July 29, 2016

The Honorable Andy Biggs, President Arizona State Senate
1700 West Washington
Phoenix, AZ 85007

The Honorable David M. Gowan Sr., Speaker Arizona House of Representatives
1700 West Washington
Phoenix, AZ 85007

Douglas A. Ducey, Governor Thomas J. Betlach, Director

SUBJECT:  FY 2016 Appropriation Status Report for the Period Ended June 30, 2016

Dear President Biggs and Speaker Gowan:

Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended June 30, 2016.

Status Summary – AHCCCS is currently forecasting a FY 2016 surplus of $123.4 million Total Fund ($12.0 million General Fund) on a total FY 2016 appropriation of $9.0 billion Total Fund ($1.205 billion General Fund). AHCCCS will be utilizing surplus funding to administratively adjust other expenditures with dates of service from FY 2016. The projected surplus amounts in this report include projections of those administrative adjustments.

Other items that may impact the final reversion include:
Final tobacco revenue collections.
Final ADHS/BHS shortfall requirements which are being funded through AHCCCS tobacco funding surplus.
Potential Agency audit liabilities, which are detailed in the ASR.

Enrollment Update – June 2016 enrollment is 1,849,578 members, a 16,426 member increase over the prior month. Enrollment for July 2016 increased to 1,854,126 members, an increase of 4,548 members.

Major July changes by eligibility category include: 1931 for Families and Children/SOBRA – increase of 7,769; Supplemental Security Income – increase of 415; Prop 204 Restoration – decrease of 1,877; Adult Expansion - decrease of 3,072; Medicare Cost Sharing – increase of 835; and Federal Emergency Services – increase of 422.

Tobacco Funds Revenue Update –Tobacco tax collections through June 2016 are $14.3 million more than the originally appropriated projected flows. Against the revised appropriations, the collections   through   June  are  $0.5   million   to  the  negative.   In   April,   AHCCCS received

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

The Honorable Andy Biggs
The Honorable David M. Gowan, Sr. July 29, 2016
Page 2

approximately $98.9 million in Tobacco Litigation Settlement funding which is about $1.1 million lower than the FY16 appropriation of $100,000,000. AHCCCS will continue to monitor the tobacco funds revenue collections in the 13th month to determine the final impact on the FY 2016 appropriations.

If you have any questions about this report, please do not hesitate to call me at (602) 417-4458 or Jeffery Tegen at (602) 417-4705.

Sincerely,

Beth Kohler Deputy Director

Enclosure

cc:       The Honorable Douglas A. Ducey, Governor
The Honorable Don Shooter, Chairman, Senate Appropriations Committee The Honorable Justin Olson, Chairman, House Appropriations Committee
The Honorable Nancy Barto, Chairman, Senate Health and Human Services Committee The Honorable Heather Carter, Chairman, House Health Committee
Lorenzo Romero, Director, Governor’s Office of Strategic Planning and Budgeting Richard Stavneak, Director, Joint Legislative Budget Committee

Appropriation Status Report (ASR)
Fiscal Year 2016
Through June 30, 2016

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 2016……………………………….2 Appropriated Expenditures by Funding Source………………………………….……..3 Appropriated Revenue Received Detail Schedule………………………………………4

FOOTNOTES……………………………………………………………………………………….6 CASELOAD AND EXPENDITURES BY RATE CODE………………………………10

Appropriation Status Report
Appropriated Sources and Uses of Funds

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending June 30, 2016
SUMMARY OF APPROPRIATED EXPENDITURES

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

AHCCCS Operating Lump Sum	$	84,375,000		$	75,225,400		$	78,107,433		$	(2,882,033)		$	84,375,000		$	-	
AHCCCS Prop 204 Administration	16,294,400		14,970,800		11,200,356		3,770,444		16,294,400		-	
DES Eligibility	95,874,500		71,874,500		72,084,454		(209,954)		95,874,500		-	
DES Prop 204 Eligibility	44,358,700		41,358,700		38,269,396		3,089,304		44,358,700		-	
TOTAL ADMINISTRATION	240,902,600		203,429,400		199,661,639		3,767,761		240,902,600		-	

APPROPRIATIONS: ADMINISTRATION

Traditional Medicaid Services	3,802,161,800		3,872,135,000		3,618,658,723		253,476,277		3,710,647,220		91,514,580	
Proposition 204 Services	2,576,524,700		2,576,524,700		2,477,308,841		99,215,859		2,552,045,133		24,479,567	
ACA Adult Expansion	424,683,800		406,683,800		403,211,969		3,471,831		422,200,424		2,483,376	
Children's Rehabilitative Services	266,339,100		251,839,100		250,423,102		1,415,998		265,633,522		705,578	
KidsCare Services	6,295,200		6,295,200		2,078,334		4,216,866		2,060,240		4,234,960	
ALTCS Services	1,398,588,900		1,398,588,900		1,303,113,324		95,475,576		1,398,588,900		-	
Disproportionate Share Payments	5,087,100		5,087,100		-		5,087,100		5,087,100		-	
Rural Hospitals	22,650,000		22,650,000		21,988,610		661,390		22,650,000		-	
Voluntary Political Subdivision Programs	362,398,800		321,165,600		321,165,641		(41)		362,398,800		-	
TOTAL PROGRAMMATIC	8,864,729,400	8,860,969,400	8,397,948,544	463,020,856	8,741,311,339	123,418,061

TOTAL EXPENDITURES

$	9,105,632,000

$    9,064,398,800

$   8,597,610,183

$	466,788,617

$  8,982,213,939

$	123,418,061

ARIZONA  HEALTH  CARE  COST  CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending June 30, 2016 APPROPRIATED EXPENDITURES BY FUNDING SOURCE

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

Administrative Expenditures	
$	60,716,300	
$	51,537,900	
$	52,282,330	
(744,430)	
$	60,716,300	
$	-	
Proposition 204 - Administrative Expenditures

Programmatic Expenditures	21,604,300	20,280,700	17,013,713	3,266,987	21,604,300	-	
Traditional Medicaid Services	875,321,100	890,323,100	834,189,748	56,133,352	863,979,264	11,341,836
Proposition 204 Services	-	-	(24,183)	24,183	-	-
Children's Rehabilitative Services	76,987,200		72,487,200		72,346,915		140,285		76,691,069		296,131	
KidsCare Services	338,000		338,000		30,826		307,174		(90,208)		428,208	
ALTCS Services	162,880,800		162,880,800		162,880,752		48		162,880,800		-	
DSH and Rural Hospitals	7,314,600		7,314,600		6,378,210		936,390		7,314,600		-	
TOTAL GF EXPENDITURES	1,205,162,300		1,205,162,300		1,145,098,310		60,063,990		1,193,096,125		12,066,175	

Administrative Expenditures	
118,970,200		
95,114,000		
97,507,345		
(2,393,345)		
118,970,200		
-	
Proposition 204 - Administrative Expenditures	35,565,900		32,565,900		29,843,864		2,722,036		35,565,900		-	
Programmatic Expenditures Traditional Medicaid Services	
2,408,194,400		
2,463,023,900		
2,265,513,949		
197,509,951		
2,328,021,656		
80,172,744	
Proposition 204 Services	2,166,808,800		2,166,808,700		2,094,868,510		71,940,190		2,156,526,673		10,282,128	
ACA Adult Expansion	424,683,800		406,683,800		403,211,969		3,471,831		422,200,424		2,483,376	
Children's Rehabilitative Services	189,351,900		179,351,900		178,076,187		1,275,713		188,942,454		409,446	
KidsCare Services	5,587,200		5,602,200		2,047,508		3,554,692		1,780,447.63		3,806,752	
ALTCS Services and Nursing Facility Assessment	931,056,600		931,056,600		856,450,332		74,606,268		931,056,600		-	
DSH and Rural Hospitals	20,422,500		20,422,500		15,610,400		4,812,100		20,422,500		-	
Voluntary Political Subdivision Programs - See Note 5	246,916,600		214,658,700		214,658,659		41		246,916,600		-	
TOTAL FEDERAL EXPENDITURES	6,547,557,900		6,515,288,200		6,157,788,725		357,499,475		6,450,403,454		97,154,446	

Administrative Expenditures Proposition 204 - BNCF		
3,482,900		
3,482,900		
2,612,175		
870,725		
3,482,900		
-	
Traditional Medicaid Services Acute Care		49,879,700		49,879,700		49,879,700		-		49,879,700		-	
ALTCS Services		249,234,600		249,234,600		232,967,529		16,267,071		249,234,600		-	
TOTAL COUNTY EXPENDITURES		302,597,200		302,597,200		285,459,404		17,137,796		302,597,200		-	

Programmatic Expenditures	TOBACCO FUNDS											
Traditional Medicaid Services Acute Care - Medically Needy		34,498,500	34,498,500		34,498,500		-	34,498,500		-	
Proposition 204 Services - Emergency Health Services		18,162,200	18,162,200		18,162,200		-	18,162,200		-	
Proposition 204 Services - Proposition 204 Protection		41,492,900	41,492,900		41,492,900		-	41,492,900		-	
Proposition 204 Services - ATLSF		100,000,000	100,000,000		98,906,897		1,093,103	98,906,897		1,093,103	
TOTAL TOBACCO EXPENDITURES		194,153,600	194,153,600		193,060,497		1,093,103	193,060,497		1,093,103	
	OTHER									
Administrative Expenditures													

Programmatic Expenditures

Prescription Drug Rebate Program	563,000	448,000	402,212	45,788	563,000	- Programmatic Expenditures
Acute Care - Prescription Drug Rebate Program State Match	99,840,000	99,955,000		99,840,000		115,000	99,840,000		- Acute Care - Prescription Drug Rebate Program Federal  Authority	334,202,200	334,202,200	334,202,200			-	334,202,200		- Long Term Care - Prescription Drug Rebate Program State  Match		5,475,800	5,475,800		5,475,800			-	5,475,800		- Long Term Care - Prescription Drug Rebate Program Federal  Authority	26,574,200	26,574,200		26,574,200			-	26,574,200		- Proposition 204 Services - Hospital Assessment	250,060,800	250,060,800	223,902,516	26,158,284	236,956,463	13,104,337
Traditional Medicaid Services - TPL	194,700	194,700	482,752	(288,052)	194,700	- ALTCS Services - TPL		-		-	780,010	(780,010)		-	-
ALTCS Services - Nursing Facility Assessment	23,366,900	23,366,900	17,984,701	5,382,199	23,366,900	-
KidsCare Services Premiums	370,000	355,000	-	355,000	370,000	-
Freedom to Work Premiums	31,200	57,900	51,874	6,026	31,200	-
Voluntary Political Subdivision Programs - See Note 5	115,482,200	106,507,000	106,506,982	18	115,482,200	-
 	 	 	 	
TOTAL OTHER  EXPENDITURES	856,161,000	847,197,500	816,203,247	30,994,253	843,056,663	13,104,300

	TOTAL		

Administrative Expenditures		
240,902,600	
203,429,400		
199,661,639		
3,767,761		
240,902,600			
Acute Care		7,466,140,500	7,462,380,500		7,094,835,220		367,545,280		7,342,722,439			
Long Term Care		1,398,588,900	1,398,588,900		1,303,113,324		95,475,576		1,398,588,900			
TOTAL EXPENDITURES	$	9,105,632,000	$	9,064,398,800		$	8,597,610,183		$	466,788,617		$	8,982,213,939		$	

- 123,418,061
-
123,418,061

BUDGET

BUDGET
YTD

RECEIPTS
YTD

ARIZONA  HEALTH  CARE  COST  CONTAINMENT  SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending June 30, 2016

GENERAL FUND:

FEDERAL:

COUNTY:

TOBACCO FUNDS:

OTHER:

TOTAL REVENUE

$

9,105,632,000

$

9,064,398,800

$

8,876,270,060

Traditional Medicaid Services & Administrative	$	1,020,339,200		$	1,021,662,800		$	965,197,202	
Proposition 204 Services & Administrative	21,604,300		20,280,700		16,989,530	
KidsCare Services	338,000		338,000		30,826	
ALTCS Services	 	162,880,800 			 	162,880,800 			 	162,880,752 		
TOTAL	1,205,162,300		1,205,162,300		1,145,098,310	

Acute & Administrative	5,610,914,100		5,578,629,400		5,439,570,052	
KidsCare Services	5,587,200		5,602,200		2,967,542	
ALTCS Services	 	931,056,600 			 	931,056,600 			 	902,830,230 		
TOTAL	6,547,557,900		6,515,288,200		6,345,367,824	

Acute & Administrative	53,362,600		53,362,600		53,309,674	
ALTCS Services	 	249,234,600 			 	249,234,600 			 	249,234,600 		
TOTAL	302,597,200		302,597,200		302,544,274	

Traditional Medicaid Services	34,498,500		34,498,500		34,498,500	
Proposition 204 Services	 	159,655,100 			 	159,655,100 			 	158,561,997 		
TOTAL	194,153,600		194,153,600		193,060,497	

Administrative	563,000		448,000		402,212	
Acute Care - Prescription Drug Rebate Program	434,042,200		434,157,200		434,042,200	
Long Term Care - Prescription Drug Rebate Program	32,050,000		32,050,000		32,050,000	
Hospital Assessment	250,060,800		250,060,800		250,192,571	
ALTCS - Nursing Facility Assessment	23,366,900		23,366,900		231,353	
Acute TPL - Note 1	194,700		194,700		482,752	
LTC TPL - Note 1	-		-		780,010	
KidsCare TPL - Note 1	-		-		26,508	
Member Premiums - CHIP	370,000		355,000		303,676	
Member Premiums - Freedom to Work	31,200		57,900		51,874	
Voluntary Political Subdivision - State Match	 	115,482,200 			 	106,507,000 			 	171,635,998 		
TOTAL	856,161,000		847,197,500		890,199,154	

 	

Appropriation Status Report
Footnotes

FY 16 Total

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending June 30, 2016

Note 1:	Third Party Liability Collections: Gross Collections:	June 2016		June 2015		July 1, 2015
June 30, 2016		July 1, 2014
June 30, 2015	
	Acute	$	257,715		$	731,017		$	5,490,063		$	5,597,091	
	LTC	427,620		72,983		3,339,609		3,205,896	
	KidsCare	-		616		133,263		40,431	
	Total TPL Collections	$	685,335		$	804,616		$	8,962,935		$	8,843,418	

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets:
Acute	$	24,038		$	112,095		$	482,752		$	762,353	
LTC	75,889		15,285		780,010		725,893	
KidsCare	-		84		26,508		6,367	
Total Expenditure Offsets	$	99,927		$	127,464		$	1,289,270		$	1,494,613	

Note 2:	Authorized Positions	1,029.2	
	Actual Positions as of June 30, 2016	1,006.0	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending June 30, 2016

Note 3:	Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2015	

$	2,853,728	
	Revenues	6,301,707	
	Transfers-In	 	560,709 		
	Total Revenues	 	6,862,416 		
	Expenditures	6,741,330	
	Transfers-out	 	1,840,132 		
	Total Expenditures	 	8,581,462 		
	Ending Balance June 30, 2016	  $	1,134,682 		

Of the $1,134,682 ending balance, $739,333 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through July 2016.

Note 4:

Summary of HHS Office of Inspector General Questioned Costs.

Schedule of Outstanding Liabilities As of June 30, 2016

Description		Amount		Type	

School Based Claiming Medicaid Administrative Costs		
18,941,355		
HHS-OIG & AHCCCS Self Reported	
School Based Claiming Direct Services Costs		19,923,489		HHS-OIG	
		38,864,844			

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2016 APPROPRIATION STATUS REPORT
For the Period Ending June 30, 2016

Note 5:	Summary of Voluntary Political Subdivision Contribution Expenditures.			

As of June 30, 2016 Expenditures		
		State Match		Federal		Total	
	
DSH Voluntary	
$	12,713,241		
$	26,141,866		
$	38,855,107	
	GME Voluntary	52,396,919		111,328,965		163,725,884	
	Safety Net Care Pool	41,396,821		77,187,829		118,584,650	
	Total Voluntary Political Subdivision Program Expenditures	$	106,506,982		$	214,658,659		$	321,165,641	

Note 6:

The following is a summary of $218,889,592 Total Fund ($39,394,210 General Fund and $9,525,344 Hospital Assessment Fund) administrative adjustment transactions processed through December 2015 that either pay for or transfer expenditures with dates of service prior to June 30,  2015.
.

FY 2015 YTD June 30, 2016
State Match	Expenditure	ALTCS	Total	
Funds	Authority Funds	Fund	Fund	

Traditional Medicaid Services	$	38,289,534		$	83,762,109		$	-	$	122,051,643	
Proposition 204 Services	9,525,344		35,416,308		-	44,941,652	
ACA Adult Expansion	-		6,518,930		-	6,518,930	
KidsCare - Children Services	55,321		345,660		-	400,981	
Children's Rehabilitative Services	1,049,356		1,880,510		-	2,929,866	
Long Term Care	-		-		42,046,521	42,046,521	
Total	$	48,919,554		$	127,923,518		$	42,046,521		$	218,889,592	

Appropriation Status Report
Caseload and Expenditures by Rate Code

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending June 30, 2016

TITLE XIX TRADITIONAL

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

TOTAL

CAPITATION - ACUTE	272,366,959	276,316,415	279,166,770	275,407,979	274,717,280	321,423,200	271,362,223	272,095,883	272,355,528	270,015,053	270,948,098	274,247,052	3,330,422,439	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	6,699,728	0	0	6,699,728	
CAPITATION - LTC	182,421,827	195,322,105	184,831,914	185,793,257	198,420,332	189,544,234	185,883,929	199,185,388	186,873,769	186,800,013	200,538,826	188,415,015	2,284,030,608	
MENTAL HEALTH - CHILD	24,739,142	24,849,877	25,557,281	28,336,540	28,517,836	31,518,669	28,859,923	28,380,653	28,823,640	28,770,870	28,667,776	28,932,616	335,954,822	
MENTAL HEALTH - ADULT	11,323,471	11,730,505	12,433,438	944,236	956,134	1,949,346	771,078	766,629	757,951	734,014	728,408	748,026	43,843,237	
MENTAL HEALTH - GENERAL	15,232,013	15,779,544	16,725,109	16,942,470	17,155,946	15,591,227	13,835,480	13,755,647	13,599,949	13,170,446	13,069,860	13,421,854	178,279,545	
MENTAL HEALTH - CMDP	14,633,559	14,896,415	14,987,440	15,967,464	16,435,700	18,339,912	17,026,041	16,807,060	16,873,663	17,031,087	17,366,118	17,381,255	197,745,715	
CHILDREN'S REHAB SERVICES	3,716,383	3,722,744	3,729,851	5,297,337	5,295,399	5,319,974	5,455,020	5,450,009	5,442,457	5,445,914	5,466,226	5,482,322	59,823,638	
FEE FOR SERVICE - ACUTE	39,309,584	42,687,182	52,163,025	35,355,326	39,335,094	43,637,685	33,373,888	37,727,621	43,368,229	38,406,669	40,756,539	46,436,017	492,556,859	
FFS - PRIOR QUARTER COVERAGE	597,940	670,476	751,216	607,419	638,824	734,158	723,075	606,255	821,459	620,137	598,933	487,692	7,857,583	
EMERGENCY SERVICES - FEDERAL	4,601,455	4,572,491	5,962,347	5,124,819	4,140,929	5,688,268	4,450,762	4,173,846	8,111,942	7,930,509	5,975,873	5,358,305	66,091,546	
FFS - FAMILY PLANNING	-39	0	0	0	0	0	0	0	0	0	0	0	-39	
FFS MEDICAID IN PUBLIC SCHOOLS	676,499	194,086	533,578	397,621	384,665	756,763	450,088	606,337	811,813	473,549	833,003	1,012,823	7,130,823	
INPATIENT INMATES FFS	94,140	163,355	30,952	166,197	96,395	235,228	148,485	181,967	153,706	251,781	58,937	224,810	1,805,953	
QMB - FEE FOR SERVICE	293,437	211,412	493,735	374,616	274,232	543,181	277,299	336,648	529,055	429,691	403,369	574,477	4,741,152	
MOHAVE COUNTY INMATES FFS	0	177	0	4,575	0	9,164	0	0	170	0	0	0	14,087	
COCHISE COUNTY INMATES FFS	0	0	0	0	586	0	57	4,196	0	0	0	0	4,839	
MARICOPA CTY INMATES FFS	20,878	34,445	52,415	33,509	11,088	28,421	29,734	32,892	42,452	45,440	46,157	71,607	449,038	
PINAL COUNTY INMATES FFS	0	791	4,402	328	5,014	5,310	6,835	218	7,317	6,631	429	3,290	40,565	
YAVAPAI COUNTY INMATES FFS	0	0	0	0	0	8,608	0	21	0	0	0	0	8,630	
PIMA COUNTY INMATES FFS	339	2,845	4,099	8,752	867	3,962	-72	1,288	1,337	0	0	0	23,416	
FEE FOR SERVICE - LTC	8,618,281	9,030,245	12,244,181	8,955,714	9,411,357	11,193,029	9,149,200	9,448,572	10,992,893	9,756,948	9,853,772	11,477,770	120,131,962	
LFFS - PRIOR QUARTER COVERAGE	15,486	33,993	32,196	21,120	18,430	22,655	12,515	59,722	35,967	7,476	19,162	32,855	311,577	
LFFS MEDICAID IN PUBLIC SCHOOLS	1,303,186	520,396	1,333,715	799,779	799,536	1,430,086	941,904	1,244,422	1,542,255	972,580	1,787,026	2,099,879	14,774,764	
REINSURANCE - ACUTE	7,490,557	6,963,077	9,713,101	10,354,036	7,487,802	9,748,571	2,985,446	11,137,891	9,623,325	6,832,486	6,308,470	9,951,976	98,596,737	
REINSURANCE - LTC	4,045,763	3,839,634	5,041,535	4,350,748	5,856,334	3,769,395	3,174,328	2,438,655	2,645,182	2,385,483	3,233,613	3,874,256	44,654,925	
SMIB - ACUTE	9,829,585	10,084,385	10,344,498	10,630,380	10,758,366	10,820,128	12,607,558	12,692,750	12,667,321	12,879,077	13,418,300	12,628,953	139,361,301	
HIB - ACUTE	261,769	274,050	304,238	305,977	291,872	302,007	303,696	331,309	367,799	268,692	366,173	367,402	3,744,983	
Q1	2,399,485	1,983,017	1,927,946	1,981,086	1,974,022	1,905,403	2,072,651	2,017,375	1,458,507	2,091,077	2,388,528	2,129,003	24,328,098	
SMIB - LTC	2,846,826	2,859,916	2,858,311	2,859,099	2,866,769	2,884,480	3,334,042	3,299,110	3,341,122	3,332,189	3,318,073	3,339,312	37,139,247	
HIB - LTC	269,425	275,672	269,873	259,133	272,905	271,807	270,456	282,746	283,468	204,899	280,113	284,539	3,225,037	
	607,107,950	627,019,248	641,497,165	611,279,516	626,123,714	677,684,870	597,505,643	623,065,109	621,532,273	615,562,439	626,431,781	628,983,105	7,503,792,814	

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending June 30, 2016

TITLE XIX PROP 204

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

TOTAL

CAPITATION - ACUTE	171,977,268	169,158,780	168,592,407	201,257,676	199,521,303	235,448,237	205,650,359	205,514,246	206,407,386	206,401,578	204,392,132	206,446,032	2,380,767,405	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	1,747,009	0	0	1,747,009	
MENTAL HEALTH - CHILD	92,936	74,950	64,999	62,503	47,177	60,406	28,621	21,828	18,432	16,154	12,426	11,059	511,492	
MENTAL HEALTH - ADULT	14,130,226	13,753,412	13,745,030	1,449,862	1,458,767	2,988,321	1,363,117	1,361,161	1,369,399	1,369,591	1,360,171	1,368,877	55,717,933	
MENTAL HEALTH - GENERAL	19,007,580	18,500,700	18,489,426	26,014,924	26,174,705	26,546,243	24,458,452	24,423,355	24,571,172	24,574,631	24,405,608	24,561,816	281,728,611	
MENTAL HEALTH - CMDP	0	0	0	1,009	0	0	0	0	0	1,009	1,009	2,018	5,046	
CHILDREN'S REHAB SERVICES	13,342	14,176	13,759	16,233	15,769	17,161	18,131	18,608	20,516	21,948	22,902	23,856	216,400	
FEE FOR SERVICE - ACUTE	23,420,195	26,360,064	31,634,361	22,488,296	25,630,747	29,732,231	23,746,555	26,589,875	29,445,227	26,048,154	28,975,434	35,455,554	329,526,693	
FFS - PRIOR QUARTER COVERAGE	1,097,380	946,602	1,480,013	991,315	851,991	752,086	812,910	983,171	801,675	802,902	685,411	596,440	10,801,896	
EMERGENCY SERVICES - FEDERAL	1,615,009	1,756,056	2,298,814	2,324,017	1,395,634	1,620,895	1,262,081	1,473,419	2,518,890	2,126,391	1,989,154	1,946,065	22,326,426	
FEDERAL ESP CHRONIC SERVICES	0	0	0	0	0	0	381	0	0	0	0	0	381	
FFS MEDICAID IN PUBLIC SCHOOLS	5,786	3,204	5,139	1,380	897	4,447	3,240	3,492	2,300	533	2,956	2,801	36,176	
INPATIENT INMATES FFS	600,012	766,289	566,467	395,868	507,796	802,928	570,913	698,310	1,142,205	1,149,825	491,072	578,172	8,269,856	
MARICOPA CTY INMATES FFS	144,942	138,543	33,662	174,594	33,475	165,593	246,302	120,342	199,833	167,423	71,575	129,002	1,625,285	
YAVAPAI COUNTY INMATES FFS	306	0	166	9,252	485	161	990	243	0	0	995	2,378	14,976	
PINAL COUNTY INMATES FFS	8,167	-1,654	11,736	3,532	14,776	12,078	8,551	16,196	5,012	11,022	11,772	3,978	105,166	
PIMA COUNTY INMATES FFS	16,737	14,619	968	21,330	11,636	5,547	222	9,490	3,405	10,275	3,783	15,281	113,293	
MOHAVE COUNTY INMATES FFS	0	4,084	692	373	10,051	15,369	123	191	0	672	0	-87	31,467	
COCONINO COUNTY INMATES FFS	152	3,842	0	274	1,126	0	0	2,970	0	0	0	0	8,364	
COCHISE COUNTY INMATES FFS	0	0	0	0	480	210	2,974	0	0	609	6,844	1,019	12,136	
REINSURANCE - ACUTE	3,024,281	3,235,285	3,273,260	5,216,265	4,459,353	3,409,309	1,371,470	3,818,302	2,437,508	3,260,174	2,561,422	5,268,504	41,335,133	
SMIB - ACUTE	5,190,825	5,190,446	5,117,460	5,152,132	4,954,096	4,968,092	5,781,412	5,787,241	5,803,082	5,747,110	5,540,113	5,155,363	64,387,370	
HIB - ACUTE	8,649	8,527	5,656	8,584	4,192	4,192	4,233	4,233	6,473	3,288	4,500	4,089	66,619	
	240,353,793	239,927,923	245,334,015	265,589,419	265,094,455	306,553,506	265,331,036	270,846,673	274,752,515	273,460,298	270,539,279	281,572,219	3,199,355,131	

SUBTOTAL

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending June 30, 2016

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE
TITLE XIX ACA ADULT EXPANSION

TOTAL

CAPITATION - ACUTE	22,690,376	23,251,291	24,201,251	29,417,656	29,997,586	33,503,941	31,696,431	33,123,165	32,894,898	33,739,805	33,924,719	32,726,125	361,167,243	
CAPITATION - RURAL HOSPITAL	0	0	0	0	0	0	0	0	0	3,959,253	0	0	3,959,253	
MENTAL HEALTH - CHILD	0	0	0	41	0	0	41	124	124	124	166	124	746	
MENTAL HEALTH - ADULT	2,206,578	2,297,715	2,413,383	228,016	237,878	360,470	247,498	259,095	259,847	268,107	267,706	259,139	9,305,430	
MENTAL HEALTH - GENERAL	2,968,226	3,090,821	3,246,414	4,091,302	4,268,263	4,542,373	4,440,857	4,648,946	4,662,441	4,810,655	4,803,454	4,649,740	50,223,492	
CHILDREN'S REHAB SERVICES	417	417	417	0	0	0	0	0	0	477	1,431	1,431	4,591	
FEE FOR SERVICE - ACUTE	1,757,826	2,095,785	2,416,332	1,869,494	1,862,135	2,333,128	1,787,248	1,841,089	2,310,528	2,157,616	2,292,115	2,415,369	25,138,666	
FFS - PRIOR QUARTER COVERAGE	160,594	215,500	316,274	262,679	334,688	251,090	169,817	161,614	277,124	236,881	182,560	168,329	2,737,150	
EMERGENCY SERVICES - FEDERAL	1,701,575	1,999,988	3,176,831	2,397,434	1,935,178	2,586,750	2,498,424	2,253,745	3,885,436	3,407,174	3,539,590	3,192,996	32,575,121	
FEDERAL ESP CHRONIC SERVICES	0	0	0	0	0	0	0	0	341	0	0	0	341	
FFS MEDICAID IN PUBLIC SCHOOLS	0	0	0	0	0	0	0	64	205	94	143	429	936	
INPATIENT INMATES FFS	6,351	35,816	34,047	9,398	35,244	52,674	13,907	2,877	44,673	50,234	27,072	7,575	319,869	
MARICOPA CTY INMATES FFS	15,154	0	0	149	0	0	0	1,344	0	0	0	223	16,869	
PINAL COUNTY INMATES FFS	0	0	0	0	0	0	0	0	0	0	0	10	10	
REINSURANCE - ACUTE	276,372	479,010	344,794	397,029	359,861	225,309	150,630	615,514	442,999	406,924	410,947	762,143	4,871,532	
SMIB - ACUTE	1,469	734	839	629	839	944	1,847	1,949	1,583	4,287	1,534	974	17,630	
SUBTOTAL TOTAL TITLE XIX	31,784,937	33,467,076	36,150,580	38,673,829	39,031,673	43,856,679	41,006,701	42,909,526	44,780,200	49,041,630	45,451,437	44,184,609	490,338,877	
	879,246,680	900,414,248	922,981,760	915,542,763	930,249,842	1,028,095,055	903,843,380	936,821,309	941,064,989	938,064,366	942,422,498	954,739,933	11,193,486,822	

TITLE XXI KIDSCARE

KidsCare - CAPITATION	183,782	170,409	173,186	164,735	157,227	237,286	145,036	134,596	138,961	125,403	119,710	113,266	1,863,597	
KidsCare - FEE FOR SERVICE	-819	774	436	1,805	404	335	15	140	230	117	206	253	3,896	
KidsCare - MENTAL HEALTH	37,408	35,365	34,530	36,831	35,192	42,452	32,067	30,376	29,528	27,613	25,520	24,336	391,218	
KidsCare - REINSURANCE	162	30,495	70,989	57,122	103,826	25,397	86	25,622	104,594	52,989	38,285	35	509,602	

220,533	237,043	279,141	260,493	296,650	305,470	177,205	190,734	273,311	206,122	183,721	137,890	2,768,313	

TOTAL TITLE XXI

879,467,213	900,651,004	923,260,901	915,803,257	930,546,492	1,028,400,525	904,020,585	937,012,042	941,338,300	938,270,489	942,606,218	954,877,823	11,196,254,849	

GRAND TOTAL

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	487.67	0.00	0.00	-487.67		0.00		
1003	TANF 06-13 M & F WIT	113.17	113.17	113.17	114.37	114.37	156.60	114.91	114.91	114.91	114.91	114.91	0.00		1,299.40		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	162.83	0.00	0.00	0.00	0.00	0.00	159.03	330.49		652.35		
1005	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,279.22	3,797.31		6,076.53		
1006	TANF 21-44 MALE WITH	91,470.48	100,935.93	114,056.53	29,730.44	30,795.93	37,326.41	28,770.18	23,811.49	30,012.38	35,086.14	44,449.20	47,224.52		613,669.63		
1007	TANF 21-44 FEMALE WI	262,969.81	321,024.00	366,691.13	93,778.32	95,564.51	105,731.27	102,211.44	89,493.44	79,924.83	79,478.28	87,686.17	102,575.44		1,787,128.64		
1008	TANF 45-64 M & F WIT	456,857.48	533,329.59	618,899.14	153,616.98	162,064.99	169,735.99	168,805.46	161,844.72	155,323.73	151,749.02	148,145.71	150,437.15		3,030,809.96		
1009	TANF 65+ M & F WITH	130,859.20	158,119.22	182,105.63	43,807.61	41,203.16	47,386.45	36,764.90	41,202.65	43,510.83	40,821.96	41,417.70	49,271.56		856,470.87		
100F	TANF 21-44 MALE WITH	3,124.94	3,371.26	1,066.32	1,235.50	433.09	661.05	235.42	100.66	328.78	165.42	865.10	620.86		12,208.40		
100G	TANF 21-44 FEMALE WI	6,088.86	5,158.50	4,029.73	604.18	1,064.56	319.24	830.22	62.06	2,184.26	757.66	1,732.51	1,036.61		23,868.39		
100H	TANF 44-64 M & F WIT	43,752.90	40,165.14	12,382.66	7,340.32	868.81	2,130.60	4,966.65	5,607.20	832.65	4,838.30	8,883.50	4,103.63		135,872.36		
100J	TANF 65+ M & F WITH	30,736.25	17,071.36	1,805.26	3,147.18	0.00	462.01	329.45	0.00	1,090.86	333.72	2,333.35	4,930.75		62,240.19		
1011	TANF <1 M & F NON-ME	7,317,911.15	7,330,064.00	6,810,085.94	6,752,430.01	6,885,407.96	8,489,462.43	6,705,198.41	6,704,299.71	6,553,485.55	6,305,585.56	6,131,986.63	6,108,056.34		82,093,973.69		
1012	TANF 01-05 M & F NON	5,120,069.24	4,255,241.15	3,820,804.71	3,463,337.50	3,013,110.39	5,011,473.07	2,389,877.98	2,101,396.67	1,919,713.70	1,863,050.49	1,855,043.13	2,057,938.54		36,871,056.57		
1013	TANF 06-13 M & F NON	8,517,151.93	7,122,208.02	6,407,880.79	5,781,174.88	4,987,581.30	8,075,406.66	3,758,665.88	3,262,379.37	2,991,241.44	2,841,696.96	2,778,595.44	3,105,990.20		59,629,972.87		
1014	TANF 14-20 MALE NON-	2,727,086.79	2,467,883.88	2,310,485.87	2,118,291.66	1,897,764.46	2,755,592.87	1,558,570.22	1,423,173.32	1,346,796.28	1,276,043.17	1,237,648.44	1,360,128.45		22,479,465.41		
1015	TANF 14-20 FEMALE N	5,165,143.02	4,749,211.72	4,482,122.34	3,898,517.39	3,521,357.35	5,143,183.63	3,078,652.35	2,819,018.06	2,693,953.54	2,580,039.52	2,564,604.80	2,745,510.73		43,441,314.45		
1016	TANF 21-44 MALE NON-	5,413,848.55	5,881,009.18	6,413,970.06	4,199,543.45	4,283,530.08	5,063,491.42	4,343,235.61	4,295,113.41	4,248,867.60	4,065,817.03	4,100,111.58	4,345,866.65		56,654,404.62		
1017	TANF 21-44 FEMALE N O	26,519,446.98	27,563,602.69	29,211,296.32	21,814,659.48	21,700,333.91	26,938,380.02	21,958,442.61	21,443,536.77	20,946,382.78	20,006,126.10	19,892,785.59	20,783,680.63		278,778,673.88		
1018	TANF 45-64 M & F NON	11,340,403.80	12,200,886.15	13,314,078.59	8,505,687.29	8,526,844.27	10,220,186.73	8,658,377.98	8,604,601.21	8,644,283.41	8,254,486.63	8,247,591.63	8,725,946.38		115,243,374.07		
1019	TANF 65+ M & F NON-M	50,940.78	55,345.09	63,094.36	35,864.95	34,947.04	41,877.20	36,723.84	34,137.90	33,205.56	31,820.13	31,061.59	34,141.13		483,159.57		
101A	TANF < 1 M & F NON-M	1,483,647.90	1,229,135.61	596,433.59	1,591,704.20	1,242,886.90	1,748,319.94	1,410,545.03	786,166.24	1,022,789.79	985,281.94	1,122,710.80	1,078,852.88		14,298,474.82		
101B	TANF 01-05 M & F NON	18,930.19	10,452.99	13,969.51	21,291.05	8,127.92	12,666.37	13,738.01	17,334.97	9,571.54	16,423.43	36,404.13	44,397.77		223,307.88		
101C	TANF 06-13 M & F NON	13,827.52	10,991.93	10,596.95	24,089.70	7,386.13	8,920.56	11,015.60	5,102.34	10,341.26	21,348.95	62,709.48	45,916.69		232,247.11		
101D	TANF 14-20 MALE NON-	30,653.81	23,910.41	11,522.68	26,798.62	9,274.23	9,614.88	8,434.80	7,920.64	11,000.58	22,844.79	46,205.12	38,975.67		247,156.23		
101E	TANF 14-20 FEMALE N O	56,482.84	48,295.58	35,281.43	34,103.87	17,747.19	21,343.15	22,638.34	19,568.78	27,129.01	46,828.45	66,666.15	75,865.69		471,950.48		
101F	TANF 21-44 MALE NON-	441,372.83	443,539.24	240,851.96	193,781.66	93,373.63	105,684.74	106,107.39	102,597.85	125,092.10	170,600.25	207,617.74	199,691.09		2,430,310.48		
101G	TANF 21-44 FEMALE N O	967,547.84	939,350.71	551,924.22	458,482.24	314,016.32	266,567.51	305,275.97	300,490.82	335,065.89	457,291.62	544,541.27	568,983.83		6,009,538.24		
101H	TANF 44-64 M & F NON	673,153.96	695,670.20	390,666.92	248,353.01	134,308.24	126,224.28	153,889.31	183,845.78	133,589.05	202,935.00	240,524.90	243,923.33		3,427,083.98		
101J	TANF 65+ N & F NON-M	13,593.90	8,104.86	11,870.70	676.55	2,534.13	4,132.50	1,949.50	1,420.23	0.00	2,901.30	104.80	9,779.32		57,067.79		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	503.59	0.00	0.00	0.00	0.00	487.78	487.78	0.00	0.00		1,479.15		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	228.55	0.00	1,518.09	1,784.45	0.00		3,531.09		
1026	TANF 21-44 MALE WITH	39,781.26	52,613.13	69,409.48	17,011.53	12,616.89	12,420.55	15,215.78	15,640.80	16,893.24	13,628.72	13,104.70	11,543.19		289,879.27		
1027	TANF 21-44 FEMALE WI	112,487.20	155,750.38	178,197.45	42,604.92	49,730.74	52,435.62	44,117.53	42,935.81	34,441.50	37,223.00	38,715.29	37,669.84		826,309.28		
1028	TANF 45-64 M & F WIT	142,957.26	219,266.01	262,802.70	39,010.80	49,106.64	59,623.01	50,856.10	54,128.75	48,866.04	40,984.85	36,336.56	40,408.69		1,044,347.41		
1029	TANF 65+ M & F WITH	53,811.16	84,861.43	103,507.94	16,738.86	19,102.86	21,396.49	20,442.35	20,112.95	19,711.04	17,550.04	14,317.48	12,052.85		403,605.45		

O

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102F	TANF 21-44 MALE WITH	0.00	349.97	22.18	283.30	0.00	0.00	0.00	0.00	0.00	0.00	41.77	0.00		697.22		
102G	TANF 21-44 FEMALE WI	894.71	245.67	322.44	0.00	0.00	395.42	119.25	173.25	0.00	0.00	0.00	429.03		2,579.77		
102H	TANF 44-64 M & F WIT	814.72	5,425.27	2,007.41	0.00	1,518.50	0.00	0.00	0.00	0.00	417.15	23.07	1,672.71		11,878.83		
102J	TANF 65+ M & F WITH	958.54	944.87	0.00	2,333.94	0.00	0.00	0.00	0.00	0.00	178.81	0.00	524.51		4,940.67		
2100	SSI AGED WITH MEDIC	646,891.69	640,426.15	626,324.88	741,218.85	763,396.08	912,983.06	800,177.94	813,327.93	798,093.80	794,830.83	821,877.85	870,926.88		9,230,475.94		
210Z	SSI AGED WITH MEDIC A	42,792.60	35,137.07	23,993.14	22,253.33	24,247.34	19,520.95	19,495.37	19,890.65	18,143.62	24,027.67	40,828.10	24,046.79		314,376.63		
2110	SSI AGED NON-MEDICA	4,841,984.49	4,755,477.85	4,841,046.00	5,319,754.55	5,244,733.49	6,162,557.25	5,104,276.41	5,130,074.42	5,108,582.02	4,887,567.55	4,861,870.24	4,738,446.11		60,996,370.38		
211Z	SSI AGED NON-MEDICA R	168,114.98	120,300.70	81,292.69	107,483.51	100,740.24	114,287.30	119,704.75	175,066.51	111,843.10	141,277.45	183,299.52	155,190.49		1,578,601.24		
2120	SSI AGED WITH QMB	2,773,140.25	2,801,949.97	2,812,690.87	4,298,415.06	4,308,900.56	5,095,008.46	4,363,995.06	4,398,672.58	4,569,732.50	4,519,560.67	4,805,932.79	5,014,947.84		49,762,946.61		
212Z	SSI AGED WITH QMB P P	5,569.66	5,916.01	9,571.88	5,721.66	6,731.50	3,193.40	5,058.59	3,360.61	3,840.72	6,421.17	4,884.16	6,572.35		66,841.71		
2200	SSI DISABLED WITH M E	1,438,779.65	1,356,642.89	1,368,850.54	1,750,088.66	1,712,310.36	1,880,846.57	1,729,865.54	1,747,698.04	1,749,844.45	1,732,920.84	2,189,098.61	2,365,874.25		21,022,820.40		
220Z	SSI DISABLED WITH M E	21,320.23	23,148.40	24,683.29	18,921.57	10,281.93	14,271.27	14,439.89	14,991.40	12,804.89	14,590.53	19,896.53	17,516.30		206,866.23		
2210	SSI DISABLED NON-ME D	55,077,622.81	54,829,218.00	54,812,398.76	59,204,588.11	59,278,100.88	69,163,873.56	59,481,048.89	59,301,825.99	59,336,977.25	59,064,702.16	59,281,583.44	59,061,630.78		707,893,570.63		
221Z	SSI DISABLED NON-ME D	491,291.42	492,991.62	460,508.70	398,574.48	381,824.33	470,632.81	438,715.10	417,817.56	416,781.56	549,572.74	504,729.34	457,719.49		5,481,159.15		
2220	SSI DISABLED WITH Q	10,386,804.88	10,418,005.20	10,514,240.11	14,112,652.81	14,189,750.86	15,045,495.81	14,303,641.89	14,362,561.61	14,750,430.51	14,939,771.34	15,066,487.93	15,256,599.79		163,346,442.74		
222Z	SSI DISABLED WITH Q M	5,921.17	7,380.90	10,401.43	3,840.12	2,524.99	1,306.61	2,738.93	4,557.97	2,678.40	2,723.90	3,357.12	4,397.69		51,829.23		
2300	SSI BLIND WITH MEDIC	4,363.55	4,060.83	3,780.74	6,282.61	6,337.48	8,054.88	6,870.52	7,139.89	6,935.36	7,040.92	6,195.74	6,195.74		73,258.26		
230Z	SSI BLIND WITH MEDIC	448.85	0.00	0.00	0.00	0.00	1,400.03	0.00	56.44	85.57	80.25	0.00	0.00		2,071.14		
2310	SSI BLIND NON-MEDIC A	353,568.15	356,359.13	362,835.95	397,898.39	397,764.11	482,839.14	417,031.99	418,997.08	421,466.68	415,449.43	415,304.84	413,657.19		4,853,172.08		
231Z	SSI BLIND NON-MEDIC A	3,440.09	12,852.23	5,876.17	7,201.16	2,280.81	13,964.20	7,166.70	5,902.93	3,187.32	4,466.88	1,595.10	34.16		67,967.75		
2320	SSI BLIND WITH QMB	44,041.31	43,688.31	44,085.09	52,049.43	51,728.72	56,683.73	49,268.31	49,546.44	49,775.92	50,191.93	50,979.06	51,324.50		593,362.75		
232Z	SSI BLIND WITH QMB P	0.00	0.00	2.91	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.91		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	238.60	462.29	-700.89	0.00		0.00		
4302	SOBRA CHILD 01-05 M	541.57	1,125.47	-453.71	224.19	224.19	260.25	224.91	224.91	224.91	224.91	149.34	335.78		3,306.72		
4303	SOBRA CHILD 06-13 M	227.07	227.07	276.11	244.30	1,116.27	1,036.83	1,061.37	946.46	1,020.69	946.46	1,111.51	1,116.20		9,330.34		
4304	SOBRA CHILD 14-20 MA	162.24	162.24	162.24	0.00	-162.83	198.38	0.00	0.00	282.94	315.45	1,876.96	315.45		3,313.07		
4305	SOBRA CHILD 14-20 FE	789.59	840.59	831.97	868.03	704.35	1,568.24	1,896.27	2,134.53	1,509.17	2,167.70	3,189.00	2,358.16		18,857.60		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,935.90	0.00	-2,935.90	0.00		0.00		
430B	SOBRA CHILD 01-05 M	49.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	255.34	0.00		304.95		
430C	SOBRA CHILD 06-13 M	0.00	0.00	95.88	47.55	77.04	0.00	0.00	0.00	19.37	0.00	0.00	0.00		239.84		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	419.05	0.00	108.29	0.00		527.34		
430E	SOBRA CHILD 14-20 FE	0.00	120.83	193.23	-73.98	-119.25	0.00	0.00	0.00	0.00	162.14	0.00	0.00		282.97		
4311	SOBRA CHILD <1 M & F	19,081,996.88	19,048,366.58	17,788,960.54	18,398,080.15	18,949,300.54	22,353,310.47	17,644,405.08	18,103,709.20	18,570,135.61	18,772,012.29	18,666,974.52	18,783,986.77		226,161,238.63		
4312	SOBRA CHILD 01-05 M	19,072,224.87	20,064,623.31	21,072,490.25	21,576,275.67	22,390,417.25	25,747,478.39	23,497,937.91	23,829,863.40	23,910,286.69	23,928,306.37	23,840,571.57	23,636,488.98		272,566,964.66		
4313	SOBRA CHILD 06-13 M	25,452,339.99	27,401,384.87	29,128,878.55	26,788,281.50	27,455,119.36	31,872,811.53	28,972,941.33	29,242,293.95	29,596,802.27	29,695,108.27	29,702,354.50	29,960,870.31		345,269,186.43		
4314	SOBRA CHILD 14-20 MA	8,607,044.24	8,948,118.85	9,523,338.23	8,708,264.72	8,805,134.23	10,221,259.84	9,174,817.99	9,323,412.03	9,371,481.54	9,286,419.04	9,174,017.05	9,379,278.27		110,522,586.03		

A

R

M

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
13,024,273.87	13,595,781.00	14,432,717.70	13,314,992.12	13,452,811.30	15,664,057.38	14,037,152.48	14,285,459.16	14,286,732.09	14,139,882.48	13,897,253.79	14,239,501.16	168,370,614.53	
1,266,381.59	1,304,281.60	634,368.33	1,482,032.17	977,262.62	1,098,964.98	63,622.62	722,163.04	627,444.79	819,667.04	632,866.53	1,024,317.89	10,653,373.20	
494,252.81	475,898.40	360,178.32	407,643.39	262,251.61	248,010.60	271,540.03	285,522.70	281,974.96	350,717.77	343,257.67	401,699.08	4,182,947.34	
634,059.19	670,453.45	453,423.37	439,439.88	292,079.09	274,008.02	282,295.62	287,299.33	301,871.12	340,145.08	440,662.90	373,034.44	4,788,771.49	
467,748.21	431,434.92	303,172.79	265,677.52	189,364.34	182,262.95	177,918.24	199,621.43	151,192.39	187,821.01	252,370.55	269,852.23	3,078,436.58	
506,841.24	521,342.83	357,514.83	325,476.02	233,036.41	227,826.88	230,531.24	256,907.98	214,615.87	263,090.79	286,173.20	349,343.77	3,772,701.06	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	447.85	418.95	0.00	0.00	0.00	866.80	
329.97	0.00	220.65	332.81	115.27	299.36	0.00	0.00	229.81	668.93	487.80	114.91	2,799.51	
755.82	0.00	107.48	558.29	399.46	1,577.25	411.36	1,037.18	103.17	320.83	317.88	159.99	5,748.71	
623.74	0.00	162.24	137.86	272.28	450.17	0.00	0.00	154.87	265.32	138.79	0.00	2,205.27	
490.95	259.91	523.40	0.00	0.00	1,031.53	0.00	0.00	466.96	0.00	0.00	0.00	2,772.75	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	70.20	0.00	0.00	0.00	0.00	70.20	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	140.88	0.00	140.88	
28,646.09	29,529.54	34,810.47	37,003.71	22,770.15	24,460.37	22,927.68	27,517.14	29,767.39	29,124.13	28,109.44	31,280.89	345,947.00	
856.00	405.55	405.55	898.29	898.29	1,365.91	898.29	898.29	898.29	898.29	2,505.73	4,027.55	14,956.03	
667.73	637.69	427.13	403.02	162.14	432.77	318.82	590.42	125.53	1,180.09	1,735.35	765.31	7,446.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	11.54	0.00	11.54	
791.84	960.27	778.66	664.29	689.41	1,113.84	900.22	1,705.68	1,850.21	2,077.04	2,263.15	1,730.79	15,525.40	
1,153,204.41	1,243,589.20	1,321,708.44	1,331,054.56	1,405,473.49	1,350,428.51	1,054,815.01	1,104,515.96	1,146,978.48	1,168,888.00	1,198,870.55	1,189,121.06	14,668,647.67	
4,969,763.44	5,543,577.71	6,104,353.53	6,666,900.29	7,018,557.84	6,624,611.50	5,287,100.31	5,535,954.65	5,761,262.03	5,806,090.39	5,997,471.23	6,135,777.89	71,451,420.81	
29,226.73	32,189.69	33,578.00	41,189.47	41,350.99	43,398.65	34,884.14	30,714.35	33,529.21	32,102.30	32,172.05	32,897.07	417,232.65	
0.00	98.71	0.00	0.00	43.67	0.00	0.00	0.00	0.00	0.00	110.93	61.69	315.00	
77,023.42	77,726.43	48,097.14	49,640.39	42,451.40	43,034.61	52,196.23	47,256.44	46,004.34	71,734.96	53,145.23	76,197.59	684,508.18	
331,612.75	308,457.61	239,213.41	224,480.35	178,215.34	181,213.77	209,298.69	195,747.73	201,549.59	304,247.68	263,208.42	307,980.61	2,945,225.95	
3,630.96	10,740.73	531.17	334.55	0.00	588.34	0.00	1,231.29	4,856.48	2,326.94	4,071.57	521.38	28,833.41	
2,329.77	2,829.66	4,481.72	4,273.54	4,730.15	7,022.63	4,272.15	5,525.45	11,776.44	14,910.63	16,683.06	14,059.01	92,894.21	
0.00	2,426.39	2,426.39	2,242.66	2,242.66	2,242.66	2,361.11	2,242.66	0.00	2,242.66	2,242.66	2,242.66	22,912.51	
218.29	0.00	0.00	0.00	0.00	0.00	169.46	0.00	0.00	251.61	169.46	0.00	808.82	
0.00	0.00	0.00	0.00	0.00	0.00	122.33	0.00	0.00	0.00	0.00	0.00	122.33	
-12.50	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-12.50	

RATE CODE	DESCRIPTION 4315	SOBRA CHILD 14-20 FE
431A	SOBRA CHILD < 1 M &

431B	SOBRA CHILD 01-05 M

431C	SOBRA CHILD 6-13 M&
F
431D	SOBRA CHILD 14-20 MA

431E	SOBRA CHILD 14-20 FE

4321	SOBRA CHILD <1 M & F

4322	SOBRA CHILD 01-05 M

4323	SOBRA CHILD 06-13 M

4324	SOBRA CHILD 14-20 MA

4325	SOBRA CHILD 14-20 FE

432A	SOBRA CHILD < 1 M &

432B	SOBRA CHILD 01-05 M

5007	SOBRA PREG 21-44 FE
M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
500H	SOBRA PREG 45-64 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
502H	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT
SUBTOTAL:

248,764,079.13   252,354,794.67   254,464,913.27   246,135,180.96   245,353,522.07   290,175,954.31  242,885,635.24   242,934,062.77   243,407,082.96   241,956,430.32   242,710,634.96  246,706,304.03	2,997,848,594.69

9910	TANF & SOBRA CHILDR E	3,483,562.65	3,047,996.25	2,907,424.24	2,225,583.72	2,475,483.80	2,699,633.43	2,359,982.88	2,057,153.87	2,101,519.46	1,987,717.20	1,811,193.64	1,658,697.03	
9920	SSI W/MEDICARE KICK	66,760.99	67,334.84	73,848.44	60,848.38	72,108.82	36,734.16	61,091.07	41,626.41	55,846.52	48,375.74	36,563.99	50,028.43	
9921	SSI W/O MEDICARE KIC	253,912.66	175,567.47	201,893.70	182,160.74	179,014.54	246,059.59	185,727.70	156,155.58	182,645.21	159,116.58	180,389.15	147,724.16	
9950	S.O.B.R.A. KICK PAYM	12,465,299.69	13,765,854.41	14,897,401.05	13,552,095.42	13,016,280.12	13,122,762.07	11,790,756.24     12,615,623.07	12,323,843.70	11,690,081.66	12,139,174.74	12,049,436.24	

 
28,815,948.17	
671,167.79	
2,250,367.08	
153,428,608.41	

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	16,269,535.99	17,056,752.97	18,080,567.43	16,020,688.26	15,742,887.28	16,105,189.25	14,397,557.89	14,870,558.93	14,663,854.89	13,885,291.18	14,167,321.52	13,905,885.86		185,166,091.45		

