
828.03	
1.00	
5.00	
1.00	
26.00	
17.83	
134.92	
59.00	
2.48	
157.67	
121.47	
1,984.68	
675.19	
0.71	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
370G	ADULT <40% EXP FEMA	0.77	1.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.02		
	L																
370H	ADULT <40% EXP M&F	1.06	2.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.63		
	4																
3714	ADULT <40% EXP MALE	16,296.11	16,547.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,843.61		
3715	ADULT <40% EXP FEMA	15,279.36	15,591.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,870.52		
	L																
3716	ADULT <40% EXP MALE	125,277.55	127,778.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		253,055.56		
3717	ADULT <40% EXP FEMA	73,204.28	74,751.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,955.97		
	L																
3718	ADULT <40% EXP M&F	122,914.04	124,492.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		247,406.97		
	4																
3719	ADULT <40% EXP M&F	75.00	90.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		165.00		
	6																
371D	ADULT <40% EXP MALE	135.47	133.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		269.34		
371E	ADULT <40% EXP FEMA	133.09	144.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		277.52		
	L																
371F	ADULT <40% EXP MALE	1,532.37	1,610.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,143.09		
371G	ADULT <40% EXP FEMA	810.20	996.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,806.50		
	L																
371H	ADULT <40% EXP M&F	1,351.39	1,451.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,802.43		
	4																
371J	ADULT <40% EXP M&F	1.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
	6																
3724	ADULT <40% EXP MALE	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
3726	ADULT <40% EXP MALE	45.00	45.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		90.39		
3727	ADULT <40% EXP FEMA	26.00	25.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51.99		
	L																
3728	ADULT <40% EXP M&F	164.40	173.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		337.71		
	4																
3729	ADULT <40% EXP M&F	14.00	16.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.12		
	6																
372F	ADULT <40% EXP MALE	0.00	0.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.54		
372H	ADULT <40% EXP M&F	3.06	1.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.83		
	4																
SUBTOTAL:	467,224.19	474,662.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		941,887.11		

376.00

135.00

9935	BIRTH SUPP PAYMENT A	66.00	69.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9937	BIRTH SUPP PAYMENT
A	156.00	220.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	222.00	289.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

511.00

3904	NEWLY ELIGIBLE MALE	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3905	NEWLY ELIGIBLE FEMA L	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	138.43	142.00	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	82.73	84.00	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	2,164.90	2,181.39	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	2,350.03	2,449.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390G	NEWLY ELIGIBLE FEMA
L	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390H	NEWLY ELIGIBLE M&F 4	0.03	0.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,660.40	4,532.44	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	4,822.55	4,677.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
4.00	
280.43	
166.73	
4,346.29	
4,799.31	
0.03	
0.69	
9,192.84	
9,500.09	

ACC CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	35,073.27	35,016.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		70,089.46		
3917	NEWLY ELIGIBLE FEMA	48,465.23	48,349.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96,814.26		
	L																
3918	NEWLY ELIGIBLE M&F	40,243.92	40,106.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,350.59		
	4																
3919	NEWLY ELIGIBLE M&F	172.54	190.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		362.83		
	6																
391D	NEWLY ELIGIBLE MALE	20.07	42.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.04		
391E	NEWLY ELIGIBLE FEMA	34.22	32.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66.27		
	L																
391F	NEWLY ELIGIBLE MALE	216.41	266.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		482.83		
391G	NEWLY ELIGIBLE FEMA	237.61	301.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		539.15		
	L																
391H	NEWLY ELIGIBLE M&F	325.34	333.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		658.77		
	4																
391J	NEWLY ELIGIBLE M&F	0.00	1.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.55		
	6																
3926	NEWLY ELIGIBLE MALE	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
3927	NEWLY ELIGIBLE FEMA	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
	L																
3928	NEWLY ELIGIBLE M&F	27.99	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53.99		
	4																
3929	NEWLY ELIGIBLE M&F	116.00	127.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		243.00		
	6																
SUBTOTAL:	139,169.70	138,878.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		278,048.15		

9939	BIRTH SUPP PAYMENT N	166.00	172.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	166.00	172.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

338.00

338.00

4403	SOBRA 100-133% M&F
6	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.83	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	2.00	1.00	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	41,505.73	41,260.75	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	15,113.96	15,187.42	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	14,658.48	14,645.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441A	SOBRA 100-133% M&F
<	0.16	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	226.41	311.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441D	SOBRA 100-133% MALE	57.49	94.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
441E	SOBRA 100-133% FEMA L	78.80	104.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	71,645.86	71,608.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
1.83	
3.00	
82,766.48	
30,301.38	
29,303.99	
0.16	
538.38	
151.85	
183.54	
2.00	
143,254.61	

9944	BIRTH SUPP PAYMENT S	6.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14.00

14.00

264.20

26.89

4517	BC PATIENT FEMALE 2 1	13.83	13.06	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	130.31	133.89	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	14.99	16.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

31.81

ACC CAPITATION - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
451G	BC PATIENT FEMALE 2	0.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.16		
	1																
451H	BC PATIENT FEMALE 4	3.62	3.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.64		
	5																
451J	BC PATIENT FEMALE 6	2.72	0.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.87		
	5																
4617	CC PATIENT FEMALE 2	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
	1																
4618	CC PATIENT FEMALE 4	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
	5																
SUBTOTAL:	177.63	178.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		356.57		

8600	SSI BLIND FREEDOM/W O	15.00	16.00	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	1.00	1.00	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	3.00	3.00	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	2,450.13	2,434.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO M	13.10	36.98	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	438.86	431.21	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	9.39	3.35	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	790.18	787.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
872Z	SSI DISABLED FREEDO M	3.01	2.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,723.67	3,716.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

31.00	
2.00	
6.00	
4,884.86	
50.08	
870.07	
12.74	
1,578.05	
5.81	
7,440.61	

TOTAL:	1,959,172.01	1,974,891.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,934,063.56		

ACUTE CAPITATION - AMERICAN INDIAN A - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	16.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.60		
1011	TANF <1 M & F NON-ME	33.20	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.00		
1012	TANF 01-05 M & F NON	33.20	66.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
1013	TANF 06-13 M & F NON	99.60	132.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232.40		
1015	TANF 14-20 FEMALE N	49.80	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		99.60		
	O																
1016	TANF 21-44 MALE NON-	132.80	149.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		282.20		
1017	TANF 21-44 FEMALE N	564.40	713.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,278.20		
	O																
1018	TANF 45-64 M & F NON	265.60	282.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		547.80		
1019	TANF 65+ M & F NON-M	0.00	16.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.60		
2120	SSI AGED WITH QMB	83.00	132.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		215.80		
2200	SSI DISABLED WITH M	33.20	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.00		
	E																
2210	SSI DISABLED NON-ME	315.40	348.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		664.00		
	D																
2220	SSI DISABLED WITH Q	132.80	166.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		298.80		
	M																
4311	SOBRA CHILD <1 M & F	249.00	265.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		514.60		
4312	SOBRA CHILD 01-05 M	1,195.20	1,411.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,606.20		
4313	SOBRA CHILD 06-13 M	1,228.40	1,460.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,689.20		
4314	SOBRA CHILD 14-20 MA	464.80	581.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,045.80		
4315	SOBRA CHILD 14-20 FE	415.00	498.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		913.00		
5015	SOBRA PREG 14-20 FE	49.80	83.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132.80		
	M																
5017	SOBRA PREG 21-44 FE	149.40	199.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		348.60		
	M																
SUBTOTAL:	5,511.20	6,656.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,167.80		

1109	TANF EXPANDED 65+ M
&	16.60	16.60	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	66.40	49.80	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	332.00	398.40	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	149.40	215.80	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	16.60	16.60	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	166.00	182.60	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	49.80	66.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	796.80	946.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

33.20	
116.20	
730.40	
365.20	
33.20	
348.60	
116.20	
1,743.00	

3509	ADULT 40-100% M&F 65	16.60	16.60	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	16.60	16.60	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	99.60	116.20	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	33.20	33.20	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	132.80	166.00	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	16.60	16.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

33.20	
33.20	
215.80	
66.40	
298.80	
33.20	

ACUTE CAPITATION - AMERICAN INDIAN A - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	33.20	49.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.00		
3715	ADULT <40% EXP FEMA	49.80	66.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.20		
	L																
3716	ADULT <40% EXP MALE	365.20	415.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		780.20		
3717	ADULT <40% EXP FEMA	232.40	265.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		498.00		
	L																
3718	ADULT <40% EXP M&F	630.80	813.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,444.20		
	4																
SUBTOTAL:	1,626.80	1,975.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,602.20		

3916	NEWLY ELIGIBLE MALE	49.80	66.40	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	99.60	116.20	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	116.20	116.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	265.60	298.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

116.20	
215.80	
232.40	
564.40	

4413	SOBRA 100-133% M&F
6	49.80	166.00	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	33.20	83.00	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	49.80	66.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	132.80	315.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

215.80	
116.20	
116.20	
448.20	

8710

SSI DISABLED FREEDO M

33.20

33.20

18,558.80

16.60	16.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
16.60	16.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,349.80	10,209.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL: TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN A - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
1011	TANF <1 M & F NON-ME	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1012	TANF 01-05 M & F NON	2.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1013	TANF 06-13 M & F NON	6.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
1015	TANF 14-20 FEMALE N	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
	O																
1016	TANF 21-44 MALE NON-	8.00	9.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.00		
1017	TANF 21-44 FEMALE N	34.00	43.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.00		
	O																
1018	TANF 45-64 M & F NON	16.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
1019	TANF 65+ M & F NON-M	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2120	SSI AGED WITH QMB	5.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
2200	SSI DISABLED WITH M	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
	E																
2210	SSI DISABLED NON-ME	19.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40.00		
	D																
2220	SSI DISABLED WITH Q	8.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18.00		
	M																
4311	SOBRA CHILD <1 M & F	15.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31.00		
4312	SOBRA CHILD 01-05 M	72.00	85.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		157.00		
4313	SOBRA CHILD 06-13 M	74.00	88.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		162.00		
4314	SOBRA CHILD 14-20 MA	28.00	35.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		63.00		
4315	SOBRA CHILD 14-20 FE	25.00	30.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55.00		
5015	SOBRA PREG 14-20 FE	3.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
	M																
5017	SOBRA PREG 21-44 FE	9.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
	M																
SUBTOTAL:	332.00	401.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		733.00		

1109	TANF EXPANDED 65+ M
&	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	4.00	3.00	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	20.00	24.00	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	9.00	13.00	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	1.00	1.00	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	10.00	11.00	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	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	48.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
7.00	
44.00	
22.00	
2.00	
21.00	
7.00	
105.00	

3509	ADULT 40-100% M&F 65	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	1.00	1.00	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	6.00	7.00	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	2.00	2.00	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	8.00	10.00	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	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	
2.00	
13.00	
4.00	
18.00	
2.00	

ACUTE CAPITATION - AMERICAN INDIAN A - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
3715	ADULT <40% EXP FEMA	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.00		
	L																
3716	ADULT <40% EXP MALE	22.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.00		
3717	ADULT <40% EXP FEMA	14.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30.00		
	L																
3718	ADULT <40% EXP M&F	38.00	49.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.00		
	4																
SUBTOTAL:	98.00	119.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		217.00		

3916	NEWLY ELIGIBLE MALE	3.00	4.00	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	6.00	7.00	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	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	16.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.00	
13.00	
14.00	
34.00	

4413	SOBRA 100-133% M&F
6	3.00	10.00	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	2.00	5.00	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	3.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8.00	19.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13.00	
7.00	
7.00	
27.00	

8710

SSI DISABLED FREEDO M

2.00

2.00

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

SUBTOTAL:

TOTAL:	503.00	615.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,118.00		

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
1009	TANF 65+ M & F WITH	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
1011	TANF <1 M & F NON-ME	1,662.57	1,700.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,363.36		
1012	TANF 01-05 M & F NON	2,923.83	3,114.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,038.76		
1013	TANF 06-13 M & F NON	3,401.58	3,458.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,860.49		
1014	TANF 14-20 MALE NON-	1,337.70	1,356.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,694.51		
1015	TANF 14-20 FEMALE N	1,509.69	1,547.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,057.60		
	O																
1016	TANF 21-44 MALE NON-	4,433.52	4,509.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,943.48		
1017	TANF 21-44 FEMALE N	14,523.60	14,523.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,047.20		
	O																
1018	TANF 45-64 M & F NON	5,599.23	5,675.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,274.90		
1019	TANF 65+ M & F NON-M	95.55	76.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.99		
1028	TANF 45-64 M & F WIT	38.22	38.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76.44		
1029	TANF 65+ M & F WITH	38.22	57.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95.55		
2100	SSI AGED WITH MEDIC	305.76	343.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		649.74		
	A																
2110	SSI AGED NON-MEDICA	477.75	554.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,031.94		
	R																
2120	SSI AGED WITH QMB	2,503.41	2,484.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,987.71		
2200	SSI DISABLED WITH M	649.74	707.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,356.81		
	E																
2210	SSI DISABLED NON-ME	10,778.04	10,816.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,594.30		
	D																
2220	SSI DISABLED WITH Q	4,395.30	4,337.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,733.27		
	M																
2300	SSI BLIND WITH MEDIC	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
2310	SSI BLIND NON-MEDIC	191.10	210.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		401.31		
	A																
2320	SSI BLIND WITH QMB	38.22	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.33		
4311	SOBRA CHILD <1 M & F	3,822.00	4,089.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,911.54		
4312	SOBRA CHILD 01-05 M	31,149.30	30,900.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,050.17		
4313	SOBRA CHILD 06-13 M	30,862.65	31,091.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		61,954.62		
4314	SOBRA CHILD 14-20 MA	9,058.14	9,096.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,154.50		
4315	SOBRA CHILD 14-20 FE	8,924.37	9,019.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,944.29		
5013	SOBRA PREG 09-13 FE	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
	M																
5015	SOBRA PREG 14-20 FE	114.66	76.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191.10		
	M																
5017	SOBRA PREG 21-44 FE	1,471.47	1,356.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,828.28		
	M																
SUBTOTAL:	140,382.06	141,242.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281,624.07		

1107	TANF EXPANDED 21-44	38.22	38.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	76.44	76.44	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
&	324.87	324.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

76.44	
152.88	
649.74	
38.22	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	76.44	95.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.99		
1116	TANF EXPANDED 21-44	2,312.31	2,254.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,567.29		
1117	TANF EXPANDED 21-44	6,229.86	6,210.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,440.61		
1118	TANF EXPANDED 45-64	3,363.36	3,401.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,764.94		
1126	TANF EXPANDED 21-44	95.55	95.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		191.10		
1127	TANF EXPANDED 21-44	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
1128	TANF EXPANDED 45-64	458.64	458.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		917.28		
1129	TANF EXPANDED 65+ M	783.51	802.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,586.13		
	&																
2400	SSI AGED EXPANDED	57.33	57.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.66		
	WI																
2420	SSI AGED EXPANDED	3,076.71	3,076.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,153.42		
	WI																
2520	SSI BLIND EXPANDED	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
	W																
2600	SSI DISABLED EXPAND	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
	E																
2610	SSI DISABLED EXPAND	229.32	248.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		477.75		
	E																
2620	SSI DISABLED EXPAND	1,452.36	1,452.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,904.72		
	E																
SUBTOTAL:	18,651.36	18,670.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,321.83		

3506	ADULT 40-100% MALE 2	19.11	19.11	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	19.11	19.11	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	95.55	76.44	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	554.19	554.19	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	573.30	554.19	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	1,796.34	1,739.01	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	1,586.13	1,605.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	3,726.45	3,535.35	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	19.11	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	57.33	57.33	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	19.11	19.11	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	1,968.33	1,949.22	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	1,758.12	1,777.23	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	16,052.40	16,377.27	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	8,389.29	8,599.50	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	17,218.11	17,313.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	19.11	19.11	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	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	38.22	38.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	53,909.31	54,291.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

38.22	
38.22	
171.99	
1,108.38	
1,127.49	
3,535.35	
3,191.37	
7,261.80	
19.11	
114.66	
38.22	
3,917.55	
3,535.35	
32,429.67	
16,988.79	
34,531.77	
38.22	
38.22	
76.44	
108,200.82	

ACUTE CAPITATION - AMERICAN INDIAN B - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3907	NEWLY ELIGIBLE FEMA	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
	L																
3908	NEWLY ELIGIBLE M&F	248.43	305.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		554.19		
	4																
3909	NEWLY ELIGIBLE M&F	248.43	267.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		515.97		
	6																
3914	NEWLY ELIGIBLE MALE	95.55	114.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210.21		
3915	NEWLY ELIGIBLE FEMA	382.20	401.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		783.51		
	L																
3916	NEWLY ELIGIBLE MALE	2,579.85	2,541.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,121.48		
3917	NEWLY ELIGIBLE FEMA	3,611.79	3,535.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,147.14		
	L																
3918	NEWLY ELIGIBLE M&F	4,337.97	4,165.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,503.95		
	4																
3919	NEWLY ELIGIBLE M&F	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38.22		
	6																
SUBTOTAL:	11,542.44	11,370.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,912.89		

4413	SOBRA 100-133% M&F
6	3,038.49	3,057.60	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	1,337.70	1,395.03	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	1,165.71	1,203.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,541.90	5,656.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,096.09	
2,732.73	
2,369.64	
11,198.46	

4518	BC PATIENT FEMALE 4 5	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	19.11	19.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

38.22

38.22

8700	SSI DISABLED FREEDO M	114.66	114.66	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	38.22	38.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	152.88	152.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

229.32	
76.44	
305.76	

461,602.05

230,199.06	231,402.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1007	TANF 21-44 FEMALE WI	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1009	TANF 65+ M & F 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		
1011	TANF <1 M & F NON-ME	87.00	89.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		176.00		
1012	TANF 01-05 M & F NON	153.00	163.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		316.00		
1013	TANF 06-13 M & F NON	178.00	181.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		359.00		
1014	TANF 14-20 MALE NON-	70.00	71.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		141.00		
1015	TANF 14-20 FEMALE N	79.00	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		160.00		
	O																
1016	TANF 21-44 MALE NON-	232.00	236.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		468.00		
1017	TANF 21-44 FEMALE N	760.00	760.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,520.00		
	O																
1018	TANF 45-64 M & F NON	293.00	297.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		590.00		
1019	TANF 65+ M & F NON-M	5.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1028	TANF 45-64 M & F WIT	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
1029	TANF 65+ M & F WITH	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
2100	SSI AGED WITH MEDIC	16.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00		
	A																
2110	SSI AGED NON-MEDICA	25.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.00		
	R																
2120	SSI AGED WITH QMB	131.00	130.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		261.00		
2200	SSI DISABLED WITH M	34.00	37.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71.00		
	E																
2210	SSI DISABLED NON-ME	564.00	566.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,130.00		
	D																
2220	SSI DISABLED WITH Q	230.00	227.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		457.00		
	M																
2300	SSI BLIND WITH MEDIC	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		
2310	SSI BLIND NON-MEDIC	10.00	11.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21.00		
	A																
2320	SSI BLIND WITH QMB	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
4311	SOBRA CHILD <1 M & F	200.00	214.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		414.00		
4312	SOBRA CHILD 01-05 M	1,630.00	1,617.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,247.00		
4313	SOBRA CHILD 06-13 M	1,615.00	1,627.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,242.00		
4314	SOBRA CHILD 14-20 MA	474.00	476.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		950.00		
4315	SOBRA CHILD 14-20 FE	467.00	472.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		939.00		
5013	SOBRA PREG 09-13 FE	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		
	M																
5015	SOBRA PREG 14-20 FE	6.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
	M																
5017	SOBRA PREG 21-44 FE	77.00	71.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		148.00		
	M																
SUBTOTAL:	7,346.00	7,391.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,737.00		

1107	TANF EXPANDED 21-44	2.00	2.00	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	4.00	4.00	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
&	17.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.00	
8.00	
34.00	
2.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1115	TANF EXPANDED 14-20	4.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9.00		
1116	TANF EXPANDED 21-44	121.00	118.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		239.00		
1117	TANF EXPANDED 21-44	326.00	325.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		651.00		
1118	TANF EXPANDED 45-64	176.00	178.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		354.00		
1126	TANF EXPANDED 21-44	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1127	TANF EXPANDED 21-44	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		
1128	TANF EXPANDED 45-64	24.00	24.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48.00		
1129	TANF EXPANDED 65+ M	41.00	42.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.00		
	&																
2400	SSI AGED EXPANDED	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
	WI																
2420	SSI AGED EXPANDED	161.00	161.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		322.00		
	WI																
2520	SSI BLIND EXPANDED	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		
	W																
2600	SSI DISABLED EXPAND	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		
	E																
2610	SSI DISABLED EXPAND	12.00	13.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25.00		
	E																
2620	SSI DISABLED EXPAND	76.00	76.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152.00		
	E																
SUBTOTAL:	976.00	977.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,953.00		

3506	ADULT 40-100% MALE 2	1.00	1.00	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	1.00	1.00	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	5.00	4.00	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	29.00	29.00	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	30.00	29.00	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	94.00	91.00	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	83.00	84.00	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	195.00	185.00	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	1.00	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	3.00	3.00	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	1.00	1.00	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	103.00	102.00	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	92.00	93.00	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	840.00	857.00	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	439.00	450.00	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	901.00	906.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3719	ADULT <40% EXP M&F 6	1.00	1.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F 4	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,821.00	2,841.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
2.00	
9.00	
58.00	
59.00	
185.00	
167.00	
380.00	
1.00	
6.00	
2.00	
205.00	
185.00	
1,697.00	
889.00	
1,807.00	
2.00	
2.00	
4.00	
5,662.00	

ACUTE CAPITATION - AMERICAN INDIAN B - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3907	NEWLY ELIGIBLE FEMA	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		
	L																
3908	NEWLY ELIGIBLE M&F	13.00	16.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
	4																
3909	NEWLY ELIGIBLE M&F	13.00	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27.00		
	6																
3914	NEWLY ELIGIBLE MALE	5.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11.00		
3915	NEWLY ELIGIBLE FEMA	20.00	21.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.00		
	L																
3916	NEWLY ELIGIBLE MALE	135.00	133.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		268.00		
3917	NEWLY ELIGIBLE FEMA	189.00	185.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		374.00		
	L																
3918	NEWLY ELIGIBLE M&F	227.00	218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		445.00		
	4																
3919	NEWLY ELIGIBLE M&F	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		
	6																
SUBTOTAL:	604.00	595.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,199.00		

4413	SOBRA 100-133% M&F
6	159.00	160.00	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	70.00	73.00	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	61.00	63.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	290.00	296.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

319.00	
143.00	
124.00	
586.00	

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

2.00

8700	SSI DISABLED FREEDO M	6.00	6.00	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	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12.00	
4.00	
16.00	

TOTAL:	12,046.00	12,109.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,155.00		

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	171.00	171.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		342.00		
1009	TANF 65+ M & F WITH	57.00	85.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.50		
1011	TANF <1 M & F NON-ME	2,536.50	2,337.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,873.50		
1012	TANF 01-05 M & F NON	4,018.50	4,588.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,607.00		
1013	TANF 06-13 M & F NON	7,210.50	7,666.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,877.00		
1014	TANF 14-20 MALE NON-	2,137.50	2,308.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,446.00		
1015	TANF 14-20 FEMALE N	3,933.00	4,218.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,151.00		
	O																
1016	TANF 21-44 MALE NON-	14,506.50	14,763.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,269.50		
1017	TANF 21-44 FEMALE N	61,474.50	63,241.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		124,716.00		
	O																
1018	TANF 45-64 M & F NON	23,170.50	23,883.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,053.50		
1019	TANF 65+ M & F NON-M	114.00	114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228.00		
1028	TANF 45-64 M & F WIT	85.50	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		142.50		
1029	TANF 65+ M & F WITH	0.00	28.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.50		
2100	SSI AGED WITH MEDIC	3,249.00	3,306.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,555.00		
	A																
2110	SSI AGED NON-MEDICA	1,567.50	1,567.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,135.00		
	R																
2120	SSI AGED WITH QMB	16,359.00	16,615.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,974.50		
2200	SSI DISABLED WITH M	7,552.50	7,894.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,447.00		
	E																
2210	SSI DISABLED NON-ME	35,482.50	35,995.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,478.00		
	D																
2220	SSI DISABLED WITH Q	18,183.00	18,411.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,594.00		
	M																
2300	SSI BLIND WITH MEDIC	28.50	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.50		
2310	SSI BLIND NON-MEDIC	769.50	769.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,539.00		
	A																
2320	SSI BLIND WITH QMB	313.50	342.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		655.50		
4311	SOBRA CHILD <1 M & F	4,987.50	4,930.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,918.00		
4312	SOBRA CHILD 01-05 M	59,508.00	59,536.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119,044.50		
4313	SOBRA CHILD 06-13 M	91,371.00	91,969.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183,340.50		
4314	SOBRA CHILD 14-20 MA	26,248.50	26,932.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		53,181.00		
4315	SOBRA CHILD 14-20 FE	27,103.50	27,303.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,406.50		
5007	SOBRA PREG 21-44 FE	0.00	28.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.50		
	M																
5013	SOBRA PREG 09-13 FE	28.50	28.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.00		
	M																
5015	SOBRA PREG 14-20 FE	712.50	627.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,339.50		
	M																
5017	SOBRA PREG 21-44 FE	5,272.50	5,529.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,801.50		
	M																
5018	SOBRA PREG 45-64 FE	28.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.50		
	M																
SUBTOTAL:	418,180.50	425,305.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		843,486.00		

142.50

1106	TANF EXPANDED 21-44	85.50	57.00	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	85.50	85.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

171.00

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	427.50	513.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		940.50		
1109	TANF EXPANDED 65+ M	855.00	798.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,653.00		
	&																
1114	TANF EXPANDED 14-20	85.50	85.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.00		
1115	TANF EXPANDED 14-20	228.00	142.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		370.50		
1116	TANF EXPANDED 21-44	6,811.50	6,754.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,566.00		
1117	TANF EXPANDED 21-44	23,769.00	23,484.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,253.00		
1118	TANF EXPANDED 45-64	13,879.50	13,879.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,759.00		
1119	TANF EXPANDED 65+ M	114.00	114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228.00		
	&																
1126	TANF EXPANDED 21-44	142.50	142.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		285.00		
1127	TANF EXPANDED 21-44	228.00	228.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		456.00		
1128	TANF EXPANDED 45-64	1,453.50	1,453.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,907.00		
1129	TANF EXPANDED 65+ M	1,681.50	1,710.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,391.50		
	&																
2400	SSI AGED EXPANDED	285.00	285.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		570.00		
	WI																
2410	SSI AGED EXPANDED N	199.50	199.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		399.00		
	O																
2420	SSI AGED EXPANDED	10,573.50	10,858.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,432.00		
	WI																
2520	SSI BLIND EXPANDED	114.00	114.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		228.00		
	W																
2600	SSI DISABLED EXPAND	28.50	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		85.50		
	E																
2610	SSI DISABLED EXPAND	342.00	285.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		627.00		
	E																
2620	SSI DISABLED EXPAND	3,676.50	3,676.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,353.00		
	E																
SUBTOTAL:	65,065.50	64,923.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		129,988.50		

3508	ADULT 40-100% M&F 45	85.50	114.00	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	142.50	142.50	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	1,197.00	1,225.50	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	1,425.00	1,567.50	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	4,987.50	4,987.50	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	5,158.50	5,101.50	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	10,573.50	10,773.00	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	57.00	57.00	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	285.00	313.50	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	171.00	171.00	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	6,241.50	6,384.00	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	7,552.50	7,866.00	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	55,204.50	56,116.50	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	32,803.50	33,829.50	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	61,218.00	61,788.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

199.50	
285.00	
2,422.50	
2,992.50	
9,975.00	
10,260.00	
21,346.50	
114.00	
598.50	
342.00	
12,625.50	
15,418.50	
111,321.00	
66,633.00	
123,006.00	

ACUTE CAPITATION - AMERICAN INDIAN D - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	57.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.00		
3727	ADULT <40% EXP FEMA
L	28.50	28.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.00		
3728	ADULT <40% EXP M&F 4	57.00	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.00		
SUBTOTAL:	187,245.00	190,579.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		377,824.50		

3906	NEWLY ELIGIBLE MALE	28.50	28.50	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	741.00	627.00	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	997.50	1,026.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	883.50	798.00	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	1,111.50	940.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	6,099.00	6,070.50	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	10,830.00	10,630.50	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	11,656.50	11,514.00	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	171.00	142.50	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	28.50	28.50	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	28.50	57.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	32,575.50	31,863.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

57.00	
1,368.00	
2,023.50	
1,681.50	
2,052.00	
12,169.50	
21,460.50	
23,170.50	
313.50	
57.00	
85.50	
64,438.50	

4413	SOBRA 100-133% M&F
6	6,327.00	6,498.00	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	2,878.50	2,935.50	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	2,536.50	2,565.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	11,742.00	11,998.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,825.00	
5,814.00	
5,101.50	
23,740.50	

8700	SSI DISABLED FREEDO M	199.50	199.50	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	57.00	57.00	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	28.50	28.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	285.00	285.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

399.00	
114.00	
57.00	
570.00	

1,440,048.00

715,093.50	724,954.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1008	TANF 45-64 M & F WIT	6.00	6.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
1009	TANF 65+ M & F WITH	2.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1011	TANF <1 M & F NON-ME	89.00	82.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		171.00		
1012	TANF 01-05 M & F NON	141.00	161.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		302.00		
1013	TANF 06-13 M & F NON	253.00	269.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		522.00		
1014	TANF 14-20 MALE NON-	75.00	81.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		156.00		
1015	TANF 14-20 FEMALE N	138.00	148.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		286.00		
	O																
1016	TANF 21-44 MALE NON-	509.00	518.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,027.00		
1017	TANF 21-44 FEMALE N	2,157.00	2,219.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,376.00		
	O																
1018	TANF 45-64 M & F NON	813.00	838.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,651.00		
1019	TANF 65+ M & F NON-M	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
1028	TANF 45-64 M & F WIT	3.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5.00		
1029	TANF 65+ M & F WITH	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
2100	SSI AGED WITH MEDIC	114.00	116.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		230.00		
	A																
2110	SSI AGED NON-MEDICA	55.00	55.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110.00		
	R																
2120	SSI AGED WITH QMB	574.00	583.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,157.00		
2200	SSI DISABLED WITH M	265.00	277.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		542.00		
	E																
2210	SSI DISABLED NON-ME	1,245.00	1,263.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,508.00		
	D																
2220	SSI DISABLED WITH Q	638.00	646.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,284.00		
	M																
2300	SSI BLIND WITH MEDIC	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
2310	SSI BLIND NON-MEDIC	27.00	27.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54.00		
	A																
2320	SSI BLIND WITH QMB	11.00	12.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23.00		
4311	SOBRA CHILD <1 M & F	175.00	173.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		348.00		
4312	SOBRA CHILD 01-05 M	2,088.00	2,089.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,177.00		
4313	SOBRA CHILD 06-13 M	3,206.00	3,227.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,433.00		
4314	SOBRA CHILD 14-20 MA	921.00	945.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,866.00		
4315	SOBRA CHILD 14-20 FE	951.00	958.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,909.00		
5007	SOBRA PREG 21-44 FE	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
	M																
5013	SOBRA PREG 09-13 FE	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		
	M																
5015	SOBRA PREG 14-20 FE	25.00	22.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47.00		
	M																
5017	SOBRA PREG 21-44 FE	185.00	194.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		379.00		
	M																
5018	SOBRA PREG 45-64 FE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.00		
	M																
SUBTOTAL:	14,673.00	14,923.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,596.00		

5.00

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

6.00

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1108	TANF EXPANDED 45-64	15.00	18.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33.00		
1109	TANF EXPANDED 65+ M	30.00	28.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.00		
	&																
1114	TANF EXPANDED 14-20	3.00	3.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6.00		
1115	TANF EXPANDED 14-20	8.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13.00		
1116	TANF EXPANDED 21-44	239.00	237.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		476.00		
1117	TANF EXPANDED 21-44	834.00	824.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,658.00		
1118	TANF EXPANDED 45-64	487.00	487.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		974.00		
1119	TANF EXPANDED 65+ M	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
	&																
1126	TANF EXPANDED 21-44	5.00	5.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
1127	TANF EXPANDED 21-44	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00		
1128	TANF EXPANDED 45-64	51.00	51.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		102.00		
1129	TANF EXPANDED 65+ M	59.00	60.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		119.00		
	&																
2400	SSI AGED EXPANDED	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.00		
	WI																
2410	SSI AGED EXPANDED N	7.00	7.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.00		
	O																
2420	SSI AGED EXPANDED	371.00	381.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		752.00		
	WI																
2520	SSI BLIND EXPANDED	4.00	4.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8.00		
	W																
2600	SSI DISABLED EXPAND	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3.00		
	E																
2610	SSI DISABLED EXPAND	12.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.00		
	E																
2620	SSI DISABLED EXPAND	129.00	129.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		258.00		
	E																
SUBTOTAL:	2,283.00	2,278.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,561.00		