SUBTOTAL:

3100	TRANSPLANT OPTION 1	70.26	89.42	82.50	82.50	94.60	99.00	99.00	99.00	66.00	52.80	66.00	49.50	
310Z	TRANSPLANT OPTION	94.74	75.58	0.00	0.00	4.40	0.00	0.00	0.00	0.00	79.20	0.00	0.00	
	165.00	165.00	82.50	82.50	99.00	99.00	99.00	99.00	66.00	132.00	66.00	49.50	

950.58	
253.92	
1,204.50	

1
SUBTOTAL:

1106	TANF EXPANDED 21-44	167,462.38	144,030.22	123,318.86	348,239.33	330,998.49	327,013.61	293,372.02	308,791.80	307,036.35	287,221.24	281,363.08	282,002.85	
1107	TANF EXPANDED 21-44	599,045.66	537,386.92	489,127.06	1,038,594.89	978,957.19	998,025.53	900,412.62	907,719.68	908,596.01	895,102.54	863,165.59	862,064.15	
1108	TANF EXPANDED 45-64	1,023,600.25	911,053.14	848,021.18	1,766,284.56	1,717,007.59	1,898,559.74	1,646,749.25	1,641,033.66	1,668,794.15	1,645,108.31	1,607,382.98	1,633,057.16	
1109	TANF EXPANDED 65+
M&	274,415.40	245,636.00	232,837.24	502,261.74	493,090.82	555,592.30	475,594.93	482,211.24	489,065.07	494,877.38	482,139.42	494,024.46	
110F	TANF EXPANDED 21-44	3,682.62	630.49	1,486.57	3,392.63	3,061.27	1,445.35	1,532.16	2,681.33	1,799.43	3,643.61	4,914.19	2,761.99	
110G	TANF EXPANDED 21-44	520.84	324.33	2,552.22	7,103.54	4,282.02	3,757.64	4,112.14	3,033.02	3,825.80	6,072.25	8,883.85	4,206.29	
110H	TANF EXPANDED 45-64	161.40	385.93	27,647.67	33,347.53	20,685.44	12,573.42	14,788.08	19,770.84	16,572.32	28,320.12	27,473.22	32,815.25	
110J	TANF EXPANDED 65+
M&	0.00	1,210.32	15,631.07	6,020.54	4,765.67	5,992.18	6,238.92	4,550.01	4,586.50	8,210.63	7,662.05	5,925.24	
1111	TANF EXPANDED <1 M
&F	6,325.21	4,355.65	762.79	1,466.00	1,466.00	6,164.56	959.74	471.96	0.00	0.00	0.00	15.17	
1112	TANF EXPANDED 01-05	48,437.22	37,053.66	33,123.81	29,396.05	22,170.25	40,683.70	12,458.19	9,990.22	7,748.03	6,629.89	4,371.01	4,205.65	
1113	TANF EXPANDED 06-13	155,432.39	123,651.13	108,415.58	93,138.60	75,107.67	137,286.25	45,721.14	34,834.76	29,636.75	26,565.28	21,262.59	18,078.69	
1114	TANF EXPANDED 14-20	114,898.22	90,180.24	76,789.22	121,834.46	112,376.36	164,931.05	104,108.53	99,928.56	97,182.96	92,755.35	89,817.19	87,036.42	
1115	TANF EXPANDED 14-20	375,463.35	278,983.53	236,525.33	455,399.24	446,636.13	633,451.47	511,369.76	483,329.78	485,759.30	495,675.69	504,101.63	492,663.91	
1116	TANF EXPANDED 21-44	3,292,450.62	2,886,484.77	2,569,959.71	5,025,954.65	4,942,910.96	6,009,674.15	5,107,974.70	5,065,789.75	5,109,844.17	5,045,025.68	4,994,298.28	5,039,386.82	
1117	TANF EXPANDED 21-44	11,884,383.87	10,291,379.14	9,057,760.96	17,098,041.17	16,741,566.94	20,837,934.57	18,135,306.62	17,987,316.07	18,277,785.98	18,342,636.81	18,147,117.98	18,298,549.28	
1118	TANF EXPANDED 45-64	7,186,338.24	6,353,222.09	5,768,022.81	11,349,562.98	11,255,706.50	13,412,203.34	11,705,309.17	11,619,640.14	11,663,707.38	11,371,222.80	11,202,611.53	11,401,649.17	
1119	TANF EXPANDED 65+
M&	38,116.96	34,638.80	32,844.67	50,449.55	48,551.01	54,580.40	49,262.22	49,972.15	48,378.86	43,614.98	42,152.48	40,420.12	
111A	TANF EXPANDED <1 M
&F	0.00	0.00	-402.42	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111B	TANF EXPANDED 01-05	0.00	51.33	0.00	0.00	0.00	14.09	0.00	182.22	635.80	277.13	26.41	0.00	
111C	TANF EXPANDED 06-13	60.93	0.00	0.00	166.42	306.00	60.93	12.33	0.00	11.25	10.92	148.23	592.37	
111D	TANF EXPANDED 14-20	91.04	817.44	2,346.34	1,783.04	4,380.55	2,916.80	2,166.48	3,767.22	2,019.51	3,517.32	7,280.20	8,875.08	
111E	TANF EXPANDED 14-20	1,428.69	1,919.48	6,274.89	9,908.99	8,959.07	6,906.83	7,798.29	9,471.42	7,485.20	11,385.88	11,349.69	20,948.45	
111F	TANF EXPANDED 21-44	16,857.80	16,840.28	88,070.74	149,530.14	129,309.81	123,356.30	133,296.48	127,509.01	119,985.50	167,146.76	173,177.92	196,332.66	
111G	TANF EXPANDED 21-44	38,462.54	45,149.24	202,727.99	318,834.43	259,990.85	233,575.81	282,025.05	253,578.80	256,991.42	374,635.39	392,734.35	399,022.24	
111H	TANF EXPANDED 45-64	12,792.72	53,531.20	181,490.33	247,343.76	197,107.31	238,384.88	202,701.94	217,655.72	176,268.15	228,878.78	259,904.23	193,898.69	
111J	TANF EXPANDED 65+
M&	10,074.33	0.00	1,610.12	15,133.53	1,008.68	3,362.50	12,031.53	3,016.57	2,364.07	3,318.66	2,189.87	2,512.42	
1125	TANF EXPANDED 14-20	259.91	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	77,277.63	71,347.76	61,838.93	77,526.90	106,393.69	141,787.79	142,497.14	145,291.67	152,337.34	133,834.07	139,888.07	149,046.45	
1127	TANF EXPANDED 21-44	214,717.61	193,927.68	179,884.44	245,571.04	327,309.88	412,966.19	430,483.37	448,380.89	455,301.06	451,214.15	435,107.46	441,597.81	
1128	TANF EXPANDED 45-64	242,994.86	222,897.30	210,610.65	289,864.60	387,477.49	506,717.56	500,993.90	517,029.17	532,025.45	505,586.63	495,252.57	493,997.27	
1129	TANF EXPANDED 65+	89,535.41	77,417.22	73,153.41	82,720.03	108,728.23	148,924.61	151,914.73	158,094.56	170,273.52	181,842.66	173,556.62	167,324.71	

3,200,850.23	
9,978,197.84	
18,006,651.97	
5,221,746.00	
31,031.64	
48,673.94	
234,541.22	
70,793.13	
21,987.08	
256,267.68	
869,130.83	
1,251,838.56	
5,399,359.12	
55,089,754.26	
195,099,779.39	
124,289,196.15	
532,982.20	
-402.42	
1,186.98	
1,369.38	
39,961.02	
103,836.88	
1,441,413.40	
3,057,728.11	
2,209,957.71	
56,622.28	
259.91	
1,399,067.44	
4,236,461.58	
4,905,447.45	
1,583,485.71	

M&

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	406.00	246.72	273.24	148.50	1,391.61	1,660.72	562.18	325.98	537.50	680.91	6,233.36	
0.00	681.07	726.03	964.10	648.57	537.96	1,154.70	860.84	127.81	1,335.73	1,548.87	1,357.44	9,943.12	
10.59	0.00	1,235.44	3,753.28	2,524.51	3,607.70	638.24	4,455.98	3,780.82	4,039.21	3,146.35	3,380.03	30,572.15	
0.00	0.00	6,378.93	344.31	4,119.33	5,140.99	1,028.83	761.06	1,228.30	4,573.10	1,667.48	105.24	25,347.57	
90,318.38	78,003.38	74,504.07	71,589.26	68,291.67	87,163.90	64,453.13	72,449.66	62,753.37	77,420.94	84,472.44	88,966.59	920,386.79	
28,495.79	37,821.60	22,409.28	21,024.30	14,619.96	20,639.55	11,037.06	13,574.15	10,937.45	16,253.00	21,560.79	20,382.93	238,755.86	
929,746.50	864,149.68	813,310.62	351,969.12	320,177.38	502,076.63	219,435.89	208,221.70	172,110.53	135,150.07	142,433.10	128,779.83	4,787,561.05	
7,401.77	16,962.83	8,306.20	4,276.52	3,695.68	4,224.09	1,447.14	3,241.36	3,618.13	4,416.17	21,990.94	10,377.00	89,957.83	
5,235,551.09	5,187,661.49	5,133,746.28	4,943,310.23	4,730,309.58	5,377,961.60	4,556,076.95	4,491,431.68	4,451,541.83	4,274,700.25	4,021,711.27	3,941,239.76	56,345,242.01	
7,997.68	5,766.54	4,987.33	5,330.17	2,179.50	3,525.88	2,827.84	5,983.58	2,042.61	11,302.42	12,066.48	5,174.12	69,184.15	
0.00	0.00	0.00	140.23	140.23	140.23	140.23	140.23	140.23	140.23	140.23	140.23	1,262.07	
1,458.65	1,458.65	1,458.65	755.69	755.69	869.56	0.00	0.00	0.00	0.00	0.00	0.00	6,756.89	
124.99	124.99	124.99	130.02	130.02	214.81	130.02	130.02	130.02	130.02	130.02	130.02	1,629.94	
159,975.75	157,902.91	154,039.57	218,895.60	207,386.21	239,347.71	231,849.47	258,398.76	247,224.99	286,115.62	309,607.66	315,600.93	2,786,345.18	
17,956.66	21,077.50	16,146.29	10,542.62	5,850.05	8,936.66	10,113.57	9,065.35	9,852.23	11,365.25	12,640.02	9,516.89	143,063.09	
2,642,788.10	2,565,161.03	2,574,872.47	2,863,962.71	2,808,377.77	3,045,057.86	2,747,705.93	2,565,586.20	2,418,699.91	2,152,141.36	2,045,874.67	1,901,514.83	30,331,742.84	
33,355.68	32,438.70	29,106.19	22,550.86	20,810.52	30,567.23	19,261.47	25,900.90	18,839.67	40,538.81	24,078.81	24,725.37	322,174.21	
7,540,307.86	7,645,491.81	7,856,549.93	10,670,749.62	10,778,061.56	11,298,685.05	11,070,787.28	11,029,521.05	10,623,129.96	10,053,074.62	9,511,117.40	9,319,890.88	117,397,367.02	
6,428.48	5,511.39	8,031.41	4,310.82	1,836.82	3,073.81	1,560.51	3,301.91	2,202.01	2,084.62	1,723.04	3,477.16	43,541.98	
42,577,206.07	39,244,718.86	37,338,771.85	58,563,716.52	57,700,500.16	67,550,763.27	59,822,231.30	59,299,727.37	59,024,939.38	57,929,438.31	56,595,779.76	56,548,450.93	652,196,243.78	

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

112F

TANF EXPANDED 21-44

112G

112H

TANF EXPANDED 21-44

TANF EXPANDED 45-64

112J

2400

240Z

2410

241Z

2420

242Z

2500

2510

2520

2600

260Z

2610

261Z

2620

262Z

TANF EXPANDED 65+
M&
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
NO
SSI AGED EXPANDED
NO
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI BLIND EXPANDED
W
SSI BLIND EXPANDED
N
SSI BLIND EXPANDED
W
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

E
SUBTOTAL:

9911	SB PAYMENT FOR TAN F	638,069.14	744,028.48	692,146.52	1,079,073.38	867,744.81	1,551,281.98	1,457,853.88	1,337,791.04	1,321,393.12	1,155,802.41	1,350,400.72	1,112,465.23	
9922	SB PAYMENT FOR SSI E	12,450.73	18,552.72	24,748.20	6,290.91	12,607.20	12,655.86	12,028.11	6,316.29	12,655.86	12,729.90	0.00	0.00	
9923	SB PAYMENT FOR SSI	5,743.01	5,963.77	0.00	6,235.33	0.00	0.00	0.00	0.00	0.00	0.00	6,235.33	6,290.91	
	656,262.88	768,544.97	716,894.72	1,091,599.62	880,352.01	1,563,937.84	1,469,881.99	1,344,107.33	1,334,048.98	1,168,532.31	1,356,636.05	1,118,756.14	

13,308,050.71	
131,035.78	
30,468.35	
13,469,554.84	

E
SUBTOTAL:

3614	AHC CARE/MI MALE 14-	0.00	1,436.95	0.00	0.00	0.00	149.14	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	125.06	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	1,436.95	0.00	0.00	0.00	274.20	0.00	0.00	0.00	0.00	0.00	0.00	

1,586.09	
125.06	
1,711.15	

SUBTOTAL:

3504	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	475.74	0.00	911.90	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	1,375.20	0.00	
3506	ADULT 40-100% MALE 2	8,422.52	3,645.97	6,549.05	6,920.85	6,749.84	15,246.55	5,143.30	4,845.63	7,696.82	6,573.58	5,979.42	10,803.58	
3507	ADULT 40-100% FEMAL E	14,179.59	8,854.37	9,129.40	10,935.03	15,132.78	9,333.14	5,542.92	3,828.23	7,678.11	4,750.26	4,310.24	697.34	
3508	ADULT 40-100% M&F 45	36,321.61	26,956.15	25,017.05	64,607.16	49,522.12	74,441.74	47,502.86	60,152.88	68,779.32	30,237.00	59,597.22	44,159.45	
3509	ADULT 40-100% M&F 65	22,353.25	22,570.84	21,631.31	35,593.28	25,767.82	17,836.37	11,672.15	12,552.09	20,573.80	15,964.57	12,373.60	9,400.35	
350F	ADULT 40-100% MALE 2	3,964.50	465.31	2,008.05	3,379.72	872.11	0.00	0.00	459.43	612.90	0.00	2,272.05	606.24	
350G	ADULT 40-100% FEMAL	0.00	0.00	0.00	2,924.56	0.00	457.81	0.00	1,724.48	1,480.14	846.74	1,133.61	0.00	

1,387.64	
1,375.20	
88,577.11	
94,371.41	
587,294.56	
228,289.43	
14,640.31	
8,567.34	

E

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6,365.04	6,197.78	10,677.21	13,210.50	2,142.45	5,432.06	4,183.93	28,335.02	25,608.84	12,870.65	26,463.98	-11,159.98	130,327.48	
7,372.56	5,207.00	0.00	2,056.55	357.79	7,661.84	1,332.88	20,532.02	6,353.47	2,793.35	28,946.59	4,487.72	87,101.77	
1,324,584.01	1,440,655.36	1,514,833.49	1,566,211.25	1,665,256.44	1,984,883.57	1,872,667.57	1,927,483.56	1,996,084.38	2,101,758.19	2,276,944.14	2,337,876.55	22,009,238.51	
1,633,845.08	1,727,407.10	1,811,455.28	1,845,511.21	1,949,540.67	2,348,680.27	2,176,541.43	2,242,833.24	2,286,783.23	2,391,562.24	2,552,122.64	2,563,103.62	25,529,386.01	
7,573,355.50	7,578,276.66	7,770,879.64	8,378,901.15	8,463,151.65	10,011,398.23	8,761,850.23	8,889,458.57	8,869,719.32	8,895,001.39	8,982,280.00	9,147,809.84	103,322,082.18	
6,410,679.09	6,346,041.90	6,476,413.17	6,980,125.28	6,982,308.75	8,356,713.50	7,184,025.95	7,299,113.79	7,319,928.48	7,395,078.43	7,400,798.61	7,527,729.66	85,678,956.61	
15,191,483.66	15,250,141.05	15,625,452.65	16,626,431.57	16,759,472.47	19,876,479.58	17,359,739.78	17,754,934.89	17,830,685.98	18,003,463.80	18,088,851.72	18,316,023.41	206,683,160.56	
16,506.64	15,041.42	15,084.02	22,447.95	13,832.15	20,370.03	12,054.26	6,999.64	9,642.10	16,259.19	17,824.25	18,523.99	184,585.64	
148,997.70	115,709.11	88,931.32	77,872.89	78,610.60	74,037.41	91,239.55	91,182.08	119,748.64	182,252.27	131,306.25	166,630.77	1,366,518.59	
144,852.52	143,422.42	95,008.93	105,596.06	74,569.94	82,977.04	119,502.32	97,959.49	112,122.23	185,880.07	139,301.20	126,566.34	1,427,758.56	
646,088.27	613,079.90	479,928.59	471,628.16	336,866.99	413,200.04	403,697.51	459,136.16	388,448.01	498,252.50	541,152.91	636,431.15	5,887,910.19	
458,558.32	429,699.96	368,800.73	356,601.53	246,284.78	355,331.06	338,219.87	366,505.47	273,571.49	305,310.69	377,229.02	363,604.34	4,239,717.26	
1,204,084.30	1,016,417.29	728,945.34	784,761.29	597,289.00	758,626.02	802,383.13	743,712.38	661,749.49	824,931.99	890,054.97	947,382.86	9,960,338.06	
27,457.81	15,740.35	20,203.21	13,703.32	28,147.70	3,538.93	12,732.65	2,749.32	6,512.57	3,379.05	33,934.25	1,192.62	169,291.78	
351.97	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	351.97	
1,168.26	0.00	0.00	0.00	905.24	584.84	914.43	-349.98	658.41	165.72	4,428.22	4,578.49	13,053.63	
668.80	1,504.94	0.00	366.57	441.10	2,105.01	2,683.76	889.55	930.65	507.39	1,413.99	1,250.30	12,762.06	
10,626.75	7,689.50	12,719.11	12,289.73	10,883.20	14,398.75	12,861.10	8,971.05	17,543.37	4,963.05	6,661.83	5,736.21	125,343.65	
2,416.71	4,002.70	1,585.00	5,981.76	4,387.94	5,346.12	2,711.73	2,585.84	5,433.31	1,776.93	3,648.46	0.00	39,876.50	
0.00	0.00	0.00	0.00	0.00	162.24	0.00	0.00	492.11	450.54	0.00	0.00	1,104.89	
0.00	531.77	0.00	21.80	0.00	0.00	0.00	0.00	0.00	585.70	0.00	320.63	1,459.90	
16.98	1,224.13	886.83	72.11	0.00	1,096.69	1,002.81	5,277.83	1,939.31	690.58	346.25	821.87	13,375.39	
0.00	0.00	0.00	3,228.03	616.59	2,867.30	457.81	526.47	130.80	0.00	0.00	0.00	7,827.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	464.14	0.00	224.22	3,986.09	3,073.50	7,747.95	
0.00	0.00	0.00	0.00	0.00	170.51	0.00	0.00	0.00	0.00	0.00	0.00	170.51	
34,143.30	26,154.77	20,573.49	39,142.26	28,932.51	26,253.84	35,940.46	32,898.39	42,775.50	22,385.18	26,239.50	23,668.30	359,107.50	
12,691.88	18,567.70	11,647.93	10,314.66	6,489.86	16,865.89	19,177.00	12,350.37	16,822.95	10,807.02	16,886.57	15,500.40	168,122.23	
47,370.84	58,639.06	54,729.62	114,253.12	92,664.47	99,216.03	92,080.32	81,739.02	116,609.98	68,650.88	108,500.22	92,457.85	1,026,911.41	
8,255.13	8,986.58	12,316.96	18,221.48	9,722.62	8,101.26	6,854.86	10,486.52	11,060.69	7,581.30	7,811.89	5,159.93	114,559.22	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	337.91	0.00	0.00	337.91	
3,590.13	5,678.35	4,459.00	2,315.61	2,138.02	952.88	3,315.80	2,167.25	1,853.02	7,964.76	18,328.45	1,738.66	54,501.93	
824.34	1,262.96	35.10	1,823.55	2,665.44	784.80	3,403.18	0.00	4,403.66	0.00	1,133.62	2,545.55	18,882.20	
8,737.58	10,393.47	21,133.34	9,344.88	2,526.64	10,753.79	5,476.93	4,588.76	16,370.41	15,092.55	17,848.01	7,543.42	129,809.78	
0.00	0.00	2,297.94	0.00	0.00	1,394.62	0.00	2,402.41	0.00	1,644.81	39,323.82	0.00	47,063.60	
4,383,132.32	4,528,025.34	4,668,083.27	4,798,971.65	4,966,868.66	6,197,353.47	5,122,155.64	5,070,284.60	5,374,137.33	5,517,468.11	5,631,016.22	5,559,467.13	61,816,963.74	
3,752,637.27	3,863,233.89	3,962,050.58	4,047,408.69	4,164,982.97	5,285,430.48	4,388,863.77	4,364,329.76	4,664,493.57	4,795,085.87	4,931,399.00	4,867,910.99	53,087,826.84	

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION 350H	ADULT 40-100% M&F 45
350J	ADULT 40-100% M&F 65

3514	ADULT 40-100% MALE 1

3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE 2

3517	ADULT 40-100% FEMAL
E
3518	ADULT 40-100% M&F 45

3519	ADULT 40-100% M&F 65

351D	ADULT 40-100% MALE 1

351E	ADULT 40-100% FEMAL
E
351F	ADULT 40-100% MALE 2

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

351J	ADULT 40-100% M&F 65

3525	ADULT 40-100% FEMAL
E
3526	ADULT 40-100% MALE 2

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

3529	ADULT 40-100% M&F 65

352F	ADULT 40-100% MALE 2

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

352J	ADULT 40-100% M&F 65

3704	ADULT <40% EXP MALE

3705	ADULT <40% EXP FEM
AL
3706	ADULT <40% EXP MALE

3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
370D	ADULT <40% EXP MALE

370F	ADULT <40% EXP MALE

370G	ADULT <40% EXP FEM
AL
370H	ADULT <40% EXP M&F
4
370J	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MALE

3715	ADULT <40% EXP FEM
AL

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	27,106,086.04	27,395,881.26	28,559,100.18	31,597,706.11	31,781,110.59	37,440,882.09	32,286,459.21	32,182,837.36	31,975,225.03	31,561,612.10	30,811,787.91	31,207,561.27		373,906,249.15		
3717	ADULT <40% EXP FEM AL	16,530,344.45	16,579,394.61	17,156,912.82	19,193,803.19	19,394,362.33	22,676,531.06	19,539,939.24	19,439,969.87	19,399,809.80	19,359,124.85	18,790,048.92	18,883,730.73		226,943,971.87		
3718	ADULT <40% EXP M&F 4	33,539,387.24	33,762,918.80	34,763,411.03	38,092,409.60	38,325,239.72	45,012,735.95	38,341,083.70	38,273,412.69	38,424,149.45	38,248,911.10	37,904,343.94	38,316,673.79		453,004,677.01		
3719	ADULT <40% EXP M&F 6	36,205.17	36,567.62	42,431.28	59,561.30	45,300.27	53,028.22	31,341.67	24,710.44	31,153.08	48,118.52	57,469.77	42,048.70		507,936.04		
371D	ADULT <40% EXP MALE	392,849.93	382,830.27	238,138.75	208,431.92	203,147.49	183,401.52	184,039.62	192,955.00	273,765.06	375,407.49	330,506.75	344,717.83		3,310,191.63		
371E	ADULT <40% EXP FEM AL	356,021.60	295,087.13	201,535.90	214,164.42	137,476.12	155,663.63	164,778.45	186,130.37	216,512.82	317,200.03	283,852.32	268,764.01		2,797,186.80		
371F	ADULT <40% EXP MALE	2,852,336.09	2,763,526.13	1,988,245.68	1,937,830.92	1,404,623.01	1,548,180.76	1,505,806.74	1,582,007.26	1,989,023.19	2,048,605.16	2,099,639.38	2,266,627.71		23,986,452.03		
371G	ADULT <40% EXP FEM AL	1,605,524.56	1,472,687.76	1,073,635.38	1,106,222.16	812,781.75	829,440.95	874,170.13	961,732.41	895,110.75	1,155,086.40	984,486.90	1,404,226.41		13,175,105.56		
371H	ADULT <40% EXP M&F 4	2,523,268.04	2,262,250.08	1,652,940.26	1,764,209.76	1,371,358.12	1,475,309.30	1,589,786.49	1,676,114.28	1,611,565.69	1,989,428.13	1,968,939.37	2,234,306.96		22,119,476.48		
371J	ADULT <40% EXP M&F 6	2,019.24	1,369.87	8,989.45	9,843.47	14,388.28	6,204.26	229.81	0.00	675.81	2,522.13	33,101.69	0.00		79,344.01		
3724	ADULT <40% EXP MALE	480.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	464.14	0.00	0.00		944.88		
3725	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	410.22	0.00	0.00	0.00	0.00	119.09	0.00		529.31		
3726	ADULT <40% EXP MALE	3,936.06	7,430.66	5,545.33	9,313.29	11,355.77	10,877.75	14,327.14	14,560.20	10,279.49	7,146.62	6,347.99	5,723.52		106,843.82		
3727	ADULT <40% EXP FEM AL	4,778.02	3,573.32	779.92	6,659.16	5,113.29	2,918.66	6,653.19	7,859.42	6,092.60	1,542.31	1,506.49	1,381.11		48,857.49		
3728	ADULT <40% EXP M&F	17,960.52	5,138.97	16,090.90	8,323.68	7,311.56	7,865.93	14,483.05	7,669.40	17,322.53	8,271.34	12,362.26	5,947.44		128,747.58		
3729	ADULT <40% EXP M&F 6	1,616.38	0.00	362.34	1,703.88	1,306.97	1,829.61	961.29	2,271.10	2,668.01	464.14	961.29	0.00		14,145.01		
372E	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	393.33	0.00		393.33		
372F	ADULT <40% EXP MALE	0.00	711.09	4,151.16	502.35	1,161.06	1,005.13	921.65	1,994.42	3,717.48	2,424.63	915.62	3,955.21		21,459.80		
372G	ADULT <40% EXP FEM AL	598.25	1,319.88	2,540.22	0.00	720.86	0.00	409.71	135.79	0.00	0.00	1,815.96	518.12		8,058.79		
372H	ADULT <40% EXP M&F 4	470.36	1,351.60	251.86	3,328.61	540.65	828.41	2,193.50	1,613.25	7,035.05	3,426.66	414.21	1,330.15		22,784.31		
372J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	67.48	0.00	686.88	0.00	0.00	0.00	0.00		754.36		
	128,119,986.92	128,273,464.15	129,558,529.07	140,647,189.03	140,107,399.15	165,497,664.64	143,465,516.48	144,170,770.49	145,154,015.97	146,463,304.23	145,683,149.10	147,791,156.04		1,704,932,145.27		

4

AL

SUBTOTAL:

9935	BIRTH SUPP PAYMENT A	176,469.55	272,778.55	241,599.87	270,837.95	231,084.26	214,949.85	175,607.48	181,058.62	213,114.08	203,951.98	200,133.53	268,323.78	
9937	BIRTH SUPP PAYMENT	447,342.88	597,836.74	736,611.04	684,333.12	601,967.17	620,647.36	717,122.21	518,582.16	681,267.82	636,350.68	556,433.73	719,345.57	
SUBTOTAL:	623,812.43	870,615.29	978,210.91	955,171.07	833,051.43	835,597.21	892,729.69	699,640.78	894,381.90	840,302.66	756,567.26	987,669.35	

2,649,909.50	
7,517,840.48	
10,167,749.98	

A

3904	NEWLY ELIGIBLE MALE	0.00	55.96	346.93	367.25	0.00	0.00	0.00	0.00	0.00	0.00	830.84	0.00	
3905	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,626.53	2,626.53	
3906	NEWLY ELIGIBLE MALE	2,243.33	4,164.05	5,522.85	5,309.15	5,518.15	9,318.50	10,565.88	9,835.08	14,986.01	4,372.13	11,785.67	10,346.31	
3907	NEWLY ELIGIBLE FEMA L	11,101.01	5,502.90	2,869.12	7,915.29	2,425.56	4,158.75	1,129.12	5,369.11	10,896.82	7,242.08	15,021.58	7,077.30	
3908	NEWLY ELIGIBLE M&F 4	30,815.43	20,891.02	14,759.65	37,342.86	44,998.23	60,330.54	57,389.35	61,740.71	111,899.92	40,891.37	68,923.48	47,785.37	
3909	NEWLY ELIGIBLE M&F 6	3,752.37	6,340.48	6,828.68	14,529.93	9,597.38	15,397.05	12,373.66	14,728.51	13,483.55	10,357.81	8,530.92	8,884.41	
390D	NEWLY ELIGIBLE MALE	0.00	318.47	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	154.29	0.00	0.00	2,010.66	244.03	44.06	4,408.22	1,101.81	660.08	2,868.28	1,273.26	406.71	
390G	NEWLY ELIGIBLE FEMA L	558.35	584.83	0.00	417.38	411.65	1,086.80	280.67	785.37	0.00	0.00	33.05	91.07	
390H	NEWLY ELIGIBLE M&F	20,702.19	14,075.84	19,780.97	33,511.35	12,219.55	8,555.27	11,466.53	39,025.57	10,632.91	5,454.58	17,362.27	995.83	

1,600.98	
5,253.06	
93,967.11	
80,708.64	
597,767.93	
124,804.75	
318.47	
13,171.40	
4,249.17	
193,782.86	

L

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

390J

3914

3915

3916

NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

3917

3918

3919

391D

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

391E

391F

391G

391H

391J

3926

3927

3928

3929

392F

392G

392H

392J

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE MALE

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

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

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

SUBTOTAL:

9939	BIRTH SUPP PAYMENT	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	447,193.00	474,637.31	611,997.77	433,947.37	546,326.69	623,450.35	364,975.91	
	236,215.30	208,587.25	349,383.86	403,700.10	408,446.88	447,193.00	474,637.31	611,997.77	433,947.37	546,326.69	623,450.35	364,975.91	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3,743.08	5,233.41	11,173.35	15,825.83	6,081.31	7,661.22	913.63	22,686.57	0.00	6,099.02	21,619.62	170.75	101,207.79	
520,790.75	542,267.89	590,928.22	681,452.40	726,387.85	833,795.61	798,115.51	828,889.74	851,066.36	886,833.34	963,407.74	956,869.57	9,180,804.98	
601,783.26	669,009.91	701,931.63	809,407.48	873,776.14	1,008,820.92	996,795.30	1,020,969.68	1,057,786.62	1,071,867.63	1,171,637.01	1,147,304.50	11,131,090.08	
5,010,046.71	5,234,991.72	5,512,159.07	6,893,479.88	7,146,162.82	7,824,417.74	7,340,679.20	7,644,072.48	7,628,695.42	7,679,563.47	7,614,475.47	7,408,157.50	82,936,901.48	
6,457,501.35	6,891,154.05	7,326,735.48	9,254,679.43	9,714,688.16	10,684,151.74	10,499,771.28	11,190,273.76	11,243,985.41	11,697,923.95	11,482,093.43	10,865,018.54	117,307,976.58	
7,992,989.32	8,091,976.44	8,244,535.29	10,079,365.67	10,259,563.30	11,593,254.48	10,470,856.13	10,730,897.79	10,726,172.25	10,842,950.89	10,950,364.93	10,871,955.23	120,854,881.72	
13,274.71	12,857.15	12,513.51	18,274.33	14,084.40	15,516.59	9,490.38	7,626.00	8,103.77	9,318.45	10,971.97	9,637.42	141,668.68	
48,199.73	37,609.47	40,038.27	20,046.88	15,857.23	22,443.06	17,900.44	20,251.19	35,604.48	32,915.06	34,460.91	30,263.10	355,589.82	
52,151.67	50,095.35	33,023.96	35,335.57	22,995.05	32,952.23	33,640.41	37,226.81	27,856.93	41,987.98	34,194.57	52,797.86	454,258.39	
503,095.65	399,419.06	363,419.09	317,691.28	211,805.10	242,813.42	268,572.71	222,778.17	202,897.08	244,763.69	258,338.33	293,456.14	3,529,049.72	
575,662.05	557,633.73	466,745.78	408,568.59	242,094.96	275,085.07	301,121.78	311,931.33	236,013.74	300,581.66	279,918.60	309,748.78	4,265,106.07	
598,828.85	481,913.67	459,344.28	364,265.20	257,808.17	411,137.03	361,868.37	327,977.49	268,605.32	299,975.41	339,253.03	332,759.97	4,503,736.79	
3,178.08	11,525.06	33,951.68	6,142.56	16,607.25	2,170.60	15,700.85	278.34	2,302.51	2,459.41	8,718.15	0.00	103,034.49	
282.13	198.55	587.36	3,072.08	383.64	94.99	1,900.90	464.00	0.00	958.13	915.29	2,953.05	11,810.12	
0.00	3,064.18	3,059.32	744.64	384.04	384.04	1,030.50	384.04	384.04	0.00	0.00	383.64	9,818.44	
1,925.68	968.19	772.82	1,662.87	3,871.37	2,266.86	5,347.21	3,163.33	6,964.99	2,853.95	4,169.12	995.09	34,961.48	
598.20	308.72	649.48	1,129.09	384.46	438.37	336.83	1,110.87	1,833.69	676.01	0.00	0.00	7,465.72	
0.00	81.24	11.39	0.00	0.00	0.00	0.00	0.00	0.00	364.87	132.19	398.42	988.11	
0.00	0.00	0.00	0.00	0.00	0.00	63.38	0.00	0.00	0.00	0.00	0.00	63.38	
782.69	451.48	178.82	394.81	447.38	452.69	75.19	4,192.00	118.27	198.94	210.86	66.31	7,569.44	
0.00	11.02	0.00	1,013.76	341.50	0.00	0.00	3,407.40	0.00	0.00	0.00	0.00	4,773.68	
22,454,160.88	23,042,703.84	23,851,867.00	29,013,956.22	29,589,138.68	33,056,747.63	31,221,793.43	32,511,167.15	32,460,950.17	33,193,478.11	33,301,268.82	32,361,149.40	356,058,381.33	
													
												5,108,861.79	
												5,108,861.79	

N
SUBTOTAL:

4403	SOBRA 100-133% M&F	0.00	0.00	0.00	0.00	115.08	0.00	0.00	0.00	0.00	0.00	0.00	114.91	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	100.87	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	475.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	227.07	113.90	227.80	1,524.18	1,263.32	1,497.66	1,288.17	823.42	943.08	809.44	772.59	1,444.55	
4413	SOBRA 100-133% M&F
6	2,472,060.61	2,222,646.29	2,028,673.87	5,518,655.29	5,786,559.34	6,504,075.28	6,148,562.04	6,281,853.69	6,360,847.53	6,306,691.64	6,271,339.25	5,994,471.04	
4414	SOBRA 100-133% MALE	1,124,482.78	1,019,075.04	944,477.21	2,115,166.99	2,156,414.79	2,437,464.16	2,188,063.14	2,221,233.03	2,200,581.66	2,169,490.27	2,121,030.05	2,083,693.84	
4415	SOBRA 100-133% FEMA L	1,627,175.04	1,485,905.55	1,372,014.41	3,133,836.80	3,215,261.55	3,650,054.64	3,297,801.80	3,368,365.36	3,322,121.30	3,246,602.37	3,211,695.46	3,134,880.51	
441B	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.88	26.41	0.00	292.81	0.00	
441C	SOBRA 100-133% M&F
6	16,933.27	18,946.08	66,346.90	88,725.94	53,097.98	60,583.43	66,675.86	64,738.37	57,107.10	75,382.03	74,286.55	68,635.86	
441D	SOBRA 100-133% MALE	21,389.49	17,226.07	66,017.92	64,560.80	48,242.69	43,363.06	43,378.72	50,898.34	47,069.01	50,498.55	77,331.59	62,338.55	
441E	SOBRA 100-133% FEMA	15,755.99	20,553.56	83,770.13	68,104.17	69,588.51	70,370.00	62,662.32	70,878.23	44,032.92	59,569.76	91,084.99	76,127.75	

229.99	
100.87	
475.25	
10,935.18	
61,896,435.87	
22,781,172.96	
34,065,714.79	
321.10	
711,459.37	
592,314.79	
732,498.33	

6

<

L

ACUTE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION
4424

SOBRA 100-133% MALE

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER
162.83

NOVEMBER
119.41

DECEMBER
0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

282.24

4425

SOBRA 100-133% FEMA

L
SUBTOTAL:

0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	224.33	0.00

5,278,024.25	4,784,466.49	4,561,528.24     10,991,313.12     11,330,662.67     12,767,408.23    11,808,432.05     12,058,792.32     12,032,729.01     11,909,044.06     11,848,057.62     11,421,707.01

224.33

120,792,165.07

619,991.83

619,991.83

9944	BIRTH SUPP PAYMENT	48,525.79	80,265.10	17,579.74	18,591.85	74,906.38	44,864.51	61,038.67	43,525.27	66,299.67	79,955.13	48,000.91	36,438.81	
SUBTOTAL:	48,525.79	80,265.10	17,579.74	18,591.85	74,906.38	44,864.51	61,038.67	43,525.27	66,299.67	79,955.13	48,000.91	36,438.81	

S

4517	BC PATIENT FEMALE 2 1	6,031.34	6,350.82	6,499.88	8,177.94	8,370.90	10,265.31	8,321.32	8,321.32	7,817.11	5,149.15	7,006.85	7,432.72	
4518	BC PATIENT FEMALE 4	112,672.67	110,350.85	110,314.38	108,889.84	103,615.29	121,495.14	105,250.41	104,058.38	99,652.24	92,974.64	84,926.51	81,931.78	
4519	BC PATIENT FEMALE 6 5	273.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.00	718.61	0.00	74.95	322.70	63.42	0.00	0.00	0.00	570.61	112.98	1,239.13	
451H	BC PATIENT FEMALE 4 5	3,437.97	2,627.92	3,114.12	334.55	1,454.95	1,178.69	1,124.40	2,413.66	0.00	2,527.08	1,523.59	1,534.05	
4617	CC PATIENT FEMALE 2 1	6,156.87	6,362.76	6,506.30	6,551.79	6,511.95	7,783.26	7,040.15	7,040.15	7,040.15	6,940.73	7,066.43	6,540.13	
4618	CC PATIENT FEMALE 4 5	7,757.51	7,379.70	6,916.51	7,031.99	7,031.99	7,891.31	6,117.15	6,117.15	6,229.57	5,778.61	5,398.90	4,540.53	
4619	CC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,015.62	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	323.65	0.00	217.69	443.57	284.85	0.00	0.00	0.00	655.05	471.67	0.00	
461H	CC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	513.13	0.00	0.00	0.00	
461J	CC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	84.12	0.00	0.00	0.00	0.00	0.00	
9946	SB KICK PAYMENT FOR	0.00	0.00	0.00	0.00	5,938.12	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	136,329.63	134,114.31	133,351.19	131,278.75	133,689.47	148,961.98	127,937.55	127,950.66	121,252.20	114,595.87	107,522.55	103,218.34	

89,744.66	
1,236,132.13	
273.27	
3,102.40	
21,270.98	
81,540.67	
78,190.92	
1,015.62	
2,396.48	
513.13	
84.12	
5,938.12	
1,520,202.50	

5

5

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	119.15	119.15	119.15	1,518.09	1,518.09	1,560.36	1,518.09	1,518.09	1,518.09	1,518.09	1,518.09	1,518.09	
8700	SSI DISABLED FREEDO M	1,387,627.33	1,409,227.99	1,427,434.60	1,601,635.36	1,588,056.71	1,637,025.33	1,591,790.75	1,567,952.60	1,599,792.12	1,604,864.57	1,597,994.49	1,621,960.64	
870Z	SSI DISABLED FREEDO M	14,851.04	13,861.37	11,262.22	8,619.47	2,040.24	6,583.34	4,961.16	4,382.09	4,341.45	2,575.34	7,284.36	6,159.80	
8710	SSI DISABLED FREEDO M	257,066.42	281,571.85	279,236.21	280,748.11	281,893.20	315,011.51	287,131.28	286,851.00	280,388.82	273,346.67	266,985.46	260,667.98	
871Z	SSI DISABLED FREEDO M	43,575.80	38,994.92	27,502.94	20,641.47	11,801.66	14,268.11	3,069.41	20,858.59	1,881.08	11,704.41	20,349.19	15,690.38	
8720	SSI DISABLED FREEDO	165,188.17	161,572.52	163,088.68	196,297.59	193,686.35	206,157.70	192,992.30	179,145.98	176,003.66	175,595.42	172,079.24	167,119.75	
872Z	SSI DISABLED FREEDO M	1,871.66	508.27	103.48	1,383.63	2,517.01	116.45	59.39	185.54	317.70	0.00	283.12	332.04	
	1,870,299.57	1,905,856.07	1,908,747.28	2,110,843.72	2,081,513.26	2,180,722.80	2,081,522.38	2,060,893.89	2,064,242.92	2,069,604.50	2,066,493.95	2,073,448.68	

14,062.53	
18,635,362.49	
86,921.88	
3,350,898.51	
230,337.96	
2,148,927.36	
7,678.29	
24,474,189.02	

M

SUBTOTAL:

6,072,357,087.20

467,034,603.84	468,726,485.92	471,960,427.06	506,083,311.72	504,236,168.44	590,375,377.87	508,709,012.98	510,733,293.73	511,657,811.42	510,156,435.37	509,264,948.85	513,419,210.00	

TOTAL:

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1001	TANF < 1 M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	-1.00		0.00		
1003	TANF 06-13 M & F WIT	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00		11.00		
1004	TANF 14-20 MALE WITH	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	2.00		4.00		
1005	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.00	5.00		9.00		
1006	TANF 21-44 MALE WITH	297.30	350.67	391.93	80.61	84.85	84.84	88.85	86.17	94.90	91.53	95.87	107.41		1,854.93		
1007	TANF 21-44 FEMALE WI	579.79	671.41	741.47	172.66	178.52	167.20	180.73	174.06	161.31	162.62	158.27	179.71		3,527.75		
1008	TANF 45-64 M & F WIT	870.42	1,013.58	1,168.84	270.09	273.04	266.32	287.84	284.32	268.18	265.48	254.95	279.25		5,502.31		
1009	TANF 65+ M & F WITH	306.00	373.68	430.56	102.88	96.13	94.11	87.56	94.00	98.74	96.20	98.15	116.17		1,994.18		
100F	TANF 21-44 MALE WITH	18.22	19.60	6.47	7.53	2.94	4.64	1.60	0.68	2.28	1.13	5.67	4.34		75.10		
100G	TANF 21-44 FEMALE WI	29.70	24.31	19.52	3.15	5.45	1.70	3.97	0.27	11.52	3.98	8.95	5.34		117.86		
100H	TANF 44-64 M & F WIT	97.51	98.86	32.85	17.79	2.09	6.52	15.70	13.25	3.20	13.68	27.37	11.53		340.35		
100J	TANF 65+ M & F WITH	73.60	39.19	4.37	7.48	0.00	1.80	1.15	0.00	3.46	0.80	6.79	12.77		151.41		
1011	TANF <1 M & F NON-ME	14,502.91	14,510.24	13,463.57	13,936.63	14,198.27	14,300.74	13,670.15	13,656.55	13,345.44	12,835.13	12,460.04	12,425.06		163,304.73		
1012	TANF 01-05 M & F NON	41,759.21	34,503.32	30,981.55	27,621.68	24,016.57	21,026.70	18,892.95	16,696.94	15,209.33	14,700.46	14,676.00	16,436.17		276,520.88		
1013	TANF 06-13 M & F NON	68,866.70	57,435.45	51,559.68	45,958.63	39,586.45	34,097.21	29,354.28	25,504.12	23,266.32	21,934.52	21,721.74	24,270.39		443,555.49		
1014	TANF 14-20 MALE NON-	15,523.91	13,919.00	12,939.58	11,807.22	10,522.54	9,495.84	8,497.93	7,632.07	7,156.78	6,746.33	6,605.34	7,312.60		118,159.14		
1015	TANF 14-20 FEMALE N	19,492.05	17,891.08	16,863.02	14,601.29	13,172.47	12,418.39	11,424.34	10,412.75	9,939.42	9,519.63	9,427.12	10,189.15		155,350.71		
1016	TANF 21-44 MALE NON-	32,422.89	35,110.56	38,554.07	24,200.36	24,611.24	24,754.24	24,834.01	24,572.59	24,326.12	23,298.38	23,377.72	24,748.94		324,811.12		
1017	TANF 21-44 FEMALE N O	100,171.76	104,138.61	110,548.82	79,561.23	79,226.74	80,892.09	80,005.97	78,007.69	76,290.22	72,598.93	72,177.44	75,591.91		1,009,211.41		
1018	TANF 45-64 M & F NON	26,326.13	28,376.39	30,996.33	18,878.67	18,943.85	19,080.68	19,188.73	19,070.86	19,142.51	18,244.50	18,321.31	19,381.94		255,951.90		
1019	TANF 65+ M & F NON-M	122.25	133.13	152.05	81.72	80.78	86.25	84.76	80.07	78.00	75.16	73.99	81.00		1,129.16		
101A	TANF < 1 M & F NON-M	1,323.68	1,107.58	523.24	1,443.78	1,155.18	1,652.91	1,382.43	767.94	1,007.34	964.72	1,115.26	1,087.17		13,531.23		
101B	TANF 01-05 M & F NON	323.00	173.98	234.10	366.13	146.78	232.53	252.01	191.29	165.58	285.11	644.97	754.82		3,770.30		
101C	TANF 06-13 M & F NON	235.43	179.19	176.48	403.54	132.78	157.92	91.82	90.90	184.00	389.82	1,127.66	850.09		4,019.63		
101D	TANF 14-20 MALE NON-	182.94	145.97	69.82	167.74	56.94	64.69	56.71	53.53	72.46	152.48	307.37	265.26		1,595.91		
101E	TANF 14-20 FEMALE N O	278.91	237.91	174.02	171.86	90.58	108.68	115.54	100.32	138.81	239.35	342.98	391.49		2,390.45		
101F	TANF 21-44 MALE NON-	2,653.94	2,660.54	1,444.98	1,220.10	625.84	709.14	721.44	699.27	848.75	1,162.68	1,411.06	1,357.11		15,514.85		
101G	TANF 21-44 FEMALE N O	4,819.02	4,659.58	2,737.74	2,315.36	1,601.46	1,369.81	1,564.77	1,543.92	1,723.94	2,355.55	2,815.28	2,934.43		30,440.86		
101H	TANF 44-64 M & F NON	1,604.09	1,643.02	919.13	633.40	373.54	367.88	446.09	541.55	401.37	602.26	703.65	704.16		8,940.14		
101J	TANF 65+ N & F NON-M	31.66	19.50	26.80	1.88	6.42	11.98	5.21	4.38	0.00	7.82	0.31	24.63		140.59		
1021	TANF <1 M & F WITH Q	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00		3.00		
1025	TANF 14-20 FEMALE WI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	1.00	2.00	0.00		4.00		
1026	TANF 21-44 MALE WITH	136.90	188.45	227.64	39.06	37.00	47.00	48.64	46.48	43.25	42.00	38.70	37.10		932.22		
1027	TANF 21-44 FEMALE WI	222.81	306.53	369.65	69.00	73.08	74.70	66.38	66.43	54.28	55.00	55.25	56.66		1,469.77		
1028	TANF 45-64 M & F WIT	257.30	401.73	481.56	80.44	93.69	103.67	92.98	96.98	89.00	73.28	71.93	73.06		1,915.62		
1029	TANF 65+ M & F WITH	125.59	199.79	245.43	39.43	45.00	49.00	48.00	47.09	47.00	42.50	34.90	29.53		953.26		

O

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
102F	TANF 21-44 MALE WITH	0.00	2.12	0.13	1.93	0.00	0.00	0.00	0.00	0.00	0.00	0.29	0.00		4.47		
102G	TANF 21-44 FEMALE WI	4.49	1.22	1.63	0.00	0.00	2.03	0.61	0.93	0.00	0.00	0.00	2.32		13.23		
102H	TANF 44-64 M & F WIT	1.88	12.13	4.43	0.00	3.95	0.00	0.00	0.00	0.00	1.00	0.06	4.32		27.77		
102J	TANF 65+ M & F WITH	2.37	2.17	0.00	5.12	0.00	0.00	0.00	0.00	0.00	0.50	0.00	1.46		11.62		
2100	SSI AGED WITH MEDIC	3,945.61	3,902.67	3,829.80	4,137.95	4,214.96	4,359.38	4,391.75	4,443.21	4,424.63	4,446.33	4,553.99	4,923.16		51,573.44		
210Z	SSI AGED WITH MEDIC A	450.53	377.60	249.36	270.80	307.49	255.39	261.89	279.68	249.44	332.43	566.00	335.03		3,935.64		
2110	SSI AGED NON-MEDICA	5,996.37	5,885.71	5,990.17	6,174.44	6,096.62	6,033.73	5,916.16	5,946.07	5,919.51	5,655.14	5,618.00	5,435.91		70,667.83		
211Z	SSI AGED NON-MEDICA R	323.02	229.89	155.90	195.56	189.76	198.32	204.42	302.80	201.80	241.71	313.56	264.98		2,821.72		
2120	SSI AGED WITH QMB	16,192.79	16,392.49	16,583.32	22,041.82	22,291.57	22,547.75	22,646.53	22,893.84	23,701.93	23,677.76	25,003.02	26,057.79		260,030.61		
212Z	SSI AGED WITH QMB P P	60.27	61.77	97.36	67.89	76.81	46.22	61.93	49.50	50.08	88.93	70.75	92.75		824.26		
2200	SSI DISABLED WITH M E	3,600.36	3,525.64	3,506.17	3,597.87	3,563.55	3,636.76	3,612.73	3,624.31	3,615.47	3,662.79	4,382.29	4,834.53		45,162.47		
220Z	SSI DISABLED WITH M E	236.76	251.22	272.95	225.46	135.76	185.47	192.40	201.39	176.45	205.44	260.05	243.29		2,586.64		
2210	SSI DISABLED NON-ME D	57,143.85	56,902.31	56,909.61	56,665.32	56,824.83	57,078.70	56,900.23	56,841.86	56,796.45	56,605.18	56,823.26	56,558.28		682,049.88		
221Z	SSI DISABLED NON-ME D	983.56	949.62	911.29	771.37	711.59	852.26	792.85	749.12	729.04	960.29	877.80	799.27		10,088.06		
2220	SSI DISABLED WITH Q	24,588.70	24,755.94	24,980.93	25,099.07	25,302.15	25,453.16	25,532.84	25,732.27	26,359.81	26,703.46	27,007.03	27,335.27		308,850.63		
222Z	SSI DISABLED WITH Q M	62.38	77.46	109.31	43.36	32.28	18.61	35.83	62.57	35.61	39.58	49.78	62.94		629.71		
2300	SSI BLIND WITH MEDIC	28.24	25.87	24.00	25.00	25.00	27.29	28.00	29.44	28.48	28.86	28.00	28.00		326.18		
230Z	SSI BLIND WITH MEDIC	4.45	0.00	0.00	0.00	0.00	14.70	0.00	1.00	1.51	1.13	0.00	0.00		22.79		
2310	SSI BLIND NON-MEDIC A	428.12	430.04	436.15	439.00	442.38	450.43	460.83	465.17	466.67	458.14	457.93	458.51		5,393.37		
231Z	SSI BLIND NON-MEDIC A	8.02	26.80	11.45	13.31	4.79	28.85	12.72	11.68	5.15	7.79	2.58	0.06		133.20		
2320	SSI BLIND WITH QMB	207.48	205.10	207.96	204.24	202.09	202.70	201.56	200.99	201.97	205.99	207.12	209.56		2,456.76		
232Z	SSI BLIND WITH QMB P	0.00	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.03		
4301	SOBRA CHILD <1 M & F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.51	1.00	-1.51	0.00		0.00		
4302	SOBRA CHILD 01-05 M	5.00	3.99	2.01	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.32	3.00		29.32		
4303	SOBRA CHILD 06-13 M	2.00	2.00	2.43	2.12	4.55	3.00	3.00	2.00	2.64	2.00	3.45	3.55		32.74		
4304	SOBRA CHILD 14-20 MA	1.00	1.00	1.00	0.00	-1.00	1.00	0.00	0.00	1.77	2.00	2.92	2.00		11.69		
4305	SOBRA CHILD 14-20 FE	1.00	1.19	1.13	1.25	0.62	2.64	3.00	4.00	1.36	4.16	6.00	5.00		31.35		
430A	SOBRA CHILD < 1 M &	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.93	0.00	-2.93	0.00		0.00		
430B	SOBRA CHILD 01-05 M	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4.67	0.00		5.67		
430C	SOBRA CHILD 06-13 M	0.00	0.00	1.56	0.87	1.46	0.00	0.00	0.00	0.35	0.00	0.00	0.00		4.24		
430D	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.86	0.00	0.74	0.00		3.60		
430E	SOBRA CHILD 14-20 FE	0.00	0.61	0.86	-0.25	-0.61	0.00	0.00	0.00	0.00	0.83	0.00	0.00		1.44		
4311	SOBRA CHILD <1 M & F	37,929.50	37,878.33	35,410.54	38,243.54	39,448.82	39,855.27	36,542.16	37,521.97	38,470.88	38,884.18	38,666.89	38,878.27		457,730.35		
4312	SOBRA CHILD 01-05 M	150,215.05	158,567.13	166,797.13	169,987.40	176,662.82	181,963.70	184,620.83	187,042.23	187,523.41	187,773.81	186,904.80	185,561.21		2,123,619.52		
4313	SOBRA CHILD 06-13 M	200,525.14	216,198.75	230,401.99	209,630.58	214,915.68	222,121.13	225,551.43	227,738.94	230,469.30	230,998.22	230,661.10	232,738.07		2,671,950.33		
4314	SOBRA CHILD 14-20 MA	49,529.14	51,683.40	55,100.09	50,842.03	51,365.72	52,543.25	53,287.11	54,232.15	54,459.41	54,035.98	53,355.62	54,541.49		634,975.39		