3508	ADULT 40-100% M&F 45	3.00	4.00	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	5.00	5.00	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	42.00	43.00	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	50.00	55.00	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	175.00	175.00	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	181.00	179.00	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	371.00	378.00	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	2.00	2.00	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	10.00	11.00	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	6.00	6.00	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	219.00	224.00	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	265.00	276.00	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	1,937.00	1,969.00	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	1,151.00	1,187.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3718	ADULT <40% EXP M&F
4	2,148.00	2,168.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.00	
10.00	
85.00	
105.00	
350.00	
360.00	
749.00	
4.00	
21.00	
12.00	
443.00	
541.00	
3,906.00	
2,338.00	
4,316.00	

ACUTE CAPITATION - AMERICAN INDIAN D - MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3719	ADULT <40% EXP M&F 6	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
3727	ADULT <40% EXP FEMA
L	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		
3728	ADULT <40% EXP M&F 4	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4.00		
SUBTOTAL:	6,570.00	6,687.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,257.00		

3906	NEWLY ELIGIBLE MALE	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F 4	26.00	22.00	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	35.00	36.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	31.00	28.00	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	39.00	33.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	214.00	213.00	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	380.00	373.00	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	409.00	404.00	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	6.00	5.00	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	1.00	1.00	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	1.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,143.00	1,118.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2.00	
48.00	
71.00	
59.00	
72.00	
427.00	
753.00	
813.00	
11.00	
2.00	
3.00	
2,261.00	

4413	SOBRA 100-133% M&F
6	222.00	228.00	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	101.00	103.00	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	89.00	90.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	412.00	421.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

450.00	
204.00	
179.00	
833.00	

8700	SSI DISABLED FREEDO M	7.00	7.00	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	2.00	2.00	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	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10.00	10.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14.00	
4.00	
2.00	
20.00	

TOTAL:	25,091.00	25,437.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,528.00		

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	3,960,846.26	3,897,714.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,858,560.76		
2100	SSI AGED WITH MEDIC	38,148,180.77	38,293,453.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,441,634.22		
	A																
210Z	SSI AGED WITH MEDIC	1,661,640.31	2,005,155.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,666,795.60		
	A																
2110	SSI AGED NON-MEDICA	3,979,708.32	4,055,802.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,035,511.07		
	R																
211Z	SSI AGED NON-MEDICA	97,502.69	48,461.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		145,964.44		
	R																
2120	SSI AGED WITH QMB	32,581,412.47	32,638,568.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		65,219,980.71		
212Z	SSI AGED WITH QMB P	43,668.65	23,092.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,761.50		
	P																
2200	SSI DISABLED WITH M	19,374,236.04	19,251,360.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,625,596.57		
	E																
220Z	SSI DISABLED WITH M	167,778.87	148,035.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		315,813.89		
	E																
2210	SSI DISABLED NON-ME	200,393,414.34	196,939,567.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		397,332,982.02		
	D																
221Z	SSI DISABLED NON-ME	156,152.59	196,724.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		352,877.37		
	D																
2220	SSI DISABLED WITH Q	39,839,770.07	39,004,445.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,844,215.23		
	M																
222Z	SSI DISABLED WITH Q	44,179.71	11,733.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,913.31		
	M																
2300	SSI BLIND WITH MEDIC	196,712.86	198,561.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		395,274.00		
230Z	SSI BLIND WITH MEDIC	0.00	3,620.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,620.45		
2310	SSI BLIND NON-MEDIC	1,193,137.79	1,195,821.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,388,958.89		
	A																
231Z	SSI BLIND NON-MEDIC	587.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		587.24		
	A																
2320	SSI BLIND WITH QMB	502,413.49	487,428.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		989,841.89		
SUBTOTAL:	342,341,342.47	338,399,546.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		680,740,889.16		

8700	SSI DISABLED FREEDO M	172,866.79	257,915.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	86,801.56	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	265,112.38	263,970.06	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	123,779.97	121,423.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	648,560.70	643,309.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

430,782.40	
86,801.56	
529,082.44	
245,203.62	
1,291,870.02	

682,032,759.18

342,989,903.17	339,042,856.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	705.21	711.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,416.53		
2100	SSI AGED WITH MEDIC	9,905.87	9,958.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,863.89		
	A																
210Z	SSI AGED WITH MEDIC	420.03	510.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		931.02		
	A																
2110	SSI AGED NON-MEDICA	477.19	486.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		963.37		
	R																
211Z	SSI AGED NON-MEDICA	11.60	5.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17.37		
	R																
2120	SSI AGED WITH QMB	8,695.23	8,731.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,426.44		
212Z	SSI AGED WITH QMB P	10.37	5.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.28		
	P																
2200	SSI DISABLED WITH M	4,110.57	4,142.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,253.25		
	E																
220Z	SSI DISABLED WITH M	41.78	36.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78.18		
	E																
2210	SSI DISABLED NON-ME	34,062.40	34,203.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,265.64		
	D																
221Z	SSI DISABLED NON-ME	18.19	23.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41.20		
	D																
2220	SSI DISABLED WITH Q	8,028.95	8,015.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,044.88		
	M																
222Z	SSI DISABLED WITH Q	10.10	2.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.85		
	M																
2300	SSI BLIND WITH MEDIC	39.00	40.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79.37		
230Z	SSI BLIND WITH MEDIC	0.00	1.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1.03		
2310	SSI BLIND NON-MEDIC	202.92	206.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		408.92		
	A																
231Z	SSI BLIND NON-MEDIC	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.06		
	A																
2320	SSI BLIND WITH QMB	101.00	98.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199.96		
SUBTOTAL:	66,840.47	67,179.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,020.24		

8700	SSI DISABLED FREEDO M	32.89	54.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
870Z	SSI DISABLED FREEDO
M	21.16	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	33.00	33.00	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	25.00	25.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	112.05	112.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

87.17	
21.16	
66.00	
50.00	
224.33	

TOTAL:	66,952.52	67,292.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,244.57		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	96.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		96.17		
1012	TANF 01-05 M & F NON	-125.84	-24.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-150.32		
1013	TANF 06-13 M & F NON	-752.82	-752.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,505.64		
101A	TANF < 1 M & F NON-M	0.00	-32.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-32.70		
101B	TANF 01-05 M & F NON	-85.08	-81.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-166.27		
4311	SOBRA CHILD <1 M & F	0.00	-574.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-574.93		
4312	SOBRA CHILD 01-05 M	-329.19	-98.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-427.49		
431A	SOBRA CHILD < 1 M &	0.00	-337.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-337.58		
431B	SOBRA CHILD 01-05 M	-70.70	25.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-45.19		
SUBTOTAL:	-1,267.46	-1,876.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-3,143.95		

-3,143.95

-1,267.46	-1,876.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending August 31, 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	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		
101A	TANF < 1 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
101B	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
431A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
431B	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	55,334.66	55,277.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		110,612.08		
1015	TANF 14-20 FEMALE N	2,593.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,593.76		
	O																
1017	TANF 21-44 FEMALE N	1,044.43	2,342.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,387.18		
	O																
1018	TANF 45-64 M & F NON	887.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		887.76		
101E	TANF 14-20 FEMALE N	86.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86.46		
	O																
101G	TANF 21-44 FEMALE N	0.00	3,597.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,597.80		
	O																
1020	TANF WITH QMB	0.00	1,647.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,647.48		
1028	TANF 45-64 M & F WIT	1,647.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,647.48		
210Z	SSI AGED WITH MEDIC	2,175.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,175.41		
	A																
2120	SSI AGED WITH QMB	2,455.56	4,212.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,668.18		
2200	SSI DISABLED WITH M	15,043.78	11,748.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,792.60		
	E																
2210	SSI DISABLED NON-ME	236,288.60	214,881.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		451,170.50		
	D																
221Z	SSI DISABLED NON-ME	1,340.06	2,767.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,107.33		
	D																
2220	SSI DISABLED WITH Q	79,493.24	80,130.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		159,624.10		
	M																
222Z	SSI DISABLED WITH Q	0.00	52.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.22		
	M																
4315	SOBRA CHILD 14-20 FE	768.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		768.82		
5007	SOBRA PREG 21-44 FE	2,761.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,761.10		
	M																
500G	SOBRA PREG 21-44 FE	167.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		167.34		
	M																
5010	SOBRA PREGNANT WO	1,647.48	5,888.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,536.20		
	MAN																
SUBTOTAL:	403,735.94	382,547.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		786,283.80		

1100	TANF EXPANDED FPR FI	2,593.76	2,593.76	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	1,924.40	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	19,227.78	21,821.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR
FI	6,532.68	6,532.68	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	2,593.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	2,593.76	2,593.76	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	34,430.78	34,430.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	65,378.76	72,490.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,187.52	
1,924.40	
41,049.32	
13,065.36	
2,593.76	
5,187.52	
68,861.56	
137,869.44	

3510	ADULT 40-100% FOR FI	48,374.48	50,968.24	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	1,422.38	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	1,422.38	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	167.34	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	2,593.76	2,593.76	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	333,238.78	337,753.72	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	1,171.37	1,757.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

99,342.72	
1,422.38	
1,422.38	
167.34	
5,187.52	
670,992.50	
2,928.43	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEMA	0.00	5,187.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,187.52		
	L																
3716	ADULT <40% EXP MALE	9,351.16	28,472.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,823.29		
3717	ADULT <40% EXP FEMA	5,079.71	1,188.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,268.01		
	L																
3718	ADULT <40% EXP M&F	11,603.33	10,237.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,840.81		
	4																
371E	ADULT <40% EXP FEMA	0.00	1,253.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,253.31		
	L																
371F	ADULT <40% EXP MALE	3,012.11	4,930.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,942.84		
371G	ADULT <40% EXP FEMA	5,863.61	167.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,030.95		
	L																
371H	ADULT <40% EXP M&F	83.67	1,988.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,071.77		
	4																
SUBTOTAL:	421,961.70	447,920.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		869,881.77		

3900	NEWLY ELIGIBLE FOR F	5,187.52	5,187.52	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	30,880.04	30,880.04	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	3,294.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	36,067.56	39,362.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

10,375.04	
61,760.08	
3,294.96	
75,430.08	

870Z	SSI DISABLED FREEDO M	1,594.34	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	-2,507.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-912.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,594.34	
-2,507.30	
-912.96	

1,868,552.13

926,231.00	942,321.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending August 31, 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		
1015	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	O																
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	O																
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
101E	TANF 14-20 FEMALE N	0.00	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																
101G	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	O																
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
210Z	SSI AGED WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	A																
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	E																
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	D																
221Z	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
222Z	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
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		
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																
500G	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																
5010	SOBRA PREGNANT WO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	MAN																
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	
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	
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	
1120	TANF EXPANDED FOR
FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

3510	ADULT 40-100% FOR FI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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																
371E	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																
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	0.00	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																
371H	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:	0.00	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	
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	
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	

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

0.00	
0.00	
0.00	

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 August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2120	SSI AGED WITH QMB	2,067.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,067.55		
2210	SSI DISABLED NON-ME D	0.00	-1,410.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,410.88		
5015	SOBRA PREG 14-20 FE
M	0.00	-1,460.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,460.62		
5017	SOBRA PREG 21-44 FE M	-104.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-104.31		
SUBTOTAL:	1,963.24	-2,871.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-908.26		

1116	TANF EXPANDED 21-44	-1,144.09	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	988.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-155.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-1,144.09	
988.79	
-155.30	

3716	ADULT <40% EXP MALE	-0.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-0.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-0.23

-0.23

-1,063.79

1,807.71	-2,871.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending August 31, 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		
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		
5015	SOBRA PREG 14-20 FE
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	
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	

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	
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 - DD
For The Period Ending August 31, 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	-25.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-25.74		
SUBTOTAL:	0.00	-25.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-25.74		

-25.74

0.00	-25.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - DD
For The Period Ending August 31, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1004	TANF 14-20 MALE WITH	8.26	8.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.52		
1006	TANF 21-44 MALE WITH	449.58	545.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		994.84		
1007	TANF 21-44 FEMALE WI	743.44	975.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,719.21		
1008	TANF 45-64 M & F WIT	1,662.63	2,183.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,846.59		
1009	TANF 65+ M & F WITH	920.62	1,453.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,374.58		
1010	TANF NON-MEDICARE	4,845.92	4,867.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,713.80		
1011	TANF <1 M & F NON-ME	91,976.37	89,871.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,847.88		
1012	TANF 01-05 M & F NON	163,544.91	185,858.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		349,403.47		
1013	TANF 06-13 M & F NON	318,765.16	355,758.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		674,523.51		
1014	TANF 14-20 MALE NON-	116,059.18	129,758.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		245,817.53		
1015	TANF 14-20 FEMALE N	133,881.35	147,634.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		281,515.41		
	O																
1016	TANF 21-44 MALE NON-	266,944.21	290,972.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		557,916.80		
1017	TANF 21-44 FEMALE N	880,619.48	944,561.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,825,181.41		
	O																
1018	TANF 45-64 M & F NON	231,626.07	251,992.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		483,618.97		
1019	TANF 65+ M & F NON-M	1,228.40	1,278.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,506.92		
1023	TANF 06-13 M & F WIT	7.46	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.92		
1025	TANF 14-20 FEMALE WI	7.46	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.92		
1026	TANF 21-44 MALE WITH	553.67	787.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,341.32		
1027	TANF 21-44 FEMALE WI	844.86	1,022.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,866.97		
1028	TANF 45-64 M & F WIT	979.81	1,420.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,400.73		
1029	TANF 65+ M & F WITH	752.56	973.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,725.87		
2100	SSI AGED WITH MEDIC	99,507.23	101,393.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		200,901.12		
	A																
2110	SSI AGED NON-MEDICA	72,854.03	74,598.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147,452.44		
	R																
2120	SSI AGED WITH QMB	354,793.60	356,724.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		711,517.95		
2200	SSI DISABLED WITH M	56,740.59	65,207.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121,948.54		
	E																
2210	SSI DISABLED NON-ME	597,666.78	620,412.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,218,079.07		
	D																
2220	SSI DISABLED WITH Q	250,015.02	250,322.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		500,338.00		
	M																
2300	SSI BLIND WITH MEDIC	506.84	639.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,146.58		
2310	SSI BLIND NON-MEDIC	5,319.57	5,674.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,994.53		
	A																
2320	SSI BLIND WITH QMB	2,664.77	2,669.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,334.09		
4301	SOBRA CHILD <1 M & F	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.08		
4302	SOBRA CHILD 01-05 M	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.08		
4303	SOBRA CHILD 06-13 M	29.42	29.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		58.84		
4305	SOBRA CHILD 14-20 FE	14.50	14.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29.00		
4311	SOBRA CHILD <1 M & F	208,688.99	210,039.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		418,728.81		
4312	SOBRA CHILD 01-05 M	1,316,496.60	1,323,566.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,640,063.38		

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4313	SOBRA CHILD 06-13 M	1,694,176.33	1,701,198.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,395,374.68		
4314	SOBRA CHILD 14-20 MA	532,200.55	537,631.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,069,832.01		
4315	SOBRA CHILD 14-20 FE	522,593.26	528,499.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,051,092.48		
4322	SOBRA CHILD 01-05 M	14.08	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28.16		
4323	SOBRA CHILD 06-13 M	11.17	11.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22.34		
4325	SOBRA CHILD 14-20 FE	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.04		
5007	SOBRA PREG 21-44 FE	209.96	239.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		449.72		
	M																
5008	SOBRA PREG 45-64 FE	7.46	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.92		
	M																
5013	SOBRA PREG 09-13 FE	51.34	36.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		87.76		
	M																
5015	SOBRA PREG 14-20 FE	13,873.14	13,611.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,484.48		
	M																
5017	SOBRA PREG 21-44 FE	112,849.81	117,138.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		229,988.71		
	M																
5018	SOBRA PREG 45-64 FE	510.97	557.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,068.77		
	M																
5027	SOBRA PREG 21-44 FE	231.92	250.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		482.47		
	M																
5028	SOBRA PREG 45-64 FE	44.30	58.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		103.10		
	M																
SUBTOTAL:	8,058,514.75	8,322,504.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,381,019.32		

3100	TRANSPLANT OPTION 1	0.00	4.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	4.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4.13

4.13

1106	TANF EXPANDED 21-44	1,500.43	1,529.01	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	2,628.98	2,538.26	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	10,470.08	10,414.99	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
&	7,401.12	7,645.94	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	7.46	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	14.92	14.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	1,106.48	1,034.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	6,324.72	5,941.66	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	172,724.93	173,454.22	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	487,920.83	488,381.51	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	181,190.34	182,713.92	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
&	1,080.58	1,074.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1124	TANF EXPANDED 14-20	7.04	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	7.04	7.04	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	5,175.85	5,225.63	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	10,983.65	10,859.74	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	21,091.05	21,103.47	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
&	16,492.27	16,781.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,029.44	
5,167.24	
20,885.07	
15,047.06	
7.46	
29.84	
2,141.30	
12,266.38	
346,179.15	
976,302.34	
363,904.26	
2,154.93	
7.04	
14.08	
10,401.48	
21,843.39	
42,194.52	
33,274.06	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	SSI AGED EXPANDED	2,866.12	2,927.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,793.45		
	WI																
2410	SSI AGED EXPANDED N	1,026.92	1,116.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,143.66		
	O																
2420	SSI AGED EXPANDED	238,610.26	241,015.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		479,625.36		
	WI																
2500	SSI BLIND EXPANDED	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14.08		
	W																
2510	SSI BLIND EXPANDED	37.26	40.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77.43		
	N																
2520	SSI BLIND EXPANDED	698.57	691.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,389.68		
	W																
2600	SSI DISABLED EXPAND	2,295.16	2,549.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,844.58		
	E																
2610	SSI DISABLED EXPAND	8,731.11	8,546.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,277.47		
	E																
2620	SSI DISABLED EXPAND	117,128.55	116,993.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		234,121.59		
	E																
SUBTOTAL:	1,297,521.30	1,302,615.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,600,136.34		

3504	ADULT 40-100% MALE 1	7.04	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	11.17	4.13	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	174.76	203.76	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	134.55	147.83	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	3,053.63	3,220.63	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	4,433.26	4,739.28	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	48,867.73	49,352.05	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	51,854.15	52,191.03	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	194,704.49	196,015.81	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	168,410.08	171,088.89	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	288,456.72	289,500.33	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	320.99	405.04	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	18.63	25.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3525	ADULT 40-100% FEMAL E	0.00	7.04	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	88.22	88.22	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	54.25	65.84	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	451.39	499.44	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	161.52	216.19	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	566.10	606.69	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	419.92	426.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	6,703.65	7,065.06	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	2,151.65	2,492.91	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	119,818.95	121,427.27	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	112,296.00	114,750.72	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	932,425.53	951,514.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

7.04	
15.30	
378.52	
282.38	
6,274.26	
9,172.54	
98,219.78	
104,045.18	
390,720.30	
339,498.97	
577,957.05	
726.03	
44.30	
7.04	
176.44	
120.09	
950.83	
377.71	
1,172.79	
846.88	
13,768.71	
4,644.56	
241,246.22	
227,046.72	
1,883,939.94	

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3717	ADULT <40% EXP FEMA	537,834.34	550,518.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,088,352.65		
	L																
3718	ADULT <40% EXP M&F	888,139.65	901,307.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,789,446.76		
	4																
3719	ADULT <40% EXP M&F	531.35	663.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,195.23		
	6																
3724	ADULT <40% EXP MALE	0.00	7.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7.46		
3726	ADULT <40% EXP MALE	354.92	332.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		687.88		
3727	ADULT <40% EXP FEMA	180.96	190.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		371.87		
	L																
3728	ADULT <40% EXP M&F	1,228.64	1,268.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,497.45		
	4																
3729	ADULT <40% EXP M&F	53.83	129.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		183.45		
	6																
SUBTOTAL:	3,363,908.07	3,420,474.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,784,382.33		

3904	NEWLY ELIGIBLE MALE	4.13	4.13	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	14.08	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3906	NEWLY ELIGIBLE MALE	949.84	965.18	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	596.00	603.04	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	15,158.22	15,153.63	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	16,107.34	16,983.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	33,038.34	32,318.62	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	34,322.66	33,432.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	248,387.59	249,420.23	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	342,190.75	344,411.08	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	281,795.38	281,634.60	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	1,251.48	1,399.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	35.62	28.58	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	71.66	79.12	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	191.70	180.53	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	804.20	891.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	974,918.99	977,519.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8.26	
28.16	
1,915.02	
1,199.04	
30,311.85	
33,090.96	
65,356.96	
67,755.46	
497,807.82	
686,601.83	
563,429.98	
2,650.87	
64.20	
150.78	
372.23	
1,695.40	
1,952,438.82	

4403	SOBRA 100-133% M&F
6	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4411	SOBRA 100-133% M&F
<	0.00	7.04	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	14.08	7.04	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	293,175.90	291,926.73	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	107,068.80	108,105.30	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	103,763.60	104,354.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	7.04	7.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	504,036.46	504,414.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14.08	
7.04	
21.12	
585,102.63	
215,174.10	
208,118.27	
14.08	
1,008,451.32	

4517

BC PATIENT FEMALE 2 1

83.63

83.63

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

167.26

MENTAL HEALTH CAPITATION AMOUNTS - RBHA CRISIS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4 5	834.00	860.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,694.09		
4519	BC PATIENT FEMALE 6
5	21.54	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50.54		
4617	CC PATIENT FEMALE 2 1	36.84	36.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.68		
4618	CC PATIENT FEMALE 4
5	43.08	43.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		86.16		
SUBTOTAL:	1,019.09	1,052.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,071.73		

8600	SSI BLIND FREEDOM/W O	106.02	113.48	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	7.04	7.04	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	21.96	21.96	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	17,099.84	17,341.28	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	3,233.87	3,266.61	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	5,481.01	5,596.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	25,949.74	26,346.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

219.50	
14.08	
43.92	
34,441.12	
6,500.48	
11,077.52	
52,296.62	

6012	KIDS 1-5 M & F NON-M	0.00	8.26	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-	7.04	7.04	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	21.54	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28.58	44.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8.26	
14.08	
50.54	
72.88	

S000	STATE-ONLY BHS	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	14.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

14.08

14.08

28,780,887.57

14,225,911.06	14,554,976.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending August 31, 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		
1006	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1008	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1011	TANF <1 M & F NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1012	TANF 01-05 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	O																
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	O																
1018	TANF 45-64 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1026	TANF 21-44 MALE WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1027	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1029	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC	0.00	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																
2110	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		
	R																
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	E																
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
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		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4302	SOBRA CHILD 01-05 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4305	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4311	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
5018	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
5027	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
5028	SOBRA PREG 45-64 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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

0.00

0.00

1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1124	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	
1125	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1127	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1128	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1129	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2400	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	WI																
2410	SSI AGED EXPANDED N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	O																
2420	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	WI																
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	W																
2510	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	N																
2520	SSI BLIND EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	W																
2600	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	E																
2610	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	E																
2620	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	E																
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

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	
3525	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	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F
4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3709	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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 August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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	

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	
4411	SOBRA 100-133% M&F
<	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4414	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4424	SOBRA 100-133% MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4517

BC PATIENT FEMALE 2 1

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

0.00

MENTAL HEALTH CAPITATION ENROLLMENT - RBHA CRISIS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	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		0.00		
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
4618	CC PATIENT FEMALE 4
5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

8600	SSI BLIND FREEDOM/W O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8610	SSI BLIND FREEDOM/W
O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8620	SSI BLIND FREEDOM/W O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO
M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

6012	KIDS 1-5 M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
6014	KIDS 14-19 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	

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		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	-398.00	1,557.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,159.19		
1007	TANF 21-44 FEMALE WI	2,221.64	7,423.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,644.87		
1008	TANF 45-64 M & F WIT	24,182.43	32,359.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,541.57		
1009	TANF 65+ M & F WITH	23,828.82	23,865.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,694.27		
1011	TANF <1 M & F NON-ME	1,347,974.69	2,405,965.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,753,940.22		
1012	TANF 01-05 M & F NON	532,794.91	788,914.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,321,709.47		
1013	TANF 06-13 M & F NON	1,020,964.89	1,305,806.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,326,771.23		
1014	TANF 14-20 MALE NON-	431,258.60	546,758.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		978,016.92		
1015	TANF 14-20 FEMALE N	809,590.12	1,093,711.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,903,301.77		
	O																
1016	TANF 21-44 MALE NON-	4,168,257.46	5,415,475.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,583,732.52		
1017	TANF 21-44 FEMALE N	15,544,328.69	22,324,763.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,869,092.31		
	O																
1018	TANF 45-64 M & F NON	6,183,211.43	8,122,516.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,305,727.68		
1019	TANF 65+ M & F NON-M	35,683.51	38,950.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		74,634.17		
1026	TANF 21-44 MALE WITH	640.00	672.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,312.25		
1027	TANF 21-44 FEMALE WI	2,066.26	3,186.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,253.10		
1028	TANF 45-64 M & F WIT	11,442.77	25,114.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,556.90		
1029	TANF 65+ M & F WITH	6,752.51	5,463.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,216.12		
2100	SSI AGED WITH MEDIC	396,098.54	362,362.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		758,461.48		
	A																
2110	SSI AGED NON-MEDICA	827,860.09	665,927.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,493,788.03		
	R																
2120	SSI AGED WITH QMB	1,120,737.02	1,763,392.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,884,129.05		
2200	SSI DISABLED WITH M	745,277.28	972,251.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,717,529.14		
	E																
2210	SSI DISABLED NON-ME	13,393,966.28	16,347,465.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,741,431.85		
	D																
2220	SSI DISABLED WITH Q	2,214,345.56	3,108,347.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,322,693.18		
	M																
2300	SSI BLIND WITH MEDIC	3,152.00	8,655.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,807.08		
2310	SSI BLIND NON-MEDIC	228,964.63	292,857.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		521,822.08		
	A																
2320	SSI BLIND WITH QMB	29,154.59	39,299.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		68,454.36		
4311	SOBRA CHILD <1 M & F	2,992,938.35	3,270,906.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,263,845.22		
4312	SOBRA CHILD 01-05 M	5,214,556.38	8,571,824.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,786,380.87		
4313	SOBRA CHILD 06-13 M	9,801,551.71	13,615,839.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,417,390.88		
4314	SOBRA CHILD 14-20 MA	2,931,817.75	4,368,038.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,299,856.06		
4315	SOBRA CHILD 14-20 FE	3,846,637.67	5,018,844.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,865,482.04		
5007	SOBRA PREG 21-44 FE	1,280.00	640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,920.00		
	M																
5008	SOBRA PREG 45-64 FE	167.43	732.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		900.37		
	M																
5013	SOBRA PREG 09-13 FE	421.44	5,797.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,218.73		
	M																
5015	SOBRA PREG 14-20 FE	417,105.80	453,658.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		870,764.64		
	M																
5017	SOBRA PREG 21-44 FE	2,614,236.34	3,402,391.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,016,627.40		
	M																

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	10,803.27	22,538.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,342.18		
5027	SOBRA PREG 21-44 FE
M	6.25	1,837.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,844.02		
5028	SOBRA PREG 45-64 FE M	20.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.72		
SUBTOTAL:	76,935,899.83	104,436,114.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		181,372,013.94		

1106	TANF EXPANDED 21-44	11,643.72	15,835.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	3,648.07	9,091.68	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	71,091.20	97,025.01	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
&	130,536.96	129,401.83	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	121.00	640.00	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	4,431.62	6,597.70	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	67,277.38	52,803.79	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	1,383,257.36	1,893,348.68	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	5,302,094.04	6,933,224.28	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	2,996,240.55	3,919,274.80	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
&	42,583.73	80,177.34	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	17,560.20	27,193.32	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	54,271.35	144,905.99	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	166,090.60	263,177.60	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
&	220,486.92	385,990.70	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	26,206.93	40,401.48	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	25,688.20	47,605.29	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	929,933.04	1,478,231.50	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	156.92	1,105.52	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	7,455.31	14,830.90	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	8,965.25	20,131.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	224,989.09	242,128.42	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	672,473.09	1,153,973.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	12,367,202.53	16,957,096.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

27,479.48	
12,739.75	
168,116.21	
259,938.79	
761.00	
11,029.32	
120,081.17	
3,276,606.04	
12,235,318.32	
6,915,515.35	
122,761.07	
44,753.52	
199,177.34	
429,268.20	
606,477.62	
66,608.41	
73,293.49	
2,408,164.54	
1,262.44	
22,286.21	
29,096.25	
467,117.51	
1,826,446.93	
29,324,298.96	

3506	ADULT 40-100% MALE 2	6,441.43	9,573.30	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	11,394.56	20,013.66	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	17,264.90	27,310.86	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	209,666.04	208,741.55	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	222,551.55	208,933.20	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	1,852,435.72	2,712,753.61	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	1,491,259.04	2,092,074.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

16,014.73	
31,408.22	
44,575.76	
418,407.59	
431,484.75	
4,565,189.33	
3,583,333.36	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	3,772,351.63	5,659,324.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,431,676.44		
3519	ADULT 40-100% M&F 65	5,708.88	6,455.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,164.30		
3524	ADULT 40-100% MALE 1	0.00	318.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318.69		
3528	ADULT 40-100% M&F 45	-330.49	5,168.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,838.24		
3706	ADULT <40% EXP MALE	1,134.16	1,283.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,417.93		
3707	ADULT <40% EXP FEMA	4,811.19	2,251.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,062.49		
	L																
3708	ADULT <40% EXP M&F	46,032.87	36,332.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82,364.97		
	4																
3709	ADULT <40% EXP M&F	34,546.36	44,570.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		79,117.27		
	6																
3714	ADULT <40% EXP MALE	1,085,292.29	1,667,498.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,752,791.19		
3715	ADULT <40% EXP FEMA	1,101,883.99	1,759,651.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,861,535.44		
	L																
3716	ADULT <40% EXP MALE	28,509,683.38	38,889,740.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,399,424.23		
3717	ADULT <40% EXP FEMA	15,342,951.41	22,062,344.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,405,295.82		
	L																
3718	ADULT <40% EXP M&F	26,352,944.70	36,627,378.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,980,323.31		
	4																
3719	ADULT <40% EXP M&F	9,405.55	37,852.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,257.56		
	6																
3726	ADULT <40% EXP MALE	5,420.72	10,981.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,401.99		
3727	ADULT <40% EXP FEMA	262.45	1,518.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,780.74		
	L																
3728	ADULT <40% EXP M&F	25,449.74	35,073.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,522.82		
	4																
3729	ADULT <40% EXP M&F	640.00	640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,280.00		
	6																
SUBTOTAL:	80,109,202.07	112,127,785.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		192,236,987.17		

3906	NEWLY ELIGIBLE MALE	999.35	7,283.24	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	536.01	730.59	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	92,616.49	136,292.95	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	62,821.62	97,398.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	133,382.25	159,542.38	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	190,184.93	236,172.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	1,464,039.64	2,185,575.25	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	1,961,992.22	2,538,966.83	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	3,829,570.01	4,947,995.45	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	19,338.50	26,876.19	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	577.65	2,385.70	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	2,268.23	3,289.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,758,326.90	10,342,510.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,282.59	
1,266.60	
228,909.44	
160,220.33	
292,924.63	
426,357.80	
3,649,614.89	
4,500,959.05	
8,777,565.46	
46,214.69	
2,963.35	
5,558.22	
18,100,837.05	

4412	SOBRA 100-133% M&F
1	640.00	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	801,183.21	1,168,107.14	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	288,450.68	409,252.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

640.00	
1,969,290.35	
697,703.61	

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	401,450.65	510,895.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		912,346.40		
SUBTOTAL:	1,491,724.54	2,088,255.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,579,980.36		

4518	BC PATIENT FEMALE 4 5	5,264.63	4,381.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,264.63	4,381.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,646.43

9,646.43

8700	SSI DISABLED FREEDO M	37,192.01	58,717.01	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	61,412.77	93,867.52	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	3,772.22	3,899.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	102,377.00	156,484.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

95,909.02	
155,280.29	
7,671.85	
258,861.16	

424,882,625.07

178,769,997.50	246,112,627.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	886.07	683.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,569.93		
1012	TANF 01-05 M & F NON	821.43	4,762.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,583.74		
1013	TANF 06-13 M & F NON	3,128.05	2,976.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,105.03		
1014	TANF 14-20 MALE NON-	0.00	2,304.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,304.82		
1015	TANF 14-20 FEMALE N	6,790.72	7,584.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,375.31		
	O																
1017	TANF 21-44 FEMALE N	11,689.23	22,608.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,297.41		
	O																
4311	SOBRA CHILD <1 M & F	14,320.36	61,827.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,147.56		
4312	SOBRA CHILD 01-05 M	11,537.79	10,807.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,344.95		
4313	SOBRA CHILD 06-13 M	9,382.61	11,980.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,363.44		
4314	SOBRA CHILD 14-20 MA	3,949.14	11,247.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,197.00		
4315	SOBRA CHILD 14-20 FE	1,747.46	54,724.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,471.69		
5015	SOBRA PREG 14-20 FE	16,191.70	7,700.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,891.80		
	M																
5017	SOBRA PREG 21-44 FE	103,493.71	85,950.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,444.52		
	M																
SUBTOTAL:	183,938.27	285,158.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		469,097.20		