A

R

M

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
49,621.28	51,750.56	55,046.80	51,049.83	51,597.87	53,035.15	53,708.18	54,641.30	54,653.79	54,158.61	53,272.15	54,608.61	637,144.13	
1,144.43	1,199.85	596.85	1,439.14	966.70	1,089.87	160.81	750.96	650.09	851.78	667.94	1,026.77	10,545.19	
7,397.32	7,233.01	5,425.60	5,749.99	4,037.79	3,916.92	4,211.85	4,585.99	4,476.73	5,827.16	6,095.21	6,543.17	65,500.74	
9,664.24	10,386.87	6,895.96	6,005.68	4,413.27	4,396.02	4,614.16	4,716.20	4,741.13	5,853.12	7,632.93	6,179.51	75,499.09	
2,729.60	2,547.00	1,740.21	1,587.56	1,149.00	1,156.75	1,160.65	1,263.87	955.56	1,237.70	1,622.26	1,799.08	18,949.24	
2,479.42	2,548.58	1,750.39	1,574.77	1,152.27	1,097.16	1,159.06	1,285.02	1,062.29	1,324.41	1,467.39	1,760.33	18,661.09	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.93	0.87	0.00	0.00	0.00	1.80	
3.00	0.00	2.00	3.00	1.00	2.67	0.00	0.00	2.00	6.00	4.41	1.00	25.08	
7.00	0.00	1.00	5.06	3.56	14.00	3.77	3.00	1.00	3.00	3.00	1.46	45.85	
4.00	0.00	1.00	1.00	1.56	3.00	0.00	0.00	0.90	2.00	1.00	0.00	14.46	
2.00	1.00	2.00	0.00	0.00	2.00	0.00	0.00	2.00	0.00	0.00	0.00	9.00	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.06	0.00	0.00	0.00	0.00	0.06	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.58	0.00	2.58	
44.60	44.25	49.08	47.32	34.99	31.66	30.85	40.94	42.35	47.69	51.52	54.98	520.23	
2.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	3.47	5.00	26.47	
3.37	3.12	2.16	1.67	0.83	2.31	1.57	3.02	0.64	5.29	9.07	3.92	36.97	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.00	0.03	
6.00	7.38	7.00	6.00	6.20	10.00	8.12	9.00	9.00	11.00	12.64	9.03	101.37	
4,442.88	4,822.40	5,139.99	5,199.98	5,482.55	4,565.96	4,070.37	4,268.62	4,431.19	4,526.09	4,619.54	4,580.43	56,150.00	
19,288.96	21,436.17	23,639.77	25,479.28	26,864.80	23,372.29	20,244.07	21,217.76	22,069.97	22,294.51	23,000.11	23,528.96	272,436.65	
70.02	76.99	80.34	89.62	89.99	85.34	76.00	68.18	74.99	74.40	73.95	76.83	936.65	
0.00	1.61	0.00	0.00	0.80	0.00	0.00	0.00	0.00	0.00	2.34	0.96	5.71	
380.96	386.50	238.63	248.98	217.33	220.16	268.38	241.64	238.08	369.78	273.92	382.21	3,466.57	
1,656.15	1,536.50	1,187.87	1,135.67	915.46	931.65	1,074.80	1,009.58	1,035.87	1,565.52	1,353.05	1,585.47	14,987.59	
7.91	23.95	1.29	0.93	0.00	1.63	0.00	3.63	11.90	6.68	15.02	2.16	75.10	
9.11	11.00	8.99	9.12	11.00	10.67	9.12	14.00	23.00	27.70	26.79	24.00	184.50	
0.00	1.00	1.00	1.00	1.00	1.00	1.32	1.00	0.00	1.00	1.00	1.00	10.32	
0.87	0.00	0.00	0.00	0.00	0.00	0.87	0.00	0.00	1.30	0.87	0.00	3.91	
0.00	0.00	0.00	0.00	0.00	0.00	0.48	0.00	0.00	0.00	0.00	0.00	0.48	
-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	
985,098.82	1,002,906.76	1,020,305.89	932,589.99	929,217.83	933,562.13	923,582.78	923,044.29	922,563.28	920,187.40	924,210.81	941,280.09	11,358,550.07	
													
												4,715.00	
												110.00	
												368.00	
												25,197.00	

RATE CODE	DESCRIPTION 4315	SOBRA CHILD 14-20 FE
431A	SOBRA CHILD < 1 M &

431B	SOBRA CHILD 01-05 M

431C	SOBRA CHILD 6-13 M&
F
431D	SOBRA CHILD 14-20 MA

431E	SOBRA CHILD 14-20 FE

4321	SOBRA CHILD <1 M & F

4322	SOBRA CHILD 01-05 M

4323	SOBRA CHILD 06-13 M

4324	SOBRA CHILD 14-20 MA

4325	SOBRA CHILD 14-20 FE

432A	SOBRA CHILD < 1 M &

432B	SOBRA CHILD 01-05 M

5007	SOBRA PREG 21-44 FE
M
5008	SOBRA PREG 45-64 FE
M
500G	SOBRA PREG 21-44 FE
M
500H	SOBRA PREG 45-64 FE
M
5013	SOBRA PREG 09-13 FE
M
5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
501C	SOBRA PREG 09-13 FE
M
501E	SOBRA PREG 14-20 FE
M
501G	SOBRA PREG 21-44 FE
M
501H	SOBRA PREG 45-64 FE
M
5027	SOBRA PREG 21-44 FE
M
5028	SOBRA PREG 45-64 FE
M
502G	SOBRA PREG 21-44 FE
M
502H	SOBRA PREG 45-64 FE
M
5510	SOBRA FPS FEMALE W
IT
SUBTOTAL:

9910	TANF & SOBRA CHILDR E	571.00	500.00	476.00	365.00	407.00	441.00	385.00	336.00	342.00	325.00	296.00	271.00	
9920	SSI W/MEDICARE KICK	11.00	11.00	12.00	10.00	12.00	6.00	10.00	7.00	9.00	8.00	6.00	8.00	
9921	SSI W/O MEDICARE KIC	42.00	29.00	33.00	30.00	29.00	40.00	30.00	25.00	30.00	26.00	30.00	24.00	
9950	S.O.B.R.A. KICK PAYM	2,053.00	2,266.00	2,452.00	2,223.00	2,141.00	2,155.00	1,935.00	2,070.00	2,020.00	1,917.00	1,989.00	1,976.00	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	2,677.00	2,806.00	2,973.00	2,628.00	2,589.00	2,642.00	2,360.00	2,438.00	2,401.00	2,276.00	2,321.00	2,279.00		30,390.00		

SUBTOTAL:

3100	TRANSPLANT OPTION 1	4.24	5.41	5.00	5.00	5.73	6.00	6.00	6.00	4.00	3.20	4.00	3.00	
310Z	TRANSPLANT OPTION	5.74	4.58	0.00	0.00	0.26	0.00	0.00	0.00	0.00	4.80	0.00	0.00	
	9.98	9.99	5.00	5.00	5.99	6.00	6.00	6.00	4.00	8.00	4.00	3.00	

57.58	
15.38	
72.96	

1
SUBTOTAL:

1106	TANF EXPANDED 21-44	537.81	462.89	398.21	925.69	903.23	849.28	816.35	826.08	834.14	802.53	787.22	780.80	
1107	TANF EXPANDED 21-44	1,129.92	997.50	888.94	1,799.36	1,696.49	1,573.87	1,565.40	1,575.51	1,580.33	1,557.31	1,524.57	1,542.45	
1108	TANF EXPANDED 45-64	1,914.12	1,697.63	1,569.17	3,028.13	2,948.30	2,834.97	2,802.58	2,798.46	2,862.28	2,828.98	2,781.94	2,822.45	
1109	TANF EXPANDED 65+
M&	634.27	568.85	533.33	1,133.83	1,112.02	1,083.36	1,081.24	1,095.22	1,106.90	1,116.58	1,089.36	1,113.90	
110F	TANF EXPANDED 21-44	18.70	3.61	8.79	22.01	20.26	9.49	10.14	18.25	11.97	24.97	35.05	18.37	
110G	TANF EXPANDED 21-44	2.64	1.64	12.64	32.68	21.58	19.38	21.33	15.44	20.04	31.25	45.95	21.61	
110H	TANF EXPANDED 45-64	0.86	0.82	67.38	87.22	58.75	32.60	42.40	57.76	46.32	80.51	81.55	90.90	
110J	TANF EXPANDED 65+
M&	0.00	2.64	37.58	16.71	13.76	17.67	19.64	13.69	13.78	26.53	24.04	17.10	
1111	TANF EXPANDED <1 M
&F	12.00	8.00	1.36	3.00	3.00	3.00	2.00	1.00	0.00	0.00	0.00	0.03	
1112	TANF EXPANDED 01-05	390.00	311.16	275.00	239.06	180.00	142.15	98.00	75.93	62.43	52.21	32.51	31.00	
1113	TANF EXPANDED 06-13	1,229.70	991.16	871.12	743.21	581.97	473.00	364.77	279.99	239.75	211.80	163.96	141.96	
1114	TANF EXPANDED 14-20	683.08	531.13	454.69	720.61	674.58	643.29	611.64	594.73	562.93	555.55	544.77	539.40	
1115	TANF EXPANDED 14-20	1,447.98	1,085.47	918.24	1,792.37	1,760.39	1,913.82	2,015.99	1,906.73	1,901.06	1,929.19	1,973.41	1,927.49	
1116	TANF EXPANDED 21-44	20,507.88	17,866.93	15,873.76	30,211.21	29,789.76	30,709.98	30,771.06	30,480.12	30,772.99	30,543.83	30,185.55	30,483.94	
1117	TANF EXPANDED 21-44	46,392.97	40,134.22	35,306.60	65,385.73	63,972.60	67,528.88	69,148.62	68,569.96	69,593.09	69,920.13	69,255.60	69,914.00	
1118	TANF EXPANDED 45-64	16,838.19	14,850.87	13,477.80	26,098.91	25,902.71	26,772.92	26,932.72	26,739.25	26,872.04	26,216.44	25,887.70	26,284.53	
1119	TANF EXPANDED 65+
M&	91.37	83.00	78.65	120.22	115.24	120.42	117.31	117.99	114.95	102.97	97.76	93.93	
111A	TANF EXPANDED <1 M
&F	0.00	0.00	-0.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
111B	TANF EXPANDED 01-05	0.00	0.83	0.00	0.00	0.00	0.25	0.00	4.06	11.54	4.76	0.48	0.00	
111C	TANF EXPANDED 06-13	1.00	0.00	0.00	2.80	5.00	1.00	0.22	0.00	0.25	0.20	2.32	10.03	
111D	TANF EXPANDED 14-20	0.54	5.28	14.31	10.92	28.27	20.03	14.80	24.68	13.26	23.95	50.34	59.58	
111E	TANF EXPANDED 14-20	7.24	9.73	31.24	50.14	45.83	35.66	39.98	48.74	38.58	58.92	58.68	108.07	
111F	TANF EXPANDED 21-44	101.48	104.36	529.77	956.02	855.10	845.14	904.49	871.90	814.21	1,136.65	1,179.86	1,323.81	
111G	TANF EXPANDED 21-44	197.09	224.68	1,011.19	1,606.35	1,326.72	1,205.40	1,450.30	1,305.36	1,321.77	1,929.90	2,023.87	2,058.47	
111H	TANF EXPANDED 45-64	28.12	127.83	423.04	661.57	557.64	690.42	593.63	662.72	516.88	687.25	789.64	598.22	
111J	TANF EXPANDED 65+
M&	22.31	0.00	3.65	34.70	3.11	10.46	38.52	11.84	7.65	10.01	7.15	8.21	
1125	TANF EXPANDED 14-20	1.00	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	172.31	149.33	132.42	154.79	225.85	292.60	286.79	298.57	305.48	308.45	293.21	303.85	
1127	TANF EXPANDED 21-44	382.43	351.28	318.88	364.36	502.11	662.14	695.91	715.93	726.52	708.24	680.11	687.22	
1128	TANF EXPANDED 45-64	446.94	399.71	372.79	452.31	621.33	801.22	828.64	864.66	892.53	868.70	841.98	852.28	
1129	TANF EXPANDED 65+	194.69	165.94	155.60	174.92	237.67	308.56	337.68	352.83	387.60	407.26	392.20	378.09	

8,924.23	
17,431.65	
30,889.01	
11,668.86	
201.61	
246.18	
647.07	
203.14	
33.39	
1,889.45	
6,292.39	
7,116.40	
20,572.14	
328,197.01	
735,122.40	
282,874.08	
1,253.81	
-0.35	
21.92	
22.82	
265.96	
532.81	
9,622.79	
15,661.10	
6,336.96	
157.61	
1.00	
2,923.65	
6,795.13	
8,243.09	
3,493.04	

M&

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	2.56	1.63	1.86	1.03	8.90	10.61	3.82	2.22	3.52	5.43	41.58	
0.00	3.44	3.22	4.87	3.32	2.59	5.88	4.49	0.66	6.90	7.96	6.94	50.27	
0.03	0.00	2.92	11.24	7.45	10.73	1.72	11.77	11.26	11.28	9.43	9.69	87.52	
0.00	0.00	16.30	1.06	10.74	12.39	3.26	2.13	4.67	15.48	4.33	0.16	70.52	
518.42	487.04	456.81	384.84	352.94	389.52	358.97	366.07	339.83	345.04	387.06	445.94	4,832.48	
304.76	401.03	244.49	252.11	184.84	258.54	156.32	178.68	158.85	229.94	319.55	282.64	2,971.75	
1,134.27	1,056.52	991.15	391.57	359.68	303.63	245.77	233.03	193.72	150.62	160.48	146.05	5,366.49	
13.94	39.82	16.61	7.34	6.63	7.25	2.59	5.75	6.29	7.34	37.09	18.05	168.70	
26,853.34	26,842.37	26,813.66	21,188.36	20,913.29	20,739.95	20,647.27	20,592.33	20,269.68	19,541.12	18,492.48	18,084.57	260,978.42	
86.51	60.16	53.24	60.10	29.69	45.74	42.01	76.94	29.80	150.87	155.96	75.69	866.71	
0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	9.00	
2.00	2.00	2.00	1.00	1.00	0.99	0.00	0.00	0.00	0.00	0.00	0.00	8.99	
1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	12.00	
387.35	391.10	363.58	405.75	407.66	442.08	415.01	494.78	489.00	517.12	560.48	578.05	5,451.96	
198.57	225.21	193.65	131.93	83.98	116.36	132.48	134.20	147.53	167.33	186.26	142.79	1,860.29	
2,800.72	2,719.35	2,722.76	2,696.85	2,637.63	2,667.84	2,586.05	2,409.33	2,246.15	2,016.95	1,932.55	1,809.20	29,245.38	
66.87	64.13	55.86	42.68	36.03	53.53	35.64	46.78	33.27	70.93	40.11	42.37	588.20	
15,882.49	16,101.98	16,689.39	17,152.91	17,493.44	17,902.98	18,067.75	18,082.96	17,473.89	16,708.46	15,803.94	15,357.91	202,718.10	
70.33	62.70	88.07	53.98	24.93	36.36	21.97	45.62	35.04	30.43	24.42	45.55	539.40	
141,707.24	129,594.34	122,483.07	179,619.05	176,720.38	182,594.47	184,345.74	183,024.87	183,076.73	182,119.10	178,958.40	179,264.72	2,023,508.11	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

112F

TANF EXPANDED 21-44

112G

112H

TANF EXPANDED 21-44

TANF EXPANDED 45-64

112J

2400

240Z

2410

241Z

2420

242Z

2500

2510

2520

2600

260Z

2610

261Z

2620

262Z

TANF EXPANDED 65+
M&
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
NO
SSI AGED EXPANDED
NO
SSI AGED EXPANDED
WI
SSI AGED EXPANDED
WI
SSI BLIND EXPANDED
W
SSI BLIND EXPANDED
N
SSI BLIND EXPANDED
W
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

E
SUBTOTAL:

9911	SB PAYMENT FOR TAN F	105.00	122.00	113.00	177.00	141.00	253.00	239.00	218.00	217.00	190.00	221.00	182.00	
9922	SB PAYMENT FOR SSI E	2.00	3.00	4.00	1.00	2.00	2.00	2.00	1.00	2.00	2.00	0.00	0.00	
9923	SB PAYMENT FOR SSI	1.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	
	108.00	126.00	117.00	179.00	143.00	255.00	241.00	219.00	219.00	192.00	222.00	183.00	

2,178.00	
21.00	
5.00	
2,204.00	

E
SUBTOTAL:

3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	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:

3.00

3.00

119.51

88.69

1,053.50

523.47

23.00

11.83

3504	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	2.00	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	3.00	0.00	
3506	ADULT 40-100% MALE 2	15.63	8.90	13.05	13.05	7.72	10.06	5.00	6.91	8.90	7.96	9.94	12.39	
3507	ADULT 40-100% FEMAL E	14.06	5.76	7.00	9.81	14.00	7.25	6.00	4.43	7.54	4.00	5.31	3.53	
3508	ADULT 40-100% M&F 45	67.69	54.87	49.56	121.55	98.13	69.26	87.51	107.21	133.77	62.32	119.43	82.20	
3509	ADULT 40-100% M&F 65	55.05	55.40	53.33	83.77	57.40	32.42	27.35	25.71	44.14	37.86	28.88	22.16	
350F	ADULT 40-100% MALE 2	6.92	0.67	2.82	4.93	1.49	0.00	0.00	0.78	1.09	0.00	3.27	1.03	
350G	ADULT 40-100% FEMAL	0.00	0.00	0.00	3.82	0.00	0.67	0.00	2.55	2.12	1.00	1.67	0.00	

E

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8.97	10.81	15.38	19.39	2.86	8.01	6.08	43.39	36.45	16.21	43.59	-16.89	194.25	
10.92	7.57	0.00	3.22	0.60	14.29	1.57	27.30	10.18	4.13	45.06	5.30	130.14	
3,038.92	3,290.06	3,469.54	3,459.96	3,695.68	3,984.28	4,150.82	4,261.55	4,408.82	4,643.92	5,043.70	5,179.37	48,626.62	
3,734.50	3,945.56	4,139.94	4,065.25	4,323.63	4,633.53	4,803.34	4,969.94	5,049.15	5,286.55	5,638.66	5,659.26	56,249.31	
17,324.13	17,315.90	17,767.16	18,063.18	18,254.46	18,817.24	18,834.48	19,085.44	19,007.23	19,035.02	19,167.90	19,538.78	222,210.92	
14,579.12	14,409.13	14,673.49	14,867.88	14,928.18	15,251.61	15,287.12	15,557.04	15,572.16	15,678.27	15,657.45	15,968.20	182,429.65	
35,161.66	35,276.58	36,112.19	36,443.44	36,715.66	37,786.88	37,961.23	38,751.79	38,908.66	39,246.47	39,424.93	39,884.91	451,674.40	
39.09	36.01	35.99	49.54	31.82	42.79	27.61	16.17	21.12	36.20	39.73	41.70	417.77	
223.89	174.95	140.00	114.00	120.77	109.87	134.38	137.82	180.52	273.62	196.17	255.00	2,060.99	
215.10	215.28	142.27	157.72	109.73	122.58	178.18	146.03	170.39	277.89	207.36	187.89	2,130.42	
970.65	931.86	710.83	703.38	508.69	616.54	603.19	690.09	580.58	746.49	811.61	970.86	8,844.77	
687.03	645.80	559.94	543.04	370.45	528.33	509.10	549.46	412.09	455.23	567.89	555.38	6,383.74	
1,789.29	1,532.58	1,097.36	1,161.58	880.02	1,120.60	1,190.46	1,109.60	981.45	1,232.71	1,336.66	1,416.58	14,848.89	
40.88	22.67	29.32	20.45	46.89	6.12	18.38	4.00	9.50	5.00	50.21	2.00	255.42	
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	
3.00	0.00	0.00	0.00	2.00	0.70	2.00	-0.84	1.51	0.33	3.80	3.00	15.50	
1.41	3.21	0.00	1.00	1.00	1.74	2.00	2.00	2.00	1.13	3.00	2.56	21.05	
20.96	15.68	24.16	19.28	23.00	24.79	19.36	20.38	31.92	11.06	15.51	11.34	237.44	
6.00	10.00	4.00	14.03	10.06	9.93	6.32	6.00	12.80	4.00	8.00	0.00	91.14	
0.00	0.00	0.00	0.00	0.00	0.29	0.00	0.00	0.68	0.66	0.00	0.00	1.63	
0.00	0.77	0.00	0.03	0.00	0.00	0.00	0.00	0.00	0.86	0.00	0.43	2.09	
0.03	1.83	1.26	0.12	0.00	1.69	1.47	7.67	2.29	0.93	0.57	1.16	19.02	
0.00	0.00	0.00	4.96	0.83	4.06	0.67	1.00	0.19	0.00	0.00	0.00	11.71	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.50	4.00	2.00	7.50	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
34.74	33.74	30.14	41.29	39.44	33.46	43.59	41.41	51.51	27.39	29.76	29.97	436.44	
7.49	15.61	9.78	12.41	11.03	18.57	21.17	17.69	20.46	11.00	15.01	15.72	175.94	
88.23	98.60	92.80	188.88	141.71	124.05	151.66	136.11	176.40	105.58	162.23	144.52	1,610.77	
19.67	21.38	28.72	41.00	21.63	14.00	15.00	23.61	25.00	17.03	17.48	12.36	256.88	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.50	0.00	0.00	0.50	
5.51	8.57	6.12	3.49	3.21	1.63	4.63	3.19	2.71	10.94	27.31	2.48	79.79	
1.54	1.81	0.06	2.37	3.89	1.15	5.04	0.00	6.49	0.00	1.67	3.76	27.78	
14.58	15.74	30.56	13.97	3.56	15.97	8.47	6.57	24.14	23.22	24.92	11.46	193.16	
0.00	0.00	2.73	0.00	0.00	2.00	0.00	3.37	0.00	2.96	61.36	0.00	72.42	
9,839.70	10,160.23	10,470.29	10,275.58	10,661.47	11,028.29	10,985.15	10,908.23	11,573.42	11,875.78	12,180.03	12,007.80	131,965.97	
8,418.28	8,667.97	8,908.49	8,752.70	9,023.96	9,373.43	9,485.14	9,442.54	10,101.48	10,356.84	10,666.28	10,516.90	113,714.01	

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION 350H	ADULT 40-100% M&F 45
350J	ADULT 40-100% M&F 65

3514	ADULT 40-100% MALE 1

3515	ADULT 40-100% FEMAL
E
3516	ADULT 40-100% MALE 2

3517	ADULT 40-100% FEMAL
E
3518	ADULT 40-100% M&F 45

3519	ADULT 40-100% M&F 65

351D	ADULT 40-100% MALE 1

351E	ADULT 40-100% FEMAL
E
351F	ADULT 40-100% MALE 2

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

351J	ADULT 40-100% M&F 65

3525	ADULT 40-100% FEMAL
E
3526	ADULT 40-100% MALE 2

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

3529	ADULT 40-100% M&F 65

352F	ADULT 40-100% MALE 2

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

352J	ADULT 40-100% M&F 65

3704	ADULT <40% EXP MALE

3705	ADULT <40% EXP FEM
AL
3706	ADULT <40% EXP MALE

3707	ADULT <40% EXP FEM
AL
3708	ADULT <40% EXP M&F
4
3709	ADULT <40% EXP M&F
6
370D	ADULT <40% EXP MALE

370F	ADULT <40% EXP MALE

370G	ADULT <40% EXP FEM
AL
370H	ADULT <40% EXP M&F
4
370J	ADULT <40% EXP M&F
6
3714	ADULT <40% EXP MALE

3715	ADULT <40% EXP FEM
AL

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	58,247.03	58,634.00	61,113.02	62,941.19	63,352.21	65,477.71	64,345.30	64,160.17	63,772.18	62,788.77	61,171.53	61,807.55		747,810.66		
3717	ADULT <40% EXP FEM AL	34,827.18	34,929.63	36,183.66	37,298.36	37,725.55	38,555.88	38,148.00	38,016.92	37,902.65	37,621.35	36,585.22	36,777.99		444,572.39		
3718	ADULT <40% EXP M&F 4	72,820.34	73,231.71	75,412.07	76,737.78	77,207.05	78,744.45	77,238.57	77,221.85	77,398.51	76,783.65	75,941.94	76,543.96		915,281.88		
3719	ADULT <40% EXP M&F 6	80.88	80.74	94.53	128.19	96.22	106.84	65.67	53.17	64.80	96.00	117.10	86.72		1,070.86		
371D	ADULT <40% EXP MALE	580.76	572.41	352.26	309.50	300.26	275.48	271.17	290.30	403.43	555.83	499.01	515.01		4,925.42		
371E	ADULT <40% EXP FEM AL	519.38	449.84	305.73	319.68	204.57	230.72	240.99	282.80	320.66	471.45	427.34	400.79		4,173.95		
371F	ADULT <40% EXP MALE	4,244.00	4,145.00	2,990.61	2,888.14	2,110.81	2,317.84	2,239.00	2,376.69	2,973.23	3,078.43	3,120.30	3,359.83		35,843.88		
371G	ADULT <40% EXP FEM AL	2,410.81	2,215.92	1,619.33	1,656.46	1,211.17	1,233.71	1,297.56	1,433.00	1,335.77	1,717.13	1,472.03	2,098.09		19,700.98		
371H	ADULT <40% EXP M&F 4	3,754.97	3,389.75	2,459.44	2,612.62	2,030.56	2,177.41	2,352.17	2,479.90	2,389.86	2,935.28	2,921.25	3,332.38		32,835.59		
371J	ADULT <40% EXP M&F 6	2.98	2.00	16.46	13.76	23.12	9.87	0.32	0.00	1.00	3.00	45.07	0.00		117.58		
3724	ADULT <40% EXP MALE	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00		2.00		
3725	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.29	0.00		1.29		
3726	ADULT <40% EXP MALE	9.00	8.05	8.35	11.73	10.99	9.77	16.18	12.61	11.04	7.95	6.29	6.06		118.02		
3727	ADULT <40% EXP FEM AL	6.12	3.96	3.43	7.00	7.36	2.03	8.66	7.35	7.00	1.00	2.59	3.10		59.60		
3728	ADULT <40% EXP M&F	23.78	6.39	19.82	15.21	14.20	12.68	22.17	11.96	23.22	12.26	13.44	11.19		186.32		
3729	ADULT <40% EXP M&F 6	4.00	0.00	1.00	4.00	3.00	3.90	2.00	5.00	6.00	1.00	2.00	0.00		31.90		
372E	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.46	0.00		0.46		
372F	ADULT <40% EXP MALE	0.00	0.86	5.62	0.82	1.70	1.50	1.60	2.91	5.50	4.02	1.35	5.92		31.80		
372G	ADULT <40% EXP FEM AL	0.87	1.79	3.22	0.00	1.06	0.00	0.48	0.20	0.00	0.00	2.64	0.76		11.02		
372H	ADULT <40% EXP M&F 4	0.77	1.95	0.36	4.98	0.80	1.22	3.23	2.78	10.31	4.54	0.61	1.79		33.34		
372J	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.09	0.00	1.00	0.00	0.00	0.00	0.00		1.09		
	273,979.51	274,669.50	279,217.19	284,229.49	284,415.60	292,980.18	290,836.54	292,475.75	294,205.02	295,584.22	293,955.81	297,486.25		3,454,035.06		

4

AL

SUBTOTAL:

435.00

1,229.00

1,664.00

9935	BIRTH SUPP PAYMENT A	29.00	45.00	40.00	44.00	38.00	35.00	29.00	30.00	35.00	33.00	33.00	44.00	
9937	BIRTH SUPP PAYMENT	74.00	98.00	121.00	112.00	98.00	101.00	117.00	85.00	111.00	104.00	90.00	118.00	
SUBTOTAL:	103.00	143.00	161.00	156.00	136.00	136.00	146.00	115.00	146.00	137.00	123.00	162.00	

A

3904	NEWLY ELIGIBLE MALE	0.00	0.16	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	
3905	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2.00	2.00	
3906	NEWLY ELIGIBLE MALE	6.92	5.18	4.00	8.20	10.80	13.50	12.09	12.16	21.25	11.52	23.29	16.59	
3907	NEWLY ELIGIBLE FEMA L	14.99	10.72	9.00	11.72	6.53	6.41	3.00	4.15	6.00	3.33	11.90	5.73	
3908	NEWLY ELIGIBLE M&F 4	71.56	53.47	39.78	80.22	96.10	107.50	107.44	129.96	240.11	78.60	148.04	106.01	
3909	NEWLY ELIGIBLE M&F 6	12.19	19.97	21.66	39.05	26.20	31.47	30.27	36.46	33.00	24.44	19.56	15.90	
390D	NEWLY ELIGIBLE MALE	0.00	0.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
390F	NEWLY ELIGIBLE MALE	0.45	0.00	0.00	6.15	0.60	0.12	12.89	3.82	1.74	8.45	3.66	1.00	
390G	NEWLY ELIGIBLE FEMA L	1.83	2.06	0.00	1.25	1.46	4.00	1.00	1.93	0.00	0.00	0.09	0.26	
390H	NEWLY ELIGIBLE M&F	64.25	40.88	59.19	97.73	35.73	28.14	36.38	115.81	31.30	15.20	50.88	3.12	

3.16	
4.00	
145.50	
93.48	
1,258.79	
310.17	
0.83	
38.88	
13.88	
578.61	

L

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

390J

3914

3915

3916

NEWLY ELIGIBLE M&F
6
NEWLY ELIGIBLE MALE

NEWLY ELIGIBLE FEMA L
NEWLY ELIGIBLE MALE

3917

3918

3919

391D

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

391E

391F

391G

391H

391J

3926

3927

3928

3929

392F

392G

392H

392J

NEWLY ELIGIBLE FEMA
L
NEWLY ELIGIBLE MALE

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

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

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

SUBTOTAL:

9939	BIRTH SUPP PAYMENT	39.00	34.00	57.00	67.00	67.00	73.00	77.00	100.00	71.00	89.00	102.00	60.00	
	39.00	34.00	57.00	67.00	67.00	73.00	77.00	100.00	71.00	89.00	102.00	60.00	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
10.96	14.95	34.33	49.11	17.80	22.41	2.57	68.47	0.00	17.89	61.04	0.50	300.03	
1,606.89	1,676.79	1,806.88	1,752.14	1,876.50	2,036.37	2,076.47	2,160.18	2,207.19	2,297.82	2,499.64	2,481.80	24,478.67	
1,867.46	2,072.53	2,181.57	2,102.93	2,272.05	2,488.10	2,599.72	2,661.10	2,751.45	2,861.27	3,062.55	3,000.76	29,921.49	
15,590.65	16,339.89	17,228.33	17,862.31	18,493.39	19,046.12	19,049.48	19,863.08	19,785.35	19,939.99	19,745.25	19,201.28	222,145.12	
20,086.40	21,456.04	22,844.42	23,906.19	25,104.94	26,525.34	27,185.45	29,049.38	29,183.79	30,343.40	29,785.79	28,158.69	313,629.83	
24,879.24	25,158.44	25,656.88	25,845.50	26,301.97	27,031.43	26,861.59	27,501.52	27,480.45	27,848.30	28,028.71	27,818.83	320,412.86	
43.11	41.59	40.65	49.90	38.52	39.64	25.99	21.17	22.25	25.53	29.96	26.00	404.31	
141.51	112.48	116.75	61.70	47.08	66.46	54.38	63.02	107.07	97.98	103.66	88.53	1,060.62	
153.51	153.08	97.96	106.98	67.97	97.10	99.92	109.48	82.68	125.91	101.24	157.62	1,353.45	
1,523.12	1,206.66	1,086.31	945.80	635.23	733.56	806.99	671.82	606.73	733.41	783.70	878.13	10,611.46	
1,726.49	1,680.05	1,394.47	1,209.37	730.12	830.37	899.40	941.25	712.53	905.63	839.58	937.30	12,806.56	
1,771.32	1,458.13	1,385.33	1,103.78	772.01	1,213.88	1,092.09	988.85	801.07	903.70	1,020.20	1,016.88	13,527.24	
8.86	33.37	111.19	18.08	52.44	6.35	45.98	1.00	6.74	6.46	27.89	0.00	318.36	
1.00	0.70	1.96	3.16	1.00	0.00	2.00	0.20	0.00	2.69	2.61	2.83	18.15	
0.00	3.00	3.00	2.00	1.00	1.00	2.77	1.00	1.00	0.00	0.00	1.00	15.77	
6.22	3.11	2.43	4.57	6.66	5.38	14.77	8.84	19.54	7.46	8.25	2.76	89.99	
2.00	0.96	2.00	3.03	1.00	1.00	1.00	3.00	5.00	2.00	0.00	0.00	20.99	
0.00	0.29	0.03	0.00	0.00	0.00	0.00	0.00	0.00	1.29	0.38	1.16	3.15	
0.00	0.00	0.00	0.00	0.00	0.00	0.22	0.00	0.00	0.00	0.00	0.00	0.22	
2.40	1.28	0.56	1.41	1.10	1.60	0.25	11.37	0.45	0.70	0.74	0.23	22.09	
0.00	0.03	0.00	2.96	1.00	0.00	0.00	9.00	0.00	0.00	0.00	0.00	12.99	
69,593.33	71,546.64	74,129.68	75,276.24	76,599.20	80,337.25	81,024.11	84,438.02	84,106.69	86,262.97	86,361.61	83,924.91	953,600.65	
													
												836.00	
												836.00	

N
SUBTOTAL:

4403	SOBRA 100-133% M&F	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	
4404	SOBRA 100-133% MALE	0.00	0.00	0.00	0.67	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	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4412	SOBRA 100-133% M&F
1	2.00	1.00	2.00	7.38	5.00	4.00	5.00	7.33	8.44	7.10	6.31	13.00	
4413	SOBRA 100-133% M&F
6	20,103.69	18,080.37	16,565.93	44,553.71	46,675.62	48,467.96	49,392.05	50,386.04	50,933.22	50,479.84	50,200.72	48,034.88	
4414	SOBRA 100-133% MALE	6,535.04	5,919.99	5,497.23	12,583.32	12,880.64	13,103.79	13,005.23	13,193.17	13,075.74	12,851.90	12,625.95	12,396.35	
4415	SOBRA 100-133% FEMA L	6,240.09	5,678.68	5,237.34	12,115.93	12,426.02	12,699.52	12,757.67	13,024.01	12,856.32	12,560.26	12,397.60	12,096.17	
441B	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.03	0.48	0.00	1.67	0.00	
441C	SOBRA 100-133% M&F
6	288.14	323.40	1,091.93	1,531.67	968.86	1,122.98	1,243.62	1,188.81	1,067.57	1,370.29	1,368.23	1,265.19	
441D	SOBRA 100-133% MALE	126.41	106.24	394.18	409.63	316.99	295.64	293.22	342.97	320.45	349.17	515.78	429.76	
441E	SOBRA 100-133% FEMA	81.96	103.18	421.32	344.01	343.25	358.14	324.68	362.29	224.13	305.84	470.36	392.13	

2.00	
0.67	
1.00	
68.56	
493,874.03	
133,668.35	
130,089.61	
2.18	
12,830.69	
3,900.44	
3,731.29	

6

<

L

ACUTE CAPITATION - MEMBER MONTHS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION
4424

SOBRA 100-133% MALE

JULY
0.00

AUGUST	SEPTEMBER
0.00	0.00

OCTOBER
1.00

NOVEMBER
0.73

DECEMBER
0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

1.73

4425

SOBRA 100-133% FEMA

L
SUBTOTAL:

0.00

33,377.33

0.00

30,212.86

0.00

29,209.93

0.00

71,548.32

0.00

73,618.11

0.00

76,052.03

0.00

77,021.47

0.00

78,504.65

0.00

78,486.35

0.00

77,924.40

1.00

77,587.62

0.00

74,628.48

1.00

778,171.55

102.00

102.00

9944	BIRTH SUPP PAYMENT	8.00	13.00	3.00	3.00	12.00	8.00	10.00	7.00	11.00	13.00	8.00	6.00	
SUBTOTAL:	8.00	13.00	3.00	3.00	12.00	8.00	10.00	7.00	11.00	13.00	8.00	6.00	

S

4517	BC PATIENT FEMALE 2 1	23.96	25.35	26.00	27.58	28.33	27.64	28.00	28.00	26.00	14.61	22.41	24.06	
4518	BC PATIENT FEMALE 4	251.91	246.16	245.84	240.06	227.69	233.21	231.08	228.93	223.04	211.59	187.98	184.56	
4519	BC PATIENT FEMALE 6 5	0.77	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
451G	BC PATIENT FEMALE 2 1	0.00	3.64	0.00	0.41	1.66	0.35	0.00	0.00	0.00	2.95	0.58	6.93	
451H	BC PATIENT FEMALE 4 5	10.28	5.89	8.11	0.93	5.34	3.76	3.30	8.60	0.00	6.83	4.53	5.30	
4617	CC PATIENT FEMALE 2 1	15.86	16.54	17.00	18.03	17.83	19.47	20.00	20.00	20.00	19.63	20.19	18.00	
4618	CC PATIENT FEMALE 4 5	18.00	17.00	16.00	16.00	16.00	15.00	14.00	14.00	14.03	13.00	12.00	10.00	
4619	CC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3.00	0.00	
461G	CC PATIENT FEMALE 2 1	0.00	1.45	0.00	0.96	2.16	1.51	0.00	0.00	0.00	3.36	2.09	0.00	
461H	CC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.96	0.00	0.00	0.00	
461J	CC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.32	0.00	0.00	0.00	0.00	0.00	
9946	SB KICK PAYMENT FOR	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	320.78	316.03	312.95	303.97	300.01	300.94	296.70	299.53	285.03	271.97	252.78	248.85	

301.94	
2,712.05	
0.77	
16.52	
62.87	
222.55	
175.03	
3.00	
11.53	
1.96	
0.32	
1.00	
3,509.54	

5

5

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	
8700	SSI DISABLED FREEDO M	1,505.00	1,555.45	1,576.90	1,602.26	1,594.23	1,632.59	1,633.56	1,628.89	1,659.37	1,662.98	1,683.78	1,761.20	
870Z	SSI DISABLED FREEDO M	161.37	146.05	125.37	96.31	27.40	81.11	61.34	53.48	55.38	36.78	105.55	93.43	
8710	SSI DISABLED FREEDO M	246.99	274.32	275.92	268.27	266.19	276.60	276.50	274.66	267.18	261.80	255.46	240.13	
871Z	SSI DISABLED FREEDO M	85.86	73.98	54.70	40.00	21.99	24.91	5.07	36.95	3.24	20.36	34.05	27.65	
8720	SSI DISABLED FREEDO	213.90	216.30	223.90	223.30	228.07	240.46	236.51	225.61	225.34	226.00	221.59	221.32	
872Z	SSI DISABLED FREEDO M	20.61	6.41	1.03	15.63	27.86	2.32	0.83	3.24	3.63	0.00	5.06	5.93	
	2,234.73	2,273.51	2,258.82	2,246.77	2,166.74	2,258.99	2,214.81	2,223.83	2,215.14	2,208.92	2,306.49	2,350.66	

12.00	
19,496.21	
1,043.57	
3,184.02	
428.76	
2,702.30	
92.55	
26,959.41	

M

SUBTOTAL:

TOTAL:	1,509,256.72	1,514,651.63	1,531,233.53	1,548,851.83	1,545,990.86	1,571,205.99	1,562,162.15	1,566,895.94	1,567,790.24	1,567,273.98	1,566,413.52	1,581,876.96		18,633,603.35		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,935,150.50	0.00	0.00	1,935,150.50	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,730.56	0.00	0.00	9,730.56	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,212.14	0.00	0.00	4,212.14	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,398,268.06	0.00	0.00	3,398,268.06	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	192.72	0.00	0.00	192.72	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,342,522.49	0.00	0.00	1,342,522.49	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,690,076.47	0.00	0.00	6,690,076.47	

ACUTE CAPITATION RURAL HOSPITAL - AMOUNTS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

9810

RURAL HOSP PMT TACI

9812

9814

9816

9818

9821

RURAL HOSP PMT TAC
S
RURAL HOSP PMT MAL
E
RURAL HOSP PMT FMA
L
RURAL HOSP PMT ADL
T
RURAL HOSP PMT SSI

W
SUBTOTAL:

9811	RURAL HOSP PMT TACI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	674.16	0.00	0.00	
9813	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	633.52	0.00	0.00	
9815	RURAL HOSP PMT MAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,372.16	0.00	0.00	
9817	RURAL HOSP PMT FMA L	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,669,531.20	0.00	0.00	
9819	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	372.80	0.00	0.00	
9823	RURAL HOSP PMT FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	73,424.72	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,747,008.56	0.00	0.00	

674.16	
633.52	
2,372.16	
1,669,531.20	
372.80	
73,424.72	
1,747,008.56	

S
SUBTOTAL:

9835	RURAL HOSPITAL PMT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,247,623.57	0.00	0.00	
9837	RURAL HOSPITAL PMT A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,711,628.93	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,959,252.50	0.00	0.00	

1,247,623.57	
2,711,628.93	
3,959,252.50	

A

SUBTOTAL:

9845	RURAL HOSP PMT FOR B	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	600.00	0.00	0.00	
9846	RURAL HOSP PMT FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	737.38	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,337.38	0.00	0.00	

600.00	
737.38	
1,337.38	

C
SUBTOTAL:

8,313.82

8,313.82

9887	RH PAYMENT FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,313.82	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	8,313.82	0.00	0.00	

M T
SUBTOTAL:

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00     12,405,988.73

0.00

0.00

12,405,988.73

TOTAL:

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

ACUTE CAPITATION RURAL HOSPITAL - MEMBER MONTHS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

9810

RURAL HOSP PMT TACI

9812

9814

9816

9818

9821

RURAL HOSP PMT TAC
S
RURAL HOSP PMT MAL
E
RURAL HOSP PMT FMA
L
RURAL HOSP PMT ADL
T
RURAL HOSP PMT SSI

W
SUBTOTAL:

9811	RURAL HOSP PMT TACI	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9813	RURAL HOSP PMT TAC S	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9815	RURAL HOSP PMT MAL 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	
9817	RURAL HOSP PMT FMA 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	
9819	RURAL HOSP PMT ADL T	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9823	RURAL HOSP PMT FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	

S
SUBTOTAL:

9835	RURAL HOSPITAL PMT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9837	RURAL HOSPITAL PMT A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

A

SUBTOTAL:

9845	RURAL HOSP PMT FOR B	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
9846	RURAL HOSP PMT FOR	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	

C
SUBTOTAL:

0.00

0.00

9887	RH PAYMENT FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	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 T
SUBTOTAL:

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		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
9,923.14	10,424.50	9,923.14	10,013.77	17,381.47	20,492.16	27,239.96	27,799.67	27,239.96	23,798.17	34,683.25	41,007.12	259,926.31	
2,246,124.76	2,243,143.25	2,252,388.63	2,282,295.84	2,283,614.83	2,329,163.03	2,288,974.62	2,312,334.75	2,294,801.55	2,329,465.20	2,338,515.83	2,328,766.65	27,529,588.94	
3,414.03	3,414.03	3,414.03	3,433.17	3,433.17	6,955.78	6,883.58	6,883.58	6,883.58	6,883.58	6,883.58	6,883.58	65,365.69	
31,188,469.28	36,229,127.20	31,473,122.65	31,111,647.19	36,054,042.87	31,219,612.97	30,619,272.74	35,672,776.45	30,670,123.38	30,500,842.76	35,731,027.55	30,848,257.33	391,318,322.37	
707,295.55	628,872.62	699,533.74	841,652.65	651,630.71	674,097.19	731,475.49	687,149.55	856,029.56	705,817.18	637,596.26	656,019.65	8,477,170.15	
2,884,201.93	3,146,295.69	2,948,885.35	3,040,662.77	3,335,679.23	3,063,216.81	2,952,096.08	3,254,121.17	2,950,657.78	2,931,926.66	3,181,073.22	2,815,528.86	36,504,345.55	
20,970.93	11,535.77	26,120.35	18,541.95	9,394.51	32,330.18	43,450.16	39,444.88	37,861.52	28,422.15	20,945.23	34,904.23	323,921.86	
18,966,113.95	22,019,693.90	19,185,398.15	19,009,038.07	22,054,804.25	19,319,046.10	19,042,283.66	22,091,359.25	19,090,065.59	19,109,506.84	22,459,027.19	19,253,034.14	241,599,371.09	
27,811.67	8,720.78	31,076.14	21,591.82	10,487.09	22,848.38	23,361.65	12,897.63	35,332.72	26,460.54	19,634.03	20,801.45	261,023.90	
13,803,406.37	14,998,436.84	13,783,997.15	14,011,924.66	15,406,736.15	14,477,755.73	14,294,179.54	15,712,431.84	14,374,439.34	14,462,069.03	15,806,142.22	14,691,408.01	175,822,926.88	
40,564.67	63,879.36	93,590.05	124,380.26	73,436.67	93,117.27	101,516.47	89,437.07	101,963.98	54,844.32	62,887.33	69,951.72	969,569.17	
90,370,918.56	92,527,644.78	92,067,142.80	93,105,599.36	94,991,556.18	95,648,767.77	93,400,354.30	95,656,370.93	94,045,250.29	94,042,278.43	96,250,259.26	94,996,033.46	1,127,102,176.12	
66,459.25	35,301.18	25,164.71	27,841.86	30,576.10	33,824.17	38,629.75	27,817.69	79,843.41	63,929.13	44,706.36	32,336.40	506,430.01	
21,237,804.05	22,510,241.65	21,355,507.04	21,308,948.47	22,578,485.06	21,695,984.63	21,391,282.55	22,688,860.14	21,413,285.59	21,601,569.19	22,987,267.34	21,708,423.48	262,477,659.19	
2,948.16	9,227.84	6,397.97	6,604.08	8,888.32	7,078.53	4,972.05	3,232.14	3,869.53	2,306.32	8,548.96	3,026.53	67,100.43	
64,338.16	65,260.19	64,541.02	62,567.40	68,202.65	66,548.80	68,372.70	68,592.83	65,059.47	61,912.04	68,584.16	68,354.16	792,333.58	
444,420.36	460,483.10	454,107.08	457,911.29	480,473.00	490,226.15	486,595.02	474,957.86	478,945.88	484,827.16	496,410.89	491,636.77	5,700,994.56	
130,315.90	135,811.83	130,342.85	127,684.67	131,086.80	129,801.65	127,497.03	135,174.46	130,938.82	137,252.87	140,056.22	130,482.48	1,586,445.58	

LONG TERM CARE CAPITATION - AMOUNTS
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

210Z

2110

211Z

2120

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

212Z

2200

220Z

2210

221Z

2220

222Z

2300

SSI AGED WITH QMB P
P
SSI DISABLED WITH M
E
SSI DISABLED WITH M
E
SSI DISABLED NON-ME
D
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI DISABLED WITH Q
M
SSI BLIND WITH MEDIC

2310

2320

SSI BLIND NON-MEDIC
A
SSI BLIND WITH QMB

SUBTOTAL:

182,215,500.72   195,107,514.51   184,610,652.85   185,572,339.28   198,189,909.06   189,330,867.30  185,648,437.35   198,961,641.89   186,662,591.95   186,574,111.57   200,294,248.88   188,196,856.02

2,281,364,671.38

2,284,030,608.08

8700	SSI DISABLED FREEDO M	70,007.12	77,437.98	70,007.12	70,803.89	73,814.89	71,344.62	74,872.30	79,836.70	73,619.88	86,057.13	91,435.39	82,909.70	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	19,620.38	-15,252.27	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	113,605.70	118,717.57	126,429.56	130,091.75	134,898.58	121,559.40	120,950.51	134,133.33	117,508.72	122,943.21	134,413.01	118,348.89	
871Z	SSI DISABLED FREEDO M	2,876.81	-2,876.81	4,987.53	0.00	0.00	0.00	0.00	3,141.37	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	19,836.86	21,311.74	19,836.86	20,022.25	21,709.30	20,462.48	20,048.11	21,887.06	20,048.11	16,900.68	18,728.61	16,900.68	
SUBTOTAL:	206,326.49	214,590.48	221,261.07	220,917.89	230,422.77	213,366.50	235,491.30	223,746.19	211,176.71	225,901.02	244,577.01	218,159.27	

922,146.72	
4,368.11	
1,493,600.23	
8,128.90	
237,692.74	
2,665,936.70	

184,831,913.92	185,793,257.17	198,420,331.83	189,544,233.80	185,883,928.65	199,185,388.08	186,873,768.66	186,800,012.59	200,538,825.89	188,415,015.29	

M

TOTAL:

182,421,827.21  195,322,104.99

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	3.00	3.00	3.00	3.00	5.00	6.00	8.00	8.00	8.00	7.00	10.00	12.00	76.00	
1010	TANF NON-MEDICARE	654.15	651.89	656.12	659.50	658.46	656.64	659.79	665.10	661.45	671.37	673.14	671.80	7,939.41	
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	19.00	
2100	SSI AGED WITH MEDIC	11,288.11	11,289.28	11,378.95	11,358.29	11,326.59	11,306.03	11,140.18	11,162.78	11,195.20	11,158.06	11,227.66	11,268.89	135,100.02	
210Z	A
SSI AGED WITH MEDIC	717.21	639.08	710.00	851.48	668.68	692.76	751.99	715.66	881.40	730.68	662.51	676.85	
8,698.30	
2110	A
SSI AGED NON-MEDICA	655.14	653.57	669.99	636.70	631.61	621.44	615.56	613.03	615.23	613.90	608.17	599.84	
7,534.18	
211Z	R
SSI AGED NON-MEDICA	21.10	12.50	27.34	18.34	9.95	33.27	44.42	39.22	42.74	30.44	22.23	36.41	
337.96	

2120	R
SSI AGED WITH QMB	
7,334.44	
7,374.82	
7,392.70	
7,402.32	
7,425.32	
7,457.15	
7,403.18	
7,397.98	
7,414.86	
7,433.25	
7,530.64	
7,491.72	
89,058.38	
212Z	SSI AGED WITH QMB P	27.75	9.33	32.14	22.04	11.00	24.46	26.59	14.28	36.56	27.22	20.71	21.70	273.78	

2200	P
SSI DISABLED WITH M	
4,540.03	
4,507.46	
4,531.49	
4,608.07	
4,649.47	
4,687.31	
4,696.20	
4,730.81	
4,729.29	
4,760.40	
4,745.09	
4,818.92	
56,004.54	
220Z	E
SSI DISABLED WITH M	40.61	63.99	95.38	125.93	77.65	98.95	102.57	98.56	105.74	56.24	64.39	69.98	
999.99	

2210	E
SSI DISABLED NON-ME	
25,726.52	
25,794.02	
25,992.12	
25,925.40	
25,930.65	
25,987.21	
25,945.81	
26,051.86	
26,144.32	
26,181.47	
26,265.03	
26,365.13	
312,309.54	
221Z	D
SSI DISABLED NON-ME	68.02	35.27	25.38	30.27	31.72	32.83	41.26	29.92	70.81	57.14	47.14	33.74	
503.50	
2220	D
SSI DISABLED WITH Q	6,765.32	6,778.39	6,816.99	6,805.73	6,791.71	6,793.06	6,799.81	6,813.92	6,805.25	6,884.76	6,918.57	6,918.55	
81,892.06	
222Z	M
SSI DISABLED WITH Q	2.73	7.18	7.16	6.82	9.41	7.33	5.45	4.24	4.12	2.00	9.16	3.25	
68.85	
2300	M
SSI BLIND WITH MEDIC	20.00	19.00	20.00	20.00	20.00	20.00	21.00	20.17	20.00	19.00	20.00	21.00	
240.17	
2310	SSI BLIND NON-MEDIC	128.16	130.38	131.06	129.55	134.00	134.12	136.77	135.03	135.00	137.66	138.70	139.93	1,610.36	

2320	A
SSI BLIND WITH QMB	
42.00	
42.00	
42.00	
40.83	
40.30	
40.96	
41.00	
41.55	
42.00	
44.00	
43.00	
41.99	
501.63	

LONG TERM CARE MEMBER MONTHS
For The Period Ending June 30, 2016

SUBTOTAL:

58,035.29

58,012.16

58,532.82

58,645.27

58,422.52

58,601.52

58,441.58

58,544.11

58,913.97

58,816.59

59,008.14

59,193.70

703,167.67

282.43

4.64

305.86

7.75

81.09

681.77

8700	SSI DISABLED FREEDO M	22.00	22.00	22.00	22.09	22.31	23.00	24.51	22.52	23.00	27.00	26.00	26.00	
870Z	SSI DISABLED FREEDO M	0.00	0.00	0.00	0.00	0.00	0.00	20.47	-15.83	0.00	0.00	0.00	0.00	
8710	SSI DISABLED FREEDO M	27.09	25.91	26.96	27.00	25.60	25.00	25.00	25.27	24.00	25.00	25.00	24.03	
871Z	SSI DISABLED FREEDO M	2.90	-2.90	5.03	0.00	0.00	0.00	0.00	2.72	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	7.00	7.00	7.00	7.00	7.00	7.09	7.00	7.00	7.00	6.00	6.00	6.00	
SUBTOTAL:	58.99	52.01	60.99	56.09	54.91	55.09	76.98	41.68	54.00	58.00	57.00	56.03	

M

TOTAL:	58,094.28	58,064.17	58,593.81	58,701.36	58,477.43	58,656.61	58,518.56	58,585.79	58,967.97	58,874.59	59,065.14	59,249.73		703,849.44		

MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	37.55	37.55	37.55	41.42	41.42	45.66	41.42	41.42	41.42	41.42	41.42	0.00		448.25		
1010	TANF NON-MEDICARE	6,001,729.15	5,085,321.40	4,606,746.65	4,559,389.34	4,008,130.56	4,802,606.88	3,146,884.50	2,796,222.78	2,567,708.64	2,442,164.62	2,382,105.62	2,626,814.98		45,025,825.12		
1020	TANF WITH QMB	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	41.42	41.42	0.00	0.00		124.26		
2110	SSI AGED NON-MEDICA R	37.55	75.10	75.10	82.84	82.84	82.84	41.42	82.84	41.42	82.84	0.00	0.00		684.79		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	41.42	0.00	0.00	0.00	0.00	0.00	82.84		124.26		
2200	SSI DISABLED WITH M E	37.55	37.55	37.55	82.84	165.68	174.16	248.52	248.52	207.10	248.52	0.00	0.00		1,487.99		
2210	SSI DISABLED NON-ME	430,210.35	427,168.80	423,639.10	461,128.86	457,442.48	503,226.44	451,519.42	447,336.00	442,034.24	437,809.40	435,821.24	431,016.52		5,348,352.85		
2220	SSI DISABLED WITH Q M	225.30	225.30	225.30	248.52	207.10	241.02	207.10	289.94	248.52	248.52	455.62	414.20		3,236.44		
2310	SSI BLIND NON-MEDIC A	1,464.45	1,614.65	1,689.75	1,988.16	1,988.16	2,162.00	2,071.00	2,153.84	2,153.84	2,153.84	2,153.84	2,153.84		23,747.37		
4300	SOBRA CHILD WITH ME D	225.30	225.30	187.75	165.68	207.10	335.60	165.68	124.26	289.94	331.36	331.36	455.62		3,044.95		
4310	SOBRA CHILD NON-ME DI	17,147,019.75	18,291,093.15	19,577,631.25	20,609,680.76	21,238,146.42	23,190,384.24	22,317,882.98     22,136,173.44	22,791,313.58	22,887,366.56	22,854,354.82	22,986,691.72		256,027,738.67		
4320	SOBRA CHILD WITH Q MB	525.70	0.00	187.75	455.62	165.68	869.82	165.68	82.84	248.52	455.62	289.94	124.26		3,571.43		
5010	SOBRA PREGNANT WO MAN	20,427.20	22,567.55	25,233.60	28,828.32	30,195.18	26,234.24	23,609.40	24,479.22	25,307.62	25,183.36	26,011.76	25,846.08		303,923.53		
	23,601,939.85	23,828,366.35	24,635,691.35	25,662,133.78	25,736,772.62	28,526,404.32	25,942,837.12	25,407,235.10	25,829,636.26	25,796,127.48	25,701,565.62	26,073,600.06		306,742,309.91		

D

SUBTOTAL:

1110	TANF EXPANDED FOR FI	92,861.15	74,837.15	64,811.30	62,295.68	46,970.28	60,148.88	28,496.96	21,704.08	18,307.64	15,988.12	12,094.64	10,893.46	
2610	SSI DISABLED EXPAND	37.55	37.55	37.55	41.42	41.42	49.90	41.42	41.42	41.42	41.42	82.84	41.42	
SUBTOTAL:	92,898.70	74,874.70	64,848.85	62,337.10	47,011.70	60,198.78	28,538.38	21,745.50	18,349.06	16,029.54	12,177.48	10,934.88	

509,409.34	
535.33	
509,944.67	

E

3510	ADULT 40-100% FOR FI	37.55	37.55	75.10	82.84	82.84	41.42	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED	0.00	37.55	75.10	82.84	82.84	165.68	82.84	82.84	82.84	124.26	248.52	124.26	
	37.55	75.10	150.20	165.68	165.68	207.10	82.84	82.84	82.84	124.26	248.52	124.26	

357.30	
1,189.57	
1,546.87	

FO
SUBTOTAL:

745.56

745.56

3910	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	41.42	0.00	0.00	41.42	124.26	124.26	124.26	165.68	124.26	
	0.00	0.00	0.00	41.42	0.00	0.00	41.42	124.26	124.26	124.26	165.68	124.26	

F
SUBTOTAL:

4400	SOBRA 100-133% FOR	0.00	0.00	0.00	41.42	41.42	41.42	0.00	0.00	0.00	0.00	0.00	41.42	
4410	SOBRA 100-133% FOR F	1,137,201.75	1,021,510.20	921,589.65	2,674,365.14	2,781,021.64	2,992,223.40	2,917,086.34	2,973,417.54	2,994,003.28	2,974,742.98	2,966,210.46	2,858,974.08	
	1,137,201.75	1,021,510.20	921,589.65	2,674,406.56	2,781,063.06	2,992,264.82	2,917,086.34	2,973,417.54	2,994,003.28	2,974,742.98	2,966,210.46	2,859,015.50	

165.68	
29,212,346.46	
29,212,512.14	

F

SUBTOTAL:

336,467,059.15

24,832,077.85	24,924,826.35	25,622,280.05	28,399,084.54	28,565,013.06	31,579,075.02	28,888,586.10	28,402,605.24	28,842,195.70	28,787,148.52	28,680,367.76	28,943,798.96	

TOTAL:

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00		11.00		
1010	TANF NON-MEDICARE	159,833.00	135,428.00	122,683.00	110,077.00	96,768.00	85,240.00	75,975.00	67,509.00	61,992.00	58,961.00	57,511.00	63,419.00		1,095,396.00		
1020	TANF WITH QMB	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00		3.00		
2110	SSI AGED NON-MEDICA R	1.00	2.00	2.00	2.00	2.00	2.00	1.00	2.00	1.00	2.00	0.00	0.00		17.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	2.00		3.00		
2200	SSI DISABLED WITH M E	1.00	1.00	1.00	2.00	4.00	4.00	6.00	6.00	5.00	6.00	0.00	0.00		36.00		
2210	SSI DISABLED NON-ME	11,457.00	11,376.00	11,282.00	11,133.00	11,044.00	10,970.00	10,901.00	10,800.00	10,672.00	10,570.00	10,522.00	10,406.00		131,133.00		
2220	SSI DISABLED WITH Q M	6.00	6.00	6.00	6.00	5.00	5.00	5.00	7.00	6.00	6.00	11.00	10.00		79.00		
2310	SSI BLIND NON-MEDIC A	39.00	43.00	45.00	48.00	48.00	48.00	50.00	52.00	52.00	52.00	52.00	52.00		581.00		
4300	SOBRA CHILD WITH ME D	6.00	6.00	5.00	4.00	5.00	8.00	4.00	3.00	7.00	8.00	8.00	11.00		75.00		
4310	SOBRA CHILD NON-ME DI	456,645.00	487,113.00	521,375.00	497,578.00	512,751.00	529,324.00	538,819.00	534,432.00	550,249.00	552,568.00	551,771.00	554,966.00		6,287,591.00		
4320	SOBRA CHILD WITH Q MB	14.00	0.00	5.00	11.00	4.00	21.00	4.00	2.00	6.00	11.00	7.00	3.00		88.00		
5010	SOBRA PREGNANT WO MAN	544.00	601.00	672.00	696.00	729.00	600.00	570.00	591.00	611.00	608.00	628.00	624.00		7,474.00		
	628,547.00	634,577.00	656,077.00	619,559.00	621,361.00	626,224.00	626,336.00	613,405.00	623,603.00	622,794.00	620,511.00	629,493.00		7,522,487.00		

D

SUBTOTAL:

1110	TANF EXPANDED FOR FI	2,473.00	1,993.00	1,726.00	1,504.00	1,134.00	904.00	688.00	524.00	442.00	386.00	292.00	263.00	
2610	SSI DISABLED EXPAND	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	2.00	1.00	
SUBTOTAL:	2,474.00	1,994.00	1,727.00	1,505.00	1,135.00	905.00	689.00	525.00	443.00	387.00	294.00	264.00	

12,329.00	
13.00	
12,342.00	

E

3510	ADULT 40-100% FOR FI	1.00	1.00	2.00	2.00	2.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
3710	AHC CARE EXPANDED	0.00	1.00	2.00	2.00	2.00	4.00	2.00	2.00	2.00	3.00	6.00	3.00	
	1.00	2.00	4.00	4.00	4.00	5.00	2.00	2.00	2.00	3.00	6.00	3.00	

9.00	
29.00	
38.00	

FO
SUBTOTAL:

18.00

18.00

3910	NEWLY ELIGIBLE FOR	0.00	0.00	0.00	1.00	0.00	0.00	1.00	3.00	3.00	3.00	4.00	3.00	
	0.00	0.00	0.00	1.00	0.00	0.00	1.00	3.00	3.00	3.00	4.00	3.00	

F
SUBTOTAL:

4400	SOBRA 100-133% FOR	0.00	0.00	0.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	
4410	SOBRA 100-133% FOR F	30,285.00	27,204.00	24,543.00	64,567.00	67,142.00	69,354.00	70,427.00	71,787.00	72,284.00	71,819.00	71,613.00	69,024.00	
	30,285.00	27,204.00	24,543.00	64,568.00	67,143.00	69,355.00	70,427.00	71,787.00	72,284.00	71,819.00	71,613.00	69,025.00	

4.00	
710,049.00	
710,053.00	

F

SUBTOTAL:

TOTAL:	661,307.00	663,777.00	682,351.00	685,637.00	689,643.00	696,489.00	697,455.00	685,722.00	696,335.00	695,006.00	692,428.00	698,788.00		8,244,938.00		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
67,083.83	80,473.34	92,942.96	1,873.88	1,880.20	2,409.24	183.28	176.96	170.64	158.00	145.36	129.56	247,627.25	
6,077,917.65	6,393,201.43	6,925,613.32	441,979.72	444,046.36	1,050,735.48	449,525.80	440,014.20	432,196.36	412,474.80	410,003.68	430,060.20	23,907,769.00	
24,837.03	36,897.81	45,074.61	701.52	761.56	220.68	82.16	75.84	75.84	63.20	56.88	60.04	108,907.17	
139,789.21	137,949.43	136,722.91	13,714.40	13,869.24	19,412.00	1,093.36	1,074.40	1,068.08	1,058.60	1,071.24	1,090.20	467,913.07	
205,476.17	200,433.81	204,454.07	19,576.20	19,269.68	42,553.12	17,569.60	17,594.88	17,626.48	16,883.88	16,871.24	17,013.44	795,322.57	
595,679.88	602,630.16	609,410.09	73,883.96	74,771.92	96,621.20	5,469.96	5,536.32	5,656.40	5,621.64	5,858.64	6,004.00	2,087,144.17	
134,133.59	132,327.88	130,488.10	11,537.16	11,508.72	20,634.20	2,673.36	2,622.80	2,581.72	2,607.00	2,723.92	2,831.36	456,669.81	
1,422,763.20	1,422,831.34	1,426,408.69	116,724.08	117,773.20	279,823.24	118,013.36	118,414.68	118,455.76	118,291.44	119,628.12	119,820.88	5,498,947.99	
832,159.75	837,747.23	844,561.23	70,060.36	70,610.20	107,153.96	9,160.84	9,157.68	9,233.52	9,239.84	9,366.24	9,287.24	2,817,738.09	
1,226.52	1,158.38	1,056.17	94.80	88.48	155.48	18.96	15.80	15.80	15.80	15.80	15.80	3,877.79	
14,820.45	14,650.10	14,547.89	1,295.60	1,311.40	2,962.84	1,346.16	1,371.44	1,368.28	1,343.00	1,349.32	1,346.16	57,712.64	
8,279.01	8,210.87	8,244.94	745.76	739.44	1,094.24	132.72	135.88	132.72	129.56	126.40	120.08	28,091.62	
34.07	34.07	68.14	6.32	3.16	0.00	0.00	0.00	3.16	3.16	3.16	3.16	158.40	
834,544.65	810,661.58	852,976.52	73,251.96	73,425.76	148,481.52	70,607.04	71,359.12	67,642.96	63,907.84	57,758.48	56,096.32	3,180,713.75	
68.14	34.07	34.07	3.16	3.16	3.88	0.00	0.00	0.00	0.00	0.00	0.00	146.48	
1,260.59	1,226.52	1,328.73	113.76	94.80	188.68	6.32	3.16	3.16	3.16	3.16	6.32	4,238.36	
802,586.99	894,950.76	992,561.31	98,045.32	104,024.04	141,289.04	76,955.48	80,671.64	84,138.16	85,572.80	88,119.76	89,266.84	3,538,182.14	
306.63	408.84	340.70	34.76	37.92	22.56	3.16	6.32	6.32	6.32	9.48	12.64	1,195.65	
11,162,967.36	11,575,827.62	12,286,834.45	923,642.72	934,219.24	1,913,761.36	752,841.56	748,231.12	740,375.36	717,380.04	713,110.88	733,164.24	43,202,355.95	

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

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

SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI BLIND WITH MEDIC

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4310

4320

5000

5010

5020

SOBRA CHILD WITH ME
D
SOBRA CHILD NON-ME
DI
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN

SUBTOTAL:

1100	TANF EXPANDED FPR FI	141,594.92	125,002.83	112,124.37	20,394.64	19,800.56	23,775.56	1,371.44	1,320.88	1,308.24	1,324.04	1,241.88	1,270.32	
1110	TANF EXPANDED FOR FI	3,052,160.95	2,639,368.83	2,306,811.56	405,740.84	398,852.04	875,950.72	422,868.04	418,990.72	424,072.00	423,120.84	419,644.84	424,283.72	
1120	TANF EXPANDED FOR FI	39,930.04	35,535.01	32,025.80	3,239.00	4,575.68	1,953.72	486.64	508.76	540.36	521.40	483.48	492.96	
2400	SSI AGED EXPANDED WI	14,990.80	14,173.12	13,662.07	948.00	913.24	1,955.64	41.08	50.56	60.04	69.52	75.84	82.16	
2410	SSI AGED EXPANDED	39,725.62	37,068.16	34,887.68	1,292.44	1,166.04	5,659.80	707.84	647.80	562.48	534.04	486.64	445.56	
2420	SSI AGED EXPANDED WI	952,256.50	951,711.38	949,360.55	68,407.68	67,696.68	90,973.12	3,871.00	3,899.44	3,798.32	3,532.88	3,305.36	3,267.44	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	68.14	68.14	68.14	3.16	3.16	10.92	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	34.07	34.07	34.07	3.16	3.16	7.76	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	9,505.53	9,335.18	9,198.90	850.04	894.28	2,012.24	82.16	94.80	88.48	97.96	107.44	91.64	
2610	SSI DISABLED EXPAND E	91,103.18	87,900.60	88,070.95	6,955.16	6,847.72	11,323.48	6,436.92	6,004.00	5,545.80	5,100.24	4,929.60	4,800.04	
2620	SSI DISABLED EXPAND	488,427.52	493,674.30	511,867.68	42,394.56	43,298.32	35,731.36	2,464.80	2,496.40	2,385.80	2,215.16	2,091.92	2,054.00	
	4,829,797.27	4,393,871.62	4,058,111.77	550,231.84	544,054.04	1,049,354.32	438,329.92	434,013.36	438,361.52	436,516.08	432,367.00	436,787.84	

450,529.68	
12,211,865.10	
120,292.85	
47,022.07	
123,184.10	
3,102,080.35	
6.32	
221.66	
116.29	
32,358.65	
325,017.69	
1,629,101.82	
18,041,796.58	

NO

W

E
SUBTOTAL:

11.64

11.64

3610	AHC CARE EXPANDED	0.00	0.00	0.00	0.00	0.00	11.64	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	11.64	0.00	0.00	0.00	0.00	0.00	0.00	

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	4,974.22	4,326.89	3,849.91	688.88	530.88	1,899.32	34.76	34.76	37.92	34.76	31.60	22.12	16,466.02

MENTAL HEALTH CAPITATION AMOUNTS - ADULT
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3510	ADULT 40-100% FOR FI	2,568,639.51	2,579,984.82	2,658,856.87	246,432.60	250,894.52	506,423.88	259,075.76	263,891.60	265,661.20	269,557.48	272,527.88	276,446.28		10,418,392.40		
3520	ADULT 40-100% FOR FI	1,056.17	919.89	919.89	97.96	113.76	149.16	6.32	12.64	12.64	6.32	0.00	3.16		3,297.91		
3700	ADULT <40% EXP FOR F	4,463.17	4,667.59	4,769.80	774.20	609.88	1,647.40	63.20	47.40	47.40	22.12	37.92	22.12		17,172.20		
3710	AHC CARE EXPANDED FO	6,719,966.80	6,769,163.88	7,017,568.25	651,541.44	662,468.72	1,428,717.48	665,590.80	663,138.64	665,259.00	663,435.68	655,197.56	655,589.40		27,217,637.65		
3720	AHC CARE EXPANDED	1,328.73	476.98	953.96	94.80	94.80	118.12	15.80	22.12	18.96	18.96	9.48	6.32		3,159.03		
SUBTOTAL:	9,300,428.60	9,359,540.05	9,686,918.68	899,629.88	914,712.56	1,938,955.36	924,786.64	927,147.16	931,037.12	933,075.32	927,804.44	932,089.40		37,676,125.21		

FO

3900	NEWLY ELIGIBLE FOR F	3,032.23	2,044.20	2,180.48	372.88	404.48	593.92	22.12	28.44	44.24	15.80	37.92	15.80	
3910	NEWLY ELIGIBLE FOR F	2,203,170.62	2,295,500.32	2,410,997.62	227,614.80	237,448.72	359,857.28	247,475.40	259,066.28	259,799.40	268,088.08	267,664.64	259,123.16	
3920	NEWLY ELIGIBLE FOR	374.77	170.35	204.42	28.44	25.28	18.68	0.00	0.00	3.16	3.16	3.16	0.00	
	2,206,577.62	2,297,714.87	2,413,382.52	228,016.12	237,878.48	360,469.88	247,497.52	259,094.72	259,846.80	268,107.04	267,705.72	259,138.96	

8,792.51	
9,295,806.32	
831.42	
9,305,430.25	

F
SUBTOTAL:

4410	SOBRA 100-133% FOR F	103,709.08	95,634.49	86,469.66	15,683.08	17,019.76	27,854.24	16,583.68	16,776.44	15,954.84	15,098.48	13,799.72	13,395.24	
4420	SOBRA 100-133% FOR	0.00	0.00	0.00	3.16	3.16	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	103,709.08	95,634.49	86,469.66	15,686.24	17,022.92	27,854.24	16,583.68	16,776.44	15,954.84	15,098.48	13,799.72	13,395.24	

437,978.71	
6.32	
437,985.03	

F
SUBTOTAL:

4510	BC PATIENT FOR FINA	9,471.46	9,301.11	9,267.04	837.40	799.48	2,012.92	790.00	774.20	774.20	726.80	695.20	650.96	
4610	CC PATIENT FOR FINA N	1,192.45	1,158.38	1,124.31	104.28	104.28	278.16	107.44	107.44	104.28	101.12	101.12	88.48	
	10,663.91	10,459.49	10,391.35	941.68	903.76	2,291.08	897.44	881.64	878.48	827.92	796.32	739.44	

36,100.77	
4,571.74	
40,672.51	

N

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	34.07	34.07	34.07	0.00	0.00	3.88	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	33,831.51	35,194.31	35,909.78	2,837.68	2,850.32	3,585.52	75.84	72.68	75.84	69.52	69.52	63.20	
8710	SSI DISABLED FREEDO M	7,086.56	7,938.31	8,142.73	701.52	698.36	1,303.80	673.08	660.44	657.28	628.84	622.52	654.12	
8720	SSI DISABLED FREEDO	5,178.64	5,417.13	5,655.62	426.60	439.24	546.36	6.32	6.32	9.48	9.48	9.48	9.48	
	46,130.78	48,583.82	49,742.20	3,965.80	3,987.92	5,439.56	755.24	739.44	742.60	707.84	701.52	726.80	

106.09	
114,635.72	
29,767.56	
17,714.15	
162,223.52	

M
SUBTOTAL:

108,866,600.69

27,660,274.62	27,781,631.96	28,591,850.63	2,622,114.28	2,652,778.92	5,298,137.44	2,381,692.00	2,386,883.88	2,387,196.72	2,371,712.72	2,356,285.60	2,376,041.92	

TOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1,969.00	2,362.00	2,728.00	593.00	595.00	65.00	58.00	56.00	54.00	50.00	46.00	41.00	8,617.00	
178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	142,255.00	139,245.00	136,771.00	130,530.00	129,748.00	136,095.00	1,807,130.00	
729.00	1,083.00	1,323.00	222.00	241.00	33.00	26.00	24.00	24.00	20.00	18.00	19.00	3,762.00	
4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	346.00	340.00	338.00	335.00	339.00	345.00	23,276.00	
6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	5,619.00	5,560.00	5,568.00	5,578.00	5,343.00	5,339.00	5,384.00	68,599.00	
17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	1,731.00	1,752.00	1,790.00	1,779.00	1,854.00	1,900.00	112,652.00	
3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	846.00	830.00	817.00	825.00	862.00	896.00	24,844.00	
41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	37,192.00	37,346.00	37,473.00	37,486.00	37,434.00	37,857.00	37,918.00	462,303.00	
24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	2,910.00	2,899.00	2,898.00	2,922.00	2,924.00	2,964.00	2,939.00	138,775.00	
36.00	34.00	31.00	30.00	28.00	5.00	6.00	5.00	5.00	5.00	5.00	5.00	195.00	
435.00	430.00	427.00	410.00	415.00	417.00	426.00	434.00	433.00	425.00	427.00	426.00	5,105.00	
243.00	241.00	242.00	236.00	234.00	43.00	42.00	43.00	42.00	41.00	40.00	38.00	1,485.00	
1.00	1.00	2.00	2.00	1.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	11.00	
24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	22,437.00	22,344.00	22,582.00	21,406.00	20,224.00	18,278.00	17,752.00	264,765.00	
2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
37.00	36.00	39.00	36.00	30.00	2.00	2.00	1.00	1.00	1.00	1.00	2.00	188.00	
23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	28,040.00	24,353.00	25,529.00	26,626.00	27,080.00	27,886.00	28,249.00	330,667.00	
9.00	12.00	10.00	11.00	12.00	1.00	1.00	2.00	2.00	2.00	3.00	4.00	69.00	
327,648.00	339,766.00	360,635.00	292,292.00	295,639.00	242,449.00	238,241.00	236,782.00	234,296.00	227,019.00	225,668.00	232,014.00	3,252,449.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

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

SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI BLIND WITH MEDIC

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4310

4320

5000

5010

5020

SOBRA CHILD WITH ME
D
SOBRA CHILD NON-ME
DI
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN

SUBTOTAL:

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	438.00	434.00	418.00	414.00	419.00	393.00	402.00	
1110	TANF EXPANDED FOR FI	89,585.00	77,469.00	67,708.00	128,399.00	126,219.00	131,497.00	133,819.00	132,592.00	134,200.00	133,899.00	132,799.00	134,267.00	
1120	TANF EXPANDED FOR FI	1,172.00	1,043.00	940.00	1,025.00	1,448.00	148.00	154.00	161.00	171.00	165.00	153.00	156.00	
2400	SSI AGED EXPANDED WI	440.00	416.00	401.00	300.00	289.00	16.00	13.00	16.00	19.00	22.00	24.00	26.00	
2410	SSI AGED EXPANDED	1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	224.00	205.00	178.00	169.00	154.00	141.00	
2420	SSI AGED EXPANDED WI	27,950.00	27,934.00	27,865.00	21,648.00	21,423.00	1,225.00	1,225.00	1,234.00	1,202.00	1,118.00	1,046.00	1,034.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	279.00	274.00	270.00	269.00	283.00	29.00	26.00	30.00	28.00	31.00	34.00	29.00	
2610	SSI DISABLED EXPAND E	2,674.00	2,580.00	2,585.00	2,201.00	2,167.00	2,094.00	2,037.00	1,900.00	1,755.00	1,614.00	1,560.00	1,519.00	
2620	SSI DISABLED EXPAND	14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	780.00	790.00	755.00	701.00	662.00	650.00	
	141,761.00	128,966.00	119,111.00	174,124.00	172,169.00	136,489.00	138,712.00	137,346.00	138,722.00	138,138.00	136,825.00	138,224.00	

26,754.00	
1,422,453.00	
6,736.00	
1,982.00	
5,398.00	
134,904.00	
2.00	
9.00	
5.00	
1,582.00	
24,686.00	
76,076.00	
1,700,587.00	

NO

W

E
SUBTOTAL:

0.00

0.00

3610	AHC CARE 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	11.00	11.00	12.00	11.00	10.00	7.00	842.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3510	ADULT 40-100% FOR FI	75,393.00	75,726.00	78,041.00	77,985.00	79,397.00	81,218.00	81,986.00	83,510.00	84,070.00	85,303.00	86,243.00	87,483.00		976,355.00		
3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	2.00	4.00	4.00	2.00	0.00	1.00		168.00		
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	193.00	13.00	20.00	15.00	15.00	7.00	12.00	7.00		935.00		
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	206,184.00	209,642.00	213,189.00	210,630.00	209,854.00	210,525.00	209,948.00	207,341.00	207,465.00		2,486,677.00		
3720	AHC CARE EXPANDED	39.00	14.00	28.00	30.00	30.00	3.00	5.00	7.00	6.00	6.00	3.00	2.00		173.00		
SUBTOTAL:	272,980.00	274,715.00	284,324.00	284,693.00	289,466.00	294,434.00	292,654.00	293,401.00	294,632.00	295,277.00	293,609.00	294,965.00		3,465,150.00		

FO

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	118.00	128.00	5.00	7.00	9.00	14.00	5.00	12.00	5.00	
3910	NEWLY ELIGIBLE FOR F	64,666.00	67,376.00	70,766.00	72,030.00	75,142.00	77,456.00	78,315.00	81,983.00	82,215.00	84,838.00	84,704.00	82,001.00	
3920	NEWLY ELIGIBLE FOR	11.00	5.00	6.00	9.00	8.00	1.00	0.00	0.00	1.00	1.00	1.00	0.00	
	64,766.00	67,441.00	70,836.00	72,157.00	75,278.00	77,462.00	78,322.00	81,992.00	82,230.00	84,844.00	84,717.00	82,006.00	

516.00	
921,492.00	
43.00	
922,051.00	

F
SUBTOTAL:

4410	SOBRA 100-133% FOR F	3,044.00	2,807.00	2,538.00	4,963.00	5,386.00	5,330.00	5,248.00	5,309.00	5,049.00	4,778.00	4,367.00	4,239.00	
4420	SOBRA 100-133% FOR	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	5,330.00	5,248.00	5,309.00	5,049.00	4,778.00	4,367.00	4,239.00	

53,058.00	
2.00	
53,060.00	

F
SUBTOTAL:

4510	BC PATIENT FOR FINA	278.00	273.00	272.00	265.00	253.00	249.00	250.00	245.00	245.00	230.00	220.00	206.00	
4610	CC PATIENT FOR FINA N	35.00	34.00	33.00	33.00	33.00	34.00	34.00	34.00	33.00	32.00	32.00	28.00	
	313.00	307.00	305.00	298.00	286.00	283.00	284.00	279.00	278.00	262.00	252.00	234.00	

2,986.00	
395.00	
3,381.00	

N

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	993.00	1,033.00	1,054.00	898.00	902.00	21.00	24.00	23.00	24.00	22.00	22.00	20.00	
8710	SSI DISABLED FREEDO M	208.00	233.00	239.00	222.00	221.00	210.00	213.00	209.00	208.00	199.00	197.00	207.00	
8720	SSI DISABLED FREEDO	152.00	159.00	166.00	135.00	139.00	1.00	2.00	2.00	3.00	3.00	3.00	3.00	
	1,354.00	1,426.00	1,460.00	1,255.00	1,262.00	232.00	239.00	234.00	235.00	224.00	222.00	230.00	

3.00	
5,036.00	
2,566.00	
768.00	
8,373.00	

M
SUBTOTAL:

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	756,679.00	753,700.00	755,343.00	755,442.00	750,542.00	745,660.00	751,912.00		9,405,051.00		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
90,239.27	108,250.46	125,024.24	33,623.10	33,736.50	6,548.22	3,288.60	3,175.20	3,061.80	2,835.00	2,608.20	2,324.70	414,715.29	
8,175,842.85	8,599,953.67	9,316,139.08	7,930,458.90	7,967,540.70	8,874,318.60	8,065,858.50	7,895,191.50	7,754,915.70	7,401,051.00	7,356,711.60	7,716,586.50	97,054,568.60	
33,410.07	49,633.89	60,633.09	12,587.40	13,664.70	2,022.30	1,474.20	1,360.80	1,360.80	1,134.00	1,020.60	1,077.30	179,379.15	
188,040.49	185,565.67	183,915.79	246,078.00	248,856.30	43,045.38	19,618.20	19,278.00	19,164.60	18,994.50	19,221.30	19,561.50	1,211,339.73	
276,400.73	269,617.89	275,025.83	351,256.50	345,756.60	350,807.94	315,252.00	315,705.60	316,272.60	302,948.10	302,721.30	305,272.80	3,727,037.89	
801,291.72	810,641.04	819,761.21	1,325,702.70	1,341,635.40	217,234.08	98,147.70	99,338.40	101,493.00	100,869.30	105,121.80	107,730.00	5,928,966.35	
180,432.71	178,003.72	175,528.90	207,011.70	206,501.40	70,141.68	47,968.20	47,061.00	46,323.90	46,777.50	48,875.40	50,803.20	1,305,429.31	
1,913,860.80	1,913,952.46	1,918,764.61	2,094,384.60	2,113,209.00	2,319,604.56	2,117,518.20	2,124,719.10	2,125,456.20	2,122,507.80	2,146,491.90	2,149,950.60	25,060,419.83	
1,119,397.75	1,126,913.87	1,136,079.87	1,257,095.70	1,266,961.50	292,241.88	164,373.30	164,316.60	165,677.40	165,790.80	168,058.80	166,641.30	7,193,548.77	
1,649.88	1,558.22	1,420.73	1,701.00	1,587.60	464.94	340.20	283.50	283.50	283.50	283.50	283.50	10,140.07	
19,936.05	19,706.90	19,569.41	23,247.00	23,530.50	25,780.86	24,154.20	24,607.80	24,551.10	24,097.50	24,210.90	24,154.20	277,546.42	
11,136.69	11,045.03	11,090.86	13,381.20	13,267.80	3,682.98	2,381.40	2,438.10	2,381.40	2,324.70	2,268.00	2,154.60	77,552.76	
45.83	45.83	91.66	113.40	56.70	0.00	0.00	0.00	56.70	56.70	56.70	56.70	580.22	
1,122,605.85	1,090,479.02	1,147,399.88	1,314,362.70	1,317,481.20	1,372,952.70	1,266,904.80	1,280,399.40	1,213,720.20	1,146,700.80	1,036,362.60	1,006,538.40	14,315,907.55	
91.66	45.83	45.83	56.70	56.70	5.04	0.00	0.00	0.00	0.00	0.00	0.00	301.76	
1,695.71	1,649.88	1,787.37	2,041.20	1,701.00	350.28	113.40	56.70	56.70	56.70	56.70	113.40	9,679.04	
1,079,617.31	1,203,862.44	1,335,165.39	1,759,230.90	1,866,507.30	1,658,301.12	1,380,815.10	1,447,494.30	1,509,694.20	1,535,436.00	1,581,136.20	1,601,718.30	17,958,978.56	
412.47	549.96	458.30	623.70	680.40	81.90	56.70	113.40	113.40	113.40	170.10	226.80	3,600.53	
15,016,107.84	15,571,475.78	16,527,902.05	16,572,956.40	16,762,731.30	15,237,584.46	13,508,264.70	13,425,539.40	13,284,583.20	12,871,977.30	12,795,375.60	13,155,193.80	174,729,691.83	

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

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

SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI BLIND WITH MEDIC

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4310

4320

5000

5010

5020

SOBRA CHILD WITH ME
D
SOBRA CHILD NON-ME
DI
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN

SUBTOTAL:

1100	TANF EXPANDED FPR FI	190,469.48	168,150.27	150,826.53	365,941.80	355,282.20	53,920.44	24,607.80	23,700.60	23,473.80	23,757.30	22,283.10	22,793.40	
1110	TANF EXPANDED FOR FI	4,105,680.55	3,550,404.27	3,103,057.64	7,280,223.30	7,156,617.30	8,053,951.50	7,587,537.30	7,517,966.40	7,609,140.00	7,592,073.30	7,529,703.30	7,612,938.90	
1120	TANF EXPANDED FOR FI	53,712.76	47,800.69	43,080.20	58,117.50	82,101.60	10,321.92	8,731.80	9,128.70	9,695.70	9,355.50	8,675.10	8,845.20	
2400	SSI AGED EXPANDED WI	20,165.20	19,065.28	18,377.83	17,010.00	16,386.30	3,381.84	737.10	907.20	1,077.30	1,247.40	1,360.80	1,474.20	
2410	SSI AGED EXPANDED	53,437.78	49,863.04	46,929.92	23,190.30	20,922.30	21,605.22	12,700.80	11,623.50	10,092.60	9,582.30	8,731.80	7,994.70	
2420	SSI AGED EXPANDED WI	1,280,948.50	1,280,215.22	1,277,052.95	1,227,441.60	1,214,684.10	182,600.46	69,457.50	69,967.80	68,153.40	63,390.60	59,308.20	58,627.80	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	91.66	91.66	91.66	56.70	56.70	66.78	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	45.83	45.83	45.83	56.70	56.70	10.08	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	12,786.57	12,557.42	12,374.10	15,252.30	16,046.10	4,139.10	1,474.20	1,701.00	1,587.60	1,757.70	1,927.80	1,644.30	
2610	SSI DISABLED EXPAND E	122,549.42	118,241.40	118,470.55	124,796.70	122,868.90	124,843.32	115,497.90	107,730.00	99,508.50	91,513.80	88,452.00	86,127.30	
2620	SSI DISABLED EXPAND	657,018.88	664,076.70	688,549.92	760,687.20	776,903.40	86,912.28	44,226.00	44,793.00	42,808.50	39,746.70	37,535.40	36,855.00	
	6,496,906.63	5,910,511.78	5,458,857.13	9,872,830.80	9,761,982.30	8,541,752.94	7,864,970.40	7,787,518.20	7,865,537.40	7,832,424.60	7,757,977.50	7,837,300.80	

1,425,206.72	
78,699,293.76	
349,566.67	
101,190.45	
276,674.26	
6,851,848.13	
113.40	
455.16	
260.97	
83,248.19	
1,320,599.79	
3,880,112.98	
92,988,570.48	

NO

W

E
SUBTOTAL:

15.12

15.12

3610	AHC CARE EXPANDED	0.00	0.00	0.00	0.00	0.00	15.12	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	15.12	0.00	0.00	0.00	0.00	0.00	0.00	

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	6,691.18	5,820.41	5,178.79	12,360.60	9,525.60	2,887.92	623.70	623.70	680.40	623.70	567.00	396.90	45,979.90

MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3510	ADULT 40-100% FOR FI	3,455,261.19	3,470,522.58	3,576,619.03	4,421,749.50	4,501,809.90	4,929,510.60	4,648,606.20	4,735,017.00	4,766,769.00	4,836,680.10	4,889,978.10	4,960,286.10		53,192,809.30		
3520	ADULT 40-100% FOR FI	1,420.73	1,237.41	1,237.41	1,757.70	2,041.20	351.54	113.40	226.80	226.80	113.40	0.00	56.70		8,783.09		
3700	ADULT <40% EXP FOR F	6,003.73	6,278.71	6,416.20	13,891.50	10,943.10	2,823.66	1,134.00	850.50	850.50	396.90	680.40	396.90		50,666.10		
3710	AHC CARE EXPANDED FO	9,039,509.20	9,105,687.72	9,439,834.25	11,690,632.80	11,886,701.40	13,068,590.22	11,942,721.00     11,898,721.80	11,936,767.50	11,904,051.60	11,756,234.70	11,763,265.50		135,432,717.69		
3720	AHC CARE EXPANDED	1,787.37	641.62	1,283.24	1,701.00	1,701.00	311.22	283.50	396.90	340.20	340.20	170.10	113.40		9,069.75		
SUBTOTAL:	12,510,673.40	12,590,188.45	13,030,568.92	16,142,093.10	16,412,722.20	18,004,475.16	16,593,481.80	16,635,836.70	16,705,634.40	16,742,205.90	16,647,630.30	16,724,515.50		188,740,025.83		

FO

3900	NEWLY ELIGIBLE FOR F	4,078.87	2,749.80	2,933.12	6,690.60	7,257.60	1,034.46	396.90	510.30	793.80	283.50	680.40	283.50	
3910	NEWLY ELIGIBLE FOR F	2,963,642.78	3,087,842.08	3,243,205.78	4,084,101.00	4,260,551.40	4,541,261.76	4,440,460.50	4,648,436.10	4,661,590.50	4,810,314.60	4,802,716.80	4,649,456.70	
3920	NEWLY ELIGIBLE FOR	504.13	229.15	274.98	510.30	453.60	76.86	0.00	0.00	56.70	56.70	56.70	0.00	
	2,968,225.78	3,090,821.03	3,246,413.88	4,091,301.90	4,268,262.60	4,542,373.08	4,440,857.40	4,648,946.40	4,662,441.00	4,810,654.80	4,803,453.90	4,649,740.20	

27,692.85	
50,193,580.00	
2,219.12	
50,223,491.97	

F
SUBTOTAL:

4410	SOBRA 100-133% FOR F	139,506.52	128,644.81	116,316.54	281,402.10	305,386.20	316,514.52	297,561.60	301,020.30	286,278.30	270,912.60	247,608.90	240,351.30	
4420	SOBRA 100-133% FOR	0.00	0.00	0.00	56.70	56.70	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	139,506.52	128,644.81	116,316.54	281,458.80	305,442.90	316,514.52	297,561.60	301,020.30	286,278.30	270,912.60	247,608.90	240,351.30	

2,931,503.69	
113.40	
2,931,617.09	

F
SUBTOTAL:

4510	BC PATIENT FOR FINA	12,740.74	12,511.59	12,465.76	15,025.50	14,345.10	15,710.94	14,175.00	13,891.50	13,891.50	13,041.00	12,474.00	11,680.20	
4610	CC PATIENT FOR FINA N	1,604.05	1,558.22	1,512.39	1,871.10	1,871.10	2,149.56	1,927.80	1,927.80	1,871.10	1,814.40	1,814.40	1,587.60	
	14,344.79	14,069.81	13,978.15	16,896.60	16,216.20	17,860.50	16,102.80	15,819.30	15,762.60	14,855.40	14,288.40	13,267.80	

161,952.83	
21,509.52	
183,462.35	

N

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	45.83	45.83	45.83	0.00	0.00	5.04	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	45,509.19	47,342.39	48,304.82	50,916.60	51,143.40	5,761.98	1,360.80	1,304.10	1,360.80	1,247.40	1,247.40	1,134.00	
8710	SSI DISABLED FREEDO M	9,532.64	10,678.39	10,953.37	12,587.40	12,530.70	12,738.60	12,077.10	11,850.30	11,793.60	11,283.30	11,169.90	11,736.90	
8720	SSI DISABLED FREEDO	6,966.16	7,286.97	7,607.78	7,654.50	7,881.30	762.30	113.40	113.40	170.10	170.10	170.10	170.10	
	62,053.82	65,353.58	66,911.80	71,158.50	71,555.40	19,267.92	13,551.30	13,267.80	13,324.50	12,700.80	12,587.40	13,041.00	

142.53	
256,632.88	
138,932.20	
39,066.21	
434,773.82	

M
SUBTOTAL:

510,231,648.49

37,207,818.78	37,371,065.24	38,460,948.47	47,048,696.10	47,598,912.90	46,679,843.70	42,734,790.00	42,827,948.10	42,833,561.40	42,555,731.40	42,278,922.00	42,633,410.40	

TOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1,969.00	2,362.00	2,728.00	593.00	595.00	65.00	58.00	56.00	54.00	50.00	46.00	41.00	8,617.00	
178,395.00	187,649.00	203,276.00	139,867.00	140,521.00	142,778.00	142,255.00	139,245.00	136,771.00	130,530.00	129,748.00	136,095.00	1,807,130.00	
729.00	1,083.00	1,323.00	222.00	241.00	33.00	26.00	24.00	24.00	20.00	18.00	19.00	3,762.00	
4,103.00	4,049.00	4,013.00	4,340.00	4,389.00	339.00	346.00	340.00	338.00	335.00	339.00	345.00	23,276.00	
6,031.00	5,883.00	6,001.00	6,195.00	6,098.00	5,619.00	5,560.00	5,568.00	5,578.00	5,343.00	5,339.00	5,384.00	68,599.00	
17,484.00	17,688.00	17,887.00	23,381.00	23,662.00	1,744.00	1,731.00	1,752.00	1,790.00	1,779.00	1,854.00	1,900.00	112,652.00	
3,937.00	3,884.00	3,830.00	3,651.00	3,642.00	824.00	846.00	830.00	817.00	825.00	862.00	896.00	24,844.00	
41,760.00	41,762.00	41,867.00	36,938.00	37,270.00	37,192.00	37,346.00	37,473.00	37,486.00	37,434.00	37,857.00	37,918.00	462,303.00	
24,425.00	24,589.00	24,789.00	22,171.00	22,345.00	2,910.00	2,899.00	2,898.00	2,922.00	2,924.00	2,964.00	2,939.00	138,775.00	
36.00	34.00	31.00	30.00	28.00	5.00	6.00	5.00	5.00	5.00	5.00	5.00	195.00	
435.00	430.00	427.00	410.00	415.00	417.00	426.00	434.00	433.00	425.00	427.00	426.00	5,105.00	
243.00	241.00	242.00	236.00	234.00	43.00	42.00	43.00	42.00	41.00	40.00	38.00	1,485.00	
1.00	1.00	2.00	2.00	1.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	11.00	
24,495.00	23,794.00	25,036.00	23,181.00	23,236.00	22,437.00	22,344.00	22,582.00	21,406.00	20,224.00	18,278.00	17,752.00	264,765.00	
2.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6.00	
37.00	36.00	39.00	36.00	30.00	2.00	2.00	1.00	1.00	1.00	1.00	2.00	188.00	
23,557.00	26,268.00	29,133.00	31,027.00	32,919.00	28,040.00	24,353.00	25,529.00	26,626.00	27,080.00	27,886.00	28,249.00	330,667.00	
9.00	12.00	10.00	11.00	12.00	1.00	1.00	2.00	2.00	2.00	3.00	4.00	69.00	
327,648.00	339,766.00	360,635.00	292,292.00	295,639.00	242,449.00	238,241.00	236,782.00	234,296.00	227,019.00	225,668.00	232,014.00	3,252,449.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

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

SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI BLIND WITH MEDIC

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4310

4320

5000

5010

5020

SOBRA CHILD WITH ME
D
SOBRA CHILD NON-ME
DI
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN

SUBTOTAL:

1100	TANF EXPANDED FPR FI	4,156.00	3,669.00	3,291.00	6,454.00	6,266.00	438.00	434.00	418.00	414.00	419.00	393.00	402.00	
1110	TANF EXPANDED FOR FI	89,585.00	77,469.00	67,708.00	128,399.00	126,219.00	131,497.00	133,819.00	132,592.00	134,200.00	133,899.00	132,799.00	134,267.00	
1120	TANF EXPANDED FOR FI	1,172.00	1,043.00	940.00	1,025.00	1,448.00	148.00	154.00	161.00	171.00	165.00	153.00	156.00	
2400	SSI AGED EXPANDED WI	440.00	416.00	401.00	300.00	289.00	16.00	13.00	16.00	19.00	22.00	24.00	26.00	
2410	SSI AGED EXPANDED	1,166.00	1,088.00	1,024.00	409.00	369.00	271.00	224.00	205.00	178.00	169.00	154.00	141.00	
2420	SSI AGED EXPANDED WI	27,950.00	27,934.00	27,865.00	21,648.00	21,423.00	1,225.00	1,225.00	1,234.00	1,202.00	1,118.00	1,046.00	1,034.00	
2500	SSI BLIND EXPANDED	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2510	SSI BLIND EXPANDED N	2.00	2.00	2.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	
2520	SSI BLIND EXPANDED W	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2600	SSI DISABLED EXPAND E	279.00	274.00	270.00	269.00	283.00	29.00	26.00	30.00	28.00	31.00	34.00	29.00	
2610	SSI DISABLED EXPAND E	2,674.00	2,580.00	2,585.00	2,201.00	2,167.00	2,094.00	2,037.00	1,900.00	1,755.00	1,614.00	1,560.00	1,519.00	
2620	SSI DISABLED EXPAND	14,336.00	14,490.00	15,024.00	13,416.00	13,702.00	770.00	780.00	790.00	755.00	701.00	662.00	650.00	
	141,761.00	128,966.00	119,111.00	174,124.00	172,169.00	136,489.00	138,712.00	137,346.00	138,722.00	138,138.00	136,825.00	138,224.00	

26,754.00	
1,422,453.00	
6,736.00	
1,982.00	
5,398.00	
134,904.00	
2.00	
9.00	
5.00	
1,582.00	
24,686.00	
76,076.00	
1,700,587.00	

NO

W

E
SUBTOTAL:

0.00

0.00

3610	AHC CARE 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

FO
SUBTOTAL:

3500	ADULT 40-100% FOR FI	146.00	127.00	113.00	218.00	168.00	8.00	11.00	11.00	12.00	11.00	10.00	7.00	842.00

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3510	ADULT 40-100% FOR FI	75,393.00	75,726.00	78,041.00	77,985.00	79,397.00	81,218.00	81,986.00	83,510.00	84,070.00	85,303.00	86,243.00	87,483.00		976,355.00		
3520	ADULT 40-100% FOR FI	31.00	27.00	27.00	31.00	36.00	3.00	2.00	4.00	4.00	2.00	0.00	1.00		168.00		
3700	ADULT <40% EXP FOR F	131.00	137.00	140.00	245.00	193.00	13.00	20.00	15.00	15.00	7.00	12.00	7.00		935.00		
3710	AHC CARE EXPANDED FO	197,240.00	198,684.00	205,975.00	206,184.00	209,642.00	213,189.00	210,630.00	209,854.00	210,525.00	209,948.00	207,341.00	207,465.00		2,486,677.00		
3720	AHC CARE EXPANDED	39.00	14.00	28.00	30.00	30.00	3.00	5.00	7.00	6.00	6.00	3.00	2.00		173.00		
SUBTOTAL:	272,980.00	274,715.00	284,324.00	284,693.00	289,466.00	294,434.00	292,654.00	293,401.00	294,632.00	295,277.00	293,609.00	294,965.00		3,465,150.00		

FO

3900	NEWLY ELIGIBLE FOR F	89.00	60.00	64.00	118.00	128.00	5.00	7.00	9.00	14.00	5.00	12.00	5.00	
3910	NEWLY ELIGIBLE FOR F	64,666.00	67,376.00	70,766.00	72,030.00	75,142.00	77,456.00	78,315.00	81,983.00	82,215.00	84,838.00	84,704.00	82,001.00	
3920	NEWLY ELIGIBLE FOR	11.00	5.00	6.00	9.00	8.00	1.00	0.00	0.00	1.00	1.00	1.00	0.00	
	64,766.00	67,441.00	70,836.00	72,157.00	75,278.00	77,462.00	78,322.00	81,992.00	82,230.00	84,844.00	84,717.00	82,006.00	

516.00	
921,492.00	
43.00	
922,051.00	

F
SUBTOTAL:

4410	SOBRA 100-133% FOR F	3,044.00	2,807.00	2,538.00	4,963.00	5,386.00	5,330.00	5,248.00	5,309.00	5,049.00	4,778.00	4,367.00	4,239.00	
4420	SOBRA 100-133% FOR	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	3,044.00	2,807.00	2,538.00	4,964.00	5,387.00	5,330.00	5,248.00	5,309.00	5,049.00	4,778.00	4,367.00	4,239.00	

53,058.00	
2.00	
53,060.00	

F
SUBTOTAL:

4510	BC PATIENT FOR FINA	278.00	273.00	272.00	265.00	253.00	249.00	250.00	245.00	245.00	230.00	220.00	206.00	
4610	CC PATIENT FOR FINA N	35.00	34.00	33.00	33.00	33.00	34.00	34.00	34.00	33.00	32.00	32.00	28.00	
	313.00	307.00	305.00	298.00	286.00	283.00	284.00	279.00	278.00	262.00	252.00	234.00	

2,986.00	
395.00	
3,381.00	

N

SUBTOTAL:

8600	SSI BLIND FREEDOM/W O	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
8700	SSI DISABLED FREEDO M	993.00	1,033.00	1,054.00	898.00	902.00	21.00	24.00	23.00	24.00	22.00	22.00	20.00	
8710	SSI DISABLED FREEDO M	208.00	233.00	239.00	222.00	221.00	210.00	213.00	209.00	208.00	199.00	197.00	207.00	
8720	SSI DISABLED FREEDO	152.00	159.00	166.00	135.00	139.00	1.00	2.00	2.00	3.00	3.00	3.00	3.00	
	1,354.00	1,426.00	1,460.00	1,255.00	1,262.00	232.00	239.00	234.00	235.00	224.00	222.00	230.00	

3.00	
5,036.00	
2,566.00	
768.00	
8,373.00	

M
SUBTOTAL:

TOTAL:	811,866.00	815,428.00	839,209.00	829,783.00	839,487.00	756,679.00	753,700.00	755,343.00	755,442.00	750,542.00	745,660.00	751,912.00		9,405,051.00		

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	912,101.24	848,941.48	773,707.06	781,066.62	725,564.47	827,530.30	601,441.48	556,030.63	500,528.48	461,172.41	435,944.16	466,218.06	7,890,246.39	
2210	SSI DISABLED NON-ME	339,019.30	338,090.48	337,161.66	358,241.15	375,396.36	431,901.92	388,515.05	392,551.57	391,542.44	396,588.09	370,350.71	353,195.50	4,472,554.23	
2220	D
SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,009.13	
1,009.13	
2310	M
SSI BLIND NON-MEDIC	928.82	928.82	928.82	1,009.13	1,009.13	1,114.72	0.00	0.00	0.00	0.00	0.00	1,009.13	
6,928.57	
4310	A
SOBRA CHILD NON-ME	13,288,627.74	13,621,145.30	13,792,048.18	14,711,097.14	15,234,835.61	16,974,862.22	15,937,190.09	15,756,555.82	15,870,587.51	16,039,112.22	16,420,563.36	16,514,412.45	
184,161,037.64	
5010	DI
SOBRA PREGNANT WO	19,505.22	15,789.94	16,718.76	20,182.60	13,118.69	14,702.54	9,082.17	13,118.69	16,146.08	16,146.08	20,182.60	6,054.78	
180,748.15	

MENTAL HEALTH CAPITATION AMOUNTS - CMDP
For The Period Ending June 30, 2016

MAN
SUBTOTAL:

14,560,182.32     14,824,896.02     14,920,564.48     15,871,596.64     16,349,924.26     18,250,111.70    16,936,228.79     16,718,256.71     16,778,804.51     16,913,018.80     17,247,040.83     17,341,899.05

196,712,524.11

5,045.65

5,045.65

3710	AHC CARE EXPANDED	0.00	0.00	0.00	1,009.13	0.00	0.00	0.00	0.00	0.00	1,009.13	1,009.13	2,018.26	
	0.00	0.00	0.00	1,009.13	0.00	0.00	0.00	0.00	0.00	1,009.13	1,009.13	2,018.26	

FO
SUBTOTAL:

1,033,190.73

1,033,190.73

4410	SOBRA 100-133% FOR	73,376.78	71,519.14	66,875.04	95,867.35	85,776.05	89,800.52	89,812.57	88,803.44	94,858.22	118,068.21	119,077.34	39,356.07	
	73,376.78	71,519.14	66,875.04	95,867.35	85,776.05	89,800.52	89,812.57	88,803.44	94,858.22	118,068.21	119,077.34	39,356.07	

F
SUBTOTAL:

197,750,760.49

14,633,559.10	14,896,415.16	14,987,439.52	15,968,473.12	16,435,700.31	18,339,912.22	17,026,041.36	16,807,060.15	16,873,662.73	17,032,096.14	17,367,127.30	17,383,273.38	

TOTAL:

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	982.00	914.00	833.00	774.00	719.00	652.00	596.00	551.00	496.00	457.00	432.00	462.00	7,868.00	
2210	SSI DISABLED NON-ME	365.00	364.00	363.00	355.00	372.00	392.00	385.00	389.00	388.00	393.00	367.00	350.00	4,483.00	
2220	D
SSI DISABLED WITH Q	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	
1.00	
2310	M
SSI BLIND NON-MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	
7.00	
4310	A
SOBRA CHILD NON-ME	14,307.00	14,665.00	14,849.00	14,578.00	15,097.00	15,449.00	15,793.00	15,614.00	15,727.00	15,894.00	16,272.00	16,365.00	
184,610.00	
5010	DI
SOBRA PREGNANT WO	21.00	17.00	18.00	20.00	13.00	13.00	9.00	13.00	16.00	16.00	20.00	6.00	
182.00	

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
For The Period Ending June 30, 2016

MAN
SUBTOTAL:

15,676.00

15,961.00

16,064.00

15,728.00

16,202.00

16,507.00

16,783.00

16,567.00

16,627.00

16,760.00

17,091.00

17,185.00

197,151.00

5.00

5.00

3710	AHC CARE EXPANDED	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	2.00	
	0.00	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	2.00	

FO
SUBTOTAL:

1,040.00

1,040.00

4410	SOBRA 100-133% FOR	79.00	77.00	72.00	95.00	85.00	87.00	89.00	88.00	94.00	117.00	118.00	39.00	
	79.00	77.00	72.00	95.00	85.00	87.00	89.00	88.00	94.00	117.00	118.00	39.00	

F
SUBTOTAL:

TOTAL:	15,755.00	16,038.00	16,136.00	15,824.00	16,287.00	16,594.00	16,872.00	16,655.00	16,721.00	16,878.00	17,210.00	17,226.00		198,196.00		