3718

ADULT <40% EXP M&F 4

-113.30

-113.30

-113.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
-113.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

SUBTOTAL:

3916	NEWLY ELIGIBLE MALE	0.00	-28.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-28.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-28.84

-28.84

4413	SOBRA 100-133% M&F
6	14,755.26	4,166.26	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	12,548.50	1,232.66	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	1,375.67	350.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28,679.43	5,749.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

18,921.52	
13,781.16	
1,725.81	
34,428.49	

TOTAL:	212,504.40	290,879.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		503,383.55		

FEDERAL EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	3,466.55	16,847.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,314.24		
1012	TANF 01-05 M & F NON	-35,847.56	54,688.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,840.64		
1013	TANF 06-13 M & F NON	131,456.83	164,746.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		296,203.00		
1014	TANF 14-20 MALE NON-	81,818.54	96,175.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,994.45		
1015	TANF 14-20 FEMALE N	141,844.54	252,474.19	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		394,318.73		
	O																
1016	TANF 21-44 MALE NON-	0.00	92.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92.38		
1017	TANF 21-44 FEMALE N	1,308,906.52	2,009,733.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,318,639.84		
	O																
1018	TANF 45-64 M & F NON	1,526.36	19,247.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,773.84		
2100	SSI AGED WITH MEDIC	17,236.44	22,460.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,697.04		
	A																
2110	SSI AGED NON-MEDICA	1,449,858.16	1,919,819.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,369,677.55		
	R																
2120	SSI AGED WITH QMB	314.34	4,134.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,448.34		
2200	SSI DISABLED WITH M	58.65	929.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		988.41		
	E																
2210	SSI DISABLED NON-ME	14,412.47	8,784.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		23,196.74		
	D																
2220	SSI DISABLED WITH Q	0.00	1,588.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,588.86		
	M																
SUBTOTAL:	3,115,051.84	4,571,722.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,686,774.06		

1106	TANF EXPANDED 21-44	58.65	1,707.73	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	2,507.33	1,677.02	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	103.38	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
&	42.80	451.88	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	937.82	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	7,579.68	13,633.24	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	562,530.55	805,383.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,823,845.81	2,222,829.32	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	1,369,322.76	1,228,603.22	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
&	18,009.32	22,576.32	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	281.27	156.69	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	15,013.07	24,486.50	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	2,078.95	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	3,569.28	3,859.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	9.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,804,848.61	4,326,406.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,766.38	
4,184.35	
103.38	
494.68	
937.82	
21,212.92	
1,367,914.51	
4,046,675.13	
2,597,925.98	
40,585.64	
437.96	
39,499.57	
2,078.95	
7,429.16	
9.14	
8,131,255.57	

3907	NEWLY ELIGIBLE FEMA L	46.11	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	11,145.56	22,148.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	44,505.05	78,715.47	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	66,697.01	46,869.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

46.11	
33,293.70	
123,220.52	
113,566.47	

FEDERAL EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3916	NEWLY ELIGIBLE MALE	1,174,202.95	1,278,542.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,452,745.48		
3917	NEWLY ELIGIBLE FEMA L	497,537.80	689,655.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,187,193.78		
3918	NEWLY ELIGIBLE M&F
4	3,964,151.60	4,675,132.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,639,283.70		
3919	NEWLY ELIGIBLE M&F 6	581.00	8,679.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,260.05		
SUBTOTAL:	5,758,867.08	6,799,742.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,558,609.81		

28,376,639.44

12,678,767.53	15,697,871.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	370,613.70	607,732.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		978,345.94		
8040	SLMB	778.55	408.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,186.58		
8050	QI1	677.88	240.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		918.17		
SUBTOTAL:	372,070.13	608,380.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		980,450.69		

TOTAL:	372,070.13	608,380.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		980,450.69		

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	3,996.57	15,726.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,722.73		
1012	TANF 01-05 M & F NON	3,907.76	11,425.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,333.73		
1013	TANF 06-13 M & F NON	173,416.36	210,844.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		384,261.14		
1014	TANF 14-20 MALE NON-	35,995.11	64,008.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,003.41		
1015	TANF 14-20 FEMALE N	148,590.64	141,115.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		289,705.69		
	O																
1016	TANF 21-44 MALE NON-	1,441,221.73	2,231,141.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,672,363.00		
1017	TANF 21-44 FEMALE N	6,110,847.38	9,231,000.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,341,847.54		
	O																
1018	TANF 45-64 M & F NON	982,406.54	1,620,013.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,602,420.32		
1026	TANF 21-44 MALE WITH	0.00	640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		640.00		
1028	TANF 45-64 M & F WIT	1,151.36	62,867.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		64,019.00		
2100	SSI AGED WITH MEDIC	91,034.59	172,593.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		263,627.93		
	A																
2110	SSI AGED NON-MEDICA	18,610.89	58,040.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		76,651.25		
	R																
2120	SSI AGED WITH QMB	193,591.28	221,795.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		415,386.98		
2200	SSI DISABLED WITH M	233,925.65	323,624.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		557,550.61		
	E																
2210	SSI DISABLED NON-ME	3,371,406.68	4,608,112.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,979,519.51		
	D																
2220	SSI DISABLED WITH Q	424,938.49	812,173.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,237,111.65		
	M																
2300	SSI BLIND WITH MEDIC	0.00	149.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		149.83		
2310	SSI BLIND NON-MEDIC	112,461.70	111,190.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		223,652.08		
	A																
2320	SSI BLIND WITH QMB	1,244.66	96.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,341.00		
4311	SOBRA CHILD <1 M & F	4,674.29	14,371.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,046.10		
4312	SOBRA CHILD 01-05 M	372,182.57	350,582.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		722,765.33		
4313	SOBRA CHILD 06-13 M	3,772,287.24	4,496,541.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,268,828.51		
4314	SOBRA CHILD 14-20 MA	881,815.75	1,093,576.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,975,392.34		
4315	SOBRA CHILD 14-20 FE	1,467,919.03	1,812,068.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,279,987.19		
5007	SOBRA PREG 21-44 FE	0.00	82.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		82.80		
	M																
5015	SOBRA PREG 14-20 FE	40,062.17	40,087.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		80,149.18		
	M																
5017	SOBRA PREG 21-44 FE	362,082.85	327,610.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		689,693.43		
	M																
5018	SOBRA PREG 45-64 FE	0.00	308.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308.42		
	M																
SUBTOTAL:	20,249,771.29	28,031,789.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		48,281,560.70		

1107	TANF EXPANDED 21-44	0.00	1.77	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	268.24	264.71	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	31,952.00	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	1,834.25	-1,683.32	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	2,610.83	1,616.80	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	379,149.07	735,563.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1.77	
532.95	
31,952.00	
150.93	
4,227.63	
1,114,712.19	

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	891,310.21	1,525,335.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,416,646.07		
1118	TANF EXPANDED 45-64	406,041.29	559,350.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		965,391.57		
1119	TANF EXPANDED 65+ M	1,315.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,315.84		
	&																
1126	TANF EXPANDED 21-44	85.11	139.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		224.81		
1127	TANF EXPANDED 21-44	4,641.06	2,722.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,363.67		
1128	TANF EXPANDED 45-64	71,247.48	30,262.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,510.30		
1129	TANF EXPANDED 65+ M	36,247.07	141,433.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		177,680.18		
	&																
2410	SSI AGED EXPANDED N	640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		640.00		
	O																
2420	SSI AGED EXPANDED	103,368.20	78,903.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,272.06		
	WI																
2520	SSI BLIND EXPANDED	15,187.18	23,456.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,643.66		
	W																
2600	SSI DISABLED EXPAND	30,634.33	64,620.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		95,254.33		
	E																
2610	SSI DISABLED EXPAND	18,170.71	10,266.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,437.60		
	E																
2620	SSI DISABLED EXPAND	247,714.55	419,040.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		666,754.96		
	E																
SUBTOTAL:	2,210,465.42	3,623,247.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,833,712.52		

3509	ADULT 40-100% M&F 65	657.92	640.00	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	4,233.24	8,308.62	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	43,332.77	69,713.60	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	235,500.13	489,282.82	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	188,389.95	266,654.40	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	313,750.99	500,515.05	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	230.22	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	168.61	4,025.39	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	24.18	986.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	398,306.74	707,611.51	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	351,353.32	576,178.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	10,691,434.83	16,565,461.96	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	5,722,167.06	8,713,857.12	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	5,934,315.56	8,741,000.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3727	ADULT <40% EXP FEMA L	603.97	1,762.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F
4	3,829.35	7,791.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	23,888,068.62	36,654,020.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,297.92	
12,541.86	
113,046.37	
724,782.95	
455,044.35	
814,266.04	
230.22	
4,194.00	
1,011.06	
1,105,918.25	
927,532.17	
27,256,896.79	
14,436,024.18	
14,675,315.89	
2,366.02	
11,620.73	
60,542,088.80	

3906	NEWLY ELIGIBLE MALE	8,606.97	761.54	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	7,774.07	8,183.66	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	3,576.60	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	5,503.98	6,251.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,368.51	
15,957.73	
3,576.60	
11,755.92	

FFS TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3915	NEWLY ELIGIBLE FEMA	40,039.65	41,032.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		81,072.61		
	L																
3916	NEWLY ELIGIBLE MALE	384,209.84	604,491.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		988,701.57		
3917	NEWLY ELIGIBLE FEMA	216,243.58	440,811.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		657,054.73		
	L																
3918	NEWLY ELIGIBLE M&F	282,873.54	356,524.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		639,397.98		
	4																
3919	NEWLY ELIGIBLE M&F	970.42	164.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,134.90		
	6																
SUBTOTAL:	949,798.65	1,458,221.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,408,020.55		

4413	SOBRA 100-133% M&F
6	54,038.09	87,212.19	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	55,271.77	69,787.85	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	69,804.62	62,400.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	179,114.48	219,400.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

141,250.28	
125,059.62	
132,205.22	
398,515.12	

8700	SSI DISABLED FREEDO M	428.11	874.91	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	1,554.71	640.00	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	90.18	-6,888.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,073.00	-5,373.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,303.02	
2,194.71	
-6,798.45	
-3,300.72	

0.00

0.00

0.00

0.00

TOTAL:

47,479,291.46

69,981,305.51

0.00

0.00

0.00

0.00

0.00

0.00

117,460,596.97

STATE ONLY TRBHA FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	10,408.44	15,200.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		25,609.08		
1017	TANF 21-44 FEMALE N	25,776.08	72,497.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		98,273.73		
	O																
1018	TANF 45-64 M & F NON	5,829.04	11,090.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,919.73		
2210	SSI DISABLED NON-ME	56,044.75	72,148.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		128,193.42		
	D																
2220	SSI DISABLED WITH Q	2,431.00	3,112.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,543.00		
	M																
SUBTOTAL:	100,489.31	174,049.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		274,538.96		

1116	TANF EXPANDED 21-44	0.00	4,638.96	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	6,531.12	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	5,118.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,118.78	11,170.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,638.96	
6,531.12	
5,118.78	
16,288.86	

3516	ADULT 40-100% MALE 2	0.00	5,412.12	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	10,237.56	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	9,897.78	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	221,935.88	307,072.53	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	117,461.62	124,957.29	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	63,784.11	58,833.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	423,316.95	496,275.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

5,412.12	
10,237.56	
9,897.78	
529,008.41	
242,418.91	
122,617.83	
919,592.61	

3916	NEWLY ELIGIBLE MALE	4,265.65	2,559.39	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	14,103.36	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	14,876.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,265.65	31,539.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

6,825.04	
14,103.36	
14,876.52	
35,804.92	

TOTAL:	533,190.69	713,034.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,246,225.35		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending August 31, 2022		
RATE COD	E	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1016	TANF 21-44 MALE NON-	4,513.64	538.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	5,051.79		
1017	TANF 21-44 FEMALE N O	0.00	385.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	385.44		
2100	SSI AGED WITH MEDIC
A	53,351.62	62,635.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	115,987.43		
2110	SSI AGED NON-MEDICA R	180,527.01	99,463.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	279,990.05		
2120	SSI AGED WITH QMB	685.12	12,497.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,182.43		
2200	SSI DISABLED WITH M E	12,313.20	11,128.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,441.30		
2210	SSI DISABLED NON-ME
D	5,958.83	12,910.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	18,869.07		
2220	SSI DISABLED WITH Q M	9,385.95	10,702.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	20,088.31		
5017	SOBRA PREG 21-44 FE
M	2,802.70	1,919.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,722.16		
SUBTOTAL	:	269,538.07	212,179.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	481,717.98		

1128	TANF EXPANDED 45-64	68.75	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	19,179.40	1,688.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND
E	6,152.30	565.64	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	14,767.40	4,348.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	40,167.85	6,602.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

68.75	
20,867.78	
6,717.94	
19,116.18	
46,770.65	

3516	ADULT 40-100% MALE 2	0.00	93.74	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	332.11	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	168,752.94	105,566.81	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	13,140.53	72,925.65	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	234,573.19	321,531.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	416,798.77	500,117.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

93.74	
332.11	
274,319.75	
86,066.18	
556,104.88	
916,916.66	

3916	NEWLY ELIGIBLE MALE	9,530.65	36,215.54	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	18,510.66	55,500.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	28,041.31	91,715.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

45,746.19	
74,010.70	
119,756.89	

4414	SOBRA 100-133% MALE	1,961.94	133.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,961.94	133.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,095.24

2,095.24

1,567,257.42

756,507.94	810,749.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
3716	ADULT <40% EXP MALE	1,175.40	199.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,375.23		
SUBTOTAL:	1,175.40	199.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,375.23		

TOTAL:	1,175.40	199.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,375.23		

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 31, 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	2,694.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,694.93		
1015	TANF 14-20 FEMALE N	0.00	3,618.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,618.02		
	O																
1016	TANF 21-44 MALE NON-	13,703.38	22,953.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,656.90		
1017	TANF 21-44 FEMALE N	5,169.98	534.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,704.58		
	O																
5015	SOBRA PREG 14-20 FE	0.00	73.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		73.98		
	M																
5017	SOBRA PREG 21-44 FE	5,016.89	279.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,296.12		
	M																
SUBTOTAL:	23,890.25	30,154.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		54,044.53		

1117	TANF EXPANDED 21-44	64.01	-43.08	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	3,904.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	64.01	3,861.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

20.93	
3,904.15	
3,925.08	

3514	ADULT 40-100% MALE 1	0.00	1,145.27	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	160.03	955.98	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	-1,374.56	1,133.68	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	75,809.36	184,402.82	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	8,987.20	22,772.81	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	8,556.68	43,463.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	92,138.71	253,873.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,145.27	
1,116.01	
-240.88	
260,212.18	
31,760.01	
52,020.11	
346,012.70	

3916	NEWLY ELIGIBLE MALE	0.00	4,639.66	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	1,021.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	5,660.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,639.66	
1,021.11	
5,660.77	

409,643.08

116,092.97	293,550.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 31, 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	993.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		993.78		
SUBTOTAL:	0.00	993.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		993.78		

1126	TANF EXPANDED 21-44	34.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	34.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

34.57

34.57

TOTAL:	34.57	993.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,028.35		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 31, 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	10,215.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,215.38		
1017	TANF 21-44 FEMALE N	685.69	3,448.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,134.23		
	O																
2100	SSI AGED WITH MEDIC	5,273.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,273.51		
	A																
2210	SSI DISABLED NON-ME	0.00	147.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		147.05		
	D																
2220	SSI DISABLED WITH Q	0.00	20,289.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,289.95		
	M																
SUBTOTAL:	5,959.20	34,100.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		40,060.12		

3716	ADULT <40% EXP MALE	91.40	12,795.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEMA L	0.00	69.63	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	453.74	4,941.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	545.14	17,807.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

12,887.35	
69.63	
5,395.60	
18,352.58	

58,412.70

6,504.34	51,908.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
5017	SOBRA PREG 21-44 FE M	2,811.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,811.41		
SUBTOTAL:	2,811.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,811.41		

1117	TANF EXPANDED 21-44	3,549.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,549.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,549.24

3,549.24

3716	ADULT <40% EXP MALE	195.48	3,548.29	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	288.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	484.34	3,548.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

3,743.77	
288.86	
4,032.63	

TOTAL:	6,844.99	3,548.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,393.28		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	775.15	3,550.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,325.17		
2100	SSI AGED WITH MEDIC	2,866,900.75	3,332,263.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,199,164.23		
	A																
2110	SSI AGED NON-MEDICA	174,510.84	217,632.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		392,143.69		
	R																
2120	SSI AGED WITH QMB	4,369,201.05	4,783,876.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,153,077.77		
2200	SSI DISABLED WITH M	399,002.09	490,580.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		889,582.74		
	E																
2210	SSI DISABLED NON-ME	4,293,703.61	4,792,087.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,085,791.56		
	D																
2220	SSI DISABLED WITH Q	1,155,285.44	1,433,595.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,588,881.15		
	M																
2300	SSI BLIND WITH MEDIC	5,019.69	106.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,125.73		
2310	SSI BLIND NON-MEDIC	41,256.12	51,702.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,958.44		
	A																
2320	SSI BLIND WITH QMB	6,625.86	8,765.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,391.58		
SUBTOTAL:	13,312,280.60	15,114,161.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,426,442.06		

8710	SSI DISABLED FREEDO M	0.00	-10.41	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	3,856.44	4,820.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,856.44	4,810.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-10.41	
8,676.99	
8,666.58	

28,435,108.64

13,316,137.04	15,118,971.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending August 31, 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	-80.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-80.43		
2210	SSI DISABLED NON-ME
D	400.80	121.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		521.86		
SUBTOTAL:	400.80	40.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441.43		

TOTAL:	400.80	40.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		441.43		

INPATIENT DOC INMATES LTC FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
2210	SSI DISABLED NON-ME D	308.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308.20		
SUBTOTAL:	308.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		308.20		

308.20

308.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending August 31, 2022		
RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
1012	TANF 01-05 M & F NON	54,474.06	21,261.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	75,735.73		
1013	TANF 06-13 M & F NON	123,495.49	55,100.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	178,596.32		
1014	TANF 14-20 MALE NON-	16,718.45	7,135.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,853.81		
1015

2210	TANF 14-20 FEMALE N O
SSI DISABLED NON-ME	5,045.06

305,084.36	2,644.25

149,547.77	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	0.00

0.00	7,689.31

454,632.13		

2220	D
SSI DISABLED WITH Q	
397.64	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

397.64		

2310	M
SSI BLIND NON-MEDIC	
4,570.63	
343.74	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

4,914.37		

4312	A
SOBRA CHILD 01-05 M	
230,286.19	
95,772.48	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

326,058.67		
4313	SOBRA CHILD 06-13 M	476,917.86	181,750.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	658,667.89		
4314	SOBRA CHILD 14-20 MA	45,986.15	13,590.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	59,576.49		
4315	SOBRA CHILD 14-20 FE	19,320.45	4,344.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23,665.19		
SUBTOTAL:	1,282,296.34	531,491.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,813,787.55	

2610	SSI DISABLED EXPAND E	44.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	44.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

44.60

44.60

3514	ADULT 40-100% MALE 1	46.08	46.08	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	158.49	58.08	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	2,152.35	1,088.07	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	453.06	131.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,809.98	1,323.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

92.16	
216.57	
3,240.42	
584.26	
4,133.41	

3914	NEWLY ELIGIBLE MALE	0.00	28.22	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	46.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	46.08	28.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

28.22	
46.08	
74.30	

4413	SOBRA 100-133% M&F
6	79,937.07	31,315.11	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	10,630.32	3,235.13	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	3,231.22	730.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	93,798.61	35,280.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

111,252.18	
13,865.45	
3,961.33	
129,078.96	

TOTAL:	1,378,995.61	568,123.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,947,118.82		

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	36,892.97	18,815.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,708.36		
2200	SSI DISABLED WITH M	1,568.39	418.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,986.74		
	E																
2210	SSI DISABLED NON-ME	1,521,265.14	750,780.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,272,046.08		
	D																
2220	SSI DISABLED WITH Q	2,822.88	1,485.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,308.59		
	M																
2310	SSI BLIND NON-MEDIC	8,125.62	3,445.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,570.65		
	A																
SUBTOTAL:	1,570,675.00	774,945.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,345,620.42		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

2,345,620.42

TOTAL:

1,570,675.00

774,945.42

ACC REINSURANCE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1011	TANF <1 M & F NON-ME	1,847,136.01	-1,504,304.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		342,831.11		
1012	TANF 01-05 M & F NON	113,548.37	134,887.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		248,435.77		
1013	TANF 06-13 M & F NON	249,612.78	46,643.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		296,256.36		
1014	TANF 14-20 MALE NON-	255,787.79	607,830.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		863,618.06		
1015	TANF 14-20 FEMALE N	627,311.73	191,964.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		819,275.98		
	O																
1016	TANF 21-44 MALE NON-	154,614.56	221,995.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		376,610.53		
1017	TANF 21-44 FEMALE N	725,210.22	453,830.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,179,040.98		
	O																
1018	TANF 45-64 M & F NON	488,563.90	478,674.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		967,238.40		
2100	SSI AGED WITH MEDIC	63,030.34	-21,547.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		41,483.14		
	A																
2110	SSI AGED NON-MEDICA	34,885.90	43,676.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,562.31		
	R																
2200	SSI DISABLED WITH M	44,543.77	88,799.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		133,343.71		
	E																
2210	SSI DISABLED NON-ME	6,909,456.51	7,600,015.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,509,471.88		
	D																
2300	SSI BLIND WITH MEDIC	0.00	38,586.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		38,586.48		
2310	SSI BLIND NON-MEDIC	28,732.06	-11,773.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,958.75		
	A																
4311	SOBRA CHILD <1 M & F	3,881,002.94	2,405,198.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,286,201.57		
4312	SOBRA CHILD 01-05 M	509,762.18	493,739.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,003,501.34		
4313	SOBRA CHILD 06-13 M	1,721,111.87	1,575,843.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,296,954.99		
4314	SOBRA CHILD 14-20 MA	794,035.91	1,198,547.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,992,582.93		
4315	SOBRA CHILD 14-20 FE	441,167.31	471,806.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		912,974.21		
5017	SOBRA PREG 21-44 FE	10,134.16	-12,746.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-2,612.39		
	M																
SUBTOTAL:	18,899,648.31	14,501,667.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,401,316.11		

1107	TANF EXPANDED 21-44	119.15	16.39	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	44.52	4,697.10	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	137,019.94	323,363.52	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	718,569.74	-76,163.20	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	127,745.24	24,512.49	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	-77.77	48.68	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	49,397.63	74.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	218,715.73	168,629.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,251,534.18	445,178.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

135.54	
4,741.62	
460,383.46	
642,406.54	
152,257.73	
-29.09	
49,472.00	
387,345.32	
1,696,713.12	

3507	ADULT 40-100% FEMAL E	0.00	-35,136.84	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	47,173.22	129,467.85	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	20,872.12	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	282,750.28	267,408.03	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	82,878.51	154,988.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-35,136.84	
176,641.07	
20,872.12	
550,158.31	
237,867.29	

ACC REINSURANCE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	1,268,324.96	278,622.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,546,947.36		
3707	ADULT <40% EXP FEMA	0.00	-1,113.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,113.09		
	L																
3714	ADULT <40% EXP MALE	154,752.01	35,754.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		190,506.24		
3715	ADULT <40% EXP FEMA	94,524.70	90,245.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		184,769.73		
	L																
3716	ADULT <40% EXP MALE	2,229,958.09	2,053,993.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,283,951.22		
3717	ADULT <40% EXP FEMA	377,232.12	342,859.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		720,092.06		
	L																
3718	ADULT <40% EXP M&F	2,382,687.36	2,431,984.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,814,672.29		
	4																
SUBTOTAL:	6,941,153.37	5,749,074.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,690,227.76		

3908	NEWLY ELIGIBLE M&F 4	624.62	392.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	79,305.88	73,647.28	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	602.28	113.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	289,834.48	236,318.75	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	180,255.36	293,951.55	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	899,934.56	521,921.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	1,450,557.18	1,126,345.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,016.82	
152,953.16	
715.98	
526,153.23	
474,206.91	
1,421,856.48	
2,576,902.58	

4413	SOBRA 100-133% M&F
6	263,017.45	468,809.79	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	110,823.99	405,359.95	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	79,989.51	21,908.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	453,830.95	896,078.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

731,827.24	
516,183.94	
101,898.29	
1,349,909.47	

4518	BC PATIENT FEMALE 4 5	-17,280.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-17,280.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-17,280.08

-17,280.08

TOTAL:	28,979,443.91	22,718,345.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		51,697,788.96		

LONG TERM CARE REINSURANCE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	48,147.45	104,511.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		152,659.04		
2100	SSI AGED WITH MEDIC	123,512.01	85,314.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		208,826.22		
	A																
2110	SSI AGED NON-MEDICA	66,128.21	18,758.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,887.04		
	R																
2200	SSI DISABLED WITH M	339,136.02	254,700.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		593,836.18		
	E																
2210	SSI DISABLED NON-ME	5,963,284.46	7,884,544.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,847,829.24		
	D																
2310	SSI BLIND NON-MEDIC	24,080.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		24,080.83		
	A																
SUBTOTAL:	6,564,288.98	8,347,829.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,912,118.55		

8710	SSI DISABLED FREEDO M	0.00	106,162.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	106,162.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

106,162.54

106,162.54

15,018,281.09

6,564,288.98	8,453,992.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACC SMIB
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	49,689.60	56,943.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		106,633.50		
1010	TANF NON-MEDICARE	850.50	850.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,701.00		
1020	TANF WITH QMB	61,738.40	59,217.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		120,956.20		
2100	SSI AGED WITH MEDIC	133,265.20	164,781.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		298,046.40		
	A																
2110	SSI AGED NON-MEDICA	654,795.90	656,683.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,311,479.10		
	R																
2120	SSI AGED WITH QMB	7,114,160.70	7,237,119.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,351,280.60		
2200	SSI DISABLED WITH M	114,223.10	121,252.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		235,475.80		
	E																
2210	SSI DISABLED NON-ME	575,677.80	581,460.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,157,137.90		
	D																
2220	SSI DISABLED WITH Q	4,922,405.60	4,893,758.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,816,164.10		
	M																
2300	SSI BLIND WITH MEDIC	-170.10	1,530.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,360.80		
2310	SSI BLIND NON-MEDIC	5,273.10	4,252.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,525.60		
	A																
2320	SSI BLIND WITH QMB	50,306.40	49,839.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		100,145.70		
4320	SOBRA CHILD WITH Q	680.40	510.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,190.70		
	MB																
5020	SOBRA PREGNANT WO	4,932.90	5,613.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,546.20		
	MAN																
8000	SMIB ONLY NOT ELIGIB	0.00	-170.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-170.10		
8020	QMB ONLY	1,243,237.50	1,252,035.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,495,273.30		
8040	SLMB	7,733,664.80	7,797,621.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15,531,285.80		
8888	SMIB ONLY NOT ELIGIB	-13,072.50	-16,457.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-29,530.30		
9999	SMIB ONLY NOT ELIGIB	312,728.90	392,015.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		704,743.90		
SUBTOTAL:	22,964,388.20	23,258,858.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		46,223,246.20		

1100	TANF EXPANDED FPR FI	296,946.50	307,898.30	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	850.50	510.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1120	TANF EXPANDED FOR FI	1,299,954.30	1,302,978.90	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	35,626.00	35,676.00	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	1,020.60	1,020.60	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	5,858,571.20	5,925,209.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2500	SSI BLIND EXPANDED W	0.00	170.10	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	16,669.80	17,180.10	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	28,156.60	23,271.90	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	2,895,366.30	2,896,275.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	10,433,161.80	10,510,190.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

604,844.80	
1,360.80	
2,602,933.20	
71,302.00	
2,041.20	
11,783,780.40	
170.10	
33,849.90	
51,428.50	
5,791,641.80	
20,943,352.70	

3520	ADULT 40-100% FOR FI	14,928.80	18,309.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3720	AHC CARE EXPANDED FO	36,663.50	35,994.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	51,592.30	54,303.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

33,238.00	
72,658.00	
105,896.00	

3920

NEWLY ELIGIBLE FOR F

25,004.70

30,596.40

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

0.00

0.00

55,601.10

ACC SMIB
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
SUBTOTAL:	25,004.70	30,596.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		55,601.10		

8620	SSI BLIND FREEDOM/W O	680.40	510.30	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	127,665.10	124,773.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	128,345.50	125,283.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,190.70	
252,438.50	
253,629.20	

TOTAL:	33,602,492.50	33,979,232.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		67,581,725.20		

ACC HIB
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	-499.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-499.00		
1020	TANF WITH QMB	2,495.00	2,495.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,990.00		
2100	SSI AGED WITH MEDIC	1,272.00	1,272.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,544.00		
	A																
2120	SSI AGED WITH QMB	865,637.50	910,204.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,775,841.90		
2210	SSI DISABLED NON-ME	0.00	1,497.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,497.00		
	D																
2220	SSI DISABLED WITH Q	406,065.00	425,894.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		831,959.70		
	M																
2320	SSI BLIND WITH QMB	3,767.00	3,767.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,534.00		
8020	QMB ONLY	7,232.80	7,232.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,465.60		
9999	SMIB ONLY NOT ELIGIB	6,362.70	-8,237.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,874.80		
SUBTOTAL:	1,292,333.00	1,344,125.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,636,458.40		

1100	TANF EXPANDED FPR FI	499.00	499.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED
WI	6,262.00	6,262.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	6,761.00	6,761.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

998.00	
12,524.00	
13,522.00	

2,649,980.40

1,299,094.00	1,350,886.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

Q1
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
8050	QI1	3,643,897.70	3,640,493.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,284,391.40		
9999	SMIB ONLY NOT ELIGIB	78,207.20	76,295.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		154,502.70		
SUBTOTAL:	3,722,104.90	3,716,789.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,438,894.10		

TOTAL:	3,722,104.90	3,716,789.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,438,894.10		

LTC SMIB
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2100	SSI AGED WITH MEDIC	1,137,651.50	1,128,771.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,266,423.30		
	A																
2110	SSI AGED NON-MEDICA	260,528.40	263,355.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		523,883.70		
	R																
2120	SSI AGED WITH QMB	1,452,223.60	1,457,856.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,910,080.40		
2200	SSI DISABLED WITH M	429,780.90	434,913.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		864,694.30		
	E																
2210	SSI DISABLED NON-ME	6,463.80	5,953.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,417.30		
	D																
2220	SSI DISABLED WITH Q	1,343,056.80	1,341,468.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,684,525.20		
	M																
2300	SSI BLIND WITH MEDIC	3,402.00	3,402.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,804.00		
2310	SSI BLIND NON-MEDIC	170.10	170.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		340.20		
	A																
2320	SSI BLIND WITH QMB	17,010.00	17,010.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,020.00		
SUBTOTAL:	4,650,287.10	4,652,901.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,303,188.40		

8720	SSI DISABLED FREEDO M	2,211.30	2,211.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,211.30	2,211.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,422.60

4,422.60

9,307,611.00

4,652,498.40	4,655,112.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LTC HIB
For The Period Ending August 31, 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	499.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		499.00		
2120	SSI AGED WITH QMB	388,575.70	396,658.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		785,234.30		
2200	SSI DISABLED WITH M E	323.00	1,771.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,094.00		
2220	SSI DISABLED WITH Q
M	4,990.00	3,992.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,982.00		
SUBTOTAL:	393,888.70	402,920.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796,809.30		

TOTAL:	393,888.70	402,920.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		796,809.30		