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	1,008.42	1,008.42	1,008.42	1,474.32	1,474.32	1,474.32	1,510.40	1,510.40	1,510.40	1,510.40	3,020.80	3,776.00		20,286.62		
1010	TANF NON-MEDICARE	133,111.44	130,590.39	131,598.81	194,610.24	194,610.24	193,135.92	197,862.40	196,352.00	195,596.80	194,841.60	195,596.80	196,352.00		2,154,258.64		
1011	TANF <1 M & F NON-ME	9,104.82	10,355.64	10,355.64	9,632.28	11,760.84	10,286.52	9,144.32	8,190.08	10,177.60	9,422.40	6,003.52	4,294.08		108,727.74		
1012	TANF 01-05 M & F NON	25,956.96	17,113.95	14,612.31	18,336.96	14,543.64	11,297.04	8,667.20	7,235.84	5,327.36	4,929.28	4,929.28	6,439.68		139,389.50		
1013	TANF 06-13 M & F NON	30,058.50	22,049.37	18,296.91	20,548.44	17,956.08	13,425.60	9,302.40	8,149.12	7,672.00	3,975.04	5,485.44	4,452.16		161,371.06		
1014	TANF 14-20 MALE NON-	8,513.34	6,845.58	6,098.97	5,921.88	5,921.88	4,530.48	4,174.08	4,452.16	3,696.96	3,219.84	5,684.48	5,128.32		64,187.97		
1015	TANF 14-20 FEMALE N	9,017.55	7,766.73	8,687.88	9,905.64	7,777.08	8,787.60	6,638.72	4,452.16	3,418.88	3,418.88	5,406.40	5,804.48		81,082.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	927.60	0.00	0.00	0.00	0.00	0.00	0.00		927.60		
1017	TANF 21-44 FEMALE N O	833.88	833.88	833.88	927.60	1,391.40	1,391.40	1,431.36	1,431.36	1,431.36	1,431.36	1,431.36	1,908.48		15,277.32		
2110	SSI AGED NON-MEDICA R	416.94	416.94	416.94	463.80	463.80	463.80	477.12	0.00	0.00	0.00	0.00	0.00		3,119.34		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	477.12	477.12	0.00	0.00	0.00		954.24		
2200	SSI DISABLED WITH M E	8,571.57	9,492.72	12,013.77	18,155.64	19,629.96	19,629.96	21,145.60	23,411.20	23,888.32	22,377.92	26,432.00	27,664.32		232,412.98		
2210	SSI DISABLED NON-ME D	3,071,131.98	3,075,185.07	3,070,908.99	4,422,630.00	4,413,676.56	4,434,590.40	4,544,230.40	4,533,774.72	4,534,529.92	4,535,165.12	4,535,124.16	4,548,518.72		49,719,466.04		
2220	SSI DISABLED WITH Q M	24,444.48	25,452.90	25,957.11	37,512.24	40,460.88	40,460.88	44,676.80	43,921.60	43,921.60	47,896.64	53,104.00	57,158.08		484,967.21		
2300	SSI BLIND WITH MEDIC	504.21	504.21	504.21	737.16	737.16	737.16	755.20	755.20	755.20	755.20	755.20	755.20		8,255.31		
2310	SSI BLIND NON-MEDIC A	27,624.87	28,129.08	27,624.87	39,640.80	39,831.24	39,094.08	40,821.76	40,543.68	41,298.88	42,054.08	41,020.80	43,286.40		450,970.54		
4311	SOBRA CHILD <1 M & F	21,273.72	19,935.63	18,180.60	24,292.56	22,164.00	24,375.48	25,003.52	26,314.88	21,028.48	26,991.04	26,712.96	24,725.44		280,998.31		
4312	SOBRA CHILD 01-05 M	137,425.89	146,162.22	148,906.26	180,325.32	185,783.40	191,871.12	190,816.32	191,849.60	196,778.88	195,467.52	198,131.20	197,056.96		2,160,574.69		
4313	SOBRA CHILD 06-13 M	130,832.34	140,421.96	154,045.26	197,710.08	200,468.28	209,255.88	222,698.56	227,826.88	221,308.16	222,461.44	229,577.28	230,054.40		2,386,660.52		
4314	SOBRA CHILD 14-20 MA	30,970.02	33,141.99	36,060.57	45,851.52	45,578.16	44,186.76	52,076.48	55,296.32	54,143.04	54,699.20	53,466.88	53,466.88		558,937.82		
4315	SOBRA CHILD 14-20 FE	35,226.69	37,815.60	35,886.03	47,433.36	48,278.04	50,679.96	53,469.76	55,378.24	55,179.20	54,224.96	54,025.92	54,503.04		582,100.80		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	416.94	463.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		880.74		
5015	SOBRA PREG 14-20 FE M	3,005.85	2,588.91	2,171.97	2,592.36	3,056.16	1,664.76	1,232.32	1,232.32	954.24	1,709.44	1,709.44	1,232.32		23,150.09		
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	477.12	0.00	0.00		477.12		
	3,709,033.47	3,715,811.19	3,724,586.34	5,279,166.00	5,275,563.12	5,302,266.72	5,436,134.72	5,432,554.88	5,423,094.40	5,427,028.48	5,447,617.92	5,466,576.96		59,639,434.20		

O

SUBTOTAL:

1113	TANF EXPANDED 06-13	416.94	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	463.80	0.00	463.80	477.12	477.12	0.00	0.00	477.12	477.12	
1116	TANF EXPANDED 21-44	416.94	416.94	416.94	463.80	463.80	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	463.80	0.00	477.12	0.00	0.00	0.00	0.00	0.00	
	833.88	416.94	416.94	927.60	927.60	463.80	954.24	477.12	0.00	0.00	477.12	477.12	

416.94	
2,836.08	
2,178.42	
940.92	
6,372.36	

SUBTOTAL:

3514	ADULT 40-100% MALE 1	833.88	833.88	833.88	927.60	1,391.40	1,391.40	1,431.36	2,385.60	2,385.60	2,385.60	954.24	1,908.48	
3515	ADULT 40-100% FEMAL E	833.88	833.88	833.88	463.80	463.80	463.80	477.12	954.24	954.24	1,431.36	1,431.36	1,431.36	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	463.80	0.00	463.80	477.12	477.12	477.12	477.12	477.12	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	463.80	0.00	0.00	0.00	477.12	477.12	477.12	477.12	477.12	
3714	ADULT <40% EXP MALE	6,254.10	7,087.98	6,671.04	6,029.40	6,029.40	6,029.40	6,679.68	6,679.68	8,111.04	8,588.16	9,542.40	9,542.40	

 
17,662.92	
10,572.72	
3,313.20	
2,849.40	
87,244.68	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM AL	3,752.46	4,169.40	4,169.40	5,101.80	5,101.80	6,029.40	6,202.56	6,202.56	7,156.80	7,633.92	8,588.16	8,111.04		72,219.30		
3716	ADULT <40% EXP MALE	416.94	416.94	416.94	1,391.40	927.60	927.60	477.12	477.12	477.12	477.12	477.12	1,431.36		8,314.38		
3717	ADULT <40% EXP FEM AL	416.94	416.94	416.94	463.80	927.60	1,391.40	1,431.36	477.12	477.12	477.12	477.12	477.12		7,850.58		
	12,508.20	13,759.02	13,342.08	15,305.40	14,841.60	16,696.80	17,176.32	18,130.56	20,516.16	21,947.52	22,424.64	23,378.88		210,027.18		

SUBTOTAL:

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	477.12	1,431.36	954.24	
3915	NEWLY ELIGIBLE FEMA	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	477.12	
SUBTOTAL:	416.94	416.94	416.94	0.00	0.00	0.00	0.00	0.00	0.00	477.12	1,431.36	1,431.36	

2,862.72	
1,727.94	
4,590.66	

L

4413	SOBRA 100-133% M&F
6	4,760.88	4,343.94	3,927.00	12,332.16	13,996.92	11,404.56	13,637.44	12,206.08	13,160.32	12,683.20	11,928.00	10,019.52	
4414	SOBRA 100-133% MALE	1,755.03	1,755.03	921.15	4,447.56	3,983.76	4,447.56	3,816.96	3,816.96	4,294.08	3,816.96	3,816.96	3,339.84	
4415	SOBRA 100-133% FEMA	833.88	833.88	416.94	1,391.40	1,855.20	1,855.20	1,431.36	1,431.36	1,908.48	2,385.60	2,862.72	2,385.60	
	7,349.79	6,932.85	5,265.09	18,171.12	19,835.88	17,707.32	18,885.76	17,454.40	19,362.88	18,885.76	18,607.68	15,744.96	

124,400.02	
40,211.85	
19,591.62	
184,203.49	

L
SUBTOTAL:

60,044,627.89

3,730,142.28	3,737,336.94	3,744,027.39	5,313,570.12	5,311,168.20	5,337,134.64	5,473,151.04	5,468,616.96	5,462,973.44	5,468,338.88	5,490,558.72	5,507,609.28	

TOTAL:

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	4.00	5.00		29.00		
1010	TANF NON-MEDICARE	264.00	259.00	261.00	264.00	264.00	262.00	262.00	260.00	259.00	258.00	259.00	260.00		3,132.00		
1011	TANF <1 M & F NON-ME	21.00	24.00	24.00	19.00	23.00	21.00	18.00	16.00	19.00	18.00	12.00	9.00		224.00		
1012	TANF 01-05 M & F NON	61.00	40.00	34.00	36.00	29.00	22.00	17.00	14.00	10.00	8.00	8.00	10.00		289.00		
1013	TANF 06-13 M & F NON	70.00	51.00	42.00	39.00	34.00	26.00	16.00	13.00	12.00	6.00	8.00	7.00		324.00		
1014	TANF 14-20 MALE NON-	20.00	16.00	14.00	11.00	11.00	8.00	7.00	7.00	6.00	5.00	9.00	9.00		123.00		
1015	TANF 14-20 FEMALE N	21.00	18.00	20.00	19.00	15.00	16.00	11.00	7.00	6.00	6.00	9.00	11.00		159.00		
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
1017	TANF 21-44 FEMALE N O	2.00	2.00	2.00	2.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	4.00		33.00		
2110	SSI AGED NON-MEDICA R	1.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00		7.00		
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	1.00	0.00	0.00	0.00		2.00		
2200	SSI DISABLED WITH M E	17.00	19.00	24.00	25.00	27.00	27.00	28.00	31.00	32.00	30.00	35.00	37.00		332.00		
2210	SSI DISABLED NON-ME D	6,177.00	6,184.00	6,175.00	6,182.00	6,168.00	6,196.00	6,194.00	6,175.00	6,176.00	6,175.00	6,172.00	6,189.00		74,163.00		
2220	SSI DISABLED WITH Q M	49.00	51.00	52.00	52.00	56.00	56.00	61.00	60.00	60.00	66.00	74.00	79.00		716.00		
2300	SSI BLIND WITH MEDIC	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00		12.00		
2310	SSI BLIND NON-MEDIC A	56.00	57.00	56.00	56.00	57.00	56.00	57.00	57.00	58.00	59.00	58.00	61.00		688.00		
4311	SOBRA CHILD <1 M & F	46.00	43.00	39.00	40.00	36.00	39.00	39.00	40.00	33.00	42.00	42.00	39.00		478.00		
4312	SOBRA CHILD 01-05 M	298.00	320.00	327.00	311.00	321.00	330.00	323.00	324.00	332.00	331.00	336.00	332.00		3,885.00		
4313	SOBRA CHILD 06-13 M	287.00	310.00	341.00	342.00	345.00	361.00	377.00	386.00	377.00	380.00	392.00	393.00		4,291.00		
4314	SOBRA CHILD 14-20 MA	68.00	73.00	80.00	80.00	80.00	77.00	87.00	92.00	89.00	89.00	87.00	87.00		989.00		
4315	SOBRA CHILD 14-20 FE	78.00	84.00	80.00	84.00	87.00	91.00	94.00	98.00	97.00	95.00	94.00	95.00		1,077.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		2.00		
5015	SOBRA PREG 14-20 FE M	7.00	6.00	5.00	5.00	6.00	3.00	2.00	2.00	2.00	3.00	3.00	2.00		46.00		
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	1.00	0.00	0.00		1.00		
	7,546.00	7,561.00	7,581.00	7,572.00	7,566.00	7,600.00	7,600.00	7,589.00	7,575.00	7,578.00	7,606.00	7,630.00		91,004.00		

O

SUBTOTAL:

1113	TANF EXPANDED 06-13	1.00	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	1.00	0.00	1.00	1.00	1.00	0.00	0.00	1.00	1.00	
1116	TANF EXPANDED 21-44	1.00	1.00	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	1.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	
	2.00	1.00	1.00	2.00	2.00	1.00	2.00	1.00	0.00	0.00	1.00	1.00	

1.00	
6.00	
5.00	
2.00	
14.00	

SUBTOTAL:

3514	ADULT 40-100% MALE 1	2.00	2.00	2.00	2.00	3.00	3.00	3.00	5.00	5.00	5.00	2.00	4.00	
3515	ADULT 40-100% FEMAL E	2.00	2.00	2.00	1.00	1.00	1.00	1.00	2.00	2.00	3.00	3.00	3.00	
3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	1.00	0.00	1.00	1.00	1.00	1.00	1.00	1.00	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	1.00	0.00	0.00	0.00	1.00	1.00	1.00	1.00	1.00	
3714	ADULT <40% EXP MALE	15.00	17.00	16.00	13.00	13.00	13.00	14.00	14.00	17.00	18.00	20.00	20.00	

 
38.00	
23.00	
7.00	
6.00	
190.00	

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3715	ADULT <40% EXP FEM AL	9.00	10.00	10.00	11.00	11.00	13.00	13.00	13.00	15.00	16.00	18.00	17.00		156.00		
3716	ADULT <40% EXP MALE	1.00	1.00	1.00	3.00	2.00	2.00	1.00	1.00	1.00	1.00	1.00	3.00		18.00		
3717	ADULT <40% EXP FEM AL	1.00	1.00	1.00	1.00	2.00	3.00	3.00	1.00	1.00	1.00	1.00	1.00		17.00		
	30.00	33.00	32.00	33.00	32.00	36.00	36.00	38.00	43.00	46.00	47.00	49.00		455.00		

SUBTOTAL:

3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.00	2.00	
3915	NEWLY ELIGIBLE FEMA	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	
SUBTOTAL:	1.00	1.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	1.00	3.00	3.00	

6.00	
4.00	
10.00	

L

4413	SOBRA 100-133% M&F
6	11.00	10.00	9.00	26.00	29.00	24.00	28.00	25.00	27.00	26.00	25.00	21.00	
4414	SOBRA 100-133% MALE	4.00	4.00	2.00	9.00	8.00	9.00	8.00	8.00	9.00	8.00	8.00	7.00	
4415	SOBRA 100-133% FEMA	2.00	2.00	1.00	3.00	4.00	4.00	3.00	3.00	4.00	5.00	6.00	5.00	
	17.00	16.00	12.00	38.00	41.00	37.00	39.00	36.00	40.00	39.00	39.00	33.00	

261.00	
84.00	
42.00	
387.00	

L
SUBTOTAL:

TOTAL:	7,596.00	7,612.00	7,627.00	7,645.00	7,641.00	7,674.00	7,677.00	7,664.00	7,658.00	7,664.00	7,696.00	7,716.00		91,870.00		

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-286.63	
0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-286.63	

1006	TANF 21-44 MALE WITH	13,748.51	11,706.46	23,270.89	8,748.57	7,149.61	14,460.00	3,194.53	1,092.57	4,020.51	1,640.49	2,891.10	3,163.94	
1007	TANF 21-44 FEMALE WI	17,026.44	13,867.21	25,370.63	22,346.09	17,592.65	23,508.63	17,515.57	17,394.35	18,811.72	5,970.14	10,335.29	7,361.89	
1008	TANF 45-64 M & F WIT	29,543.51	38,496.50	56,571.19	54,075.02	32,676.28	26,439.35	11,308.56	10,333.60	13,834.50	11,779.18	13,224.54	12,446.62	
1009	TANF 65+ M & F WITH	9,711.26	9,427.79	29,391.90	16,563.16	12,496.08	8,552.14	6,374.27	9,839.90	6,684.57	8,719.62	3,039.66	5,982.23	
1011	TANF <1 M & F NON-ME	1,290,959.10	1,245,523.04	1,285,302.05	905,574.17	963,537.08	1,018,793.29	1,098,938.02	1,167,621.49	1,393,494.73	989,712.40	861,788.07	1,144,914.84	
1012	TANF 01-05 M & F NON	1,257,382.93	1,081,951.02	933,354.82	539,709.66	757,662.16	586,695.92	442,817.74	422,555.75	429,550.76	372,765.11	346,828.87	420,499.59	
1013	TANF 06-13 M & F NON	1,882,318.21	1,589,351.98	1,841,982.47	862,977.79	1,029,797.97	773,563.19	461,596.57	407,893.17	362,611.93	353,841.59	262,808.33	319,806.39	
1014	TANF 14-20 MALE NON-	349,688.37	397,522.68	308,438.57	514,200.50	224,937.19	172,869.70	114,807.96	104,596.61	135,873.26	75,239.88	83,803.62	94,620.79	
1015	TANF 14-20 FEMALE N O	618,162.51	955,347.31	724,128.67	410,827.38	435,390.45	506,608.57	304,973.91	267,364.55	343,076.17	224,280.59	289,643.92	274,456.47	
1016	TANF 21-44 MALE NON-	1,720,458.08	1,835,554.52	2,506,066.57	1,727,158.48	1,426,837.45	1,681,835.03	1,519,545.50	1,517,622.85	1,716,325.37	1,529,077.81	1,587,876.44	2,048,650.29	
1017	TANF 21-44 FEMALE N O	6,255,681.23	6,847,408.50	8,911,141.15	5,718,928.09	5,916,678.41	6,203,234.59	4,843,007.69	5,346,047.51	6,014,474.27	4,731,567.12	5,499,937.74	6,613,966.33	
1018	TANF 45-64 M & F NON	2,241,687.50	2,225,717.52	3,261,573.62	2,183,571.68	2,053,071.73	2,231,511.27	1,809,130.45	1,947,442.44	2,184,548.78	1,896,964.51	2,199,609.57	2,754,818.34	
1019	TANF 65+ M & F NON-M	10,320.41	9,670.04	10,279.84	5,969.00	700.00	7,531.73	12,607.29	2,489.62	2,008.17	1,000.63	2,262.00	3,680.00	
1026	TANF 21-44 MALE WITH	700.00	568.89	2,023.45	1,345.49	471.14	2,049.70	-0.09	757.91	-795.52	-530.44	837.07	961.43	
1027	TANF 21-44 FEMALE WI	1,268.82	1,174.29	4,000.44	2,990.62	509.85	3,715.39	1,466.16	9,792.04	3,745.74	1,437.93	2,826.90	2,897.21	
1028	TANF 45-64 M & F WIT	6,682.12	19,778.64	18,075.17	3,448.75	7,147.15	2,792.40	935.87	3,817.11	5,130.56	5,424.30	3,172.61	8,010.77	
1029	TANF 65+ M & F WITH	5,507.74	3,496.54	5,763.29	2,613.98	4,407.36	5,084.03	82.87	321.47	835.65	43.56	359.44	61.40	
2100	SSI AGED WITH MEDIC A	167,284.72	163,478.22	201,904.18	127,579.30	163,117.16	143,402.07	138,838.96	100,955.06	115,057.59	102,290.44	111,103.49	195,536.73	
2110	SSI AGED NON-MEDICA R	125,205.47	128,787.96	211,507.53	151,466.88	159,319.29	137,030.36	79,330.72	104,082.71	122,697.74	147,913.69	102,328.12	173,417.46	
2120	SSI AGED WITH QMB	326,875.26	398,974.35	518,146.67	350,297.01	301,912.77	527,473.67	312,502.09	431,984.17	491,704.98	474,893.20	533,307.58	551,938.78	
2200	SSI DISABLED WITH M E	306,269.94	461,879.30	527,481.62	417,867.71	349,136.11	497,895.47	257,476.73	311,838.41	351,602.56	316,639.37	364,766.61	535,925.86	
2210	SSI DISABLED NON-ME	8,070,657.42	8,785,140.60	10,377,505.66	6,855,292.97	7,625,934.11	8,790,935.35	6,487,472.46	7,149,338.35	8,605,092.22	7,888,870.62	8,767,494.92	9,708,722.31	
2220	SSI DISABLED WITH Q M	1,017,428.75	1,228,462.25	1,678,808.77	1,093,787.83	1,003,545.35	1,548,474.33	959,104.40	1,168,128.25	1,458,952.67	1,150,850.61	1,262,079.52	1,454,338.24	
2300	SSI BLIND WITH MEDIC	2,615.94	1,503.84	1,485.61	614.91	454.23	1,086.50	1,772.52	1,810.10	1,465.51	1,552.05	661.36	9,334.44	
2310	SSI BLIND NON-MEDIC A	117,830.33	100,119.21	107,909.34	69,161.53	71,428.41	92,614.23	61,535.87	65,945.33	66,188.40	69,501.60	83,011.81	103,293.31	
2320	SSI BLIND WITH QMB	16,751.49	16,898.33	16,514.76	11,295.59	10,808.18	24,001.83	9,887.38	13,553.32	14,945.44	16,701.65	16,326.93	21,120.35	
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	0.00	884.64	8.89	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	700.00	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	411.40	79.40	0.00	0.00	
4311	SOBRA CHILD <1 M & F	2,174,749.48	2,074,877.06	2,217,875.37	1,618,780.76	2,184,782.52	2,371,204.59	2,055,582.50	2,206,041.64	2,830,393.06	2,732,483.31	2,382,811.85	2,872,325.71	
4312	SOBRA CHILD 01-05 M	2,763,871.20	2,834,483.06	3,569,126.85	2,468,077.70	3,433,325.87	4,111,942.13	3,124,080.99	4,062,923.99	4,593,546.76	3,910,103.35	4,141,408.11	4,298,101.47	
4313	SOBRA CHILD 06-13 M	3,762,824.46	4,361,436.75	6,065,640.01	3,546,216.84	4,651,190.92	5,314,301.34	4,145,955.36	4,435,539.88	5,177,069.20	5,636,202.01	5,512,485.06	5,145,058.92	
4314	SOBRA CHILD 14-20 MA	939,030.81	1,434,713.92	1,458,821.66	973,466.61	1,231,404.84	1,393,367.62	1,039,905.54	1,174,919.15	1,451,591.65	1,187,804.67	1,244,253.21	1,494,989.02	

95,087.18	
197,100.61	
310,728.85	
126,782.58	
13,366,158.28	
7,591,774.33	
10,148,549.59	
2,576,599.13	
5,354,260.50	
20,817,008.39	
72,902,072.63	
26,989,647.41	
68,518.73	
8,389.03	
35,825.39	
84,415.45	
28,577.33	
1,730,547.92	
1,643,087.93	
5,220,010.53	
4,698,779.69	
99,112,456.99	
15,023,960.97	
24,357.01	
1,008,539.37	
188,805.25	
1,261.53	
700.00	
490.80	
27,721,907.85	
43,310,991.48	
57,753,920.75	
15,024,268.70	

D

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	1,301,099.71	1,480,601.04	1,858,178.99	1,598,217.67	1,508,100.10	1,780,284.94	1,341,359.36	1,854,063.98	1,731,347.86	1,428,299.75	1,642,050.36	2,035,878.48		19,559,482.24		
5007	SOBRA PREG 21-44 FE M	0.00	700.00	700.00	0.00	21.79	885.87	2,158.62	1,054.83	601.96	591.47	1,540.86	1,858.68		10,114.08		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	4,357.53	1,572.17	700.00	0.00	350.00	0.00	0.00	1,609.29	2,582.75	9,984.57		21,156.31		
5015	SOBRA PREG 14-20 FE M	396,630.45	405,096.39	479,727.39	392,622.76	525,109.97	463,461.69	314,495.69	442,194.06	373,712.68	331,518.59	340,885.04	497,375.58		4,962,830.29		
5017	SOBRA PREG 21-44 FE	1,708,550.06	2,049,753.34	2,625,202.28	1,982,900.83	2,364,318.56	2,224,181.36	1,616,865.05	2,090,744.67	2,370,240.47	1,976,763.71	2,142,301.24	2,725,280.93		25,877,102.50		
5018	SOBRA PREG 45-64 FE M	4,193.00	14,500.38	2,450.00	1,822.16	1,347.29	4,635.72	2,106.99	6,217.94	5,797.37	11,731.59	6,939.28	-6,846.00		54,895.72		
5027	SOBRA PREG 21-44 FE	0.00	0.00	12.47	0.00	0.00	0.00	122.80	0.00	13.42	0.00	235.84	1,667.55		2,052.08		
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.44	972.25	393.04	892.00	1,627.05		4,107.78		
	38,912,715.23	42,227,968.93	51,870,791.41	34,642,089.66	38,477,020.03	42,696,424.00	32,599,206.90	36,858,542.22	42,398,004.36	37,595,727.83	39,831,595.75	45,547,236.86		483,657,323.18		

M

M

SUBTOTAL:

3,778.10

3,778.10

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	85.42	0.00	215.79	8.94	1,913.80	29.86	1,524.29	
	0.00	0.00	0.00	0.00	0.00	85.42	0.00	215.79	8.94	1,913.80	29.86	1,524.29	

1
SUBTOTAL:

1103	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	240.24	368.00	0.00	
1104	TANF EXPANDED 14-20	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	10,284.15	10,175.29	17,463.56	6,713.81	6,727.53	20,648.76	12,222.44	6,469.57	16,041.72	16,792.07	27,024.35	23,118.08	
1107	TANF EXPANDED 21-44	22,395.39	24,471.89	35,137.04	29,098.84	37,436.02	54,111.83	25,753.21	37,544.22	46,247.87	22,541.27	37,987.27	50,044.57	
1108	TANF EXPANDED 45-64	62,335.76	91,660.22	84,344.30	47,375.02	62,250.31	116,500.56	85,964.71	94,142.74	113,370.04	104,268.47	115,808.14	113,849.73	
1109	TANF EXPANDED 65+	23,910.19	20,501.26	32,963.26	25,925.52	28,936.18	44,064.76	32,925.55	36,555.48	51,233.02	52,398.11	64,485.85	57,642.38	
1111	TANF EXPANDED <1 M
&F	0.00	107.79	0.00	0.00	0.00	0.00	0.00	10,572.08	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	5,732.86	4,829.90	1,724.46	1,174.70	2,883.38	1,131.53	157.18	700.00	2,193.04	754.00	660.72	1,104.00	
1113	TANF EXPANDED 06-13	30,078.23	19,474.68	25,336.13	9,267.93	12,274.86	4,119.40	6,989.95	4,081.97	3,187.71	2,493.76	2,820.63	1,548.25	
1114	TANF EXPANDED 14-20	15,858.70	9,308.99	5,711.38	9,618.73	16,742.54	15,829.30	13,628.21	25,278.96	17,711.99	11,837.79	7,490.49	11,506.50	
1115	TANF EXPANDED 14-20	28,001.63	22,720.99	43,056.85	16,406.84	35,978.34	30,101.90	48,938.98	21,152.12	32,015.69	26,577.10	29,007.55	48,829.67	
1116	TANF EXPANDED 21-44	362,417.96	353,624.60	512,350.28	353,039.43	652,149.40	732,627.85	547,986.30	691,986.06	831,793.09	622,571.45	718,068.98	758,650.57	
1117	TANF EXPANDED 21-44	1,288,260.07	1,258,732.85	1,300,199.98	1,114,194.80	1,720,889.74	2,092,356.07	1,846,659.18	2,022,623.52	2,272,005.03	2,025,751.95	2,303,396.80	2,571,469.84	
1118	TANF EXPANDED 45-64	704,691.67	705,276.22	792,023.29	747,280.96	1,128,424.43	1,399,438.12	1,119,850.30	1,479,753.31	1,712,417.59	1,374,348.12	1,577,677.55	1,770,865.59	
1119	TANF EXPANDED 65+
M&	4.35	1,208.05	2,125.17	1,050.00	1,233.56	5,642.06	1,421.04	4,243.61	1,769.51	647.53	4,120.00	2,652.43	
1126	TANF EXPANDED 21-44	1,500.26	3,544.35	2,230.96	1,605.60	1,457.35	10,220.20	4,910.43	17,196.24	33,652.25	14,059.86	22,969.48	17,038.19	
1127	TANF EXPANDED 21-44	2,664.74	2,843.89	7,168.40	2,711.75	2,663.79	5,379.10	2,965.73	10,412.75	8,900.15	7,975.07	12,202.62	4,262.99	
1128	TANF EXPANDED 45-64	9,867.91	10,323.33	12,735.99	9,612.64	14,560.72	27,604.05	23,241.13	40,218.45	30,699.43	25,643.72	42,829.55	39,103.41	
1129	TANF EXPANDED 65+
M&	7,716.84	9,382.71	9,968.24	4,051.32	6,051.95	12,685.96	16,685.68	18,941.10	18,596.14	19,464.27	15,026.16	20,942.55	
2400	SSI AGED EXPANDED WI	22,942.06	38,024.62	25,791.81	23,668.51	15,918.51	19,779.67	9,221.30	7,563.99	10,437.33	12,950.88	16,188.70	13,840.91	
2410	SSI AGED EXPANDED NO	67,166.54	76,848.41	85,275.84	56,641.92	14,405.42	-6,248.62	27,759.57	6,894.62	14,304.97	9,287.19	8,727.89	8,494.64	
2420	SSI AGED EXPANDED WI	381,632.77	433,733.65	560,695.33	355,819.68	312,801.61	402,841.73	287,149.02	342,898.10	387,850.64	359,660.72	351,765.66	338,484.90	
2600	SSI DISABLED EXPAND E	12,133.96	14,195.83	29,503.82	33,613.80	21,605.09	25,316.76	20,282.52	22,118.60	22,690.42	20,608.44	18,902.69	30,698.96	
2610	SSI DISABLED EXPAND	300,375.73	232,843.02	283,300.90	217,797.74	205,261.69	195,292.13	256,913.01	238,778.45	154,090.29	164,732.31	156,944.99	222,673.25	

1,308.24	
350.00	
173,681.33	
422,769.42	
1,091,870.00	
471,541.56	
10,679.87	
23,045.77	
121,673.50	
160,523.58	
382,787.66	
7,137,265.97	
21,816,539.83	
14,512,047.15	
26,117.31	
130,385.17	
70,150.98	
286,440.33	
159,512.92	
216,328.29	
369,558.39	
4,515,333.81	
271,670.89	
2,629,003.51	

M&

E

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
285,198.27	311,126.24	453,402.95	307,810.33	270,330.08	426,260.66	264,912.45	354,964.61	400,100.25	325,975.87	349,104.15	425,690.76	4,174,876.62	
3,645,170.04	3,654,958.78	4,322,859.94	3,374,479.87	4,570,982.50	5,635,703.78	4,656,537.89	5,495,090.55	6,182,008.17	5,221,580.19	5,883,578.22	6,532,512.17	59,175,462.10	

3308	AHC CARE M&F 45-64 W	21.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-95.91	0.00	0.00	0.00	0.00	0.00	-8.71	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	-527.88	0.00	-316.00	0.00	0.00	-453.42	-381.79	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	-12,669.89	0.00	0.00	-883.27	-304.13	-3,862.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-13,272.06	0.00	-316.00	-883.27	-304.13	-4,315.42	-390.50	0.00	0.00	0.00	0.00	0.00	

 
21.62	
-104.62	
-1,679.09	
-17,719.29	
-19,481.38	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	-1,057.32	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	-99.09	0.00	0.00	-90.89	0.00	0.00	0.00	-197.86	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	60.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	-2,238.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	-4,604.13	0.00	-55.93	
3616	AHC CARE/MI MALE 21-	-23,081.14	-52.99	-475.87	-491.04	0.00	-6,343.50	-20.32	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	-672.13	0.00	1,251.30	-100.95	0.00	-2,268.00	0.00	-2,555.66	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	48,625.18	0.00	1,316.38	0.00	0.00	-7,299.48	0.00	0.00	0.00	0.00	0.00	-107.53	
SUBTOTAL:	22,658.87	-52.99	14,341.74	-591.99	0.00	-17,059.19	-20.32	-2,555.66	0.00	-4,801.99	0.00	-163.46	

 
-1,057.32	
-387.84	
60.75	
-2,238.34	
7,653.51	
-30,464.86	
-4,345.44	
42,534.55	
11,755.01	

3506	ADULT 40-100% MALE 2	100.62	646.90	826.55	497.49	10.06	856.86	1,069.02	1,858.79	1,822.67	1,285.95	-501.83	-1,090.05	
3507	ADULT 40-100% FEMAL E	350.00	-297.96	350.00	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	4,048.26	5,152.04	8,303.45	2,673.83	5,233.53	5,325.14	10,702.23	5,851.40	8,541.99	535.76	9,524.25	3,836.58	
3509	ADULT 40-100% M&F 65	1,136.72	650.66	2,304.18	777.55	2,786.50	2,656.76	367.82	123.99	1,443.91	231.63	381.21	953.20	
3514	ADULT 40-100% MALE 1	28,154.57	16,919.86	20,598.17	29,661.34	27,712.23	37,580.94	41,908.79	37,993.00	32,505.45	33,256.09	39,907.46	51,360.68	
3515	ADULT 40-100% FEMAL E	63,740.82	68,857.24	154,389.86	65,722.76	76,922.52	65,038.38	42,310.21	67,697.22	69,756.52	49,950.55	87,019.61	77,429.32	
3516	ADULT 40-100% MALE 2	595,422.82	648,844.84	749,505.91	775,688.96	602,174.53	708,732.51	810,029.73	690,624.50	911,327.86	804,495.90	888,956.08	1,086,168.69	
3517	ADULT 40-100% FEMAL	448,531.84	490,065.88	644,008.43	391,103.49	455,793.22	454,636.85	383,720.88	497,374.37	568,875.75	502,427.40	562,363.82	765,917.01	
3518	ADULT 40-100% M&F 45	1,779,103.67	1,877,742.95	2,130,964.95	1,387,795.56	1,631,187.19	1,873,844.72	1,631,110.70	1,710,645.51	1,990,367.28	1,782,663.71	2,154,890.99	2,432,191.72	
3519	ADULT 40-100% M&F 65	700.00	1,114.00	4,797.69	17,145.46	700.00	2,450.00	1,092.24	1,050.00	1,071.06	13,036.71	12,619.08	47,662.84	
3526	ADULT 40-100% MALE 2	0.00	74.88	136.07	0.61	350.00	0.00	0.00	0.00	99.44	0.00	61.40	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	45.52	341.77	0.00	0.00	
3528	ADULT 40-100% M&F 45	101.17	60.44	121.84	0.00	0.00	62.84	0.00	0.00	139.94	902.27	847.93	770.78	
3529	ADULT 40-100% M&F 65	0.00	0.00	380.98	90.66	380.22	120.88	103.71	278.87	1,063.00	640.90	0.00	18.42	
3705	ADULT <40% EXP FEM AL	0.00	5.04	59.40	0.00	0.00	0.00	4.35	61.40	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	254.18	187.24	2,147.85	720.29	183.04	2,139.90	710.15	794.19	1,633.86	5,538.67	5,596.37	655.96	
3707	ADULT <40% EXP FEM AL	3,196.60	2,984.95	5,735.57	5,555.83	3,319.35	11,243.02	3,917.52	535.05	1,398.23	591.75	0.00	649.85	
3708	ADULT <40% EXP M&F	20,398.58	29,175.88	21,993.36	25,199.18	23,133.12	24,274.24	12,893.26	18,257.36	19,368.00	21,156.87	15,911.51	17,898.93	
3709	ADULT <40% EXP M&F	662.62	898.69	1,365.10	1,918.68	573.77	221.31	248.38	485.23	0.00	1,150.34	936.10	889.81	

7,383.03	
402.04	
69,728.46	
13,814.13	
397,558.58	
888,835.01	
9,271,972.33	
6,164,818.94	
22,382,508.95	
103,439.08	
722.40	
387.29	
3,007.21	
3,077.64	
130.19	
20,561.70	
39,127.72	
249,660.29	
9,350.03	

E

4

6

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	222,884.44	394,365.52	460,111.11	290,538.55	301,852.22	316,910.70	209,200.65	351,331.06	245,132.00	199,937.04	343,957.67	397,689.08		3,733,910.04		
3715	ADULT <40% EXP FEM AL	310,676.54	280,914.28	359,791.31	268,309.43	294,507.23	353,631.22	293,885.85	337,307.92	367,114.90	263,356.55	394,812.97	404,932.08		3,929,240.28		
3716	ADULT <40% EXP MALE	5,628,508.71	6,879,358.31	8,226,675.54	5,692,613.38	6,424,354.58	7,064,928.46	5,710,963.95	6,116,850.11	6,433,015.94	5,817,311.19	6,326,085.12	7,842,181.61		78,162,846.90		
3717	ADULT <40% EXP FEM AL	3,131,984.98	3,612,847.61	4,415,525.36	3,018,805.67	3,263,582.99	3,938,144.69	2,814,367.59	3,323,535.99	3,679,812.69	3,373,769.13	3,450,382.72	4,189,517.53		42,212,276.95		
3718	ADULT <40% EXP M&F	7,505,601.56	8,385,725.63	10,052,601.97	7,135,426.84	7,938,678.59	9,242,278.61	7,114,978.63	7,926,659.09	8,921,833.44	7,950,474.10	8,790,386.53	11,595,828.01		102,560,473.00		
3719	ADULT <40% EXP M&F 6	20,526.57	6,525.97	34,180.45	3,932.97	6,156.96	11,148.55	6,217.59	6,975.10	4,539.12	2,679.16	3,529.59	6,921.00		113,333.03		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	368.00	0.00		736.00		
3727	ADULT <40% EXP FEM AL	166.20	0.00	0.00	0.00	0.00	350.00	350.00	0.00	0.00	0.00	0.00	0.00		866.20		
3728	ADULT <40% EXP M&F 4	-612.98	2,336.87	599.83	1,113.03	476.91	1,324.77	274.77	1,050.00	2,310.25	5,080.45	3,809.17	822.26		18,585.33		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194.20	10.04	0.00		204.24		
	19,765,638.49	22,705,157.72	27,297,474.93	19,115,291.56	21,060,068.76	24,117,901.35	19,090,428.02	21,097,340.15	23,263,218.82	20,831,376.09	23,091,855.79	28,923,205.31		270,358,956.99		

4

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	21.47	708.58	404.29	0.00	101.64	0.00	2,206.84	1,985.01	48.25	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	2,100.00	392.10	350.00	350.00	350.00	0.00	838.07	1,018.13	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	8,274.29	12,110.91	11,447.94	6,297.36	4,582.34	14,254.41	4,184.08	1,191.85	8,667.13	3,654.35	4,760.13	16,612.19	
3909	NEWLY ELIGIBLE M&F 6	291.65	74.97	0.00	1,418.20	2,273.85	1,370.89	310.18	1,221.62	583.12	713.07	466.51	2,492.27	
3914	NEWLY ELIGIBLE MALE	6,715.58	7,956.39	28,873.22	11,240.21	10,919.77	17,488.78	11,053.95	9,201.50	8,963.80	21,989.71	17,806.58	37,982.67	
3915	NEWLY ELIGIBLE FEMA L	22,792.35	34,855.60	21,227.56	25,293.64	28,961.83	39,091.53	24,651.94	40,600.22	33,218.76	43,911.01	59,301.23	40,868.97	
3916	NEWLY ELIGIBLE MALE	305,610.01	396,142.75	488,332.18	433,207.58	284,638.88	490,839.64	300,754.78	341,854.67	413,690.33	440,517.04	472,206.07	477,740.11	
3917	NEWLY ELIGIBLE FEMA L	365,563.44	469,279.85	562,236.94	478,333.08	462,900.24	666,374.15	481,198.37	504,371.44	758,419.76	681,876.38	694,909.56	678,491.90	
3918	NEWLY ELIGIBLE M&F 4	1,046,431.51	1,175,014.10	1,299,604.63	912,240.75	1,066,051.25	1,102,594.49	962,994.87	942,329.91	1,085,969.23	961,729.23	1,040,256.67	1,161,132.75	
3919	NEWLY ELIGIBLE M&F 6	700.00	0.00	2,450.00	1,050.00	700.00	350.00	1,750.00	0.00	164.48	0.00	368.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71.47	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	47.11	350.00	59.40	0.00	48.25	10.07	0.00	145.14	13.39	0.00	55.47	0.00	
	1,757,825.94	2,095,784.57	2,416,331.87	1,869,494.39	1,862,134.99	2,333,128.25	1,787,248.17	1,841,089.46	2,310,528.07	2,157,615.76	2,292,115.23	2,415,369.11	

6,876.08	
5,398.30	
96,036.98	
11,216.33	
190,192.16	
414,774.64	
4,845,534.04	
6,803,955.11	
12,756,349.39	
7,532.48	
71.47	
728.83	
25,138,665.81	

4

4
SUBTOTAL:

4412	SOBRA 100-133% M&F	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	274.77	
4413	SOBRA 100-133% M&F
6	208,919.81	208,659.92	145,887.27	356,231.37	470,925.81	559,700.27	435,224.20	502,373.49	599,023.51	533,895.42	583,652.53	524,887.90	
4414	SOBRA 100-133% MALE	89,702.86	89,764.24	51,754.79	154,905.56	148,369.44	154,735.22	171,746.40	155,565.47	129,054.20	95,129.72	116,693.19	140,320.92	
4415	SOBRA 100-133% FEMA	72,034.45	135,577.62	72,403.64	179,192.24	176,144.29	203,844.54	143,597.42	184,770.46	212,895.75	156,805.69	205,733.65	199,255.08	
	370,657.12	434,001.78	270,045.70	690,329.17	796,139.54	918,280.03	750,568.02	842,709.42	940,973.46	785,830.83	906,079.37	864,738.67	

974.77	
5,129,381.50	
1,497,742.01	
1,942,254.83	
8,570,353.11	

1

L
SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	5,936.00	6,300.97	5,519.97	999.09	457.38	700.00	350.00	350.00	0.00	736.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	1,513.47	2,898.87	2,896.09	4,542.74	42,584.08	9,620.42	19,560.00	9,371.41	11,540.42	13,672.01	9,736.27	7,360.46	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.40	0.00	0.00	29.24	
4617	CC PATIENT FEMALE 2 1	8,655.21	1,050.00	485.19	7,330.09	-18.31	700.00	140.57	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	4,085.95	1,050.00	2,131.49	2,168.06	0.00	0.00	477.80	0.00	68.47	1,481.55	59.33	1,985.93	

21,349.41	
135,296.24	
51.64	
18,342.75	
13,508.58	

5

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	20,190.63	11,299.84	11,032.74	15,039.98	43,023.15	11,020.42	20,528.37	9,721.41	11,631.29	15,889.56	9,795.60	9,375.63		188,548.62		

SUBTOTAL:

847,221,930.58

8700	SSI DISABLED FREEDO M	3,861.91	11,145.71	10,454.38	6,107.64	5,084.31	10,824.80	3,234.54	11,561.27	8,806.49	4,653.18	8,764.29	11,503.84	
8710	SSI DISABLED FREEDO M	2,100.00	2,528.61	332.93	1,759.52	13,816.87	1,050.00	350.00	4,815.46	6,771.98	1,707.22	44.47	0.00	
8720	SSI DISABLED FREEDO	59.40	237.60	367.94	0.00	10.26	0.00	0.00	54.94	2,032.04	946.32	229.71	1,638.04	
SUBTOTAL:	6,021.31	13,911.92	11,155.25	7,867.16	18,911.44	11,874.80	3,584.54	16,431.67	17,610.51	7,306.72	9,038.47	13,141.88	

96,002.36	
35,277.06	
5,576.25	
136,855.67	

86,213,717.58	59,713,116.53	66,827,976.28	75,703,043.44	58,907,691.09	66,158,585.01	75,123,983.62	66,612,438.79	72,024,088.29	84,306,940.46	

M

TOTAL:

64,487,605.57

71,142,743.92

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending June 30, 2016

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1006	TANF 21-44 MALE WITH	0.00	79.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	21.79	0.00	0.00	100.94	
1007	TANF 21-44 FEMALE WI	0.00	0.00	0.00	0.00	0.00	12.47	0.00	0.00	0.00	88.95	0.00	97.63	199.05	
1008	TANF 45-64 M & F WIT	0.00	0.00	64.35	0.00	208.35	57.88	0.00	0.00	1,741.47	154.46	98.83	705.83	3,031.17	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	1,311.75	0.00	0.00	0.00	0.00	13.45	0.00	0.00	1,325.20	
1011	TANF <1 M & F NON-ME	439.67	11,488.16	5,242.20	3,484.30	7,484.68	7,020.38	1,372.50	4,559.67	1,252.84	8,191.98	6,054.76	28,855.34	85,446.48	
1012	TANF 01-05 M & F NON	1,999.68	0.00	6,173.64	0.00	177.03	57.31	0.00	2,537.49	2,118.94	577.56	93.00	189.02	13,923.67	
1013	TANF 06-13 M & F NON	0.00	0.00	-29.23	37.11	314.79	409.90	279.94	-77.87	2,547.85	0.00	12,179.70	8,488.56	24,150.75	
1014	TANF 14-20 MALE NON-	1,639.96	371.56	1,298.43	1,214.10	4,020.29	977.96	48.87	2,339.30	3,778.06	1,608.39	6,111.94	1,091.11	24,499.97	
1015	TANF 14-20 FEMALE N	10,367.88	4,369.23	19,961.56	6,311.54	3,726.06	2,690.31	9,837.71	9,941.07	24,032.76	14,397.02	6,356.99	6,039.68	118,031.81	

1016	O
TANF 21-44 MALE NON-	
27,978.02	
35,547.13	
51,358.56	
38,612.37	
40,905.00	
50,432.24	
29,787.33	
47,120.66	
53,047.20	
27,432.84	
50,488.65	
41,133.50	
493,843.50	
1017	TANF 21-44 FEMALE N	85,071.84	122,995.47	128,349.71	151,849.80	85,693.87	133,933.74	151,562.92	158,767.56	160,552.67	118,137.11	120,627.31	43,245.42	1,460,787.42	

1018	O
TANF 45-64 M & F NON	
19,601.63	
63,726.19	
20,776.67	
18,549.31	
28,491.67	
41,639.63	
46,527.79	
80,416.65	
92,502.55	
55,748.19	
41,810.53	
29,670.23	
539,461.04	
2100	SSI AGED WITH MEDIC	4,288.93	2,161.00	6,039.80	3,610.04	6,310.04	9,322.70	2,791.86	9,847.88	21,030.41	4,079.89	13,427.72	5,212.95	88,123.22	
2110	A
SSI AGED NON-MEDICA	16,932.19	33,017.03	46,637.60	18,239.09	16,129.07	54,594.05	4,788.76	8,599.35	20,725.80	47,835.16	45,361.15	19,267.23	
332,126.48	
2120	R
SSI AGED WITH QMB	0.00	807.00	131.79	1,379.48	288.97	25.56	238.50	125.82	133.38	0.00	1,347.91	68.08	
4,546.49	
2200	SSI DISABLED WITH M	488.66	1,617.07	3,610.05	1,642.17	3,477.20	5,815.21	1,683.14	2,500.96	5,972.70	7,641.48	1,258.73	515.33	36,222.70	
2210	E
SSI DISABLED NON-ME	39,007.48	95,497.11	23,513.88	6,329.44	33,843.11	15,669.91	13,471.38	6,126.55	48,631.41	66,101.09	15,882.64	21,350.16	
385,424.16	

2220	D
SSI DISABLED WITH Q	
0.00	
1,277.10	
1,336.18	
934.55	
209.71	
96.81	
0.00	
0.00	
687.60	
27.14	
0.00	
35.17	
4,604.26	
2310	M
SSI BLIND NON-MEDIC	0.00	0.00	0.00	812.46	700.00	875.48	0.00	0.00	0.00	350.00	0.00	0.00	
2,737.94	

4311	A
SOBRA CHILD <1 M & F	
117,403.64	
23,297.12	
59,254.42	
35,673.44	
67,380.83	
113,499.55	
71,543.07	
35,891.36	
55,084.76	
49,931.89	
123,011.36	
53,049.48	
805,020.92	
4312	SOBRA CHILD 01-05 M	64,184.72	52,686.05	65,786.94	66,664.94	55,185.47	50,219.69	40,749.56	38,609.61	83,319.77	56,586.00	28,132.93	42,313.78	644,439.46	
4313	SOBRA CHILD 06-13 M	34,405.76	34,320.87	47,228.07	40,773.76	40,430.70	52,470.13	167,539.54	45,523.31	46,763.87	34,029.99	16,527.50	21,078.55	581,092.05	
4314	SOBRA CHILD 14-20 MA	34,112.02	13,654.57	40,427.51	19,191.40	55,948.06	42,767.75	27,873.44	24,593.48	17,117.66	11,275.83	15,813.22	19,996.18	322,771.12	
4315	SOBRA CHILD 14-20 FE	25,544.79	41,450.78	33,073.65	31,045.68	27,206.23	30,313.34	36,811.72	14,069.64	19,010.66	9,842.28	16,242.50	19,929.38	304,540.65	
5007	SOBRA PREG 21-44 FE	1,316.92	-622.54	620.43	373.01	0.00	0.00	0.00	0.00	295.24	114.05	0.00	-313.16	1,783.95	
5015	M
SOBRA PREG 14-20 FE	17,081.33	30,674.40	30,351.24	28,628.36	24,395.73	18,499.32	16,365.78	17,807.82	22,922.79	19,205.03	13,088.22	17,329.99	
256,350.01	
5017	M
SOBRA PREG 21-44 FE	77,766.50	80,269.95	104,810.09	109,667.47	114,599.68	69,726.40	73,096.12	81,771.79	101,626.20	69,001.37	45,534.48	90,272.81	
1,018,142.86	

5018	M
SOBRA PREG 45-64 FE	
0.00	
28.27	
0.00	
0.00	
-28.27	
1,541.56	
83.27	
28.84	
625.41	
962.19	
14.05	
0.00	
3,255.32	
8040	M SLMB	6,944.53	49.41	807.03	-83.03	73.45	0.00	34.58	1,075.71	0.00	0.00	-6.20	0.00	
8,895.48	
8050	QI1	959.34	1,438.39	130.47	132.01	0.00	31.17	57.74	0.00	0.00	0.00	0.00	0.00	2,749.12	

SUBTOTAL:

587,535.49

650,200.47	696,955.04	585,072.80	618,483.47	702,700.45	696,545.52	592,176.65	785,522.00	603,355.13	579,457.92	469,622.25	7,567,627.19

3,349.89

1,001.27

14,806.24

141.48

1106	TANF EXPANDED 21-44	0.00	93.33	88.81	2,077.39	12.33	0.00	1,050.00	6.45	21.58	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	264.36	294.74	124.24	62.89	255.04	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1108	TANF EXPANDED 45-64	773.33	420.71	6,906.69	1,311.67	883.95	1,690.40	1,257.44	919.37	7.78	0.96	142.32	491.62	
1109	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	122.80	0.00	18.68	

M&

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1114	TANF EXPANDED 14-20	515.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	229.62		744.72		
1115	TANF EXPANDED 14-20	1,224.74	4,420.72	764.15	3,746.47	0.00	0.00	0.00	0.00	0.00	221.60	110.80	6,235.71		16,724.19		
1116	TANF EXPANDED 21-44	13,694.50	13,902.95	27,807.18	11,482.37	18,513.51	10,877.18	13,425.14	864.92	1,201.10	4,057.08	717.01	7,595.59		124,138.53		
1117	TANF EXPANDED 21-44	31,143.56	46,456.94	70,887.40	33,885.09	33,000.10	15,326.63	17,091.45	23,316.76	10,728.11	14,944.24	5,383.13	15,722.32		317,885.73		
1118	TANF EXPANDED 45-64	29,015.56	33,956.75	60,010.71	18,273.86	33,687.02	21,583.85	-510.85	7,451.35	1,663.35	2,228.50	44,134.91	10,110.31		261,605.32		
1119	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	0.00	0.00	10,132.11	1,817.74	1,091.48	463.25	3,354.34		16,858.92		
2400	SSI AGED EXPANDED	2,377.90	12,618.70	12,271.07	5,527.40	15,781.06	14,405.54	4,462.00	6,540.46	5,919.34	20,036.25	6,313.31	17,370.96		123,623.99		
2410	SSI AGED EXPANDED NO	979.32	10,480.42	0.00	3,960.00	1,445.40	-3,716.92	285.17	0.00	249.90	57.40	1,320.75	9.55		15,070.99		
2420	SSI AGED EXPANDED WI	550.98	1,286.23	328.44	378.82	327.11	134.82	1,901.11	604.06	305.72	0.00	293.79	692.82		6,803.90		
2600	SSI DISABLED EXPAND E	2,818.70	1,835.75	7,785.00	2,326.61	1,030.79	2,145.67	4,113.01	111.94	5,713.92	3,225.04	5,719.38	2,886.66		39,712.47		
2610	SSI DISABLED EXPAND E	3,572.35	3,805.02	18,910.75	13,966.80	2,598.34	1,128.87	116.78	2,986.58	919.23	4,953.28	1,165.79	2,395.18		56,518.97		
2620	SSI DISABLED EXPAND E	260.03	91.97	253.43	619.21	133.42	173.46	0.00	15.22	973.78	0.00	2,146.06	32.74		4,699.32		
	87,190.43	129,664.23	206,137.87	97,618.58	107,668.07	63,749.50	43,191.25	52,949.22	29,521.55	50,938.63	67,910.50	67,146.10		1,003,685.93		

WI

SUBTOTAL:

3508	ADULT 40-100% M&F 45	39.84	0.00	636.68	0.00	6.87	832.12	35.00	0.00	1.69	79.17	0.00	197.07	
3514	ADULT 40-100% MALE 1	7,354.73	2,210.13	9,226.86	10,267.58	8,018.15	1,056.03	1,001.74	1,101.67	817.81	1,483.95	1,661.20	10,477.40	
3515	ADULT 40-100% FEMAL	4,053.85	7,409.16	13,107.92	8,412.79	4,417.22	9,718.21	8,774.71	1,886.22	8,315.13	9,686.74	2,087.47	3,765.09	
3516	ADULT 40-100% MALE 2	22,487.77	47,727.87	38,141.10	50,616.29	39,471.83	46,695.20	31,559.03	29,842.62	41,392.16	16,631.34	33,985.82	21,823.37	
3517	ADULT 40-100% FEMAL E	32,478.15	34,588.71	42,476.30	26,676.78	23,987.36	29,835.33	18,907.11	32,675.55	17,076.85	12,907.52	22,661.12	41,669.78	
3518	ADULT 40-100% M&F 45	115,109.31	85,155.48	173,866.91	145,967.88	74,682.01	78,190.18	228,412.04	86,660.18	70,960.55	98,079.92	113,969.97	80,223.42	
3519	ADULT 40-100% M&F 65	0.00	83.25	1,075.63	243.08	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	35.04	0.00	128.60	309.42	104.58	83.91	0.00	0.00	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	1,587.28	0.00	57.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	926.28	
3707	ADULT <40% EXP FEM AL	947.85	0.00	377.50	1,293.45	265.02	0.00	0.00	0.00	0.00	0.00	0.00	256.72	
3708	ADULT <40% EXP M&F	0.00	0.00	350.00	0.00	0.00	0.00	14.41	42.68	0.00	446.67	142.13	0.00	
3714	ADULT <40% EXP MALE	-3,202.73	15,501.02	18,183.71	10,358.26	16,379.49	3,249.11	8,077.80	8,476.52	16,599.09	63,265.21	11,421.55	13,359.30	
3715	ADULT <40% EXP FEM	8,301.75	16,458.77	17,720.35	17,356.78	22,093.55	9,994.84	3,889.25	10,607.81	9,525.98	4,758.62	5,909.42	2,835.29	
3716	ADULT <40% EXP MALE	167,516.26	204,690.38	358,830.19	199,648.63	205,387.98	182,804.58	164,588.69	183,990.26	291,256.94	208,168.07	160,192.61	119,972.21	
3717	ADULT <40% EXP FEM AL	161,052.04	116,919.92	123,724.40	87,699.35	97,976.52	61,746.47	85,889.56	65,397.36	89,375.74	56,235.39	73,148.19	48,753.43	
3718	ADULT <40% EXP M&F 4	492,428.69	286,192.87	473,719.11	334,168.08	251,532.72	264,130.42	218,569.58	509,517.40	226,831.70	280,220.91	192,320.59	183,872.89	
3726	ADULT <40% EXP MALE	0.00	0.00	2,252.43	677.92	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3728	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	23.72	0.00	0.00	0.00	1,161.26	
	1,010,189.83	816,937.56	1,273,874.71	893,696.29	744,323.30	688,336.40	769,718.92	930,221.99	772,153.64	751,963.51	617,500.07	529,293.51	

1,828.44	
54,677.25	
81,634.51	
420,374.40	
335,940.56	
1,351,277.85	
1,401.96	
661.55	
2,570.58	
3,140.54	
995.89	
181,668.33	
129,452.41	
2,447,046.80	
1,067,918.37	
3,713,504.96	
2,930.35	
1,184.98	
9,798,209.73	

E

4

AL

4
SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	76.00	0.00	0.00	230.05	0.00	0.00	0.00	0.00	0.00	
3907	NEWLY ELIGIBLE FEMA L	125.54	0.00	50.15	0.00	0.00	0.00	0.00	0.00	0.00	0.00	6,474.95	27.49	
3908	NEWLY ELIGIBLE M&F	90.99	700.00	234.31	0.00	276.64	0.00	213.94	21.82	70.22	219.01	843.61	1,184.09	

306.05	
6,678.13	
3,854.63	

4

ACUTE FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3914	NEWLY ELIGIBLE MALE	654.68	234.01	6,077.75	2,071.23	3,663.82	307.69	524.43	2,767.69	4,758.35	2,322.59	1,679.04	3,457.05		28,518.33		
3915	NEWLY ELIGIBLE FEMA L	4,655.16	13,237.05	2,758.11	1,970.89	1,064.48	3,576.02	2,542.00	4,542.23	3,408.12	1,406.59	1,003.28	2,744.78		42,908.71		
3916	NEWLY ELIGIBLE MALE	33,428.04	33,670.17	77,463.51	55,695.29	104,128.36	58,693.91	43,857.31	35,051.94	83,243.55	80,651.33	59,105.89	21,478.66		686,467.96		
3917	NEWLY ELIGIBLE FEMA L	33,130.96	36,088.32	65,921.67	74,500.38	52,468.71	45,771.22	28,027.28	52,197.86	64,634.93	53,004.88	50,455.68	45,196.40		601,398.29		
3918	NEWLY ELIGIBLE M&F	88,508.51	131,570.76	163,768.01	128,365.27	173,085.98	142,740.97	94,421.96	67,032.79	121,009.27	99,276.54	62,997.11	94,240.98		1,367,018.15		
SUBTOTAL:	160,593.88	215,500.31	316,273.51	262,679.06	334,687.99	251,089.81	169,816.97	161,614.33	277,124.44	236,880.94	182,559.56	168,329.45		2,737,150.25		

4

4412	SOBRA 100-133% M&F
1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	824.77	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	4,059.93	12,186.74	21,110.23	15,342.31	11,795.63	23,287.90	14,713.89	6,564.92	23,413.21	14,032.91	11,064.13	13,184.40	
4414	SOBRA 100-133% MALE	5,335.47	2,393.38	14,375.66	2,342.66	3,270.98	1,893.85	7,149.43	760.22	3,442.07	1,877.63	2,664.54	1,003.65	
4415	SOBRA 100-133% FEMA	867.96	4,065.21	16,099.57	3,552.16	3,166.06	6,247.80	4,525.10	2,673.99	7,383.42	871.82	2,699.72	2,605.82	
	10,263.36	18,645.33	51,585.46	21,237.13	18,232.67	31,429.55	26,388.42	9,999.13	35,063.47	16,782.36	16,428.39	16,793.87	

824.77	
170,756.20	
46,509.54	
54,758.63	
272,849.14	

L
SUBTOTAL:

3,219.09

3,219.09

4518	BC PATIENT FEMALE 4	0.00	0.00	0.00	124.56	1,945.58	0.00	0.00	0.00	0.00	0.00	0.00	1,148.95	
	0.00	0.00	0.00	124.56	1,945.58	0.00	0.00	0.00	0.00	0.00	0.00	1,148.95	

5
SUBTOTAL:

8700	SSI DISABLED FREEDO	141.21	1,493.16	2,014.03	306.31	0.00	27.56	92.28	756.38	873.03	0.00	0.00	29.25	
8710	SSI DISABLED FREEDO M	0.00	137.00	661.16	678.06	162.48	0.00	48.87	3,322.76	0.00	0.00	3,047.18	97.29	
	141.21	1,630.16	2,675.19	984.37	162.48	27.56	141.15	4,079.14	873.03	0.00	3,047.18	126.54	

5,733.21	
8,154.80	
13,888.01	

M

SUBTOTAL:

TOTAL:	1,855,914.20	1,832,578.06	2,547,501.78	1,861,412.79	1,825,503.56	1,737,333.27	1,705,802.23	1,751,040.46	1,900,258.13	1,659,920.57	1,466,903.62	1,252,460.67		21,396,629.34		

FAMILY PLANNING SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION
5510

SOBRA FPS FEMALE W
IT

JULY
-39.37

AUGUST	SEPTEMBER

0.00

0.00

OCTOBER	NOVEMBER
0.00	0.00

DECEMBER
0.00

JANUARY
0.00

FEBRUARY
0.00

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

-39.37

SUBTOTAL:	-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-39.37	
															
TOTAL:	-39.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-39.37	

FEDERAL EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1009	TANF 65+ M & F WITH	0.00	0.00	0.00	0.00	0.00	0.00	837.48	0.00	0.00	0.00	0.00	0.00		837.48		
1011	TANF <1 M & F NON-ME	0.00	455.46	3,231.96	0.00	2,515.08	1,013.45	383.08	93.19	912.23	526.59	18,667.58	9,473.14		37,271.76		
1012	TANF 01-05 M & F NON	3,325.77	8,684.64	18,795.85	24,960.25	9,691.63	12,197.50	21,583.68	6,607.26	43,346.34	42,498.51	35,292.06	27,895.20		254,878.69		
1013	TANF 06-13 M & F NON	54,626.02	34,912.76	80,372.41	58,900.82	34,549.85	51,854.16	48,001.49	71,497.01	96,250.56	144,987.19	98,321.36	76,387.77		850,661.40		
1014	TANF 14-20 MALE NON-	65,319.99	60,239.51	137,076.35	98,293.54	77,609.81	159,897.23	61,604.89	67,461.91	108,773.37	151,749.53	141,792.32	144,159.80		1,273,978.25		
1015	TANF 14-20 FEMALE N O	458,200.55	295,670.00	478,042.95	469,964.35	337,229.42	431,546.68	354,063.14	314,537.89	527,009.92	582,424.90	395,992.30	347,703.43		4,992,385.53		
1016	TANF 21-44 MALE NON-	60,888.08	100,933.93	31,723.66	82,988.49	117,876.44	146,067.61	96,582.23	143,587.50	260,670.29	214,291.33	226,864.20	139,496.19		1,621,969.95		
1017	TANF 21-44 FEMALE N O	2,670,623.86	2,730,005.88	3,324,170.96	2,879,155.76	2,469,546.65	3,202,404.78	2,369,438.49	2,239,111.05	4,698,671.32	4,774,396.65	3,056,156.35	2,782,016.81		37,195,698.56		
1018	TANF 45-64 M & F NON	115,318.65	114,094.17	197,992.93	147,100.97	130,195.57	184,591.56	244,088.53	212,412.20	353,970.52	291,004.99	312,648.98	316,969.70		2,620,388.77		
1019	TANF 65+ M & F NON-M	974.37	580.16	36,530.93	189.47	5,569.41	908.59	2,030.43	1,232.20	18,953.67	5,000.72	13,019.11	18,452.24		103,441.30		
2100	SSI AGED WITH MEDIC A	1,028.00	1,134.36	2,508.08	3,684.44	9,408.49	13,782.91	14,408.61	3,801.23	13,388.49	6,838.62	7,510.71	7,327.36		84,821.30		
2110	SSI AGED NON-MEDICA R	767,030.64	976,118.47	1,135,999.12	1,013,075.24	667,723.02	878,890.18	786,495.73	845,723.02	1,373,759.25	1,424,210.88	1,312,524.73	1,045,691.92		12,227,242.20		
2120	SSI AGED WITH QMB	0.00	1,247.40	0.00	491.05	0.00	30.26	0.00	0.00	0.00	0.00	902.33	1,251.56		3,922.60		
2200	SSI DISABLED WITH M E	15,487.16	14,895.52	19,590.18	15,828.97	7,325.35	7,561.88	13,231.61	12,318.35	16,646.04	11,364.42	4,684.27	5,861.60		144,795.35		
2210	SSI DISABLED NON-ME	388,846.01	233,518.99	496,312.04	330,185.22	270,923.16	597,379.32	438,012.70	255,428.45	599,589.63	281,214.19	350,506.71	434,370.39		4,676,286.81		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	764.97	142.20	0.00	35.09	0.00	0.00	989.73	1,247.40		3,179.39		
2310	SSI BLIND NON-MEDIC	-213.81	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-213.81		
	4,601,455.29	4,572,491.25	5,962,347.42	5,124,818.57	4,140,928.85	5,688,268.31	4,450,762.09	4,173,846.35	8,111,941.63	7,930,508.52	5,975,872.74	5,358,304.51		66,091,545.53		

D

A
SUBTOTAL:

1106	TANF EXPANDED 21-44	942.36	1,534.47	1,505.09	822.46	57.30	121.67	57.30	718.25	1,569.76	3,566.80	48.53	0.00	
1107	TANF EXPANDED 21-44	926.52	718.33	594.32	890.41	738.79	229.18	553.96	57.30	803.06	1,414.66	803.20	1,442.67	
1108	TANF EXPANDED 45-64	2,965.50	1,071.83	1,199.19	627.92	4,088.32	0.00	0.00	0.00	-1,801.37	0.00	0.00	0.00	
1109	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	107.93	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <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	160.42	
1112	TANF EXPANDED 01-05	0.00	0.00	312.04	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	137.60	1,128.98	0.00	0.00	
1114	TANF EXPANDED 14-20	1,190.91	3,724.52	4,105.86	9,094.01	4,525.62	0.00	0.00	830.92	700.11	0.00	-3,441.10	587.80	
1115	TANF EXPANDED 14-20	10,061.00	21,034.78	16,389.70	20,183.82	22,986.62	7,516.98	2,501.96	5,344.01	15,369.13	18,848.78	7,272.04	10,748.57	
1116	TANF EXPANDED 21-44	354,391.46	305,914.64	598,525.42	505,905.51	304,707.27	391,261.66	216,293.07	358,011.75	454,998.05	435,672.66	477,484.57	440,946.80	
1117	TANF EXPANDED 21-44	755,978.61	983,459.10	1,040,015.43	1,183,824.04	701,830.49	822,396.86	756,845.93	776,624.15	1,467,576.31	1,206,113.58	900,949.33	852,458.38	
1118	TANF EXPANDED 45-64	334,689.08	312,771.14	498,580.17	493,587.41	273,748.47	300,128.22	254,634.73	280,931.39	455,141.28	402,961.11	501,524.15	501,492.23	
1119	TANF EXPANDED 65+
M&	5,837.82	4,006.70	13,397.27	6,670.37	1,703.95	965.56	7,008.44	3,657.03	11,697.59	-7,101.82	13,495.60	2,186.12	
1126	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	779.03	753.90	0.00	755.74	190.88	
2400	SSI AGED EXPANDED WI	3,738.85	228.58	31.65	378.59	28.32	492.32	200.13	1,289.11	250.98	4,660.98	5,330.89	12,551.65	
2410	SSI AGED EXPANDED	91,019.49	40,318.46	59,658.59	49,583.24	58,225.17	37,166.59	16,710.77	32,073.51	61,013.58	42,637.29	35,818.88	49,224.93	
2420	SSI AGED EXPANDED	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	981.45	741.96	702.60	

10,943.99	
9,172.40	
8,151.39	
107.93	
160.42	
312.04	
1,266.58	
21,318.65	
158,257.39	
4,844,112.86	
11,448,072.21	
4,610,189.38	
63,524.63	
2,479.55	
29,182.05	
573,450.50	
2,426.01	

NO

WI

FEDERAL EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION
2600

JULY
698.31

AUGUST	SEPTEMBER
742.38	385.05

OCTOBER
49.30

NOVEMBER
660.78

DECEMBER
697.68

JANUARY
981.64

FEBRUARY
57.30

MARCH
0.00

APRIL
0.00

MAY
0.00

JUNE
0.00

TOTAL

4,272.44

2610

SSI DISABLED EXPAND
E
SSI DISABLED EXPAND

E
SUBTOTAL:

34,997.13	35,849.69	53,494.32	45,988.82	18,108.10	55,317.19	4,986.48

1,597,437.04	1,711,374.62	2,288,194.10	2,317,605.90	1,391,409.20	1,616,401.84	1,260,774.41

11,640.20	46,573.91	15,506.39	40,943.02	71,237.22

1,472,013.95	2,514,783.89	2,126,390.86	1,981,726.81	1,943,930.27

434,642.47

22,222,042.89

11.67

2,986.55

7,743.37

3,237.29

228.24

307.21

1,672.15

8,001.40

18,362.44

61,823.50

9.55

104,383.37

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	11.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3516	ADULT 40-100% MALE 2	631.64	303.33	2,007.60	0.00	0.00	0.00	0.00	0.00	0.00	0.00	43.98	0.00	
3517	ADULT 40-100% FEMAL	0.00	3,220.32	764.56	0.00	470.90	2,523.03	764.56	0.00	0.00	0.00	0.00	0.00	
3518	ADULT 40-100% M&F 45	363.70	744.09	123.30	1,408.45	277.68	0.00	0.00	0.00	320.07	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F 4	0.00	83.87	0.00	0.00	0.00	0.00	0.00	144.37	0.00	0.00	0.00	0.00	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	96.03	153.89	0.00	0.00	57.29	0.00	0.00	0.00	0.00	
3715	ADULT <40% EXP FEM AL	0.00	689.22	934.06	0.00	0.00	0.00	0.00	48.87	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	3,173.56	985.83	1,307.20	1,210.89	1,112.96	27.45	9.55	173.96	0.00	0.00	0.00	0.00	
3717	ADULT <40% EXP FEM AL	7,385.92	3,761.60	4,166.17	795.15	144.37	119.24	0.00	0.00	0.00	0.00	0.00	1,989.99	
3718	ADULT <40% EXP M&F 4	6,017.10	34,892.69	1,317.28	2,900.81	2,053.73	1,823.06	532.91	981.00	3,776.34	0.00	7,383.59	144.99	
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.55	0.00	0.00	0.00	
SUBTOTAL:	17,571.92	44,680.95	10,620.17	6,411.33	4,225.20	4,492.78	1,307.02	1,405.49	4,105.96	0.00	7,427.57	2,134.98	

E

6

3906	NEWLY ELIGIBLE MALE	0.00	0.00	61.58	57.52	40.91	260.93	0.00	2,371.26	1,195.27	3,181.10	1,878.04	4,792.65	
3907	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	947.60	6.15	0.00	0.00	2,654.67	0.00	
3908	NEWLY ELIGIBLE M&F 4	3,134.87	5,350.82	1,445.22	2,455.88	3,337.80	7,501.84	344.52	3,180.23	1,535.26	2,941.75	433.27	2,557.60	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	294.80	0.00	0.00	0.00	0.00	0.00	410.10	367.26	334.00	
3914	NEWLY ELIGIBLE MALE	22,970.43	28,098.00	35,654.89	64,365.00	22,203.74	56,797.49	115,313.60	-58,571.35	55,032.00	73,947.20	54,064.17	245,713.84	
3915	NEWLY ELIGIBLE FEMA L	30,691.94	32,607.21	67,119.06	43,281.81	32,340.03	33,939.64	47,549.41	17,582.16	53,987.93	57,257.90	68,209.18	46,007.21	
3916	NEWLY ELIGIBLE MALE	433,489.69	517,176.26	860,044.12	689,690.10	619,841.62	735,186.70	506,476.45	764,181.12	773,226.84	707,972.04	790,067.73	659,391.00	
3917	NEWLY ELIGIBLE FEMA L	300,086.49	238,508.95	403,994.50	295,796.76	356,891.79	448,073.55	369,933.52	429,222.30	578,613.23	576,358.66	513,926.22	438,790.13	
3918	NEWLY ELIGIBLE M&F 4	894,595.81	1,176,047.32	1,802,982.03	1,288,816.29	895,641.23	1,294,633.12	1,452,260.05	1,085,396.95	2,396,481.86	1,952,213.32	2,090,544.96	1,793,584.78	
3919	NEWLY ELIGIBLE M&F	15,863.94	1,457.81	4,116.70	11,314.92	4,086.67	9,586.01	4,959.54	9,141.17	25,353.15	32,156.06	15,482.54	2,463.05	
3927	NEWLY ELIGIBLE FEMA L	46.58	46.58	718.50	666.40	737.18	713.70	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	695.06	694.80	694.15	694.28	57.30	57.30	639.47	1,234.74	10.22	735.89	1,961.93	-637.91	
	1,701,574.81	1,999,987.75	3,176,830.75	2,397,433.76	1,935,178.27	2,586,750.28	2,498,424.16	2,253,744.73	3,885,435.76	3,407,174.02	3,539,589.97	3,192,996.35	

13,839.26	
3,608.42	
34,219.06	
1,406.16	
715,589.01	
530,573.48	
8,056,743.67	
4,950,196.10	
18,123,197.72	
135,981.56	
2,928.94	
6,837.23	
32,575,120.61	

L

6

4
SUBTOTAL:

TOTAL:	7,918,039.06	8,328,534.57	11,437,992.44	9,846,269.56	7,471,741.52	9,895,913.21	8,211,267.68	7,901,010.52	14,516,267.24	13,464,073.40	11,504,617.09	10,497,366.11		120,993,092.40		

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	381.05	0.00	0.00	0.00	0.00	0.00	381.05	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	381.05	0.00	0.00	0.00	0.00	0.00	381.05	
														
													341.03	
4
SUBTOTAL:													

341.03	

FEDERAL ESP CHRONIC SERVICES
For The Period Ending June 30, 2016

722.08

3918	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	341.03	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	341.03	0.00	0.00	0.00	

0.00	0.00	0.00	0.00	0.00	0.00	381.05	0.00	341.03	0.00	0.00	0.00	

TOTAL:

QMB - FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8020	QMB ONLY	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	277,299.18	336,625.36	529,055.48	429,541.31	403,381.99	574,477.44		4,740,992.80		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.47	0.00	0.00	-13.21	0.00		9.26		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	149.96	0.00	0.00		149.96		
	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	277,299.18	336,647.83	529,055.48	429,691.27	403,368.78	574,477.44		4,741,152.02		

SUBTOTAL:

TOTAL:	293,436.77	211,412.30	493,734.53	374,615.82	274,231.57	543,181.05	277,299.18	336,647.83	529,055.48	429,691.27	403,368.78	574,477.44		4,741,152.02		

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	3,673.21	7.39	0.00	-3,628.64		51.96		
1017	TANF 21-44 FEMALE N O	3,227.31	2,397.42	0.00	5,425.92	0.00	0.00	2,234.31	843.73	0.00	0.00	0.00	2,377.80		16,506.49		
2100	SSI AGED WITH MEDIC A	15,412.32	89,978.84	21,245.35	45,417.87	26,065.20	121,503.30	55,073.43	12,660.82	32,213.81	109,490.07	35,270.74	105,934.17		670,265.92		
2110	SSI AGED NON-MEDICA R	61,148.18	60,953.07	9,698.95	112,583.05	49,546.66	80,506.33	78,467.63	118,752.34	102,231.07	102,818.63	42,857.07	116,973.77		936,536.75		
2120	SSI AGED WITH QMB	1,093.55	171.15	0.00	0.00	6,269.41	192.50	0.00	0.00	0.00	0.00	0.00	0.00		7,726.61		
2200	SSI DISABLED WITH M E	4,280.93	0.00	0.00	0.00	121.42	30,146.45	9,920.49	34,643.38	1,618.26	0.00	1,734.46	0.00		82,465.39		
2210	SSI DISABLED NON-ME	0.00	806.03	7.57	2,769.66	0.00	0.00	0.00	12,274.33	6,413.28	31,590.09	-21,980.04	736.14		32,617.06		
2220	SSI DISABLED WITH Q M	5,933.83	6,506.08	0.00	0.00	13,921.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00		26,361.78		
4315	SOBRA CHILD 14-20 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,416.65	843.73	0.00		3,260.38		
5017	SOBRA PREG 21-44 FE M	3,043.51	2,377.80	0.00	0.00	470.90	2,879.02	2,789.29	2,792.64	7,556.14	5,458.60	211.51	2,416.65		29,996.06		
8020	QMB ONLY	0.00	164.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		164.38		
	94,139.63	163,354.77	30,951.87	166,196.50	96,395.46	235,227.60	148,485.15	181,967.24	153,705.77	251,781.43	58,937.47	224,809.89		1,805,952.78		

D

SUBTOTAL:

1107	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,974.54	0.00	8.00	0.00	
1116	TANF EXPANDED 21-44	0.00	0.00	4,142.44	100.05	690.06	17,222.60	0.00	6,246.70	0.00	417.63	5,618.12	804.56	
1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	2,416.65	0.00	0.00	
2620	SSI DISABLED EXPAND	10,918.19	376.34	0.00	992.21	0.00	0.00	0.00	1,024.28	11,311.28	6,449.81	8.00	0.00	
SUBTOTAL:	10,918.19	376.34	4,142.44	1,092.26	690.06	17,222.60	0.00	7,270.98	14,285.82	9,284.09	5,634.12	804.56	

2,982.54	
35,242.16	
2,416.65	
31,080.11	
71,721.46	

E

3516	ADULT 40-100% MALE 2	276.08	465.25	113.08	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	223.22	2,963.50	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	3,442.07	394.46	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	2,286.61	1,389.07	109,186.74	177.18	2,034.57	5,425.44	8,572.12	-269.79	29,935.60	298,744.85	13,540.20	2,945.98	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	15.96	311.68	42.53	0.00	5,063.86	6,161.28	0.00	3,757.63	0.00	
3708	ADULT <40% EXP M&F 4	48,908.37	28,993.62	20,991.36	10,383.16	30,269.24	51,544.48	9,044.78	37,307.68	85,051.66	62,946.38	19,462.20	19,595.89	
3714	ADULT <40% EXP MALE	0.00	108.35	23,795.80	2,084.65	249.30	2,427.37	0.00	1,009.98	7,350.16	0.00	231.22	439.48	
3715	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	843.73	74.15	
3716	ADULT <40% EXP MALE	282,960.57	239,237.96	160,049.34	141,590.13	133,394.48	227,715.34	294,101.69	217,747.77	364,952.82	221,880.46	121,968.11	129,901.89	
3717	ADULT <40% EXP FEM	8,006.01	55,446.91	23,944.21	15,778.68	10,519.22	55,297.61	28,330.54	58,898.95	47,546.42	55,353.17	35,006.50	14,645.99	
3718	ADULT <40% EXP M&F 4	235,458.94	434,500.79	215,685.56	224,311.09	328,728.18	442,676.83	224,084.36	367,426.67	560,773.75	500,798.01	259,410.64	407,861.69	
3719	ADULT <40% EXP M&F 6	1,495.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22,779.63	0.00	0.00	0.00	
3726	ADULT <40% EXP MALE	73.01	0.00	-57.05	0.00	0.00	0.00	0.00	0.00	9.82	160.42	90.36	0.00	
3728	ADULT <40% EXP M&F	9,628.14	5,770.49	8,615.35	434.96	1,598.89	576.24	6,779.01	188.73	0.00	657.18	31,127.77	1,902.31	
	589,093.37	765,912.44	562,324.39	394,775.81	507,105.56	785,705.84	570,912.50	691,039.14	1,127,919.10	1,140,540.47	485,438.36	577,367.38	

854.41	
3,186.72	
3,836.53	
473,968.57	
15,352.94	
424,498.82	
37,696.31	
917.88	
2,535,500.56	
408,774.21	
4,201,716.51	
24,275.27	
276.56	
67,279.07	
8,198,134.36	

AL

AL

4
SUBTOTAL:

3916	NEWLY ELIGIBLE MALE	352.61	16,903.27	22,673.32	2,578.16	12,349.75	32,515.04	325.14	2,779.90	18,592.43	17,662.58	8,357.24	5,628.57	
3917	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,095.65	105.95	0.00	0.00	
3918	NEWLY ELIGIBLE M&F	5,998.76	18,912.57	11,373.57	6,819.98	22,894.60	20,159.18	13,582.22	97.02	24,985.34	32,465.04	18,714.87	1,946.00	

140,718.01	
1,201.60	
177,949.15	

L

4

INPATIENT INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	6,351.37	35,815.84	34,046.89	9,398.14	35,244.35	52,674.22	13,907.36	2,876.92	44,673.42	50,233.57	27,072.11	7,574.57		319,868.76		

SUBTOTAL:

10,395,677.36

700,502.56	965,459.39	631,465.59	571,462.71	639,435.43	1,090,830.26	733,305.01	883,154.28	1,340,584.11	1,451,839.56	577,082.06	810,556.40	

TOTAL:

COCHISE COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016

1118	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	479.53	209.84	2,974.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	479.53	209.84	2,974.00	0.00	0.00	0.00	0.00	0.00	

3717	ADULT <40% EXP FEM	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	609.40	6,843.60	1,019.37	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	609.40	6,843.60	1,019.37	

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1017	TANF 21-44 FEMALE N	0.00	0.00	0.00	0.00	586.31	0.00	57.05	4,195.50	0.00	0.00	0.00	0.00	4,838.86	
O														
SUBTOTAL:	0.00	0.00	0.00	0.00	586.31	0.00	57.05	4,195.50	0.00	0.00	0.00	0.00	4,838.86	
														
													3,663.37	
SUBTOTAL:													3,663.37	
														
													8,472.37	
AL													

8,472.37	

TOTAL:	0.00	0.00	0.00	0.00	1,065.84	209.84	3,031.05	4,195.50	0.00	609.40	6,843.60	1,019.37		16,974.60		

COCONINO COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3716	ADULT <40% EXP MALE	0.00	3,842.02	0.00	0.00	7.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,849.39		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	274.42	1,118.71	0.00	0.00	2,970.00	0.00	0.00	0.00	0.00		4,363.13		
3718	ADULT <40% EXP M&F 4	151.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		151.74		
	151.74	3,842.02	0.00	274.42	1,126.08	0.00	0.00	2,970.00	0.00	0.00	0.00	0.00		8,364.26		

SUBTOTAL:

TOTAL:

151.74

3,842.02	0.00	274.42	1,126.08	0.00	0.00	2,970.00	0.00	0.00	0.00	0.00	8,364.26

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1014	TANF 14-20 MALE NON-	0.00	0.00	7,504.65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		7,504.65		
1016	TANF 21-44 MALE NON-	2,440.29	3,129.66	300.47	366.70	0.00	0.00	0.00	841.68	0.00	6,746.62	0.00	3,680.60		17,506.02		
1017	TANF 21-44 FEMALE N O	0.00	2,041.21	946.05	3,936.64	9,915.53	3,263.60	470.90	17,262.73	1,113.58	277.68	958.63	5,620.33		45,806.88		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	259.72	0.00		259.72		
2200	SSI DISABLED WITH M	0.00	10,751.39	0.00	0.00	0.00	288.16	1,511.73	114.34	8,766.74	13,320.72	8.00	367.13		35,128.21		
2210	SSI DISABLED NON-ME D	18,422.83	10,195.76	34,766.80	17,317.71	168.87	5,679.57	5,210.08	9,183.48	31,612.24	14,784.65	38,634.79	37,615.58		223,592.36		
2220	SSI DISABLED WITH Q	15.35	3,019.90	3,735.46	357.86	-36.16	7,396.96	55.07	903.60	96.04	140.47	6,238.73	23,970.75		45,894.03		
4314	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	13,693.10	3,171.34	0.00	3,158.03	0.00	0.00		20,022.47		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	2,411.86	836.73	0.00	0.00	0.00	0.00	0.00	0.00	0.00		3,248.59		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	3,666.59	0.00	0.00	470.90	31.06	0.00	0.00	0.00	0.00		4,168.55		
5017	SOBRA PREG 21-44 FE M	0.00	5,306.85	4,658.33	5,451.17	203.40	11,761.22	8,322.52	1,383.89	863.35	4,167.43	0.00	235.45		42,353.61		
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	2,844.19	57.17	116.96		3,018.32		
	20,878.47	34,444.77	51,911.76	33,508.53	11,088.37	28,389.51	29,734.30	32,892.12	42,451.95	45,439.79	46,157.04	71,606.80		448,503.41		

E

M

SUBTOTAL:

1116	TANF EXPANDED 21-44	3,673.93	0.00	0.00	0.00	465.47	6,297.14	0.00	0.00	0.00	0.00	0.00	280.39	
1118	TANF EXPANDED 45-64	14,172.42	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+	0.00	0.00	0.00	0.00	0.00	0.00	13,349.00	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	848.47	0.00	0.00	3,360.13	1,360.29	227.10	220.65	
2600	SSI DISABLED EXPAND E	0.00	0.00	0.00	0.00	411.22	8.27	0.00	0.00	3,707.36	0.00	2,673.16	5,835.82	
2620	SSI DISABLED EXPAND	2,757.38	5,096.64	0.00	70.22	894.75	272.89	0.00	189.29	162.48	3,362.28	1,317.25	351.39	
	20,603.73	5,096.64	0.00	70.22	1,771.44	7,426.77	13,349.00	189.29	7,229.97	4,722.57	4,217.51	6,688.25	

10,716.93	
14,172.42	
13,349.00	
6,016.64	
12,635.83	
14,474.57	
71,365.39	

M&

E
SUBTOTAL:

3516	ADULT 40-100% MALE 2	0.00	0.00	4,010.58	2,822.80	0.00	0.00	0.00	0.00	0.00	563.53	5,722.92	5,917.54	
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	16,799.05	0.00	0.00	0.00	4,879.17	3,877.33	550.13	3,197.65	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	83.10	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	1,298.03	229.50	228.46	14,809.82	0.00	4,012.40	2,870.90	5,869.44	108.32	0.00	
3716	ADULT <40% EXP MALE	69,878.66	66,286.32	10,893.65	95,669.19	16,280.98	101,325.61	73,030.88	34,823.19	76,104.65	71,027.91	34,043.38	63,650.40	
3717	ADULT <40% EXP FEM	5,251.56	3,256.51	2,374.79	13,269.40	9,235.19	18,206.53	18,896.21	20,537.17	9,037.36	17,660.91	1,028.67	12,623.16	
3718	ADULT <40% EXP M&F	49,207.81	47,104.83	15,084.95	62,449.62	5,959.28	18,944.99	137,148.13	60,229.42	101,392.31	67,578.82	26,453.97	40,122.26	
	124,338.03	133,446.71	33,662.00	174,523.61	31,703.91	158,166.12	232,952.55	120,152.31	192,602.87	162,700.61	67,357.26	122,313.36	

19,037.37	
0.00	
29,303.33	
83.10	
29,426.87	
713,014.82	
131,377.46	
631,676.39	
1,553,919.34	

AL

4
SUBTOTAL:

3916	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	149.02	0.00	0.00	0.00	1,343.71	0.00	0.00	0.00	223.22	
3918	NEWLY ELIGIBLE M&F	15,153.54	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	15,153.54	0.00	0.00	149.02	0.00	0.00	0.00	1,343.71	0.00	0.00	0.00	223.22	

1,715.95	
15,153.54	
16,869.49	

4
SUBTOTAL:

534.77

534.77

8720	SSI DISABLED FREEDO	0.00	0.00	503.71	0.00	0.00	31.06	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	503.71	0.00	0.00	31.06	0.00	0.00	0.00	0.00	0.00	0.00	

M

MARICOPA COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
TOTAL:	180,973.77	172,988.12	86,077.47	208,251.38	44,563.72	194,013.46	276,035.85	154,577.43	242,284.79	212,862.97	117,731.81	200,831.63		2,091,192.40		

PIMA COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	2,192.24	0.00	955.38	0.00	0.00	0.00	0.00		3,147.62		
1016	TANF 21-44 MALE NON-	0.00	0.00	52.80	0.00	7.98	0.00	0.00	0.00	0.00	0.00	0.00	0.00		60.78		
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	-72.49	0.00	0.00	0.00	0.00	0.00		-72.49		
2210	SSI DISABLED NON-ME D	327.15	591.37	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		918.52		
5017	SOBRA PREG 21-44 FE	11.66	2,253.21	4,046.52	8,752.09	858.70	1,769.51	0.00	332.40	1,337.32	0.00	0.00	0.00		19,361.41		
SUBTOTAL:	338.81	2,844.58	4,099.32	8,752.09	866.68	3,961.75	-72.49	1,287.78	1,337.32	0.00	0.00	0.00		23,415.84		

M

1116	TANF EXPANDED 21-44	435.29	0.00	0.00	91.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1117	TANF EXPANDED 21-44	112.96	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	195.11	3,905.24	
	548.25	0.00	0.00	91.13	0.00	0.00	0.00	0.00	0.00	0.00	195.11	3,905.24	

526.42	
112.96	
4,100.35	
4,739.73	

E
SUBTOTAL:

3516	ADULT 40-100% MALE 2	0.00	0.00	17.50	0.00	0.00	0.00	0.00	0.00	0.00	10,275.09	300.69	0.00	
3517	ADULT 40-100% FEMAL E	0.00	0.00	0.00	79.49	98.24	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	13,355.83	4,487.44	0.00	6,733.15	1,783.51	363.75	221.81	9,489.63	3,405.44	0.00	1,444.70	428.49	
3717	ADULT <40% EXP FEM AL	55.30	0.00	0.00	0.00	0.00	5,236.39	0.00	0.00	0.00	0.00	0.00	10,200.89	
3718	ADULT <40% EXP M&F	2,778.01	10,131.21	950.60	14,425.99	9,754.38	-52.78	0.00	0.00	0.00	0.00	1,842.34	746.41	
SUBTOTAL:	16,189.14	14,618.65	968.10	21,238.63	11,636.13	5,547.36	221.81	9,489.63	3,405.44	10,275.09	3,587.73	11,375.79	

10,593.28	
177.73	
41,713.75	
15,492.58	
40,576.16	
108,553.50	

4

136,709.07

17,076.20	17,463.23	5,067.42	30,081.85	12,502.81	9,509.11	149.32	10,777.41	4,742.76	10,275.09	3,782.84	15,281.03	

TOTAL:

PINAL COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1016	TANF 21-44 MALE NON-	0.00	0.00	4,241.75	0.00	467.00	0.00	0.00	0.00	593.21	1,485.00	0.00	0.00		6,786.96		
2200	SSI DISABLED WITH M E	0.00	630.38	160.15	327.76	4,219.41	5,242.80	0.00	0.00	937.14	5,146.37	428.86	3,290.10		20,382.97		
2210	SSI DISABLED NON-ME D	0.00	160.89	0.00	0.00	327.76	67.24	6,691.96	0.00	5,541.27	0.00	0.00	0.00		12,789.12		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	142.83	217.59	245.38	0.00	0.00	0.00		605.80		
	0.00	791.27	4,401.90	327.76	5,014.17	5,310.04	6,834.79	217.59	7,317.00	6,631.37	428.86	3,290.10		40,564.85		

SUBTOTAL:

1117	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	7,877.62	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	7,877.62	0.00	0.00	0.00	0.00	0.00	0.00	

 
7,877.62

7,877.62

3716	ADULT <40% EXP MALE	7.98	1,430.76	0.00	0.00	250.57	3,790.43	9,903.28	31.06	3,369.68	621.78	3,703.95	3,240.67	
3717	ADULT <40% EXP FEM AL	144.34	0.00	0.00	0.00	0.00	0.00	739.54	1,181.28	0.00	9,989.70	0.00	0.00	
3718	ADULT <40% EXP M&F	8,014.50	-3,085.25	11,735.79	3,531.90	14,525.08	409.95	-2,091.78	14,984.06	1,642.57	410.95	8,068.49	737.42	
	8,166.82	-1,654.49	11,735.79	3,531.90	14,775.65	4,200.38	8,551.04	16,196.40	5,012.25	11,022.43	11,772.44	3,978.09	

26,350.16	
12,054.86	
58,883.68	
97,288.70	

4
SUBTOTAL:

9.55

9.55

3917	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.55	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9.55	

L
SUBTOTAL:

TOTAL:	8,166.82	-863.22	16,137.69	3,859.66	19,789.82	17,388.04	15,385.83	16,413.99	12,329.25	17,653.80	12,201.30	7,277.74		145,740.72		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	0.00	8,608.34	0.00	21.43	0.00	0.00	0.00	0.00	8,629.77	
0.00	0.00	0.00	0.00	0.00	8,608.34	0.00	21.43	0.00	0.00	0.00	0.00	8,629.77	

YAVAPAI COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2210

SSI DISABLED NON-ME
D

SUBTOTAL:

3516	ADULT 40-100% MALE 2	0.00	0.00	0.00	9,251.66	323.89	160.89	0.00	0.00	0.00	0.00	0.00	0.00	
3517	ADULT 40-100% FEMAL	0.00	0.00	0.00	0.00	160.89	0.00	990.00	243.08	0.00	0.00	0.00	0.00	
3716	ADULT <40% EXP MALE	306.05	0.00	166.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	994.93	2,378.00	
SUBTOTAL:	306.05	0.00	166.26	9,251.66	484.78	160.89	990.00	243.08	0.00	0.00	994.93	2,378.00	

9,736.44	
1,393.97	
472.31	
3,372.93	
14,975.65	

E

4

306.05

0.00

166.26

9,251.66

484.78

8,769.23

990.00

264.51

0.00

0.00

994.93

2,378.00

23,605.42

TOTAL:

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2210	SSI DISABLED NON-ME	0.00	177.03	0.00	4,575.16	0.00	9,164.20	0.00	0.00	170.19	0.00	0.00	0.00	14,086.58	
D														
SUBTOTAL:	0.00	177.03	0.00	4,575.16	0.00	9,164.20	0.00	0.00	170.19	0.00	0.00	0.00	14,086.58	
														
													12,006.76	
													556.20	
E													

12,562.96	

MOHAVE COUNTY INMATES FEE FOR SERVICE
For The Period Ending June 30, 2016

1116	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	12,006.76	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	0.00	0.00	0.00	0.00	556.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	556.20	12,006.76	0.00	0.00	0.00	0.00	0.00	0.00	

3716	ADULT <40% EXP MALE	0.00	673.35	580.79	372.54	6,342.26	0.00	122.84	0.00	0.00	671.85	0.00	0.00	
3717	ADULT <40% EXP FEM	0.00	3,152.09	110.80	0.00	0.00	3,362.36	0.00	191.20	0.00	0.00	0.00	-87.20	
3718	ADULT <40% EXP M&F	0.00	258.61	0.00	0.00	3,152.09	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	4,084.05	691.59	372.54	9,494.35	3,362.36	122.84	191.20	0.00	671.85	0.00	-87.20	

8,763.63	
6,729.25	
3,410.70	
18,903.58	

AL

4
SUBTOTAL:

TOTAL:	0.00	4,261.08	691.59	4,947.70	10,050.55	24,533.32	122.84	191.20	170.19	671.85	0.00	-87.20		45,553.12		

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DD
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	350.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	0.00		1,068.00		
2100	SSI AGED WITH MEDIC A	1,867,476.11	2,106,357.37	3,001,652.11	2,153,315.25	2,357,150.67	2,661,401.68	2,147,531.09	2,267,449.08	2,638,951.32	2,228,942.38	2,231,128.71	2,675,344.26		28,336,700.03		
2110	SSI AGED NON-MEDICA R	177,147.26	101,345.13	299,519.40	157,341.85	107,732.68	129,146.89	125,043.11	148,417.98	164,724.39	155,941.28	133,371.80	200,478.97		1,900,210.74		
2120	SSI AGED WITH QMB	2,867,399.51	2,877,254.51	4,110,836.71	2,939,351.28	3,113,372.32	3,642,449.33	3,090,157.66	3,056,867.31	3,641,257.51	3,062,311.34	3,187,515.95	3,631,322.80		39,220,096.23		
2200	SSI DISABLED WITH M	543,524.04	474,214.50	724,208.95	536,644.76	552,216.34	695,544.60	497,483.69	592,629.85	582,465.93	628,315.81	639,456.08	635,012.14		7,101,716.69		
2210	SSI DISABLED NON-ME D	2,493,153.38	2,750,175.45	3,099,509.74	2,474,403.45	2,586,712.46	3,134,206.32	2,516,029.87	2,621,292.75	3,021,310.06	2,913,308.90	2,857,062.66	3,391,599.64		33,858,764.68		
2220	SSI DISABLED WITH Q	639,532.10	693,460.39	974,750.74	671,858.25	672,467.60	904,432.53	746,390.37	736,523.86	912,274.60	739,230.30	774,637.03	907,641.15		9,373,198.92		
2300	SSI BLIND WITH MEDIC	74.93	0.00	59.40	59.40	0.00	32.09	0.00	0.00	0.00	0.00	0.00	0.00		225.82		
2310	SSI BLIND NON-MEDIC A	22,797.15	14,440.58	16,725.82	12,338.81	12,877.52	11,687.97	13,325.39	11,019.07	18,112.88	16,541.88	17,087.44	21,256.28		188,210.79		
2320	SSI BLIND WITH QMB	5,463.78	7,778.92	7,725.25	5,362.02	6,671.36	7,306.13	7,918.79	6,147.01	7,790.21	6,839.94	7,758.45	8,613.49		85,375.35		
	8,616,568.26	9,025,376.85	12,234,988.12	8,951,025.07	9,409,200.95	11,186,207.54	9,143,879.97	9,440,346.91	10,986,886.90	9,751,431.83	9,848,386.12	11,471,268.73		120,065,567.25		

E

M

SUBTOTAL:

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,044.41	2,637.12	99.53	2,709.12	2,578.56	5,483.52	2,578.56	2,774.40	2,643.84	3,074.27	
8720	SSI DISABLED FREEDO	1,712.52	2,990.88	4,148.64	2,052.00	2,056.32	4,112.64	2,741.76	2,741.76	3,427.20	2,741.76	2,741.76	3,427.20	
	1,712.52	4,868.22	9,193.05	4,689.12	2,155.85	6,821.76	5,320.32	8,225.28	6,005.76	5,516.16	5,385.60	6,501.47	

31,500.67	
34,894.44	
66,395.11	

M
SUBTOTAL:

120,131,962.36

8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	9,411,356.80	11,193,029.30	9,149,200.29	9,448,572.19	10,992,892.66	9,756,947.99	9,853,771.72	11,477,770.20	

TOTAL:

LTC FEE FOR SERVICE - PRIOR QUARTER COVERAGE - EXC. ES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2100

2110

2120

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

2200

2210

2220

SSI DISABLED WITH M
E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q

M
SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4,497.83	12,645.58	24,804.14	14,473.36	13,002.49	20,599.26	2,159.50	9,692.60	14,160.62	4,837.87	15,837.19	20,715.19	157,425.63	
0.00	0.00	0.00	399.80	0.00	435.84	0.00	49,449.40	0.00	0.00	0.00	69.99	50,355.03	
0.00	83.04	41.43	0.00	81.58	0.00	0.00	0.00	28.93	0.00	565.83	250.00	1,050.81	
572.87	1,912.10	6,455.92	314.42	3,785.37	2,357.90	823.65	73.28	7,226.92	361.91	1,534.42	2,682.83	28,101.59	
10,415.23	19,351.87	894.64	5,932.66	1,560.41	-737.82	514.39	506.82	14,550.81	2,276.19	1,224.43	9,136.95	65,626.58	
0.00	0.00	0.00	0.00	0.00	0.00	9,017.63	0.00	0.00	0.00	0.00	0.00	9,017.63	
15,485.93	33,992.59	32,196.13	21,120.24	18,429.85	22,655.18	12,515.17	59,722.10	35,967.28	7,475.97	19,161.87	32,854.96	311,577.27	

TOTAL:	15,485.93	33,992.59	32,196.13	21,120.24	18,429.85	22,655.18	12,515.17	59,722.10	35,967.28	7,475.97	19,161.87	32,854.96		311,577.27		

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1012	TANF 01-05 M & F NON	44,618.60	15,435.03	41,858.69	18,932.81	15,467.04	20,642.88	14,148.50	33,536.35	23,635.37	10,619.84	27,779.40	25,750.87		292,425.38		
1013	TANF 06-13 M & F NON	101,743.02	26,444.15	55,447.66	40,252.23	32,584.91	57,732.47	40,358.50	58,653.90	53,691.86	14,151.61	56,454.99	66,782.73		604,298.03		
1014	TANF 14-20 MALE NON-	8,473.78	2,483.13	8,146.57	6,639.55	4,375.95	7,509.81	3,255.57	7,721.08	7,323.84	3,549.11	7,452.66	6,720.61		73,651.66		
1015	TANF 14-20 FEMALE N O	3,292.00	1,194.76	3,063.63	2,548.02	1,886.25	4,133.96	2,455.54	2,917.37	2,543.63	1,918.93	1,843.36	4,888.01		32,685.46		
2120	SSI AGED WITH QMB	0.00	0.00	69.53	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		69.53		
2200	SSI DISABLED WITH M E	33.88	103.18	181.14	0.00	0.00	1,721.70	0.00	502.96	1,038.60	1,127.36	53.13	931.11		5,693.06		
2210	SSI DISABLED NON-ME	252,041.30	84,309.59	219,296.65	140,342.61	148,906.14	260,843.16	184,716.19	241,806.32	315,652.30	181,505.20	318,265.69	416,144.06		2,763,829.21		
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	23.96	10.53	188.39	43.80	742.15	269.15	615.96	-196.09	235.45		1,933.30		
2300	SSI BLIND WITH MEDIC	158.70	63.48	0.00	15.87	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		238.05		
2310	SSI BLIND NON-MEDIC A	2,989.18	538.14	1,847.47	1,001.22	903.64	1,360.84	1,140.36	1,634.60	3,401.81	2,327.07	1,320.81	2,507.07		20,972.21		
2320	SSI BLIND WITH QMB	0.00	333.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		333.30		
4305	SOBRA CHILD 14-20 FE	32.20	0.00	0.00	0.00	28.30	14.24	0.00	21.68	0.00	0.00	0.00	35.62		132.04		
4312	SOBRA CHILD 01-05 M	74,849.31	21,849.59	69,541.43	41,184.72	40,971.89	82,869.18	43,752.32	56,485.23	79,048.00	47,211.45	92,833.36	102,096.27		752,692.75		
4313	SOBRA CHILD 06-13 M	138,639.38	30,827.76	103,590.12	109,202.16	99,584.08	228,223.73	113,507.83	142,796.15	230,989.71	144,456.73	226,390.82	268,946.47		1,837,154.94		
4314	SOBRA CHILD 14-20 MA	12,134.57	3,360.74	12,303.21	9,010.79	9,606.28	18,550.26	9,231.76	15,097.53	19,378.03	12,789.55	20,588.68	25,455.90		167,507.30		
4315	SOBRA CHILD 14-20 FE	3,881.60	1,365.86	4,314.96	4,418.98	4,272.97	8,147.04	4,981.34	5,921.74	7,967.56	5,459.95	7,693.75	11,262.87		69,688.62		
5015	SOBRA PREG 14-20 FE	0.00	0.00	0.00	0.00	0.00	98.89	14.20	18.08	0.00	0.00	37.84	0.00		169.01		
	642,887.52	188,308.71	519,661.06	373,572.92	358,597.98	692,036.55	417,605.91	567,855.14	744,939.86	425,732.76	760,518.40	931,757.04		6,623,473.85		

D

M
SUBTOTAL:

1112	TANF EXPANDED 01-05	126.67	308.78	524.45	84.66	8.13	232.43	39.21	0.00	20.05	-261.08	0.00	0.00	
1113	TANF EXPANDED 06-13	2,228.51	2,807.73	3,254.21	1,018.60	620.72	2,543.48	1,254.12	2,528.53	1,542.08	450.20	1,338.49	1,510.98	
1114	TANF EXPANDED 14-20	31.33	0.00	213.25	29.47	14.60	140.10	0.00	84.42	84.42	-244.24	0.00	0.00	
1115	TANF EXPANDED 14-20	135.37	38.36	7.30	96.39	7.30	7.35	0.00	0.00	0.00	0.00	0.00	0.00	
2620	SSI DISABLED EXPAND	210.61	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	2,732.49	3,154.87	3,999.21	1,229.12	650.75	2,923.36	1,293.33	2,612.95	1,646.55	-55.12	1,338.49	1,510.98	

1,083.30	
21,097.65	
353.35	
292.07	
210.61	
23,036.98	

E
SUBTOTAL:

3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	0.00	0.00	18.98	0.00	32.96	86.74	113.91	116.31	211.95	
3515	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	95.69	27.95	0.00	0.00	0.00	0.00	195.39	82.33	
3516	ADULT 40-100% MALE 2	0.00	12.33	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3707	ADULT <40% EXP FEM AL	6.83	27.28	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	1,726.70	9.31	990.53	137.29	119.45	572.34	166.36	447.55	343.62	220.37	282.20	473.13	
3715	ADULT <40% EXP FEM AL	1,319.96	0.00	149.20	14.00	31.07	48.08	48.08	0.00	223.06	253.69	1,023.73	522.97	
3716	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	856.23	1,732.17	399.03	0.00	0.00	0.00	0.00	
	3,053.49	48.92	1,139.73	151.29	246.21	1,523.58	1,946.61	879.54	653.42	587.97	1,617.63	1,290.38	

580.85	
401.36	
12.33	
34.11	
5,488.85	
3,633.84	
2,987.43	
13,138.77	

SUBTOTAL:

94.55

841.04

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	94.55	
3915	NEWLY ELIGIBLE FEMA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.08	205.03	94.08	143.39	334.46	

L

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	64.08	205.03	94.08	143.39	429.01		935.59		

SUBTOTAL:

7,167,934.24

4413	SOBRA 100-133% M&F
6	25,022.12	4,486.95	12,154.90	21,398.13	23,398.03	58,170.12	29,217.48	33,174.28	60,643.62	42,973.92	66,392.86	73,466.58	
4414	SOBRA 100-133% MALE	8,073.76	649.78	1,470.80	1,731.37	1,992.93	4,038.41	1,942.59	3,113.51	3,895.13	3,806.82	4,077.98	5,657.14	
4415	SOBRA 100-133% FEMA	515.37	640.27	290.86	918.34	676.00	2,517.58	1,322.47	2,193.68	2,333.95	1,035.47	2,013.75	1,942.10	
SUBTOTAL:	33,611.25	5,777.00	13,916.56	24,047.84	26,066.96	64,726.11	32,482.54	38,481.47	66,872.70	47,816.21	72,484.59	81,065.82	

450,498.99	
40,450.22	
16,399.84	
507,349.05	

538,716.56	399,001.17	385,561.90	761,209.60	453,328.39	609,893.18	814,317.56	474,175.90	836,102.50	1,016,053.23	

L

TOTAL:

682,284.75

197,289.50

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	831.19	0.00	115.74	154.36	496.51	387.64	62.44	0.00	256.74	104.08	596.81	797.90		3,803.41		
1010	TANF NON-MEDICARE	40,868.65	24,234.06	48,725.89	26,485.58	29,892.42	44,214.96	24,625.86	32,195.61	36,971.36	26,856.39	51,411.10	62,203.14		448,685.02		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	97.30	19.46		116.76		
2200	SSI DISABLED WITH M E	2,871.13	789.16	3,394.59	1,281.47	667.85	3,130.34	2,521.84	1,376.74	2,684.87	1,912.14	4,154.26	12,126.88		36,911.27		
2210	SSI DISABLED NON-ME	1,249,307.80	489,106.70	1,265,880.28	765,381.38	758,689.31	1,369,048.70	907,027.43	1,203,840.89	1,492,777.95	937,980.61	1,718,532.98	2,008,558.69		14,166,132.72		
2220	SSI DISABLED WITH Q M	2,114.42	-248.86	3,650.67	2,135.30	1,672.29	3,246.71	895.51	1,029.44	1,784.76	478.41	3,624.46	3,628.88		24,011.99		
2310	SSI BLIND NON-MEDIC	7,193.15	6,514.48	11,947.59	4,341.28	8,117.72	10,057.63	6,770.86	5,979.21	7,779.80	5,248.12	8,608.92	12,543.94		95,102.70		
	1,303,186.34	520,395.54	1,333,714.76	799,779.37	799,536.10	1,430,085.98	941,903.94	1,244,421.89	1,542,255.48	972,579.75	1,787,025.83	2,099,878.89		14,774,763.87		

D

A
SUBTOTAL:

TOTAL:	1,303,186.34	520,395.54	1,333,714.76	799,779.37	799,536.10	1,430,085.98	941,903.94	1,244,421.89	1,542,255.48	972,579.75	1,787,025.83	2,099,878.89		14,774,763.87		

ACUTE REINSURANCE
For The Period Ending June 30, 2016

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
98.96	0.00	0.01	17,434.82	-9,013.41	0.00	-0.01	12.17	0.00	0.00	0.00	0.00	8,532.54	
0.00	0.00	0.00	0.00	0.00	17,401.25	945.08	0.00	-17,401.25	0.00	0.00	1,057.84	2,002.92	
741,618.20	275,323.86	870,817.73	584,132.79	463,642.57	201,270.80	14,374.58	669,996.89	494,469.06	344,729.33	12,134.19	767,165.64	5,439,675.64	
59,967.01	17,049.65	46,379.51	20,619.83	151,913.04	119,032.86	10,070.95	19,531.26	21,185.49	75,484.14	96,710.94	72,775.85	710,720.53	
184,625.99	341,772.36	71,256.85	294,266.28	103,622.05	208,524.29	230,771.29	133,472.74	140,755.28	51,233.01	172,040.42	122,160.84	2,054,501.40	
12,269.60	19,354.41	57,649.19	33,553.81	369.86	44,304.16	-4,533.90	10,180.37	4,597.98	9.12	36,030.43	1,344.08	215,129.11	
18,361.96	12,714.48	18,838.21	15,383.78	25,213.02	121,039.33	18,112.88	108,048.88	22,568.61	64,147.02	-2,144.88	60,053.34	482,336.63	
161,649.37	-21,881.23	40,292.26	305,406.83	277,743.49	140,429.72	317,406.13	345,135.26	222,554.84	193,275.22	177,213.09	272,390.86	2,431,615.84	
127,936.47	159,048.89	395,075.50	504,125.42	255,419.19	305,860.33	51,147.95	146,277.97	574,915.30	268,172.00	278,259.23	289,599.73	3,355,837.98	
84,129.25	65,348.37	87,293.71	207,392.12	65,634.10	157,000.19	41,059.66	314,062.77	95,181.78	80,567.20	68,588.82	343,122.04	1,609,380.01	
0.00	0.00	0.00	0.00	6,170.15	0.00	0.00	0.00	0.00	0.00	0.00	8,777.87	14,948.02	
624.78	33,070.16	362.69	24,212.27	12,180.72	34,105.65	7,812.85	3,859.28	9,100.43	7,938.48	12,921.97	30,190.66	176,379.94	
67,861.38	195,769.67	82,798.86	187,110.03	156,837.43	149,288.35	107,679.10	242,464.68	40,814.89	41,159.33	56,651.83	141,776.97	1,470,212.52	
43,874.36	10,496.70	3,907.51	14,759.66	36,550.05	14,130.33	94,181.61	27,579.43	13,012.80	24,227.96	4,377.32	60,308.35	347,406.08	
4,045,297.65	3,940,603.94	4,946,163.58	5,434,310.93	4,089,111.34	5,950,914.30	1,392,585.91	5,743,532.97	4,690,013.45	3,096,541.27	2,958,811.90	4,586,808.21	50,874,695.45	
0.00	0.00	0.00	79,766.51	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	79,766.51	
40,412.86	2,873.76	1,068.77	-75,896.96	5,691.49	32,166.80	0.00	8,459.11	17,427.51	0.00	-8,459.11	0.00	23,744.23	
929,626.36	754,864.21	1,574,042.96	1,471,872.89	543,338.74	662,693.47	191,540.82	1,411,456.98	824,915.21	472,073.68	551,007.99	1,471,901.38	10,859,334.69	
114,463.42	359,348.65	667,111.14	108,235.95	362,899.14	277,105.60	155,548.81	225,339.91	430,819.42	328,626.45	524,041.01	487,818.06	4,041,357.56	
239,870.36	136,192.59	249,120.95	-32,500.15	196,513.15	581,907.40	218,483.01	443,895.52	500,179.92	249,872.76	437,995.22	364,438.15	3,585,968.88	
115,773.80	89,801.77	118,016.08	142,705.87	117,629.45	-526,014.65	85,800.66	182,336.96	512,847.12	352,794.37	242,339.54	196,934.26	1,630,965.23	
14,027.07	63,132.41	6,858.73	138,256.42	16,264.65	34,636.41	19,332.17	48,151.93	64,896.39	67,878.97	73,675.35	76,036.17	623,146.67	
0.00	9,507.28	408.56	4,728.20	1,067.70	335.40	3,573.89	49,455.69	58,284.77	0.00	0.00	-31,331.17	96,030.32	
8,128.10	28,115.83	25,201.81	42,704.14	18,481.98	1,987.47	1,316.45	26,555.21	96,771.15	2,378.48	4,734.02	38,871.33	295,245.97	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	13,062.07	7,808.64	20,870.71	
7,010,616.95	6,492,507.76	9,262,664.61	9,522,581.44	6,897,279.90	8,528,119.46	2,957,209.89	10,159,805.98	8,817,910.15	5,721,108.79	5,709,991.35	9,370,009.10	90,449,805.38	

RATE CODE	DESCRIPTION 1006	TANF 21-44 MALE WITH
1007	TANF 21-44 FEMALE WI

1011	TANF <1 M & F NON-ME

1012	TANF 01-05 M & F NON

1013	TANF 06-13 M & F NON

1014	TANF 14-20 MALE NON-

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

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

1019	TANF 65+ M & F NON-M

2100	SSI AGED WITH MEDIC
A
2110	SSI AGED NON-MEDICA
R
2200	SSI DISABLED WITH M
E
2210	SSI DISABLED NON-ME
D
2300	SSI BLIND WITH MEDIC

2310	SSI BLIND NON-MEDIC
A
4311	SOBRA CHILD <1 M & F

4312	SOBRA CHILD 01-05 M

4313	SOBRA CHILD 06-13 M

4314	SOBRA CHILD 14-20 MA

4315	SOBRA CHILD 14-20 FE

5015	SOBRA PREG 14-20 FE
M
5017	SOBRA PREG 21-44 FE
M
5018	SOBRA PREG 45-64 FE
M
SUBTOTAL:

1106	TANF EXPANDED 21-44	212.95	936.55	33.40	329.59	0.01	264.91	45.17	298.84	632.55	529.21	1,004.65	1.73	
1108	TANF EXPANDED 45-64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-1,794.73	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	0.00	0.00	0.00	-8.67	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	505.48	6,432.42	-7.13	0.01	0.00	298.15	0.00	0.00	0.00	0.00	11,790.15	
1116	TANF EXPANDED 21-44	33,363.51	116,852.15	141,491.01	71,614.65	61,788.94	46,079.45	214,553.76	93,537.01	94,457.66	21,466.08	123,940.47	153,068.63	
1117	TANF EXPANDED 21-44	89,055.47	57,583.74	113,446.53	118,004.81	32,641.10	61,168.93	-1,520.84	249,679.33	-12,878.16	158,301.27	76,864.44	244,819.86	
1118	TANF EXPANDED 45-64	124,365.77	99,058.09	67,841.45	378,310.42	118,897.22	113,461.46	112,547.49	219,550.04	30,885.92	87,510.24	180,049.57	142,861.34	
1119	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	2,446.74	0.00	0.00	0.00	0.00	13,605.85	0.00	0.00	
2400	SSI AGED EXPANDED	-18.11	42.85	43.82	25.93	10.31	0.00	-178.82	13.82	0.00	0.00	0.00	0.00	

4,289.56	
-1,794.73	
-8.67	
19,019.08	
1,172,213.32	
1,187,166.48	
1,675,339.01	
16,052.59	
-60.20	

M&

WI

ACUTE REINSURANCE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
2410	SSI AGED EXPANDED NO	14,090.33	42,829.44	49,706.82	46,616.48	7,100.00	-5,141.12	4,585.12	11,351.53	23,361.47	2,995.52	43,391.78	6,265.56		247,152.93		
2600	SSI DISABLED EXPAND E	35,356.98	19,953.70	40,311.53	39,071.56	75,248.39	1,399.37	430.74	9,100.38	433.36	12,060.16	3,673.32	67.87		237,107.36		
2610	SSI DISABLED EXPAND E	20,284.70	72,266.71	62,393.79	63,319.22	126,966.46	50,917.39	9,648.84	106,884.08	8,416.67	73,701.04	37,511.47	63,454.99		695,765.36		
	316,711.60	410,028.71	481,700.77	717,276.86	425,099.18	268,150.39	340,409.61	688,620.30	145,309.47	370,169.37	466,435.70	622,330.13		5,252,242.09		

SUBTOTAL:

3316	AHC CARE MALE 21-44	22.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21-	0.00	0.00	0.00	0.00	1,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	742.92	2,889.03	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	765.22	2,889.03	0.00	0.00	1,477.43	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

22.30	
1,477.43	
3,631.95	
5,131.68	

4

SUBTOTAL:

3410	MED ELIGIBILITY NON-	0.00	0.00	-5,724.35	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	9,760.41	0.00	0.00	3,581.25	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	1,239.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	28,195.73	-1,579.93	-5,079.21	0.00	-1,327.80	1,176.39	0.00	0.00	0.00	-42.09	0.00	0.00	
	37,956.14	-1,579.93	-10,803.56	3,581.25	-88.42	1,176.39	0.00	0.00	0.00	-42.09	0.00	0.00	

-5,724.35	
13,341.66	
1,239.38	
21,343.09	
30,199.78	

SUBTOTAL:

3508	ADULT 40-100% M&F 45	-1,247.11	6.67	2.28	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	4,021.81	
3514	ADULT 40-100% MALE 1	0.00	90,377.57	23.98	303.56	10,582.98	0.00	0.00	0.00	0.00	355.93	25,577.19	62,946.60	
3515	ADULT 40-100% FEMAL	9,715.08	0.00	14,961.01	39,148.26	53,075.14	0.00	0.00	198.84	7,538.05	1,710.39	12,716.32	-4,447.11	
3516	ADULT 40-100% MALE 2	42,038.64	132,978.87	147,952.07	213,702.36	158,020.09	175,535.38	62,002.68	308,900.04	153,525.49	188,229.07	88,813.78	185,677.95	
3517	ADULT 40-100% FEMAL E	69,797.48	154,862.63	143,383.48	95,096.25	34,812.53	150,935.92	2,688.91	0.00	3,904.61	0.00	20,603.58	72,320.07	
3518	ADULT 40-100% M&F 45	414,839.94	278,819.33	311,265.46	367,780.84	470,498.88	367,409.16	108,964.22	309,524.54	96,929.36	405,311.57	147,736.08	624,148.21	
3707	ADULT <40% EXP FEM AL	0.00	0.00	2,767.51	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	37,973.29	1,282.59	21,727.75	-1,549.73	0.00	21,253.88	0.00	0.00	0.00	8,323.06	0.00	1,894.74	
3714	ADULT <40% EXP MALE	150,958.00	173,540.11	140,658.64	168,686.95	205,746.27	47,735.55	92,529.83	53,362.67	169,561.02	74,271.62	16,859.87	4,795.63	
3715	ADULT <40% EXP FEM AL	103,135.79	82,987.17	49,364.34	70,131.79	15,205.08	13,225.92	12,512.37	28,359.53	5,093.03	24,174.41	22,929.89	1,066.45	
3716	ADULT <40% EXP MALE	502,179.54	650,833.61	591,737.89	1,117,820.73	788,610.97	750,365.46	70,705.12	784,944.99	639,132.55	743,107.55	823,659.24	1,052,372.54	
3717	ADULT <40% EXP FEM AL	256,435.90	98,701.30	250,260.17	399,461.42	410,941.85	345,450.11	65,666.55	159,813.61	170,264.75	112,482.09	152,076.87	362,404.73	
3718	ADULT <40% EXP M&F	1,083,021.23	1,159,557.65	1,128,258.45	2,023,672.20	1,885,371.09	1,267,187.18	615,990.59	1,484,577.46	1,046,249.45	1,332,081.42	783,628.87	2,278,492.36	
3719	ADULT <40% EXP M&F	0.00	0.00	0.00	1,152.60	0.00	883.37	0.00	0.00	0.00	0.00	384.34	479.64	
	2,668,847.78	2,823,947.50	2,802,363.03	4,495,407.23	4,032,864.88	3,139,981.93	1,031,060.27	3,129,681.68	2,292,198.31	2,890,047.11	2,094,986.03	4,646,173.62	

2,783.65	
190,167.81	
134,615.98	
1,857,376.42	
748,405.46	
3,903,227.59	
2,767.51	
90,905.58	
1,298,706.16	
428,185.77	
8,515,470.19	
2,783,959.35	
16,088,087.95	
2,899.95	
36,047,559.37	

E

4

6
SUBTOTAL:

3908	NEWLY ELIGIBLE M&F 4	75,258.45	0.00	21,217.74	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3914	NEWLY ELIGIBLE MALE	4,356.93	0.00	0.00	19,045.28	10,843.38	0.00	188.61	62,202.00	62,202.00	64,974.87	62,616.12	138,315.15	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	1,064.69	0.00	0.00	0.00	0.00	0.00	0.00	
3916	NEWLY ELIGIBLE MALE	34,179.36	117,409.93	42,037.03	103,240.00	152,204.38	53,659.73	70,924.33	114,151.58	187,753.76	128,384.13	152,495.68	173,874.69	
3917	NEWLY ELIGIBLE FEMA	-833.32	13,544.41	28,948.15	38,254.97	33,953.18	7,099.39	16,258.67	107,566.77	11,868.33	47,420.56	1,526.71	10,517.04	
3918	NEWLY ELIGIBLE M&F	163,410.54	348,055.35	252,590.82	236,488.95	162,860.24	163,485.29	63,258.33	331,593.42	181,175.18	166,144.76	194,308.47	439,436.12	

96,476.19	
424,744.34	
1,064.69	
1,330,314.60	
316,124.86	
2,702,807.47	

L

4

ACUTE REINSURANCE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	276,371.96	479,009.69	344,793.74	397,029.20	359,861.18	225,309.10	150,629.94	615,513.77	442,999.27	406,924.32	410,946.98	762,143.00		4,871,532.15		

SUBTOTAL:

4413	SOBRA 100-133% M&F
6	19,844.57	10,180.96	21,606.21	141,092.28	121,073.24	36,860.81	162.87	130,937.24	112,102.67	92,069.09	51,038.56	165,806.05	
4414	SOBRA 100-133% MALE	451,101.89	451,107.67	426,127.94	679,863.69	468,911.44	1,180,962.21	27,990.69	692,202.74	676,826.12	1,004,927.24	520,487.55	375,808.37	
4415	SOBRA 100-133% FEMA	188.17	9,280.96	106.64	4,451.52	-2,057.67	32.82	82.47	141,812.83	13,891.52	4,245.79	14,861.84	37,717.79	
SUBTOTAL:	471,134.63	470,569.59	447,840.79	825,407.49	587,927.01	1,217,855.84	28,236.03	964,952.81	802,820.31	1,101,242.12	586,387.95	579,332.21	

902,774.55	
6,956,317.55	
224,614.68	
8,083,706.78	

L

4517	BC PATIENT FEMALE 2 1	6,209.80	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4	0.00	0.00	0.00	855.98	0.00	0.00	0.00	7,109.74	0.00	7,540.92	0.00	0.00	
	6,209.80	0.00	0.00	855.98	0.00	0.00	0.00	7,109.74	0.00	7,540.92	0.00	0.00	

6,209.80	
15,506.64	
21,716.44	

5
SUBTOTAL:

41,508.88

41,508.88

8710	SSI DISABLED FREEDO	2,595.44	0.00	2,595.44	5,190.88	2,595.43	2,595.44	0.00	6,022.60	2,594.20	2,594.20	12,090.78	2,634.47	
	2,595.44	0.00	2,595.44	5,190.88	2,595.43	2,595.44	0.00	6,022.60	2,594.20	2,594.20	12,090.78	2,634.47	

M
SUBTOTAL:

144,803,402.55

10,791,209.52	10,677,372.35	13,331,154.82	15,967,330.33	12,307,016.59	13,383,188.55	4,507,545.74	15,571,706.88	12,503,831.71	10,499,584.74	9,280,838.79	15,982,622.53	

TOTAL:

LONG TERM CARE REINSURANCE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	43.57	0.00	34,024.05	4,013.54	40.56	0.00	0.00	0.00	266.86	10,639.05	18.46		49,046.09		
2100	SSI AGED WITH MEDIC A	327,108.06	281,473.61	410,214.64	182,410.50	337,086.99	210,136.17	398,027.74	254,136.53	156,719.55	158,925.57	248,776.12	109,551.42		3,074,566.90		
2110	SSI AGED NON-MEDICA R	218,322.47	133,627.59	139,813.52	145,656.58	216,314.34	137,105.95	73,558.19	33,888.42	11,340.11	82,207.60	102,689.20	93,695.49		1,388,219.46		
2200	SSI DISABLED WITH M E	644,979.13	626,909.22	541,936.81	444,452.89	492,010.90	679,427.76	730,139.16	409,632.55	481,841.68	333,411.83	476,725.95	378,914.62		6,240,382.50		
2210	SSI DISABLED NON-ME	2,840,717.50	2,796,391.98	3,888,127.51	3,540,048.52	4,792,282.42	2,737,929.54	1,970,903.40	1,738,732.48	1,996,443.79	1,808,113.90	2,394,778.59	3,292,108.44		33,796,578.07		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	61.17	91.91	28.00	0.00	0.00	0.00	0.00	-1.09		179.99		
2310	SSI BLIND NON-MEDIC	2,067.18	829.15	61,461.10	4,145.13	12,606.98	4,663.25	1,650.00	2,265.20	-1,161.52	2,556.93	3.63	-31.06		91,055.97		
	4,033,194.34	3,839,275.12	5,041,553.58	4,350,737.67	5,854,376.34	3,769,395.14	3,174,306.49	2,438,655.18	2,645,183.61	2,385,482.69	3,233,612.54	3,874,256.28		44,640,028.98		

D

A
SUBTOTAL:

14,896.33

14,896.33

8710	SSI DISABLED FREEDO	12,568.90	358.45	-18.28	10.23	1,957.76	0.00	21.05	0.00	-1.78	0.00	0.00	0.00	
	12,568.90	358.45	-18.28	10.23	1,957.76	0.00	21.05	0.00	-1.78	0.00	0.00	0.00	

M
SUBTOTAL:

TOTAL:	4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	5,856,334.10	3,769,395.14	3,174,327.54	2,438,655.18	2,645,181.83	2,385,482.69	3,233,612.54	3,874,256.28		44,654,925.31		

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
194,274.80	239,591.60	285,013.30	307,878.00	71,122.20	73,325.10	76,109.30	85,112.60	76,345.30	74,217.00	82,685.90	75,052.70	1,640,727.80	
419.60	314.70	419.60	419.60	839.20	524.50	487.20	365.40	470.30	487.20	487.20	1,096.20	6,330.70	
59,218.50	89,224.80	136,060.20	153,998.10	21,979.00	27,224.00	33,977.90	30,886.50	28,345.60	26,900.90	24,725.40	26,136.30	658,677.20	
55,177.40	57,030.30	58,179.30	62,320.40	92,112.00	76,322.10	86,876.80	100,163.30	85,856.70	86,567.10	86,420.10	99,617.30	946,642.80	
390,962.30	405,066.70	409,640.00	406,988.40	406,802.20	436,932.40	457,491.40	500,581.20	476,446.10	515,922.40	528,226.70	501,103.60	5,436,163.40	
1,817,089.90	1,837,723.90	1,860,966.00	1,885,790.10	2,434,377.40	2,464,358.80	2,872,361.20	2,877,496.60	2,907,473.80	2,989,697.50	3,015,662.90	3,147,483.00	30,110,481.10	
156,570.80	143,157.80	137,314.10	138,468.00	135,216.10	127,558.40	153,205.80	145,012.80	143,107.10	139,933.50	151,572.50	239,788.90	1,810,905.80	
332,008.50	338,302.50	334,945.70	338,302.50	337,253.50	333,791.80	391,462.30	394,361.60	396,368.10	395,586.60	392,591.70	399,929.10	4,384,903.90	
2,831,922.00	2,873,883.50	2,914,800.20	2,923,716.10	2,934,708.00	2,924,607.70	3,421,032.10	3,432,314.70	3,454,683.80	3,520,290.60	3,597,440.10	3,603,975.10	38,433,373.90	
419.60	419.60	314.70	314.70	314.70	314.70	713.90	487.20	365.40	243.60	0.00	243.60	4,151.70	
3,251.90	3,356.80	3,042.10	2,937.20	2,937.20	2,832.30	3,288.60	3,410.40	3,410.40	3,410.40	3,410.40	3,410.40	38,698.10	
25,071.10	24,336.80	25,910.30	25,805.40	26,015.20	25,176.00	29,651.60	29,861.40	36,764.80	31,796.80	30,084.60	30,206.40	340,680.40	
104.90	104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	1,045.50	1,674.90	
104.90	104.90	104.90	104.90	104.90	0.00	0.00	0.00	0.00	0.00	121.80	121.80	768.10	
1,363.70	1,363.70	1,153.90	944.10	629.40	419.60	487.20	487.20	365.40	365.40	243.60	243.60	8,066.80	
944.10	839.20	1,153.90	944.10	1,363.70	1,049.00	1,096.20	1,096.20	1,705.20	2,923.20	2,679.60	3,532.20	19,326.60	
0.00	0.00	-209.80	0.00	0.00	0.00	0.00	-226.70	-243.60	-487.20	0.00	0.00	-1,167.30	
543,517.80	550,391.10	561,940.30	555,491.40	568,562.80	566,367.00	668,106.30	685,633.30	699,569.90	724,020.40	771,948.80	717,340.40	7,612,889.50	
3,389,057.50	3,504,045.60	3,489,229.70	3,653,533.40	3,562,064.70	3,558,489.40	4,162,803.00	4,165,784.10	4,230,303.80	4,226,326.90	4,071,041.20	4,006,602.00	46,019,281.30	
-52,359.80	-26,959.30	-20,035.90	-24,127.00	-7,238.10	-13,002.70	-16,844.70	4,254.20	-19,214.10	-11,412.40	108,783.10	-230,561.20	-308,717.90	
59,066.30	19,847.50	122,106.60	172,423.40	145,913.80	190,130.30	236,588.30	208,313.90	118,766.40	126,221.40	523,500.30	-23,357.30	1,899,520.90	
9,808,185.80	10,062,146.60	10,322,154.00	10,606,357.70	10,735,182.80	10,796,525.30	12,578,894.40	12,665,395.90	12,640,890.40	12,853,011.30	13,391,625.90	12,603,009.60	139,063,379.70	

ACUTE SMIB
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

1000

TANF WITH MEDICARE

1010

1020

TANF NON-MEDICARE

TANF WITH QMB

2100

2110

2120

2200

2210

2220

2300

2310

2320

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

SSI DISABLED WITH M E
SSI DISABLED NON-ME
D
SSI DISABLED WITH Q
M
SSI BLIND WITH MEDIC

SSI BLIND NON-MEDIC A
SSI BLIND WITH QMB

4300

4320

5000

5020

8000

SOBRA CHILD WITH ME
D
SOBRA CHILD WITH Q
MB
SOBRA PREGNANT WO
MAN
SOBRA PREGNANT WO
MAN
SMIB ONLY NOT ELIGIB

8020

8040

QMB ONLY

SLMB

8888

SMIB ONLY NOT ELIGIB

9999

SMIB ONLY NOT ELIGIB

SUBTOTAL:

1100	TANF EXPANDED FPR FI	470,376.20	412,891.00	362,329.20	338,157.10	689,298.50	630,171.70	693,195.30	684,101.00	682,181.90	701,168.00	688,839.10	645,955.00	
1110	TANF EXPANDED FOR	209.80	104.90	104.90	104.90	104.90	104.90	1,309.50	801.90	365.40	3,265.30	487.20	365.40	
1120	TANF EXPANDED FOR FI	128,342.70	125,775.10	114,341.00	103,116.70	130,285.80	198,051.20	270,459.00	266,539.20	284,643.70	291,244.20	289,836.50	274,692.50	
2400	SSI AGED EXPANDED	3,042.10	1,468.60	1,253.90	419.60	209.80	314.70	243.60	243.60	243.60	0.00	-470.20	-4,019.40	
2410	SSI AGED EXPANDED NO	524.50	524.50	524.50	419.60	314.70	314.70	365.40	243.60	121.80	121.80	6,858.10	121.80	
2420	SSI AGED EXPANDED WI	2,928,537.00	2,921,828.60	2,878,145.10	2,887,841.00	2,295,255.90	2,268,575.50	2,597,155.00	2,604,289.20	2,589,349.80	2,566,780.40	2,467,257.00	2,291,608.70	
2520	SSI BLIND EXPANDED W	104.90	104.90	104.90	104.90	104.90	104.90	121.80	121.80	121.80	121.80	121.80	121.80	
2600	SSI DISABLED EXPAND E	-419.60	209.80	314.70	-104.90	314.70	209.80	-629.40	243.60	-121.80	-365.40	121.80	-1,827.00	
2620	SSI DISABLED EXPAND	1,653,183.80	1,727,813.10	1,756,040.70	1,816,932.70	1,829,709.50	1,863,111.30	2,211,003.30	2,223,027.00	2,239,720.70	2,174,177.40	2,083,529.40	1,941,523.80	
	5,183,901.40	5,190,720.50	5,113,158.90	5,146,991.60	4,945,598.70	4,960,958.70	5,773,223.50	5,779,610.90	5,796,626.90	5,736,513.50	5,536,580.70	5,148,542.60	

6,998,664.00	
7,329.00	
2,477,327.60	
2,949.90	
10,455.00	
31,296,623.20	
1,360.20	
-2,053.70	
23,519,772.70	
64,312,427.90	

FI

WI

E
SUBTOTAL:

3520	ADULT 40-100% FOR FI	3,147.00	-1,743.30	3,147.00	3,356.80	4,930.30	4,510.70	5,802.70	2,784.50	3,532.20	6,455.40	2,436.00	4,141.20	
3720	AHC CARE EXPANDED	3,776.40	1,468.60	1,153.90	1,783.30	3,566.60	2,622.50	2,385.30	4,845.20	2,923.20	4,141.20	1,096.20	2,679.60	
	6,923.40	-274.70	4,300.90	5,140.10	8,496.90	7,133.20	8,188.00	7,629.70	6,455.40	10,596.60	3,532.20	6,820.80	

42,500.50	
32,442.00	
74,942.50	

FO
SUBTOTAL:

RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3920	NEWLY ELIGIBLE FOR	1,468.60	734.30	839.20	629.40	839.20	944.10	1,847.40	1,948.80	1,583.40	4,286.80	1,534.40	974.40	17,630.00	
F														
SUBTOTAL:	1,468.60	734.30	839.20	629.40	839.20	944.10	1,847.40	1,948.80	1,583.40	4,286.80	1,534.40	974.40	17,630.00	
														
													297,921.10	
M
SUBTOTAL:													

297,921.10	

ACUTE SMIB
For The Period Ending June 30, 2016

203,766,301.20

8720	SSI DISABLED FREEDO	21,399.60	22,238.80	22,343.70	24,022.10	23,182.90	23,602.50	28,663.80	27,354.30	26,430.60	26,065.20	26,674.20	25,943.40	
	21,399.60	22,238.80	22,343.70	24,022.10	23,182.90	23,602.50	28,663.80	27,354.30	26,430.60	26,065.20	26,674.20	25,943.40	

15,021,878.80	15,275,565.50	15,462,796.70	15,783,140.90	15,713,300.50	15,789,163.80	18,390,817.10	18,481,939.60	18,471,986.70	18,630,473.40	18,959,947.40	17,785,290.80	

TOTAL:

ACUTE HIB
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0000	HIB ONLY NOT ELIGIBL	0.00	0.00	407.00	-407.00	0.00	0.00	411.00	-411.00	0.00	0.00	226.00	0.00		226.00		
1020	TANF WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	676.00	226.00	226.00	0.00	0.00		1,128.00		
2100	SSI AGED WITH MEDIC A	2,442.00	-814.00	0.00	-557.50	0.00	1,628.00	0.00	0.00	0.00	-1,292.90	0.00	596.00		2,001.60		
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	1,221.00	0.00	1,225.00	1,644.00	0.00	-2,004.30	6,802.00	0.00		8,887.70		
2120	SSI AGED WITH QMB	173,720.20	179,916.50	193,518.70	197,193.80	189,836.80	195,941.80	196,838.50	216,471.40	241,815.40	187,593.50	231,622.30	234,170.60		2,438,639.50		
2210	SSI DISABLED NON-ME D	0.00	0.00	0.00	0.00	0.00	0.00	0.00	411.00	0.00	0.00	2,055.00	0.00		2,466.00		
2220	SSI DISABLED WITH Q	88,616.20	96,125.80	110,636.10	112,246.10	100,161.10	107,121.10	104,174.70	113,062.70	123,186.70	114,270.20	123,001.60	129,758.40		1,322,360.70		
2320	SSI BLIND WITH QMB	407.00	407.00	407.00	407.00	407.00	407.00	411.00	411.00	411.00	-1,373.70	411.00	411.00		3,123.30		
8000	SMIB ONLY NOT ELIGIB	0.00	0.00	0.00	-887.30	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-887.30		
8020	QMB ONLY	4,988.10	2,953.10	3,645.00	5,761.40	4,133.40	3,726.40	4,884.60	3,988.60	3,988.60	-2,081.20	6,206.00	4,562.00		46,756.00		
9999	SMIB ONLY NOT ELIGIB	-8,404.70	-4,538.50	-4,375.40	-7,780.00	-3,887.00	-6,817.40	-4,248.70	-4,944.80	-1,829.00	-26,645.50	-4,151.10	-2,096.00		-79,718.10		
	261,768.80	274,049.90	304,238.40	305,976.50	291,872.30	302,006.90	303,696.10	331,308.90	367,798.70	268,692.10	366,172.80	367,402.00		3,744,983.40		

M

SUBTOTAL:

66,619.00

66,619.00

2420	SSI AGED EXPANDED	8,649.20	8,527.10	5,656.40	8,584.10	4,192.40	4,192.40	4,233.20	4,233.20	6,473.20	3,288.00	4,500.40	4,089.40	
	8,649.20	8,527.10	5,656.40	8,584.10	4,192.40	4,192.40	4,233.20	4,233.20	6,473.20	3,288.00	4,500.40	4,089.40	

WI
SUBTOTAL:

TOTAL:	270,418.00	282,577.00	309,894.80	314,560.60	296,064.70	306,199.30	307,929.30	335,542.10	374,271.90	271,980.10	370,673.20	371,491.40		3,811,602.40		

Q1
For The Period Ending June 30, 2016

2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	1,905,402.60	2,072,651.30	2,017,375.10	1,458,506.60	2,091,076.50	2,388,527.50	2,129,003.40	

SUBTOTAL:	2,399,485.20	1,983,016.50	1,927,946.30	1,981,085.50	1,974,021.90	1,905,402.60	2,072,651.30	2,017,375.10	1,458,506.60	2,091,076.50	2,388,527.50	2,129,003.40		24,328,098.40	
															
TOTAL:														24,328,098.40	

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
8050	QI1	2,434,626.70	1,985,923.60	1,946,933.20	1,994,198.00	1,976,010.10	1,905,772.20	3,268.80	1,709,715.40	1,923,831.00	2,075,477.00	2,385,374.10	2,151,414.60	22,492,544.70	
9999	SMIB ONLY NOT ELIGIB	-35,141.50	-2,907.10	-18,986.90	-13,112.50	-1,988.20	-369.60	2,069,382.50	307,659.70	-465,324.40	15,599.50	3,153.40	-22,411.20	1,835,553.70	

LTC SMIB
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1000	TANF WITH MEDICARE	524.50	419.60	419.60	419.60	419.60	1,573.50	730.80	730.80	974.40	609.00	487.20	2,263.50		9,572.10		
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	121.80	121.80	121.80	121.80	121.80	0.00		609.00		
1020	TANF WITH QMB	104.90	104.90	104.90	104.90	104.90	104.90	348.50	243.60	243.60	243.60	243.60	243.60		2,195.90		
2100	SSI AGED WITH MEDIC A	874,183.40	870,946.20	868,154.40	873,399.40	856,670.30	875,757.20	1,011,705.50	973,512.00	1,005,477.20	1,003,337.80	999,411.60	999,048.50		11,211,603.50		
2110	SSI AGED NON-MEDICA	155,566.70	157,769.60	157,769.60	157,664.70	161,336.20	159,657.80	185,866.80	186,841.20	185,988.60	183,796.20	188,949.70	183,535.70		2,064,742.80		
2120	SSI AGED WITH QMB	764,559.10	761,981.70	777,780.80	770,483.50	771,637.40	774,259.90	904,494.80	881,879.80	896,668.70	896,584.20	895,885.90	906,064.20		10,002,280.00		
2200	SSI DISABLED WITH M	319,840.10	329,595.80	321,623.40	322,567.50	334,134.80	337,673.10	382,974.80	388,117.20	400,929.50	392,930.90	376,829.40	385,615.90		4,292,832.40		
2210	SSI DISABLED NON-ME D	15,630.10	25,513.40	17,308.50	18,147.70	26,318.60	19,721.20	20,306.80	19,853.40	20,949.60	22,045.80	22,533.00	18,879.00		247,207.10		
2220	SSI DISABLED WITH Q M	710,227.60	707,605.10	709,170.10	710,332.50	709,958.00	709,858.00	820,671.20	840,867.40	822,582.70	825,577.00	826,668.10	836,718.50		9,230,236.20		
2300	SSI BLIND WITH MEDIC	944.10	734.30	734.30	839.20	839.20	839.20	974.40	974.40	974.40	852.60	974.40	1,096.20		10,776.70		
2310	SSI BLIND NON-MEDIC A	209.80	104.90	209.80	104.90	104.90	104.90	121.80	243.60	243.60	243.60	121.80	121.80		1,935.40		
2320	SSI BLIND WITH QMB	4,300.90	4,510.70	4,405.80	4,405.80	4,615.60	4,300.90	4,993.80	4,993.80	5,237.40	5,237.40	5,237.40	5,115.60		57,355.10		
	2,846,091.20	2,859,286.20	2,857,681.20	2,858,469.70	2,866,139.50	2,883,850.60	3,333,311.00	3,298,379.00	3,340,391.50	3,331,579.90	3,317,463.90	3,338,702.50		37,131,346.20		

R

E

SUBTOTAL:

7,900.70

7,900.70

8720	SSI DISABLED FREEDO	734.30	629.40	629.40	629.40	629.40	629.40	730.80	730.80	730.80	609.00	609.00	609.00	
SUBTOTAL:	734.30	629.40	629.40	629.40	629.40	629.40	730.80	730.80	730.80	609.00	609.00	609.00	

M

TOTAL:	2,846,825.50	2,859,915.60	2,858,310.60	2,859,099.10	2,866,768.90	2,884,480.00	3,334,041.80	3,299,109.80	3,341,122.30	3,332,188.90	3,318,072.90	3,339,311.50		37,139,246.90		

LTC HIB
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2100

2110

2120

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

2200

2220

2320

SSI DISABLED WITH M
E
SSI DISABLED WITH Q
M
SSI BLIND WITH QMB

SUBTOTAL:

269,424.80	275,671.80	269,873.10	259,132.80	272,905.10	271,807.10	270,456.20	282,746.20	283,468.20	204,899.40	280,112.90	284,539.00	

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	0.00	0.00	0.00	1,628.00	1,221.00	-407.00	0.00	0.00	-973.40	0.00	0.00	1,468.60	
407.00	0.00	1,221.00	0.00	0.00	1,221.00	0.00	0.00	1,233.00	0.00	1,233.00	0.00	5,315.00	
256,094.80	261,120.80	256,136.10	250,816.60	258,578.10	257,073.10	259,680.20	269,105.20	269,001.20	208,454.20	263,590.90	269,476.00	3,079,127.20	
0.00	407.00	0.00	407.00	-407.00	407.00	0.00	0.00	411.00	0.00	411.00	0.00	1,636.00	
12,923.00	14,144.00	12,516.00	7,909.20	13,106.00	11,885.00	11,183.00	13,641.00	12,823.00	-1,685.10	14,878.00	15,063.00	138,386.10	
0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-896.30	0.00	0.00	-896.30	
269,424.80	275,671.80	269,873.10	259,132.80	272,905.10	271,807.10	270,456.20	282,746.20	283,468.20	204,899.40	280,112.90	284,539.00	3,225,036.60	
													
												3,225,036.60	

TOTAL:

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

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

1006	TANF 21-44 MALE WITH	1,467.46	3,014.86	4,778.75	2,265.53	988.83	-1,150.92	884.20	-282.60	1,271.34	1,618.29	1,533.23	902.64	
1007	TANF 21-44 FEMALE WI	4,007.77	5,488.43	7,854.61	6,151.20	4,092.39	6,828.92	3,379.94	3,407.68	2,962.20	2,221.35	2,761.74	1,258.49	
1008	TANF 45-64 M & F WIT	8,300.31	14,284.07	22,892.61	20,087.85	12,197.99	7,355.41	4,426.36	4,175.97	4,017.54	4,959.72	4,736.97	4,357.66	
1009	TANF 65+ M & F WITH	4,262.82	6,279.98	9,729.78	6,523.30	6,273.31	2,746.00	2,570.35	2,626.64	3,113.93	4,582.98	1,844.87	4,127.51	
1011	TANF <1 M & F NON-ME	706,541.50	682,073.88	661,237.30	404,783.59	599,501.44	591,608.68	621,469.66	677,687.46	800,105.24	590,718.15	497,105.87	780,477.63	
1012	TANF 01-05 M & F NON	969,410.73	801,705.50	673,128.09	375,548.29	575,579.34	450,777.80	338,642.60	329,100.87	325,586.65	310,794.44	272,354.69	309,910.33	
1013	TANF 06-13 M & F NON	1,633,637.26	1,349,156.15	1,576,752.74	664,270.88	879,050.47	654,493.49	411,907.45	297,914.87	310,558.34	294,159.31	215,612.98	255,070.36	
1014	TANF 14-20 MALE NON-	262,704.72	279,116.04	271,658.86	463,703.61	191,251.40	144,292.51	100,365.49	85,993.18	98,170.68	63,834.87	71,127.29	85,288.23	
1015	TANF 14-20 FEMALE N O	478,631.67	795,039.67	607,159.78	297,693.87	324,099.85	380,342.43	237,949.60	209,661.78	231,542.66	179,723.60	206,259.96	211,688.36	
1016	TANF 21-44 MALE NON-	1,118,523.79	1,179,594.23	1,675,989.50	1,029,311.82	1,020,453.22	1,144,174.34	865,821.45	998,023.57	991,554.86	1,023,201.11	1,076,504.34	1,325,033.05	
1017	TANF 21-44 FEMALE N O	4,416,969.19	4,825,798.89	6,329,680.67	3,816,257.90	4,234,828.82	4,469,372.90	3,380,658.45	3,986,912.11	4,001,228.32	3,495,772.27	4,110,671.84	4,787,627.28	
1018	TANF 45-64 M & F NON	1,478,215.20	1,497,596.26	2,105,951.76	1,291,244.17	1,313,943.20	1,451,193.32	1,120,390.09	1,259,222.62	1,427,925.92	1,380,086.60	1,585,448.80	1,842,028.76	
1019	TANF 65+ M & F NON-M	5,703.98	4,317.50	4,221.17	3,150.00	700.00	350.00	2,450.00	1,050.00	350.00	1,068.00	2,262.00	3,680.00	
1026	TANF 21-44 MALE WITH	700.00	210.84	544.76	130.83	419.67	141.05	249.09	-47.61	3.66	0.00	0.00	74.84	
1027	TANF 21-44 FEMALE WI	855.92	822.87	1,936.87	1,147.97	426.32	218.83	223.14	506.97	379.36	726.10	796.35	770.90	
1028	TANF 45-64 M & F WIT	3,634.52	8,293.46	6,324.26	2,792.64	3,162.60	1,913.90	653.61	1,667.80	1,702.59	2,460.02	720.26	3,190.51	
1029	TANF 65+ M & F WITH	2,256.22	1,398.03	4,606.47	1,605.11	1,827.30	758.92	81.16	279.43	715.23	43.56	357.59	61.40	
2100	SSI AGED WITH MEDIC A	51,457.56	41,686.19	96,120.74	33,984.56	29,250.14	35,691.27	31,687.44	36,033.43	37,819.89	54,106.68	48,842.00	103,391.93	
2110	SSI AGED NON-MEDICA R	60,414.26	72,757.77	86,289.46	47,067.16	74,476.35	68,323.34	38,010.52	55,366.93	45,435.93	59,517.98	50,723.67	66,021.01	
2120	SSI AGED WITH QMB	145,603.01	196,624.00	255,370.13	143,751.63	126,739.98	184,307.37	123,845.47	169,819.40	163,457.44	243,986.81	261,268.51	234,762.26	
2200	SSI DISABLED WITH M E	118,193.79	139,630.47	151,342.90	119,909.21	78,796.47	118,798.48	85,544.29	95,889.13	101,974.68	160,733.21	147,330.97	192,973.54	
2210	SSI DISABLED NON-ME	3,959,038.86	4,322,461.60	5,500,714.34	3,203,783.82	4,183,126.66	4,481,420.16	3,626,990.97	3,798,442.91	4,020,156.73	4,222,488.28	4,777,257.90	5,240,908.87	
2220	SSI DISABLED WITH Q M	327,062.97	435,664.94	615,950.69	349,244.88	330,111.22	433,897.25	294,451.23	340,423.14	376,095.07	459,621.46	452,965.23	444,530.48	
2300	SSI BLIND WITH MEDIC	1,289.05	551.00	712.94	606.14	408.83	568.69	421.47	481.41	510.11	1,506.40	661.36	442.06	
2310	SSI BLIND NON-MEDIC A	50,186.61	38,392.80	56,042.79	39,540.77	41,693.79	55,240.86	34,406.29	43,511.85	38,045.18	39,992.06	51,019.89	52,526.29	
2320	SSI BLIND WITH QMB	3,801.09	7,726.54	6,797.06	2,292.59	3,643.67	9,793.29	5,651.93	4,931.97	4,929.02	7,579.98	4,897.42	4,814.30	
4303	SOBRA CHILD 06-13 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	0.00	884.64	0.00	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	700.00	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	411.40	79.40	0.00	0.00	
4311	SOBRA CHILD <1 M & F	1,574,251.07	1,423,643.90	1,543,846.70	1,024,305.43	1,429,503.95	1,497,472.87	1,371,721.36	1,509,236.50	1,767,787.27	1,823,774.82	1,445,335.76	1,881,515.50	
4312	SOBRA CHILD 01-05 M	2,244,228.98	2,250,185.12	2,701,838.18	1,843,748.57	2,742,656.35	3,016,734.01	2,462,344.83	3,162,458.55	3,561,498.18	3,125,163.42	3,194,477.43	3,415,784.92	
4313	SOBRA CHILD 06-13 M	3,142,386.43	3,632,568.25	5,087,632.31	2,636,227.61	3,879,239.65	4,290,040.50	3,377,653.35	3,508,568.09	3,988,078.66	4,807,064.48	4,438,204.43	4,344,991.58	
4314	SOBRA CHILD 14-20 MA	747,001.51	1,133,294.81	1,132,611.39	698,721.56	879,239.15	1,089,357.27	792,309.44	916,657.99	1,029,270.52	920,278.31	1,006,616.04	1,242,008.27	

17,291.61	
50,414.72	
111,792.46	
54,681.47	
7,613,310.40	
5,732,539.33	
8,542,584.30	
2,117,506.88	
4,159,793.23	
13,448,185.28	
51,855,778.64	
17,753,246.70	
29,302.65	
2,427.13	
8,811.60	
36,516.17	
13,990.42	
600,071.83	
724,404.38	
2,249,536.01	
1,511,117.14	
51,336,791.10	
4,860,018.56	
8,159.46	
540,599.18	
66,858.86	
1,252.64	
700.00	
490.80	
18,292,395.13	
33,721,118.54	
47,132,655.34	
11,587,366.26	

D

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	984,792.86	1,180,701.71	1,436,210.29	1,243,516.66	1,117,437.11	1,415,114.91	1,013,657.53	1,508,575.86	1,317,700.51	1,100,468.94	1,278,585.77	1,577,506.44		15,174,268.59		
5007	SOBRA PREG 21-44 FE M	0.00	700.00	700.00	0.00	0.00	0.00	2,101.86	0.00	470.90	350.00	0.00	0.00		4,322.76		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	350.00	350.00	700.00	0.00	350.00	0.00	0.00	1,104.00	780.82	2,208.00		5,842.82		
5015	SOBRA PREG 14-20 FE M	237,999.22	275,437.95	329,140.16	268,427.33	331,831.13	313,180.11	196,297.40	285,715.60	259,281.99	227,381.24	224,393.26	308,526.38		3,257,611.77		
5017	SOBRA PREG 21-44 FE	1,131,352.11	1,456,601.24	1,697,144.79	1,250,264.34	1,615,075.39	1,490,352.46	954,856.86	1,289,612.04	1,460,713.12	1,335,333.98	1,359,262.19	1,807,742.80		16,848,311.32		
5018	SOBRA PREG 45-64 FE M	4,193.00	1,958.21	2,450.00	1,400.00	974.78	3,500.00	1,050.00	805.12	3,500.00	2,298.00	3,644.00	1,086.00		26,859.11		
5027	SOBRA PREG 21-44 FE	0.00	0.00	12.47	0.00	0.00	0.00	122.80	0.00	13.42	0.00	0.00	144.90		293.59		
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	61.40	0.00		61.40		
	25,879,075.44	28,064,777.16	34,666,425.32	21,293,810.82	26,033,700.77	27,809,210.42	21,505,597.68	24,584,430.66	26,378,706.54	25,948,799.82	26,797,311.47	30,537,433.48		319,499,279.58		

M

M

SUBTOTAL:

0.00

0.00

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

1103	TANF EXPANDED 06-13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	700.00	240.24	368.00	0.00	
1104	TANF EXPANDED 14-20	0.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1106	TANF EXPANDED 21-44	2,193.53	4,316.53	6,771.33	2,886.65	2,350.20	4,237.24	4,634.99	4,630.52	3,816.01	5,597.39	4,777.37	6,227.84	
1107	TANF EXPANDED 21-44	3,881.00	7,550.93	10,740.46	8,070.42	13,935.59	14,868.15	7,753.45	10,923.61	8,891.76	10,104.56	10,668.79	12,484.68	
1108	TANF EXPANDED 45-64	17,862.89	29,601.36	33,234.71	16,412.58	23,674.85	27,349.19	27,630.63	37,396.38	28,331.98	35,566.73	45,616.09	43,069.08	
1109	TANF EXPANDED 65+	11,589.10	11,907.56	11,276.99	10,530.63	13,763.00	21,247.05	16,376.58	18,888.24	17,179.50	21,459.66	24,689.79	26,369.11	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,050.00	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	5,250.00	4,248.00	1,409.52	1,050.00	2,799.61	1,050.00	22.19	700.00	1,759.55	754.00	368.00	1,104.00	
1113	TANF EXPANDED 06-13	26,366.06	18,797.44	23,244.19	7,174.88	11,102.45	3,580.32	3,668.00	3,500.00	3,159.55	2,493.76	2,540.00	1,472.00	
1114	TANF EXPANDED 14-20	8,195.40	8,023.36	4,043.91	8,114.99	7,921.72	10,943.76	12,154.50	16,592.96	11,135.99	5,474.00	3,197.80	7,342.00	
1115	TANF EXPANDED 14-20	25,647.40	20,633.17	39,263.74	13,550.27	27,645.11	25,079.57	35,664.06	18,253.86	25,452.27	20,096.96	21,991.87	28,114.23	
1116	TANF EXPANDED 21-44	278,711.63	257,235.68	319,438.15	250,318.04	486,697.89	566,858.25	408,012.26	529,552.17	549,826.85	465,901.35	489,926.73	551,464.12	
1117	TANF EXPANDED 21-44	1,001,394.14	971,890.27	1,008,971.33	811,845.95	1,363,608.61	1,643,131.70	1,349,304.50	1,506,203.50	1,564,192.96	1,494,267.93	1,799,188.09	1,943,257.51	
1118	TANF EXPANDED 45-64	498,055.24	489,955.39	559,480.77	459,352.65	784,932.63	1,017,857.14	771,060.88	1,014,086.77	1,077,636.83	940,362.38	1,151,041.28	1,263,965.11	
1119	TANF EXPANDED 65+
M&	0.00	0.00	2,125.17	1,050.00	1,233.56	5,331.53	1,400.00	4,200.00	1,769.51	584.00	4,120.00	2,576.00	
1126	TANF EXPANDED 21-44	460.06	495.48	1,008.03	215.52	525.49	633.68	527.74	1,175.01	952.93	1,428.08	1,650.33	3,485.69	
1127	TANF EXPANDED 21-44	1,085.12	2,207.71	3,464.62	1,332.43	1,918.49	2,695.19	2,163.37	3,474.05	1,048.80	2,381.97	6,000.73	1,049.07	
1128	TANF EXPANDED 45-64	2,666.83	4,370.29	2,032.68	1,945.34	2,866.93	2,905.40	3,321.63	5,566.95	6,707.97	7,565.80	8,773.54	8,225.07	
1129	TANF EXPANDED 65+
M&	3,939.78	7,378.95	8,307.81	2,632.75	3,304.47	3,820.10	5,190.17	7,563.13	8,905.24	8,510.49	8,851.98	7,536.69	
2400	SSI AGED EXPANDED WI	15,824.15	18,656.13	11,154.82	10,621.62	8,971.28	7,959.68	7,881.09	5,958.01	9,897.73	9,035.43	10,236.74	11,126.53	
2410	SSI AGED EXPANDED NO	44,953.28	27,103.71	42,572.30	50,664.46	11,766.38	12,339.75	7,713.39	7,107.45	13,699.28	7,708.69	8,554.00	6,733.56	
2420	SSI AGED EXPANDED WI	165,461.94	213,135.45	288,519.65	144,543.45	123,666.38	152,813.58	113,177.58	142,847.01	147,575.79	185,139.94	192,950.86	149,747.29	
2600	SSI DISABLED EXPAND E	6,769.93	6,974.26	11,598.68	8,264.20	12,953.02	9,238.59	5,484.78	4,785.88	8,289.82	10,764.60	9,455.79	11,996.93	
2610	SSI DISABLED EXPAND	109,481.97	123,966.21	147,456.41	74,149.48	84,743.70	94,217.58	135,488.74	90,250.95	79,294.56	91,196.78	91,425.42	134,093.18	

1,308.24	
350.00	
52,439.60	
119,873.40	
365,746.47	
205,277.21	
1,050.00	
20,514.87	
107,098.65	
103,140.39	
301,392.51	
5,153,943.12	
16,457,256.49	
10,027,787.07	
24,389.77	
12,558.04	
28,821.55	
56,948.43	
75,941.56	
127,323.21	
240,916.25	
2,019,578.92	
106,576.48	
1,255,764.98	

M&

E

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
85,508.30	104,493.60	148,434.94	93,586.84	88,605.26	103,855.75	84,879.10	89,887.12	101,628.35	131,017.61	130,437.68	117,189.19	1,279,523.74	
2,315,297.75	2,332,941.48	2,684,900.21	1,978,313.15	3,078,986.62	3,732,013.20	3,003,509.63	3,524,593.57	3,671,853.23	3,457,652.35	4,026,830.88	4,338,628.88	38,145,520.95	

3308	AHC CARE M&F 45-64 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	
3316	AHC CARE MALE 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	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	-316.00	0.00	0.00	-330.00	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	0.00	-3,862.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-316.00	0.00	0.00	-4,192.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
-646.00	
-3,862.00	
-4,508.00	

3400	MED ELIGIBILITY W/ 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	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-4,544.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	0.00	-52.99	0.00	0.00	0.00	-5,828.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	-2,268.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	-6,446.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	-52.99	0.00	0.00	0.00	-14,542.00	0.00	0.00	0.00	-4,544.00	0.00	0.00	