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	-1,038.00	1,337.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299.38		
1007	TANF 21-44 FEMALE WI	2,112.52	7,211.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,324.40		
1008	TANF 45-64 M & F WIT	10,960.80	15,959.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,920.71		
1009	TANF 65+ M & F WITH	20,376.22	19,614.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		39,990.62		
1011	TANF <1 M & F NON-ME	898,127.92	1,030,910.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,929,038.41		
1012	TANF 01-05 M & F NON	450,642.51	665,225.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,115,868.37		
1013	TANF 06-13 M & F NON	750,214.45	959,564.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,709,779.01		
1014	TANF 14-20 MALE NON-	199,206.76	313,747.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		512,954.71		
1015	TANF 14-20 FEMALE N	450,043.99	589,401.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,039,445.96		
	O																
1016	TANF 21-44 MALE NON-	1,663,462.54	2,418,583.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,082,045.86		
1017	TANF 21-44 FEMALE N	7,451,162.54	10,032,452.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,483,614.57		
	O																
1018	TANF 45-64 M & F NON	3,929,760.76	5,581,549.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,511,310.06		
1019	TANF 65+ M & F NON-M	19,544.00	36,507.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,051.14		
1026	TANF 21-44 MALE WITH	640.00	640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,280.00		
1027	TANF 21-44 FEMALE WI	2,066.26	2,741.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,807.83		
1028	TANF 45-64 M & F WIT	8,889.46	8,607.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,496.49		
1029	TANF 65+ M & F WITH	6,599.90	5,021.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,621.38		
2100	SSI AGED WITH MEDIC	179,428.02	190,463.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		369,891.19		
	A																
2110	SSI AGED NON-MEDICA	323,695.29	450,415.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		774,110.93		
	R																
2120	SSI AGED WITH QMB	639,104.35	1,096,957.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,736,061.41		
2200	SSI DISABLED WITH M	375,923.91	446,050.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		821,974.64		
	E																
2210	SSI DISABLED NON-ME	7,118,764.14	8,882,179.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,000,944.08		
	D																
2220	SSI DISABLED WITH Q	865,080.39	1,255,972.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,121,053.03		
	M																
2300	SSI BLIND WITH MEDIC	2,289.52	8,067.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,357.06		
2310	SSI BLIND NON-MEDIC	115,572.68	156,014.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		271,587.26		
	A																
2320	SSI BLIND WITH QMB	8,731.81	22,832.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,564.03		
4311	SOBRA CHILD <1 M & F	1,385,284.36	1,966,629.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,351,913.50		
4312	SOBRA CHILD 01-05 M	3,892,410.65	5,915,007.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,807,418.42		
4313	SOBRA CHILD 06-13 M	5,985,144.89	8,973,701.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,958,845.91		
4314	SOBRA CHILD 14-20 MA	1,783,118.38	2,580,560.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,363,678.99		
4315	SOBRA CHILD 14-20 FE	2,440,689.79	3,361,490.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,802,179.83		
5007	SOBRA PREG 21-44 FE	1,280.00	640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,920.00		
	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	3,200.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,200.00		
	M																
5015	SOBRA PREG 14-20 FE	225,270.71	222,785.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		448,056.37		
	M																
5017	SOBRA PREG 21-44 FE	1,345,744.76	1,802,512.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,148,257.12		
	M																

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	7,524.00	5,770.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,294.45		
5027	SOBRA PREG 21-44 FE
M	0.00	122.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122.51		
5028	SOBRA PREG 45-64 FE M	20.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20.72		
SUBTOTAL:	42,557,851.00	59,030,449.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		101,588,300.35		

1106	TANF EXPANDED 21-44	3,061.66	5,724.17	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	744.62	5,627.21	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	47,578.32	48,661.83	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
&	79,889.66	85,348.38	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	121.00	640.00	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	3,442.00	5,760.00	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	22,591.66	25,124.80	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	770,468.90	997,172.53	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	2,994,053.76	3,852,334.56	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	2,251,265.15	2,954,995.19	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
&	24,375.16	42,967.72	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	10,275.59	12,211.05	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	16,704.41	21,953.69	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	82,754.90	127,129.41	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
&	109,055.04	198,054.93	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	22,239.42	28,232.60	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	25,412.84	46,433.81	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	588,079.70	937,367.70	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	640.00	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	4,229.72	4,037.72	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	3,640.60	12,882.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	179,649.80	164,980.08	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	265,153.12	351,682.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	7,504,787.03	9,929,962.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

8,785.83	
6,371.83	
96,240.15	
165,238.04	
761.00	
9,202.00	
47,716.46	
1,767,641.43	
6,846,388.32	
5,206,260.34	
67,342.88	
22,486.64	
38,658.10	
209,884.31	
307,109.97	
50,472.02	
71,846.65	
1,525,447.40	
640.00	
8,267.44	
16,522.85	
344,629.88	
616,835.89	
17,434,749.43	

3506	ADULT 40-100% MALE 2	418.00	2,408.09	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	3,706.39	13,319.47	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	10,743.61	19,514.28	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	74,105.62	88,958.23	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	164,501.00	147,348.44	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	807,949.93	1,188,809.37	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	875,995.66	1,033,824.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,826.09	
17,025.86	
30,257.89	
163,063.85	
311,849.44	
1,996,759.30	
1,909,820.09	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	2,562,355.47	3,656,767.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,219,123.13		
3519	ADULT 40-100% M&F 65	5,708.88	6,455.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,164.30		
3524	ADULT 40-100% MALE 1	0.00	318.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		318.69		
3528	ADULT 40-100% M&F 45	-543.25	3,553.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,009.75		
3706	ADULT <40% EXP MALE	902.07	1,244.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,147.00		
3707	ADULT <40% EXP FEMA	640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		640.00		
	L																
3708	ADULT <40% EXP M&F	24,007.82	23,611.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		47,618.96		
	4																
3709	ADULT <40% EXP M&F	12,254.84	9,711.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,966.21		
	6																
3714	ADULT <40% EXP MALE	346,491.49	415,053.69	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		761,545.18		
3715	ADULT <40% EXP FEMA	523,699.83	728,595.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,252,295.01		
	L																
3716	ADULT <40% EXP MALE	6,780,128.86	9,550,012.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,330,141.16		
3717	ADULT <40% EXP FEMA	4,542,281.76	6,546,330.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		11,088,612.57		
	L																
3718	ADULT <40% EXP M&F	12,192,873.00	16,960,065.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,152,938.50		
	4																
3719	ADULT <40% EXP M&F	9,275.69	32,994.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		42,270.18		
	6																
3726	ADULT <40% EXP MALE	-120.10	1,709.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,589.50		
3727	ADULT <40% EXP FEMA	121.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		121.00		
	L																
3728	ADULT <40% EXP M&F	13,197.70	15,972.78	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,170.48		
	4																
3729	ADULT <40% EXP M&F	640.00	640.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,280.00		
	6																
SUBTOTAL:	28,951,335.27	40,447,218.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69,398,554.14		

3906	NEWLY ELIGIBLE MALE	1,000.35	991.80	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	126.70	640.00	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	47,479.90	79,609.49	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	42,923.41	69,902.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	42,479.78	58,243.32	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	100,185.20	118,866.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	742,278.94	1,091,638.38	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	1,483,759.42	1,902,808.59	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	2,745,240.31	3,516,610.32	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	18,772.38	26,184.58	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	519.00	4.00	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	2,067.79	2,996.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	5,226,833.18	6,868,495.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

1,992.15	
766.70	
127,089.39	
112,825.91	
100,723.10	
219,051.59	
1,833,917.32	
3,386,568.01	
6,261,850.63	
44,956.96	
523.00	
5,064.39	
12,095,329.15	

4412	SOBRA 100-133% M&F
1	640.00	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	536,849.93	755,121.82	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	211,073.04	290,421.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

640.00	
1,291,971.75	
501,494.27	

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	327,697.81	385,041.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		712,738.98		
SUBTOTAL:	1,076,260.78	1,430,584.22	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,506,845.00		

4518	BC PATIENT FEMALE 4 5	4,964.00	4,359.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,964.00	4,359.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

9,323.00

9,323.00

8700	SSI DISABLED FREEDO M	19,844.50	29,472.28	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	28,380.11	28,854.81	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	3,563.41	2,389.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	51,788.02	60,716.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

49,316.78	
57,234.92	
5,952.56	
112,504.26	

203,145,605.33

85,373,819.28	117,771,786.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	28,812.35	48,232.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,044.89		
8040	SLMB	147.38	65.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		212.44		
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:	28,959.73	48,297.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,257.33		

TOTAL:	28,959.73	48,297.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,257.33		

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 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	19,860.92	9,296.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,157.33		
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	114.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		114.55		
1014	TANF 14-20 MALE NON-	0.00	824.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		824.16		
1015	TANF 14-20 FEMALE N	893.24	9.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		902.38		
	O																
1016	TANF 21-44 MALE NON-	296.53	1,633.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,929.54		
1017	TANF 21-44 FEMALE N	1,393.78	10,834.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,227.79		
	O																
1018	TANF 45-64 M & F NON	1,307.53	-2,994.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,687.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	522.55	331.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		854.07		
	A																
2110	SSI AGED NON-MEDICA	6,637.05	1,276.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,913.71		
	R																
2120	SSI AGED WITH QMB	0.00	945.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		945.53		
2200	SSI DISABLED WITH M	36.37	-1,217.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-1,180.86		
	E																
2210	SSI DISABLED NON-ME	494,484.75	40,616.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		535,101.35		
	D																
2220	SSI DISABLED WITH Q	531.58	698.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,229.58		
	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	271,461.63	20,751.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		292,212.69		
4312	SOBRA CHILD 01-05 M	4,301.04	430.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,731.13		
4313	SOBRA CHILD 06-13 M	150.76	343.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		494.33		
4314	SOBRA CHILD 14-20 MA	1,049.78	1,757.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,807.01		
4315	SOBRA CHILD 14-20 FE	830.15	98.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		928.90		
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	83.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		83.93		
	M																
5017	SOBRA PREG 21-44 FE	-3,281.68	12,916.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		9,634.39		
	M																

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 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		
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:	800,559.91	98,664.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		899,224.51		

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	
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	549.13	974.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	1,590.05	-1,517.53	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	77.99	1,259.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	116.85	190.78	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	-2,673.22	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	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	36.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-302.26	906.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,523.18	
72.52	
1,337.36	
0.00	
0.00	
0.00	
0.00	
0.00	
307.63	
0.00	
-2,673.22	
0.00	
0.00	
0.00	
0.00	
36.94	
604.41	

3506	ADULT 40-100% MALE 2	0.00	104.81	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	19.17	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	2,776.17	23,200.00	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	1,773.28	1,428.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

104.81	
0.00	
0.00	
19.17	
0.00	
25,976.17	
3,201.56	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	13,029.97	4,839.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		17,869.79		
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		
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		0.00		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3707	ADULT <40% EXP FEMA	0.00	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	0.00	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																
3709	ADULT <40% EXP M&F	160.99	348.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		509.12		
	6																
3714	ADULT <40% EXP MALE	1,193.91	36,105.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,299.19		
3715	ADULT <40% EXP FEMA	0.00	321.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		321.55		
	L																
3716	ADULT <40% EXP MALE	24,461.72	67,584.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		92,045.86		
3717	ADULT <40% EXP FEMA	2,075.34	20,782.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		22,858.23		
	L																
3718	ADULT <40% EXP M&F	172,263.35	17,677.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		189,940.55		
	4																
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	6																
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	L																
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	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:	217,734.73	172,411.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		390,146.00		

3906	NEWLY ELIGIBLE MALE	0.00	4,112.76	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	448.71	27.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	262.40	105.20	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	1,081.14	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	2,909.84	4,796.22	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	3,719.45	3,221.48	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	2,078.67	2,400.93	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	
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:	10,500.21	14,664.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

4,112.76	
0.00	
0.00	
476.35	
367.60	
1,081.14	
7,706.06	
6,940.93	
4,479.60	
0.00	
0.00	
0.00	
25,164.44	

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	136.96	88.49	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	375.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
225.45	
375.55	

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	512.51	88.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		601.00		

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

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	

1,315,740.36

1,029,005.10	286,735.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	341,603.45	559,499.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		901,103.15		
8040	SLMB	631.17	342.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		974.14		
8050	QI1	677.88	240.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		918.17		
SUBTOTAL:	342,912.50	560,082.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		902,995.46		

TOTAL:	342,912.50	560,082.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		902,995.46		

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	775.15	3,458.85	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,234.00		
2100	SSI AGED WITH MEDIC	634,264.52	620,341.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,254,606.03		
	A																
2110	SSI AGED NON-MEDICA	87,196.60	95,081.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		182,278.49		
	R																
2120	SSI AGED WITH QMB	831,496.15	789,832.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,621,328.89		
2200	SSI DISABLED WITH M	129,297.50	127,356.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		256,653.57		
	E																
2210	SSI DISABLED NON-ME	1,583,977.79	1,817,427.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,401,405.10		
	D																
2220	SSI DISABLED WITH Q	225,872.28	225,414.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		451,286.28		
	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	27,296.32	38,846.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,142.94		
	A																
2320	SSI BLIND WITH QMB	882.00	1,280.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,162.00		
SUBTOTAL:	3,521,058.31	3,719,038.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,240,097.30		

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	

7,240,097.30

3,521,058.31	3,719,038.99	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	91.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		91.17		
2100	SSI AGED WITH MEDIC	32,285.85	38,985.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		71,271.39		
	A																
2110	SSI AGED NON-MEDICA	-540.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-540.05		
	R																
2120	SSI AGED WITH QMB	254.47	4,173.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,427.92		
2200	SSI DISABLED WITH M	2,721.03	15,302.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,023.49		
	E																
2210	SSI DISABLED NON-ME	12,848.31	24,771.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37,619.89		
	D																
2220	SSI DISABLED WITH Q	-483.36	778.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		295.53		
	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	-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		
	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:	46,567.25	84,103.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,670.34		

8710	SSI DISABLED FREEDO M	0.00	-10.41	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	-10.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

-10.41	
0.00	
-10.41	

TOTAL:	46,567.25	84,092.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130,659.93		

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	640.00	219.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		859.81		
1007	TANF 21-44 FEMALE WI	109.12	211.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		320.47		
1008	TANF 45-64 M & F WIT	13,221.63	16,399.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,620.86		
1009	TANF 65+ M & F WITH	3,452.60	4,251.05	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,703.65		
1011	TANF <1 M & F NON-ME	429,985.85	1,365,721.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,795,707.24		
1012	TANF 01-05 M & F NON	82,107.53	123,688.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		205,796.23		
1013	TANF 06-13 M & F NON	270,750.44	346,127.23	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		616,877.67		
1014	TANF 14-20 MALE NON-	232,051.84	232,186.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		464,238.05		
1015	TANF 14-20 FEMALE N	358,652.89	504,300.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		862,953.43		
	O																
1016	TANF 21-44 MALE NON-	2,504,498.39	2,995,258.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,499,757.12		
1017	TANF 21-44 FEMALE N	8,088,616.34	12,281,477.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,370,093.92		
	O																
1018	TANF 45-64 M & F NON	2,252,143.14	2,543,961.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,796,104.62		
1019	TANF 65+ M & F NON-M	16,139.51	2,443.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,583.03		
1026	TANF 21-44 MALE WITH	0.00	32.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.25		
1027	TANF 21-44 FEMALE WI	0.00	445.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		445.27		
1028	TANF 45-64 M & F WIT	2,553.31	16,507.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,060.41		
1029	TANF 65+ M & F WITH	152.61	442.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		594.74		
2100	SSI AGED WITH MEDIC	216,147.97	171,568.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		387,716.22		
	A																
2110	SSI AGED NON-MEDICA	491,162.19	214,235.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		705,397.83		
	R																
2120	SSI AGED WITH QMB	481,632.67	665,489.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,147,122.11		
2200	SSI DISABLED WITH M	369,317.00	527,418.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		896,735.36		
	E																
2210	SSI DISABLED NON-ME	5,763,937.46	7,424,631.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,188,569.25		
	D																
2220	SSI DISABLED WITH Q	1,348,733.59	1,851,676.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,200,410.57		
	M																
2300	SSI BLIND WITH MEDIC	862.48	587.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,450.02		
2310	SSI BLIND NON-MEDIC	113,391.95	136,842.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		250,234.82		
	A																
2320	SSI BLIND WITH QMB	20,422.78	16,467.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		36,890.33		
4311	SOBRA CHILD <1 M & F	1,336,110.85	1,283,491.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,619,602.49		
4312	SOBRA CHILD 01-05 M	1,317,359.88	2,655,857.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,973,217.76		
4313	SOBRA CHILD 06-13 M	3,814,778.07	4,640,014.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		8,454,792.48		
4314	SOBRA CHILD 14-20 MA	1,147,614.56	1,785,720.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,933,335.03		
4315	SOBRA CHILD 14-20 FE	1,405,117.73	1,657,255.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,062,373.31		
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	167.43	732.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		900.37		
	M																
5013	SOBRA PREG 09-13 FE	421.44	2,597.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,018.73		
	M																
5015	SOBRA PREG 14-20 FE	191,751.16	230,873.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		422,624.34		
	M																
5017	SOBRA PREG 21-44 FE	1,271,773.26	1,586,962.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,858,735.89		
	M																

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5018	SOBRA PREG 45-64 FE M	3,279.27	16,768.46	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		20,047.73		
5027	SOBRA PREG 21-44 FE
M	6.25	1,715.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,721.51		
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:	33,549,063.19	45,304,581.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,853,644.92		

1106	TANF EXPANDED 21-44	8,582.06	10,111.59	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	2,903.45	3,464.47	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	23,512.88	48,363.18	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1109	TANF EXPANDED 65+ M
&	50,647.30	44,053.45	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	989.62	837.70	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	44,685.72	27,678.99	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	612,239.33	895,202.10	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	2,306,450.23	3,082,407.25	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	744,897.41	963,020.24	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
&	18,208.57	37,209.62	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	7,284.61	14,982.27	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	37,566.94	122,952.30	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	83,335.70	136,048.19	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
&	111,431.88	187,935.77	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	3,850.66	11,978.10	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	275.36	1,171.48	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	344,526.56	540,863.80	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	156.92	465.52	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	3,225.59	10,793.18	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	5,324.65	7,248.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2610	SSI DISABLED EXPAND E	45,339.29	77,148.34	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	407,283.03	802,291.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	4,862,717.76	7,026,227.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

18,693.65	
6,367.92	
71,876.06	
94,700.75	
0.00	
1,827.32	
72,364.71	
1,507,441.43	
5,388,857.48	
1,707,917.65	
55,418.19	
22,266.88	
160,519.24	
219,383.89	
299,367.65	
15,828.76	
1,446.84	
885,390.36	
622.44	
14,018.77	
12,573.40	
122,487.63	
1,209,574.10	
11,888,945.12	

3506	ADULT 40-100% MALE 2	6,023.43	7,060.40	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	7,688.17	6,694.19	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	6,521.29	7,796.58	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	135,560.42	119,764.15	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	58,050.55	61,584.76	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	1,041,709.62	1,500,744.24	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	613,490.10	1,056,821.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

13,083.83	
14,382.36	
14,317.87	
255,324.57	
119,635.31	
2,542,453.86	
1,670,311.71	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3518	ADULT 40-100% M&F 45	1,196,966.19	1,997,717.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,194,683.52		
3519	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		0.00		
3528	ADULT 40-100% M&F 45	212.76	1,615.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,828.49		
3706	ADULT <40% EXP MALE	232.09	38.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		270.93		
3707	ADULT <40% EXP FEMA	4,171.19	2,251.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,422.49		
	L																
3708	ADULT <40% EXP M&F	22,025.05	12,720.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,746.01		
	4																
3709	ADULT <40% EXP M&F	22,130.53	34,511.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		56,641.94		
	6																
3714	ADULT <40% EXP MALE	737,606.89	1,216,339.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,953,946.82		
3715	ADULT <40% EXP FEMA	578,184.16	1,030,734.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,608,918.88		
	L																
3716	ADULT <40% EXP MALE	21,705,092.80	29,237,927.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		50,943,020.56		
3717	ADULT <40% EXP FEMA	10,798,594.31	15,495,230.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,293,825.02		
	L																
3718	ADULT <40% EXP M&F	13,980,245.28	19,624,730.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		33,604,975.67		
	4																
3719	ADULT <40% EXP M&F	129.86	4,857.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,987.38		
	6																
3726	ADULT <40% EXP MALE	5,540.82	9,271.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		14,812.49		
3727	ADULT <40% EXP FEMA	141.45	1,518.29	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,659.74		
	L																
3728	ADULT <40% EXP M&F	12,252.04	19,100.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		31,352.34		
	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:	50,932,569.00	71,449,032.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		122,381,601.79		

3906	NEWLY ELIGIBLE MALE	-1.00	2,178.68	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	409.31	90.59	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3908	NEWLY ELIGIBLE M&F
4	45,136.59	56,683.46	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	19,449.50	27,468.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	90,640.07	101,193.86	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	88,918.59	117,306.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	718,850.86	1,089,140.65	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	474,513.35	632,936.76	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3918	NEWLY ELIGIBLE M&F
4	1,082,251.03	1,428,984.20	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	566.12	691.61	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	58.65	2,381.70	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	200.44	293.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	2,520,993.51	3,459,349.95	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

2,177.68	
499.90	
101,820.05	
46,918.07	
191,833.93	
206,225.07	
1,807,991.51	
1,107,450.11	
2,511,235.23	
1,257.73	
2,440.35	
493.83	
5,980,343.46	

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	264,196.32	412,896.83	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	76,969.88	118,831.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
677,093.15	
195,801.58	

ACUTE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	73,752.84	125,854.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		199,607.42		
SUBTOTAL:	414,919.04	657,583.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,072,502.15		

4518	BC PATIENT FEMALE 4 5	300.63	22.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	300.63	22.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

323.43

323.43

8700	SSI DISABLED FREEDO M	17,347.51	29,244.73	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	33,032.66	65,012.71	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	208.81	1,510.48	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	50,588.98	95,767.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

46,592.24	
98,045.37	
1,719.29	
146,356.90	

220,323,717.77

92,331,152.11	127,992,565.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 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	0.00	37.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		37.24		
1012	TANF 01-05 M & F NON	44.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		44.87		
1013	TANF 06-13 M & F NON	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1014	TANF 14-20 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1015	TANF 14-20 FEMALE N	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	O																
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
1017	TANF 21-44 FEMALE N	3,156.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,156.03		
	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	0.00	0.00	0.00		0.00		
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	0.00	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																
2110	SSI AGED NON-MEDICA	6,365.56	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,365.56		
	R																
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	E																
2210	SSI DISABLED NON-ME	16,779.93	37.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16,817.17		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
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	81.51	35.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		116.54		
4312	SOBRA CHILD 01-05 M	484.81	528.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,013.56		
4313	SOBRA CHILD 06-13 M	1,477.99	1,780.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,258.16		
4314	SOBRA CHILD 14-20 MA	35.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35.03		
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		
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 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		
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:	28,425.73	2,418.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		30,844.16		

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	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1114	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1119	TANF EXPANDED 65+ M
&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	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	
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	0.00	0.00	
2610	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND
E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

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

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3508	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	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	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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		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		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		0.00		
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3706	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3707	ADULT <40% EXP FEMA	0.00	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	0.00	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																
3709	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	6																
3714	ADULT <40% EXP MALE	0.00	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	34,216.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34,216.65		
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	7,563.07	24,905.52	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32,468.59		
	4																
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	6																
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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:	7,563.07	59,122.17	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		66,685.24		

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	
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	

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	32.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
32.21	

ACUTE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL		
4415	SOBRA 100-133% FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
SUBTOTAL:	32.21	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		32.21		

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

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	

TOTAL:	36,021.01	61,540.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		97,561.61		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 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	2,200,350.38	2,672,936.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,873,286.81		
	A																
2110	SSI AGED NON-MEDICA	87,854.29	122,550.96	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		210,405.25		
	R																
2120	SSI AGED WITH QMB	3,537,450.43	3,989,870.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,527,320.96		
2200	SSI DISABLED WITH M	266,983.56	347,922.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		614,905.68		
	E																
2210	SSI DISABLED NON-ME	2,696,877.51	2,949,889.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,646,766.57		
	D																
2220	SSI DISABLED WITH Q	929,896.52	1,207,402.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2,137,299.34		
	M																
2300	SSI BLIND WITH MEDIC	5,019.69	106.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		5,125.73		
2310	SSI BLIND NON-MEDIC	14,478.80	12,855.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,334.50		
	A																
2320	SSI BLIND WITH QMB	5,743.86	7,485.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		13,229.58		
SUBTOTAL:	9,744,655.04	11,311,019.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		21,055,674.42		

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	3,856.44	4,820.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	3,856.44	4,820.55	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
8,676.99	
8,676.99	

21,064,351.41

9,748,511.48	11,315,839.93	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 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	0.00	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																
2110	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		
	R																
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2200	SSI DISABLED WITH M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	E																
2210	SSI DISABLED NON-ME	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	D																
2220	SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	M																
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		
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		

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	

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		

QMB - FEE FOR SERVICE - IHS NON-CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	0.00	0.00	0.00	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

QMB - FEE FOR SERVICE - IHS CCA REFERRALS - EXCLUDING EMERGENCY SER
For The Period Ending August 31, 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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	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		

KidsCare - CAPITATION AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	237,194.44	224,214.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		461,409.24		
	C																
6012	KIDS 1-5 M & F NON-M	3,031,840.34	3,052,793.58	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,084,633.92		
6013	KIDS 6-13 M & F NON-	6,434,986.60	6,501,850.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,936,837.00		
6014	KIDS 14-19 MALE NON-	1,996,835.64	2,025,705.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,022,541.43		
6015	KIDS 14-19 FEMALE NO	1,958,139.80	1,983,773.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,941,913.00		
9960	KIDSCARE KICK PAYME	26,227.87	52,455.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		78,683.61		
	N																
SUBTOTAL:	13,685,224.69	13,840,793.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		27,526,018.20		

27,526,018.20

13,685,224.69	13,840,793.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

TOTAL:

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	354.74	334.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		689.60		
	C																
6012	KIDS 1-5 M & F NON-M	14,268.64	14,365.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		28,633.64		
6013	KIDS 6-13 M & F NON-	30,290.38	30,615.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60,906.13		
6014	KIDS 14-19 MALE NON-	9,383.08	9,523.39	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,906.47		
6015	KIDS 14-19 FEMALE NO	9,181.16	9,302.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		18,483.61		
9960	KIDSCARE KICK PAYME	4.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12.00		
	N																
SUBTOTAL:	63,482.00	64,149.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,631.45		

TOTAL:	63,482.00	64,149.45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		127,631.45		

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	2,505.06	2,292.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,797.30		
	C																
6012	KIDS 1-5 M & F NON-M	100,794.69	102,272.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		203,067.56		
6013	KIDS 6-13 M & F NON-	213,031.79	217,466.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		430,498.53		
6014	KIDS 14-19 MALE NON-	66,563.44	68,239.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		134,803.01		
6015	KIDS 14-19 FEMALE NO	65,119.33	66,717.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,836.48		
SUBTOTAL:	448,014.31	456,988.57	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		905,002.88		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

905,002.88

TOTAL:

448,014.31

456,988.57

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	369.00	336.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		705.00		
	C																
6012	KIDS 1-5 M & F NON-M	14,700.00	14,944.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		29,644.00		
6013	KIDS 6-13 M & F NON-	31,111.00	31,751.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		62,862.00		
6014	KIDS 14-19 MALE NON-	9,719.00	9,962.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,681.00		
6015	KIDS 14-19 FEMALE NO	9,551.00	9,783.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		19,334.00		
SUBTOTAL:	65,450.00	66,776.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,226.00		

TOTAL:	65,450.00	66,776.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		132,226.00		

KidsCare - FEE FOR SERVICE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	4,208.09	8,555.41	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		12,763.50		
	C																
6012	KIDS 1-5 M & F NON-M	51,856.10	79,595.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		131,451.34		
6013	KIDS 6-13 M & F NON-	115,869.01	183,549.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		299,418.80		
6014	KIDS 14-19 MALE NON-	104,208.27	92,518.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196,726.92		
6015	KIDS 14-19 FEMALE NO	103,837.61	128,577.66	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		232,415.27		
SUBTOTAL:	379,979.08	492,796.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		872,775.83		

0.00

0.00

0.00

0.00

0.00

0.00

0.00	0.00

0.00

0.00

872,775.83

TOTAL:

379,979.08

492,796.75

KidsCare - REINSURANCE
For The Period Ending August 31, 2022	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	0.00	35,419.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		35,419.08		
	C																
6012	KIDS 1-5 M & F NON-M	50,007.93	34,589.44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		84,597.37		
6013	KIDS 6-13 M & F NON-	208,719.93	-480,743.90	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-272,023.97		
6014	KIDS 14-19 MALE NON-	75,946.54	465,495.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		541,442.28		
6015	KIDS 14-19 FEMALE NO	180,456.21	15,635.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		196,091.55		
SUBTOTAL:	515,130.61	70,395.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		585,526.31		

TOTAL:	515,130.61	70,395.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		585,526.31		

0

0

0

00110007 DES-DD - CAP MEMBER MONTHS
For The Period Ending August 31, 2022

RJAuTEnCeO3DE0, 202DE0SCRIPTION

JULY

AUGUST  SEPTEMBER

OCTOBER	NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

1010	TANF NON-MEDICARE	695.21	701.32	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,396.53	
2100	SSI AGED WITH MEDICA	295.95	290.82	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		586.77	
2110	SSI AGED NON-MEDICAR	7.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		15.00	
2120	SSI AGED WITH QMB	464.45	465.07	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		929.52	
2200	SSI DISABLED WITH ME	2,009.45	2,021.84	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		4,031.29	
2210	SSI DISABLED NON-MED	29,533.35	29,704.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		59,237.99	
221Z	SSI DISABLED NON-MED	0.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.06	
2220	SSI DISABLED WITH QM	5,287.93	5,281.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10,569.73	
2300	SSI BLIND WITH MEDIC	26.00	26.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		52.00	
2310	SSI BLIND NON-MEDICA	172.80	175.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		347.80	
2320	SSI BLIND WITH QMB	65.00	65.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		130.00	
8700	SSI DISABLED FREEDOM	28.00	29.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		57.00	
8710	SSI DISABLED FREEDOM	8.00	8.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		16.00	
8720	SSI DISABLED FREEDOM	17.00	17.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		34.00	
SUBTOTAL:	38,610.20	38,793.49	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		77,403.69	
TOTAL:	38,610.20	38,793.49	0.00	0.0	0.00	0.0	0.00	0.00	0.00	0.0	0.00	0.00		77,403.69	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending August 31, 2022

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	425,848.04	426,868.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	852,716.32	
EPD	127,292,349.12	127,746,660.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	255,039,009.72	
TOTAL AHCCCS LTC	127,718,197.16	128,173,528.88	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	255,891,726.04	
DES/DD	215,271,706.01	210,869,327.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	426,141,033.14	
TOTAL DES LTC	215,271,706.01	210,869,327.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	426,141,033.14	
TOTAL LTC - CAP	342,989,903.17	339,042,856.01	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	682,032,759.18	

EPD/DD FEE-FOR-SERVICE	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	13,316,137.04	15,118,971.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,435,108.64	
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	13,316,137.04	15,118,971.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,435,108.64	

EPD/DD REINSURANCE - LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL AHCCCS LTC	2,774,312.66	5,265,321.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,039,634.64	
DES/DD	3,789,976.32	3,188,670.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,978,646.45	
TOTAL DES LTC	3,789,976.32	3,188,670.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,978,646.45	
TOTAL LTC - REIN	6,564,288.98	8,453,992.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	15,018,281.09	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	5,046,387.10	5,058,033.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,104,420.30	

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 August 31, 2022

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

00010306	MERCY CARE - RBHA CRISIS CAP AMOUNTS	8,578,528.64	8,783,667.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	17,362,195.84	

00010422	AZ COMPLETE HEALTH CARE - RBHA CRISIS CAP AMOUNTS	4,480,863.92	4,581,245.68	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,062,109.60	

00010497	STEWARD HEALTH CHOICE AZ - RBHA CRISIS CAP AMOUNTS	1,166,518.50	1,190,063.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,356,582.13	

00010705	HEALTH CHOICE RBHA - CAP AMOUNTS	988.79	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	988.79	

00010730	CENPATICO RBHA - CAP AMOUNTS	-457.64	-2,246.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-2,704.35	

00010789	MERCY MARICOPA RBHA - CAP AMOUNTS	625.54	-2,501.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,876.40	
			
Subtotal		
	14,227,067.75	14,550,227.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,777,295.61	

14,227,067.75	14,550,227.86	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	28,777,295.61	

GRAND TOTAL

BEHAVIORAL HEALTH EXPENDITURES BY RBHA - MEMBER MONTHS
For the Period Ending August 31, 2022

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

00010306	MERCY CARE - RBHA CRISIS CAP MEMBER MONTHS	1,218,541.00	1,247,680.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,466,221.00	
			
00010422	AZ COMPLETE HEALTH CARE - RBHA CRISIS CAP MEMBER MONTHS	600,652.00	614,108.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,214,760.00	
			
00010497	STEWARD HEALTH CHOICE AZ - RBHA CRISIS CAP MEMBER MONTHS	282,450.00	288,151.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	570,601.00	
			
00010705	HEALTH CHOICE RBHA - CAP MEMBER MONTHS	14.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	14.00	
			
00010730	CENPATICO RBHA - CAP MEMBER MONTHS	-8.17	-34.06	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-42.23	
			
00010789	MERCY MARICOPA RBHA - CAP MEMBER MONTHS	9.49	-60.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-50.81	
			
Subtotal	2,101,658.32	2,149,844.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,251,502.96	

2,101,658.32	2,149,844.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,251,502.96	

GRAND TOTAL