 
0.00	
0.00	
0.00	
0.00	
-4,544.00	
-5,880.99	
-2,268.00	
-6,446.00	
-19,138.99	

3506	ADULT 40-100% MALE 2	85.05	386.37	826.55	497.49	10.06	0.00	0.00	0.00	0.00	73.75	184.20	0.00	
3507	ADULT 40-100% FEMAL E	350.00	-297.96	350.00	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	645.75	4,143.44	2,194.34	1,695.56	2,704.25	3,850.00	1,476.96	2,354.72	1,076.80	498.57	3,681.77	1,285.49	
3509	ADULT 40-100% M&F 65	1,136.72	452.79	2,304.18	777.55	2,583.02	2,569.83	367.82	123.99	852.86	220.46	377.84	828.95	
3514	ADULT 40-100% MALE 1	26,346.12	11,086.99	17,886.95	21,098.49	19,893.94	17,236.92	22,234.89	20,546.84	20,985.98	24,086.32	30,885.29	33,156.28	
3515	ADULT 40-100% FEMAL E	39,467.46	45,163.63	63,499.13	36,273.42	42,314.87	51,690.47	26,465.02	53,090.03	58,478.22	43,228.03	73,783.86	67,308.05	
3516	ADULT 40-100% MALE 2	304,613.42	425,982.76	423,158.47	436,649.78	341,541.83	382,978.70	434,139.29	440,947.39	485,542.68	498,056.11	552,298.39	606,445.36	
3517	ADULT 40-100% FEMAL	316,477.56	364,737.12	475,335.36	280,789.77	334,025.70	333,307.13	289,200.96	374,139.32	363,291.41	357,345.93	430,220.59	510,541.14	
3518	ADULT 40-100% M&F 45	1,086,597.94	1,026,522.27	1,319,334.30	853,672.09	1,010,881.52	1,072,421.13	912,052.05	1,117,043.50	1,149,647.05	1,177,921.98	1,430,064.58	1,549,624.30	
3519	ADULT 40-100% M&F 65	700.00	1,114.00	3,500.00	17,145.46	700.00	2,450.00	700.00	1,050.00	707.39	2,576.00	1,472.00	736.00	
3526	ADULT 40-100% MALE 2	0.00	74.88	61.40	75.28	350.00	0.00	0.00	0.00	99.44	0.00	61.40	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	59.40	0.00	61.40	0.00	0.00	0.00	0.00	0.00	0.00	797.40	736.00	736.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	350.00	0.00	103.71	96.03	0.00	325.71	0.00	18.42	
3705	ADULT <40% EXP FEM AL	0.00	5.04	59.40	0.00	0.00	0.00	4.35	61.40	0.00	0.00	0.00	0.00	
3706	ADULT <40% EXP MALE	357.00	187.24	1,790.82	720.29	61.40	1,400.00	0.00	350.00	411.40	66.25	61.40	-350.00	
3707	ADULT <40% EXP FEM AL	1,396.64	1,663.61	3,351.85	967.89	729.84	749.77	838.29	420.54	66.54	0.00	0.00	649.85	
3708	ADULT <40% EXP M&F	4,997.35	11,572.19	10,426.98	9,426.39	9,118.22	13,660.61	4,596.30	6,578.36	12,738.05	15,623.06	10,932.08	7,791.33	
3709	ADULT <40% EXP M&F	550.16	545.25	1,197.56	1,260.00	0.01	35.41	472.80	358.69	0.00	1,150.34	936.10	462.17	

2,063.47	
402.04	
25,607.65	
12,596.01	
265,445.01	
600,762.19	
5,332,354.18	
4,429,411.99	
13,705,782.71	
32,850.85	
722.40	
0.00	
2,390.20	
893.87	
130.19	
5,055.80	
10,834.82	
117,460.92	
6,968.49	

E

4

6

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	165,528.85	261,775.93	267,888.88	187,172.51	179,844.48	220,568.78	145,722.03	252,843.36	151,528.75	147,632.94	207,624.51	250,767.58		2,438,898.60		
3715	ADULT <40% EXP FEM AL	208,336.04	216,013.15	264,710.67	163,391.21	226,208.55	262,779.83	201,690.71	261,729.23	269,866.06	169,682.57	311,056.89	330,322.85		2,885,787.76		
3716	ADULT <40% EXP MALE	3,029,287.38	3,988,308.94	4,654,737.86	3,315,942.24	3,506,890.83	4,090,685.06	3,200,348.28	3,888,105.17	3,325,474.61	3,618,983.36	3,702,381.33	5,046,325.91		45,367,470.97		
3717	ADULT <40% EXP FEM AL	1,927,561.48	2,317,641.88	3,111,066.30	1,949,322.89	2,217,906.35	2,765,153.12	1,907,664.16	2,380,301.97	2,495,966.19	2,284,915.12	2,421,833.06	3,059,478.72		28,838,811.24		
3718	ADULT <40% EXP M&F	4,322,313.67	5,015,624.62	5,861,943.16	3,932,359.26	4,603,664.10	5,357,117.58	4,280,190.59	4,772,648.91	4,824,753.00	4,756,402.44	5,589,557.60	7,067,463.80		60,384,038.73		
3719	ADULT <40% EXP M&F 6	1,400.00	4,739.20	2,450.00	1,017.76	4,900.00	8,050.00	5,250.00	3,867.93	2,657.34	2,648.00	3,438.00	6,606.00		47,024.23		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	368.00	0.00		736.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	350.00	350.00	0.00	0.00	0.00	0.00	0.00		700.00		
3728	ADULT <40% EXP M&F 4	0.00	476.33	0.00	700.00	350.00	1,050.00	0.00	1,050.00	2,300.63	3,503.00	1,472.00	472.75		11,374.71		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	194.20	10.04	0.00		204.24		
	11,438,207.99	13,697,919.67	16,488,135.56	11,210,955.33	12,505,028.97	14,588,104.34	11,433,868.21	13,577,707.38	13,166,444.40	13,106,299.54	14,773,436.93	18,540,670.95		164,526,779.27		

4

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	1,400.00	0.00	0.00	0.00	708.58	350.00	0.00	101.64	0.00	1,870.25	1,898.29	48.25	
3907	NEWLY ELIGIBLE FEMA L	0.00	0.00	2,100.00	392.10	350.00	350.00	350.00	0.00	838.07	1,018.13	0.00	0.00	
3908	NEWLY ELIGIBLE M&F	5,768.03	7,449.33	2,569.39	3,983.75	3,579.66	5,871.39	2,565.44	2,133.68	1,686.47	1,703.18	1,415.29	6,126.16	
3909	NEWLY ELIGIBLE M&F 6	291.65	74.97	0.00	1,418.20	2,100.00	1,197.00	181.42	1,221.62	0.00	133.76	439.73	1,497.23	
3914	NEWLY ELIGIBLE MALE	5,286.80	5,739.88	17,778.96	7,700.00	8,066.20	6,690.20	6,563.74	6,835.16	6,890.42	15,558.89	11,868.38	35,885.80	
3915	NEWLY ELIGIBLE FEMA L	18,281.55	30,911.29	16,130.09	20,252.28	19,679.81	36,346.97	19,350.21	35,561.93	26,299.89	37,114.20	48,037.95	28,581.05	
3916	NEWLY ELIGIBLE MALE	196,798.09	227,258.24	311,425.56	279,292.12	170,395.72	307,482.17	185,359.50	266,222.84	256,462.40	287,945.23	362,392.35	304,569.40	
3917	NEWLY ELIGIBLE FEMA L	271,360.04	317,416.51	433,678.80	355,651.52	362,225.89	501,784.79	359,160.19	419,451.86	563,183.55	475,042.12	535,869.36	515,806.40	
3918	NEWLY ELIGIBLE M&F 4	680,980.32	652,498.60	813,465.56	599,685.22	649,560.52	666,399.61	555,539.02	624,889.10	670,028.81	686,794.48	765,925.91	840,009.31	
3919	NEWLY ELIGIBLE M&F 6	700.00	0.00	2,450.00	1,050.00	700.00	350.00	1,750.00	0.00	0.00	0.00	368.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	71.47	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	0.00	350.00	59.40	0.00	48.25	10.07	0.00	145.14	13.39	0.00	55.47	0.00	
	1,180,866.48	1,241,698.82	1,599,657.76	1,269,425.19	1,217,414.63	1,526,832.20	1,130,819.52	1,356,634.44	1,525,403.00	1,507,180.24	1,728,270.73	1,732,523.60	

6,377.01	
5,398.30	
44,851.77	
8,555.58	
134,864.43	
336,547.22	
3,155,603.62	
5,110,631.03	
8,205,776.46	
7,368.00	
71.47	
681.72	
17,016,726.61	

4

4
SUBTOTAL:

4412	SOBRA 100-133% M&F	0.00	0.00	0.00	0.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4413	SOBRA 100-133% M&F
6	189,176.92	189,687.05	133,832.64	285,206.25	405,616.43	433,026.87	360,616.35	402,640.87	464,263.95	437,331.41	483,327.02	429,433.27	
4414	SOBRA 100-133% MALE	79,176.44	75,187.22	48,308.80	129,174.03	108,710.33	125,466.77	128,914.84	115,161.64	102,620.84	83,344.30	98,785.04	118,820.46	
4415	SOBRA 100-133% FEMA	64,105.03	76,235.87	69,956.78	127,357.54	132,904.38	171,781.34	109,962.14	153,144.66	164,706.72	130,599.97	181,822.26	168,319.57	
	332,458.39	341,110.14	252,098.22	541,737.82	647,931.14	730,274.98	599,493.33	670,947.17	731,591.51	651,275.68	763,934.32	716,573.30	

700.00	
4,214,159.03	
1,213,670.71	
1,550,896.26	
6,979,426.00	

1

L
SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	5,936.00	4,286.25	3,859.52	1,400.00	0.00	700.00	350.00	350.00	0.00	736.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	1,109.40	2,490.00	2,861.40	2,835.67	37,424.01	9,240.32	19,560.00	8,924.42	2,826.00	5,966.91	8,613.52	6,524.66	
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	29.24	
4617	CC PATIENT FEMALE 2 1	350.00	1,050.00	0.00	0.00	350.00	700.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	4,085.95	1,050.00	708.87	2,109.55	0.00	0.00	350.00	0.00	0.00	1,481.55	0.00	1,858.13	

17,617.77	
108,376.31	
29.24	
2,450.00	
11,644.05	

5

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	11,481.35	8,876.25	7,429.79	6,345.22	37,774.01	10,640.32	20,260.00	9,274.42	2,826.00	8,184.46	8,613.52	8,412.03		140,117.37		

SUBTOTAL:

8700	SSI DISABLED FREEDO M	209.72	5,846.12	5,390.39	2,833.23	2,964.70	4,834.60	1,710.43	5,663.74	2,739.16	2,667.31	3,163.59	3,238.73	
8710	SSI DISABLED FREEDO M	2,100.00	350.00	238.44	1,759.52	0.00	1,050.00	350.00	4,550.00	350.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	59.40	237.60	163.68	0.00	0.00	0.00	0.00	22.82	350.00	18.00	109.65	148.86	
SUBTOTAL:	2,369.12	6,433.72	5,792.51	4,592.75	2,964.70	5,884.60	2,060.43	10,236.56	3,439.16	2,685.31	3,273.24	3,387.59	

41,261.72	
10,747.96	
1,110.01	
53,119.69	

M

TOTAL:	41,159,756.52	45,693,704.25	55,704,123.37	36,305,180.28	43,523,800.84	48,384,226.06	37,695,608.80	43,733,824.20	45,480,263.84	44,677,533.40	48,101,671.09	55,877,629.83		546,337,322.48		

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

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

1006	TANF 21-44 MALE WITH	12,234.63	8,503.24	18,275.63	6,381.31	5,844.83	15,562.91	2,310.33	1,375.17	2,749.17	22.20	1,357.87	2,363.68	
1007	TANF 21-44 FEMALE WI	12,732.53	6,507.68	17,412.00	15,691.14	13,500.26	16,679.71	14,021.73	13,916.38	14,392.79	3,744.53	7,200.80	6,007.58	
1008	TANF 45-64 M & F WIT	20,039.18	23,077.50	31,215.80	33,021.35	18,951.23	17,550.07	6,256.38	5,877.51	9,720.88	6,679.86	8,290.68	7,023.54	
1009	TANF 65+ M & F WITH	5,432.47	3,081.30	19,647.16	10,039.86	6,222.77	5,536.97	3,803.92	7,213.26	3,570.64	4,136.64	1,194.79	1,854.72	
1011	TANF <1 M & F NON-ME	567,248.47	532,325.46	584,585.71	313,406.39	331,234.80	351,966.87	435,578.73	397,272.03	559,336.66	348,675.70	283,807.61	254,517.65	
1012	TANF 01-05 M & F NON	268,055.89	267,958.17	247,550.22	145,229.43	177,888.33	110,259.39	94,219.08	81,363.09	92,407.01	51,400.42	71,495.03	106,851.70	
1013	TANF 06-13 M & F NON	241,026.07	231,615.87	249,245.17	192,348.16	143,246.93	112,630.35	48,130.96	108,565.70	50,829.25	53,584.96	44,581.98	60,749.26	
1014	TANF 14-20 MALE NON-	82,531.85	114,669.34	34,788.77	49,531.89	31,882.75	26,605.19	14,155.92	17,860.97	36,917.25	10,009.31	12,364.16	8,783.60	
1015	TANF 14-20 FEMALE N O	132,827.40	149,313.25	111,126.28	104,486.80	105,368.86	116,329.77	60,578.87	47,997.35	104,291.25	39,315.44	73,115.85	53,271.69	
1016	TANF 21-44 MALE NON-	562,279.40	623,087.17	772,207.19	586,447.11	387,037.58	493,500.39	566,137.67	485,817.07	612,245.98	475,572.30	472,172.42	649,859.95	
1017	TANF 21-44 FEMALE N O	1,689,259.97	1,841,435.05	2,361,373.34	1,715,630.63	1,561,254.11	1,627,819.97	1,358,567.59	1,231,647.93	1,827,739.54	1,131,306.56	1,259,308.93	1,654,073.54	
1018	TANF 45-64 M & F NON	717,249.74	673,156.71	1,111,242.66	847,305.45	703,072.00	728,821.45	628,995.15	612,831.90	690,805.40	490,898.80	580,906.77	839,479.47	
1019	TANF 65+ M & F NON-M	4,366.70	5,352.54	6,058.67	2,819.00	0.00	7,181.73	10,157.29	1,395.61	1,383.49	-67.37	0.00	0.00	
1026	TANF 21-44 MALE WITH	0.00	358.05	1,478.69	1,214.66	51.47	1,908.65	-249.18	805.52	-799.18	-530.44	837.07	886.59	
1027	TANF 21-44 FEMALE WI	412.90	351.42	2,063.57	1,842.65	83.53	3,496.56	1,243.02	9,285.07	3,366.38	711.83	2,030.55	2,126.31	
1028	TANF 45-64 M & F WIT	3,047.60	9,471.40	10,036.97	633.37	3,837.08	862.71	282.26	2,149.31	3,354.02	2,964.28	1,121.12	4,820.26	
1029	TANF 65+ M & F WITH	3,251.52	2,098.51	1,156.82	1,008.87	2,580.06	4,325.11	1.71	42.04	120.42	0.00	1.85	0.00	
2100	SSI AGED WITH MEDIC A	106,798.55	110,945.57	91,003.61	88,139.93	128,224.34	103,657.60	105,406.63	59,952.13	73,657.08	45,435.08	58,095.58	80,745.10	
2110	SSI AGED NON-MEDICA R	64,152.89	46,997.31	91,231.24	102,587.31	66,008.56	55,797.17	32,896.85	42,304.98	31,047.88	56,843.53	46,273.91	70,637.56	
2120	SSI AGED WITH QMB	175,558.22	197,043.69	252,769.74	198,249.01	171,594.10	330,139.50	182,095.65	253,850.54	315,665.20	222,983.78	258,410.96	309,575.77	
2200	SSI DISABLED WITH M E	166,567.65	317,497.47	346,091.63	291,180.02	264,676.11	369,190.33	168,962.69	206,510.09	241,729.43	148,770.89	206,407.19	335,306.14	
2210	SSI DISABLED NON-ME	3,771,166.39	3,833,723.81	4,457,896.20	3,339,155.66	3,222,228.88	4,143,086.96	2,738,093.95	3,133,366.79	4,271,203.62	3,117,529.35	3,500,033.32	4,238,080.64	
2220	SSI DISABLED WITH Q M	655,176.74	747,126.30	1,013,047.49	712,906.83	646,672.11	1,057,847.13	633,172.34	773,645.46	1,028,742.93	660,570.30	771,237.15	962,658.92	
2300	SSI BLIND WITH MEDIC	1,326.89	422.13	772.67	8.77	45.40	517.81	1,351.05	1,328.69	955.40	45.65	0.00	8,892.38	
2310	SSI BLIND NON-MEDIC A	66,376.71	61,383.92	49,169.33	28,967.10	28,750.52	34,809.69	25,245.64	22,433.48	27,581.26	28,652.20	23,258.15	37,590.99	
2320	SSI BLIND WITH QMB	12,727.94	8,978.40	9,598.98	8,794.19	7,071.58	14,138.32	4,259.75	8,621.35	10,016.42	8,538.30	11,373.26	15,966.75	
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	8.89	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
4311	SOBRA CHILD <1 M & F	497,249.77	602,823.96	598,332.57	520,995.09	499,154.41	789,532.76	580,690.12	540,601.99	957,696.34	824,022.21	637,902.17	734,936.83	
4312	SOBRA CHILD 01-05 M	458,185.52	543,964.72	797,467.83	578,583.31	636,762.51	995,919.01	607,893.50	709,005.68	921,801.38	702,205.45	852,103.27	766,637.71	
4313	SOBRA CHILD 06-13 M	547,894.44	679,833.89	916,035.21	861,311.80	719,678.65	911,184.83	727,006.19	865,742.88	1,114,262.45	797,708.42	1,021,806.33	737,838.00	
4314	SOBRA CHILD 14-20 MA	142,589.40	263,389.36	296,159.45	260,211.19	332,884.37	274,789.30	162,178.99	220,962.95	372,939.26	257,572.42	230,271.59	233,866.00	

76,980.97	
141,807.13	
187,703.98	
71,734.50	
4,959,956.08	
1,714,677.76	
1,536,554.66	
440,101.00	
1,098,022.81	
6,686,364.23	
19,259,417.16	
8,624,765.50	
38,647.66	
5,961.90	
27,013.79	
42,580.38	
14,586.91	
1,052,061.20	
706,779.19	
2,867,936.16	
3,062,889.64	
43,765,565.57	
9,662,803.70	
15,666.84	
434,218.99	
120,085.24	
8.89	
0.00	
0.00	
7,783,938.22	
8,570,529.89	
9,900,303.09	
3,047,814.28	

D

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	302,021.91	271,458.30	384,496.73	294,852.74	340,518.87	334,795.25	299,503.45	308,693.49	367,377.24	293,283.69	337,780.83	423,821.36		3,958,603.86		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	21.79	885.87	56.76	1,054.83	131.06	241.47	1,491.51	1,718.89		5,602.18		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	4,007.53	1,222.17	0.00	0.00	0.00	0.00	0.00	505.29	1,483.64	7,776.57		14,995.20		
5015	SOBRA PREG 14-20 FE M	134,500.45	112,857.97	124,462.39	103,103.31	163,088.79	110,109.08	83,848.99	123,081.74	91,873.39	76,053.08	102,806.78	165,559.80		1,391,345.77		
5017	SOBRA PREG 21-44 FE	505,008.76	490,355.70	786,301.26	601,673.87	660,195.38	611,434.78	546,493.37	649,264.97	749,191.42	534,289.21	669,435.00	773,397.78		7,577,041.50		
5018	SOBRA PREG 45-64 FE M	0.00	12,542.17	0.00	422.16	372.51	1,135.72	1,056.99	5,412.82	2,297.37	1,418.33	3,186.89	83.26		27,928.22		
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	235.84	1,465.48		1,701.32		
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	223.44	915.08	335.87	830.60	1,512.71		3,817.70		
	11,929,298.55	12,793,707.33	15,798,308.51	12,019,402.53	11,380,005.47	13,780,008.91	10,144,404.34	10,951,474.21	14,591,515.16	10,395,429.54	11,554,211.45	13,560,747.07		148,898,513.07		

M

M

SUBTOTAL:

3,472.21

3,472.21

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215.79	8.94	1,749.59	29.86	1,468.03	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	215.79	8.94	1,749.59	29.86	1,468.03	

1
SUBTOTAL:

1103	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	
1104	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	
1106	TANF EXPANDED 21-44	8,090.62	5,444.07	10,692.23	3,827.16	6,983.69	16,411.52	7,405.50	2,655.78	11,663.46	10,885.29	20,133.44	15,919.39	
1107	TANF EXPANDED 21-44	17,273.14	16,429.02	21,924.74	19,870.38	22,886.57	37,194.74	17,683.38	25,167.36	36,449.41	11,146.12	26,132.41	37,022.99	
1108	TANF EXPANDED 45-64	42,647.41	59,814.53	50,487.40	30,333.33	36,325.73	82,528.89	56,627.22	55,476.59	82,093.34	65,493.95	67,066.98	65,270.03	
1109	TANF EXPANDED 65+	11,071.23	8,539.97	21,023.04	15,362.85	14,717.76	21,487.65	16,224.97	17,528.83	33,895.48	29,981.58	39,148.06	30,277.84	
1111	TANF EXPANDED <1 M
&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	9,522.08	0.00	0.00	0.00	0.00	
1112	TANF EXPANDED 01-05	394.14	374.54	145.54	124.70	83.77	81.53	134.99	0.00	433.49	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	3,697.17	677.24	2,091.94	2,093.05	1,172.41	539.08	3,321.95	581.97	28.16	0.00	280.63	76.25	
1114	TANF EXPANDED 14-20	6,680.00	533.05	1,187.06	1,282.18	3,112.99	4,396.73	1,225.34	3,269.18	6,576.00	6,072.69	4,102.93	4,164.50	
1115	TANF EXPANDED 14-20	2,354.23	2,087.82	3,793.11	2,856.57	8,261.29	4,885.23	13,274.92	1,412.21	6,563.42	3,838.65	6,388.23	20,305.96	
1116	TANF EXPANDED 21-44	76,478.73	84,826.03	112,645.22	98,803.74	144,505.55	153,594.02	130,284.56	150,344.61	229,785.84	134,640.09	193,371.65	179,208.97	
1117	TANF EXPANDED 21-44	248,164.67	258,823.73	251,229.71	263,654.55	303,030.02	403,157.28	432,032.21	450,299.99	648,404.88	459,349.09	475,664.40	567,163.59	
1118	TANF EXPANDED 45-64	195,427.93	197,298.94	217,067.90	273,091.81	329,142.75	359,879.18	321,557.21	416,612.07	584,776.55	381,798.12	390,790.78	484,715.65	
1119	TANF EXPANDED 65+
M&	4.35	149.65	0.00	0.00	0.00	0.00	21.04	43.61	0.00	63.53	0.00	76.43	
1126	TANF EXPANDED 21-44	867.04	2,844.83	954.60	1,390.08	826.35	9,191.96	4,325.39	13,867.90	31,821.12	12,631.78	21,319.15	13,444.57	
1127	TANF EXPANDED 21-44	1,490.53	614.49	3,655.77	1,321.14	723.61	2,635.90	802.36	6,847.41	7,589.89	4,933.27	6,186.15	3,131.36	
1128	TANF EXPANDED 45-64	6,588.12	5,873.05	9,500.81	7,667.30	11,046.40	23,033.92	19,919.50	33,314.92	21,762.67	18,047.09	32,631.36	29,764.67	
1129	TANF EXPANDED 65+
M&	3,777.06	2,003.76	1,660.43	1,418.57	2,747.48	8,784.16	11,495.51	11,377.97	9,690.90	10,948.83	5,977.04	12,321.72	
2400	SSI AGED EXPANDED WI	6,604.72	20,310.29	10,390.12	10,974.13	5,525.57	11,583.22	517.81	1,605.98	1,291.27	3,887.25	3,436.94	2,232.18	
2410	SSI AGED EXPANDED NO	21,709.26	49,550.80	38,796.40	5,977.46	2,279.00	-18,632.68	20,046.18	-567.93	605.69	1,578.50	173.89	1,761.08	
2420	SSI AGED EXPANDED WI	212,432.79	214,996.21	262,436.77	205,237.08	184,165.63	237,477.41	165,793.51	184,271.57	213,024.75	151,004.50	149,568.07	180,213.79	
2600	SSI DISABLED EXPAND E	4,806.76	6,477.98	17,263.02	20,022.37	7,260.02	14,046.10	12,628.26	16,886.98	13,663.76	8,142.22	7,823.56	15,875.32	
2610	SSI DISABLED EXPAND	109,739.51	100,550.95	88,862.91	27,616.73	84,045.66	86,870.54	118,947.72	147,487.93	73,464.32	73,108.52	62,523.34	87,405.80	

0.00	
0.00	
120,112.15	
289,180.26	
694,165.40	
259,259.26	
9,522.08	
1,772.70	
14,559.85	
42,602.65	
76,021.64	
1,688,489.01	
4,760,974.12	
4,152,158.89	
358.61	
113,484.77	
39,931.88	
219,149.81	
82,203.43	
78,359.48	
123,277.65	
2,360,622.08	
144,896.35	
1,060,623.93	

M&

E

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
194,924.82	195,369.54	290,524.12	205,743.06	175,024.36	301,966.96	168,378.94	251,695.49	284,728.09	185,758.53	210,240.85	289,871.12	2,754,225.88	
1,175,224.23	1,233,590.49	1,416,332.84	1,198,668.24	1,343,866.61	1,761,113.34	1,522,648.47	1,799,702.50	2,298,312.49	1,573,309.60	1,722,959.86	2,040,223.21	19,085,951.88	

3308	AHC CARE M&F 45-64 W	21.62	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3316	AHC CARE MALE 21-44	-40.77	0.00	0.00	0.00	0.00	0.00	-8.71	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	-527.88	0.00	0.00	0.00	0.00	0.00	-381.79	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	-12,669.89	0.00	0.00	-883.27	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-13,216.92	0.00	0.00	-883.27	0.00	0.00	-390.50	0.00	0.00	0.00	0.00	0.00	

 
21.62	
-49.48	
-909.67	
-13,553.16	
-14,490.69	

3400	MED ELIGIBILITY W/ M	0.00	0.00	0.00	0.00	0.00	-1,057.32	0.00	0.00	0.00	0.00	0.00	0.00	
3410	MED ELIGIBILITY NON-	0.00	0.00	-99.09	0.00	0.00	0.00	0.00	0.00	0.00	-197.86	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	60.75	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	-2,238.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	-35.45	0.00	12,349.02	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3616	AHC CARE/MI MALE 21-	-24,077.78	0.00	-475.87	-491.04	0.00	-515.50	-20.32	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	-672.13	0.00	1,335.41	-100.95	0.00	0.00	0.00	-387.32	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	-7,509.71	0.00	1,439.72	0.00	0.00	-853.48	0.00	0.00	0.00	0.00	0.00	-107.53	
SUBTOTAL:	-34,472.66	0.00	14,549.19	-591.99	0.00	-2,426.30	-20.32	-387.32	0.00	-197.86	0.00	-107.53	

 
-1,057.32	
-296.95	
60.75	
-2,238.34	
12,313.57	
-25,580.51	
175.01	
-7,031.00	
-23,654.79	

3506	ADULT 40-100% MALE 2	15.57	260.53	0.00	0.00	0.00	856.86	811.63	1,322.26	1,601.21	948.51	-701.77	-1,090.05	
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	3,307.43	1,008.60	3,349.43	978.27	2,423.66	1,343.58	8,845.20	3,469.33	7,402.79	37.19	5,750.14	2,526.43	
3509	ADULT 40-100% M&F 65	0.00	154.04	0.00	0.00	181.66	0.00	0.00	0.00	0.00	11.17	3.37	32.12	
3514	ADULT 40-100% MALE 1	1,808.45	2,617.50	2,711.22	4,567.35	7,355.62	6,540.12	19,155.21	17,446.16	6,778.06	8,578.45	8,729.15	17,952.36	
3515	ADULT 40-100% FEMAL E	19,931.75	23,276.12	89,687.54	28,119.86	34,486.40	12,214.80	15,620.35	14,451.52	10,831.78	6,100.27	10,327.18	9,517.68	
3516	ADULT 40-100% MALE 2	229,346.72	174,196.94	211,562.10	277,900.40	210,627.62	261,499.41	201,874.30	191,491.58	270,341.10	218,845.62	244,016.00	436,671.21	
3517	ADULT 40-100% FEMAL	109,841.40	105,802.51	150,353.68	93,953.55	100,102.01	113,487.37	79,903.81	93,980.77	154,512.89	133,129.37	117,987.51	239,026.86	
3518	ADULT 40-100% M&F 45	610,123.29	776,775.68	695,783.33	458,809.96	501,750.13	595,717.40	560,112.59	484,915.30	761,475.56	547,775.94	612,058.77	782,618.10	
3519	ADULT 40-100% M&F 65	0.00	0.00	1,297.69	0.00	0.00	0.00	392.24	0.00	363.67	10,356.53	11,147.08	46,926.84	
3526	ADULT 40-100% MALE 2	0.00	0.00	74.67	-74.67	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	45.52	341.77	0.00	0.00	
3528	ADULT 40-100% M&F 45	41.77	60.44	60.44	0.00	0.00	62.84	0.00	0.00	139.94	104.87	111.93	34.78	
3529	ADULT 40-100% M&F 65	0.00	0.00	380.98	90.66	30.22	120.88	0.00	182.84	1,063.00	315.19	0.00	0.00	
3705	ADULT <40% EXP FEM AL	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	-113.08	0.00	357.03	0.00	121.64	739.90	710.15	444.19	774.75	3,928.58	1,535.62	54.64	
3707	ADULT <40% EXP FEM AL	1,799.96	1,321.34	2,383.72	4,587.94	2,342.89	6,379.13	1,717.83	4.71	1,331.69	591.75	0.00	0.00	
3708	ADULT <40% EXP M&F	13,612.17	16,184.28	11,638.87	15,449.12	13,966.65	10,416.70	8,527.59	10,972.44	6,408.99	4,711.27	4,307.71	8,745.73	
3709	ADULT <40% EXP M&F	112.46	353.44	167.54	658.68	573.76	185.90	0.00	126.54	0.00	0.00	0.00	427.64	

4,024.75	
0.00	
40,442.05	
382.36	
104,239.65	
274,565.25	
2,928,373.00	
1,492,081.73	
7,387,916.05	
70,484.05	
0.00	
387.29	
617.01	
2,183.77	
0.00	
8,553.42	
22,460.96	
124,941.52	
2,605.96	

E

4

6

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	49,424.42	117,557.97	171,586.96	99,739.77	114,797.94	83,920.83	61,098.55	71,453.75	86,498.07	45,818.52	124,561.34	104,121.94		1,130,580.06		
3715	ADULT <40% EXP FEM AL	91,002.56	63,238.93	77,507.54	92,547.18	64,786.11	83,871.81	85,925.14	60,408.16	87,220.92	89,555.57	78,108.90	70,462.03		944,634.85		
3716	ADULT <40% EXP MALE	2,375,248.97	2,548,511.24	3,291,598.46	2,203,928.16	2,372,006.70	2,723,598.34	2,256,037.92	1,965,625.96	2,691,391.84	1,978,711.13	2,386,772.67	2,639,711.39		29,433,142.78		
3717	ADULT <40% EXP FEM AL	1,081,236.95	1,138,344.74	1,153,915.66	971,417.23	957,390.07	1,048,765.58	776,059.38	819,007.28	1,088,554.16	982,077.81	915,477.96	1,005,142.13		11,937,388.95		
3718	ADULT <40% EXP M&F	2,866,722.75	3,197,371.03	3,873,212.13	2,943,218.44	3,088,403.47	3,573,456.33	2,611,868.95	2,771,996.73	3,716,351.61	3,009,546.48	2,989,342.87	3,631,399.62		38,272,890.41		
3719	ADULT <40% EXP M&F 6	19,126.57	1,786.77	31,730.45	2,915.21	1,256.96	3,098.55	967.59	1,613.61	1,004.31	31.16	5.85	315.00		63,852.03		
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 FEM AL	166.20	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		166.20		
3728	ADULT <40% EXP M&F 4	-612.98	600.54	599.83	413.03	126.91	274.77	274.77	0.00	9.62	1,577.45	2,337.17	349.51		5,950.62		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	7,472,143.33	8,169,422.64	9,769,959.27	7,199,220.14	7,472,730.42	8,526,551.10	6,689,903.20	6,508,913.13	8,894,101.48	7,043,094.60	7,511,879.45	8,994,945.96		94,252,864.72		

4

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	336.59	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	1,878.61	4,565.59	8,493.20	2,313.61	1,002.68	8,383.02	1,618.64	274.17	6,927.35	1,696.80	3,164.52	9,978.09	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	173.85	173.89	128.76	0.00	0.00	579.31	26.78	109.63	
3914	NEWLY ELIGIBLE MALE	1,428.78	2,216.51	11,094.26	2,843.03	2,853.57	10,578.92	4,307.66	2,278.36	2,073.38	5,239.86	5,753.19	2,054.15	
3915	NEWLY ELIGIBLE FEMA L	4,206.93	3,731.02	4,932.18	4,863.26	5,664.92	2,744.56	5,164.87	4,467.35	6,353.53	6,580.11	8,629.45	11,685.79	
3916	NEWLY ELIGIBLE MALE	104,385.56	160,195.48	159,710.74	140,347.56	108,373.79	167,299.93	61,251.07	68,798.11	151,247.59	141,438.74	104,238.14	155,080.54	
3917	NEWLY ELIGIBLE FEMA L	89,440.86	139,303.63	118,586.92	109,708.96	85,587.46	139,516.81	113,747.00	66,017.31	162,703.51	163,077.94	140,012.02	129,387.94	
3918	NEWLY ELIGIBLE M&F 4	273,456.06	265,129.06	405,070.04	269,867.19	392,397.71	380,024.84	331,046.02	250,636.80	356,127.26	218,989.43	241,010.45	293,298.02	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	164.48	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	47.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	474,843.91	575,141.29	707,887.34	529,943.61	596,053.98	708,721.97	517,264.02	392,472.10	685,597.10	537,938.78	502,834.55	601,594.16	

336.59	
0.00	
50,296.28	
1,192.22	
52,721.67	
69,023.97	
1,522,367.25	
1,457,090.36	
3,677,052.88	
164.48	
0.00	
47.11	
6,830,292.81	

4

4
SUBTOTAL:

4412	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	274.77	
4413	SOBRA 100-133% M&F
6	18,822.56	18,033.29	11,971.57	66,627.29	61,087.04	112,144.19	68,203.82	91,771.61	121,961.96	91,957.21	93,428.94	88,559.40	
4414	SOBRA 100-133% MALE	10,518.44	14,508.22	3,138.31	25,481.01	34,844.73	28,133.55	21,604.33	39,404.07	25,244.64	11,668.29	17,184.11	20,079.38	
4415	SOBRA 100-133% FEMA	7,170.95	59,145.25	2,446.86	47,194.94	40,459.21	26,628.68	32,029.01	30,053.40	45,106.33	23,166.80	21,902.90	30,238.73	
	36,511.95	91,686.76	17,556.74	139,303.24	136,390.98	166,906.42	121,837.16	161,229.08	192,312.93	126,792.30	132,515.95	139,152.28	

274.77	
844,568.88	
251,809.08	
365,543.06	
1,462,195.79	

1

L
SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	2,014.72	1,660.45	-400.91	457.38	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	393.90	393.23	34.69	1,707.07	5,144.43	380.10	0.00	380.10	8,679.39	7,689.31	1,107.33	835.80	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	4,917.91	0.00	344.62	7,470.66	-368.31	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	0.00	0.00	1,422.62	58.51	0.00	0.00	127.80	0.00	68.47	0.00	59.33	127.80	

3,731.64	
26,745.35	
0.00	
12,364.88	
1,864.53	

5

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	5,311.81	2,407.95	3,462.38	8,835.33	5,233.50	380.10	127.80	380.10	8,747.86	7,689.31	1,166.66	963.60		44,706.40		

SUBTOTAL:

49,467.48

359.95

4,466.24

54,293.67

270,594,145.07

8700	SSI DISABLED FREEDO M	3,652.19	5,276.89	5,063.99	2,938.66	1,991.80	5,632.26	1,477.18	4,607.48	5,100.65	1,624.07	5,305.28	6,797.03	
8710	SSI DISABLED FREEDO M	0.00	0.00	94.49	0.00	0.00	0.00	0.00	265.46	0.00	0.00	0.00	0.00	
8720	SSI DISABLED FREEDO	0.00	0.00	204.26	0.00	10.26	0.00	0.00	32.12	1,682.04	928.32	120.06	1,489.18	
SUBTOTAL:	3,652.19	5,276.89	5,362.74	2,938.66	2,002.06	5,632.26	1,477.18	4,905.06	6,782.69	2,552.39	5,425.34	8,286.21	

27,733,419.01	21,096,836.49	20,936,283.02	24,946,887.80	18,997,251.35	19,818,904.65	26,677,378.65	19,688,358.25	21,431,023.12	25,347,272.99	

M

TOTAL:

21,049,296.39

22,871,233.35

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

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

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	
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	
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	
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	
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	
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	
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	
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	
1015	TANF 14-20 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
1017	TANF 21-44 FEMALE N O	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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	
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	
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	
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	
2100	SSI AGED WITH MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2110	SSI AGED NON-MEDICA R	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2120	SSI AGED WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2200	SSI DISABLED WITH M E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
2220	SSI DISABLED WITH Q M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
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	
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	
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	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
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 M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5017	SOBRA PREG 21-44 FE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5018	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
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		
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		
	0.00	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

M

SUBTOTAL:

0.00

0.00

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

1103	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	
1104	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	
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+	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1111	TANF EXPANDED <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	
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	
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 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	
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	
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	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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&

E

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

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

3308	AHC CARE M&F 45-64 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	
3316	AHC CARE MALE 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	
3317	AHC CARE FEMALE 21- 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	
3318	AHC CARE M&F 45-64 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	
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	

3400	MED ELIGIBILITY W/ 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	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 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	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
0.00	
0.00	
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	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	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	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 FEM AL	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	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
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

4

6

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3715	ADULT <40% EXP FEM AL	0.00	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		
3717	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3718	ADULT <40% EXP M&F	0.00	0.00	0.00	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	0.00	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 FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

4

SUBTOTAL:

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	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	
3928	NEWLY ELIGIBLE 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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
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

4
SUBTOTAL:

4412	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	
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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	0.00	0.00	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

L
SUBTOTAL:

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

0.00	
0.00	
0.00	
0.00	
0.00	

5

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		

SUBTOTAL:

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	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	

M

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 - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-286.63	
0.00	-286.63	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-286.63	

1006	TANF 21-44 MALE WITH	0.00	0.00	50.39	0.00	86.53	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	
1008	TANF 45-64 M & F WIT	240.08	144.26	129.07	239.42	1,322.72	0.00	625.82	183.70	0.00	139.60	23.34	938.17	
1009	TANF 65+ M & F WITH	0.00	0.00	14.96	0.00	0.00	269.17	0.00	0.00	0.00	0.00	0.00	0.00	
1011	TANF <1 M & F NON-ME	3,067.29	5,821.79	9,178.88	8,561.96	12,073.20	361.62	7,576.08	8,801.60	4,971.29	12,913.45	4,791.05	6,903.94	
1012	TANF 01-05 M & F NON	3,377.40	2,687.30	4,007.35	587.92	319.42	9,042.44	1,359.89	513.74	701.82	2,239.85	2,047.73	1,929.35	
1013	TANF 06-13 M & F NON	1,218.15	1,408.01	1,681.43	1,359.63	422.84	697.85	239.81	411.59	596.64	1,006.94	1,907.92	2,803.18	
1014	TANF 14-20 MALE NON-	3,194.76	243.36	468.28	188.25	8.93	1,651.47	0.00	0.00	517.95	1,139.25	0.00	548.96	
1015	TANF 14-20 FEMALE N O	3,183.01	6,546.81	822.11	544.54	1,469.63	553.87	196.26	783.30	336.81	3,145.53	100.59	0.00	
1016	TANF 21-44 MALE NON-	15,380.38	5,438.43	12,392.42	22,983.79	9,608.57	15,370.41	2,494.59	2,369.89	1,849.24	1,766.80	7,493.73	11,656.76	
1017	TANF 21-44 FEMALE N O	26,675.44	30,189.68	21,923.51	32,698.97	13,500.32	6,643.90	16,774.46	10,699.83	21,174.22	13,002.98	9,407.35	14,370.56	
1018	TANF 45-64 M & F NON	1,585.03	20,476.42	7,032.33	4,217.25	3,765.04	2,438.93	8,095.59	5,814.36	5,037.85	1,737.66	4,659.28	3,686.54	
1019	TANF 65+ M & F NON-M	249.73	0.00	0.00	0.00	0.00	0.00	0.00	44.01	274.68	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	
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	
1028	TANF 45-64 M & F WIT	0.00	0.00	0.00	0.00	14.61	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	
2100	SSI AGED WITH MEDIC A	241.77	1,611.38	1,217.37	578.23	1,624.74	2,126.97	1,264.25	3,360.93	104.85	1,223.64	679.53	9,371.61	
2110	SSI AGED NON-MEDICA R	371.10	7,188.56	32,792.94	1,605.68	18,626.89	9,771.81	8,423.35	6,410.80	45,935.51	29,839.98	5,315.76	36,504.18	
2120	SSI AGED WITH QMB	74.34	-102.87	2,258.84	-33.63	42.72	2,675.20	1,819.28	2,074.13	3,346.54	247.23	359.77	-3,754.31	
2200	SSI DISABLED WITH M E	274.99	1,222.09	2,462.28	265.65	1,191.01	1,835.64	215.54	1,722.46	1,448.93	537.30	1,769.71	220.36	
2210	SSI DISABLED NON-ME	25,287.18	285,986.08	63,667.08	20,539.73	10,339.15	19,142.49	6,249.43	29,799.24	44,897.80	20,238.73	204,871.78	5,034.73	
2220	SSI DISABLED WITH Q M	3,344.91	11,090.04	4,388.06	4,281.31	7,564.03	5,685.08	5,093.78	4,318.16	1,521.87	1,609.00	311.22	2,099.96	
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	
2310	SSI BLIND NON-MEDIC A	0.00	0.00	2,306.72	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2320	SSI BLIND WITH QMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
4311	SOBRA CHILD <1 M & F	3,804.18	13,609.55	4,737.03	2,907.42	3,992.10	13,526.57	4,221.82	9,210.15	5,389.08	4,072.45	15,112.72	4,507.58	
4312	SOBRA CHILD 01-05 M	23,471.36	22,204.78	19,576.43	13,090.77	16,949.49	38,403.30	12,097.72	16,014.39	25,026.74	27,594.84	19,668.45	20,991.63	
4313	SOBRA CHILD 06-13 M	51,607.75	20,148.09	23,759.65	14,546.67	8,196.12	47,233.54	13,965.41	20,889.98	21,785.68	11,008.67	11,838.15	15,970.88	
4314	SOBRA CHILD 14-20 MA	12,529.17	16,769.02	21,002.41	3,957.63	8,758.43	5,482.29	80,849.97	22,040.45	13,301.06	2,409.85	3,022.18	2,719.05	

136.92	
0.00	
3,986.18	
284.13	
85,022.15	
28,814.21	
13,753.99	
7,961.21	
17,682.46	
108,805.01	
217,061.22	
68,546.28	
568.42	
0.00	
0.00	
14.61	
0.00	
23,405.27	
202,786.56	
9,007.24	
13,165.96	
736,053.42	
51,307.42	
0.00	
2,306.72	
0.00	
0.00	
0.00	
0.00	
85,090.65	
255,089.90	
260,950.59	
192,841.51	

D

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	6,477.83	5,659.71	11,307.97	10,537.18	17,755.14	7,912.02	2,749.26	1,611.34	10,524.83	7,767.18	6,468.94	9,280.73		98,052.13		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
5015	SOBRA PREG 14-20 FE M	4,547.68	626.35	7,875.28	1,288.69	1,480.21	1,333.79	994.22	8,174.96	6,546.86	1,498.27	2,692.91	825.21		37,884.43		
5017	SOBRA PREG 21-44 FE	21,818.94	29,403.82	43,513.99	31,655.97	15,933.90	13,446.16	23,742.27	33,941.80	36,361.11	34,971.26	12,271.02	35,348.38		332,408.62		
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	8,015.26	0.00	-8,015.26		0.00		
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		
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		
	212,022.47	488,372.66	298,566.78	176,603.03	155,045.74	205,604.52	199,048.80	189,190.81	251,651.36	188,125.72	314,813.13	173,942.19		2,852,987.21		

M

M

SUBTOTAL:

305.89

305.89

3100	TRANSPLANT OPTION	0.00	0.00	0.00	0.00	0.00	85.42	0.00	0.00	0.00	164.21	0.00	56.26	
	0.00	0.00	0.00	0.00	0.00	85.42	0.00	0.00	0.00	164.21	0.00	56.26	

1
SUBTOTAL:

1103	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	
1104	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	
1106	TANF EXPANDED 21-44	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-841.65	0.00	0.00	0.00	0.00	
1107	TANF EXPANDED 21-44	0.00	0.00	26.99	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	6.07	0.00	161.42	40.61	0.00	245.33	0.00	132.07	145.23	963.76	3,965.35	
1109	TANF EXPANDED 65+	0.00	0.00	0.00	0.00	21.69	0.00	0.00	0.00	153.06	0.00	29.56	0.00	
1111	TANF EXPANDED <1 M
&F	0.00	107.79	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	88.72	207.36	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	292.72	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	983.30	246.21	480.41	221.56	5,436.61	488.81	93.00	0.00	0.00	291.10	0.00	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	17.95	137.10	0.00	169.08	0.00	0.00	0.00	0.00	
1116	TANF EXPANDED 21-44	207.41	1,374.65	40,600.36	101.94	919.82	4,161.96	2,406.31	3,257.32	-6,106.30	2,339.89	4,317.27	4,235.36	
1117	TANF EXPANDED 21-44	9,469.13	1,756.74	6,608.45	12,403.21	910.62	13,712.88	19,007.30	8,693.49	13,018.09	15,668.92	5,903.76	7,429.96	
1118	TANF EXPANDED 45-64	3,509.12	2,951.74	93.10	450.62	340.34	3,918.79	3,778.42	9,569.22	10,220.29	32,225.89	8,126.07	406.78	
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	338.53	-1,011.94	2,895.49	1,827.68	233.88	90.75	822.40	0.00	-707.17	28.20	2,173.79	482.20	
2410	SSI AGED EXPANDED 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	
2420	SSI AGED EXPANDED WI	199.65	0.00	129.18	-72.61	-17.74	189.14	200.01	0.00	0.00	2.17	49.42	71.12	
2600	SSI DISABLED EXPAND E	386.96	48.09	143.85	158.57	1,284.03	1,951.82	642.36	198.47	0.00	355.49	69.30	2,563.40	
2610	SSI DISABLED EXPAND	56,129.73	0.00	20,969.96	0.00	35,888.67	13,483.84	0.00	0.00	299.10	0.00	0.00	0.00	

0.00	
0.00	
-841.65	
26.99	
5,659.84	
204.31	
107.79	
588.80	
0.00	
8,241.00	
324.13	
57,815.99	
114,582.55	
75,590.38	
0.00	
0.00	
0.00	
0.00	
0.00	
7,173.81	
0.00	
750.34	
7,802.34	
126,771.30	

M&

E

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
479.32	0.00	3,171.06	1,161.00	1,618.58	356.00	2,262.36	2,870.22	1,574.70	0.00	272.67	254.88	14,020.79	
71,791.87	5,686.71	75,118.85	16,413.39	46,695.06	38,491.09	29,457.49	23,916.15	18,583.84	51,056.89	22,198.32	19,409.05	418,818.71	

3308	AHC CARE M&F 45-64 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	
3316	AHC CARE MALE 21-44	-55.14	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3317	AHC CARE FEMALE 21- 4	0.00	0.00	0.00	0.00	0.00	-123.42	0.00	0.00	0.00	0.00	0.00	0.00	
3318	AHC CARE M&F 45-64 N	0.00	0.00	0.00	0.00	-304.13	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	-55.14	0.00	0.00	0.00	-304.13	-123.42	0.00	0.00	0.00	0.00	0.00	0.00	

 
0.00	
-55.14	
-123.42	
-304.13	
-482.69	

3400	MED ELIGIBILITY W/ 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	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	-90.89	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-60.13	0.00	-55.93	
3616	AHC CARE/MI MALE 21-	996.64	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	-2,168.34	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	56,134.89	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	57,131.53	0.00	0.00	0.00	0.00	-90.89	0.00	-2,168.34	0.00	-60.13	0.00	-55.93	

 
0.00	
-90.89	
0.00	
0.00	
-116.06	
996.64	
-2,168.34	
56,134.89	
54,756.24	

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	95.08	0.00	205.82	0.00	0.11	0.00	0.00	0.00	0.00	0.00	0.00	24.66	
3509	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	61.23	0.00	0.00	591.05	0.00	0.00	0.00	
3514	ADULT 40-100% MALE 1	0.00	0.00	0.00	3,995.50	462.67	581.82	137.60	0.00	4,240.15	0.00	0.00	0.00	
3515	ADULT 40-100% FEMAL E	3,430.56	332.79	0.00	0.00	75.94	342.96	0.00	0.00	197.37	93.00	60.77	0.00	
3516	ADULT 40-100% MALE 2	29,537.65	17,618.83	16,528.87	11,291.25	21,952.19	24,271.07	7,106.94	5,001.69	8,897.10	56,072.03	50,137.30	16,464.50	
3517	ADULT 40-100% FEMAL	9,918.88	16,192.67	4,216.11	6,873.78	4,424.35	1,148.09	4,839.72	12,931.67	1,560.75	546.03	2,948.45	1,850.82	
3518	ADULT 40-100% M&F 45	17,006.11	11,808.33	29,317.11	13,080.91	41,130.07	22,066.42	22,774.88	14,463.63	10,232.53	25,018.45	7,858.28	19,240.31	
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	47.01	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	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	10.26	0.00	0.00	0.00	0.00	0.00	0.00	0.00	447.71	1,534.68	3,999.35	945.99	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	4,114.12	0.00	0.00	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	47.77	159.41	-72.49	153.28	0.00	57.02	-357.03	706.56	220.96	822.54	80.06	1,044.88	
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	
0.00	
325.67	
652.28	
9,417.74	
4,533.39	
264,879.42	
67,451.32	
233,997.03	
47.01	
0.00	
0.00	
0.00	
0.00	
0.00	
6,937.99	
4,114.12	
2,862.96	
0.00	

E

4

6

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	638.33	2,949.89	655.77	55.09	1,044.42	821.03	540.50	5,932.12	2,591.74	4,557.10	2,784.48	489.82		23,060.29		
3715	ADULT <40% EXP FEM AL	6,886.22	1,333.58	986.35	0.00	0.00	971.73	484.68	663.21	0.00	136.86	4,104.81	1,343.19		16,910.63		
3716	ADULT <40% EXP MALE	87,516.94	137,213.09	59,107.89	86,557.14	76,793.86	88,807.17	25,860.89	62,765.55	61,978.04	77,669.91	90,046.79	28,549.00		882,866.27		
3717	ADULT <40% EXP FEM AL	28,711.56	30,380.42	62,265.11	20,947.83	13,043.16	62,567.45	17,619.35	38,352.76	19,283.84	34,537.98	49,673.58	10,907.94		388,290.98		
3718	ADULT <40% EXP M&F	73,759.29	34,317.41	75,461.37	91,305.45	36,478.45	38,593.34	50,612.11	84,271.10	64,520.47	76,150.82	70,851.83	71,957.93		768,279.57		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	1,493.56	877.47	0.00	85.74	0.00		2,456.77		
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 FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	257,558.65	252,306.42	248,671.91	234,260.23	195,405.22	244,403.45	129,619.64	226,581.85	175,639.18	277,186.41	282,631.44	152,819.04		2,677,083.44		

4

SUBTOTAL:

3906	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	21.47	0.00	54.29	0.00	0.00	0.00	0.00	86.72	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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	53.31	236.02	159.76	279.30	
3909	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	583.12	0.00	0.00	885.41	
3914	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	219.66	0.00	0.00	0.00	714.11	185.01	0.00	
3915	NEWLY ELIGIBLE FEMA L	0.00	0.00	0.00	0.00	0.00	0.00	136.86	570.94	0.00	0.00	0.00	32.36	
3916	NEWLY ELIGIBLE MALE	2,177.20	3,667.10	6,736.60	8,363.47	683.15	8,974.66	48,801.48	2,127.19	1,269.37	6,057.33	986.26	10,072.63	
3917	NEWLY ELIGIBLE FEMA L	2,187.81	6,610.07	2,102.47	1,988.35	1,659.44	14,701.39	3,621.00	2,026.18	3,238.05	1,178.44	4,944.10	5,662.56	
3918	NEWLY ELIGIBLE M&F 4	40,072.00	12,789.89	57,847.40	7,387.87	-635.14	5,689.64	31,000.16	22,348.22	15,304.83	13,698.64	11,143.00	5,071.94	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	44,437.01	23,067.06	66,686.47	17,761.16	1,707.45	29,639.64	83,559.50	27,072.53	20,448.68	21,884.54	17,504.85	22,004.20	

162.48	
0.00	
728.39	
1,468.53	
1,118.78	
740.16	
99,916.44	
49,919.86	
221,718.45	
0.00	
0.00	
0.00	
375,773.09	

4

4
SUBTOTAL:

4412	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	
4413	SOBRA 100-133% M&F
6	0.00	332.82	31.19	1,392.55	1,273.75	5,386.27	3,719.75	3,749.35	2,648.22	1,352.74	4,458.43	555.76	
4414	SOBRA 100-133% MALE	7.98	68.80	0.00	61.55	126.58	69.79	20,204.79	211.82	782.81	-0.48	112.39	0.00	
4415	SOBRA 100-133% FEMA	169.44	0.00	0.00	636.29	424.71	-39.17	0.00	0.00	216.87	0.00	1,694.80	210.39	
	177.42	401.62	31.19	2,090.39	1,825.04	5,416.89	23,924.54	3,961.17	3,647.90	1,352.26	6,265.62	766.15	

0.00	
24,900.83	
21,646.03	
3,313.33	
49,860.19	

1

L
SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	35.03	15.79	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	22.40	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	3,387.30	0.00	140.57	-140.57	0.00	0.00	140.57	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
50.82	
22.40	
3,527.87	
0.00	

5

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	3,387.30	0.00	140.57	-140.57	0.00	0.00	140.57	0.00	57.43	15.79	0.00	0.00		3,601.09		

SUBTOTAL:

4,032.56

24,169.15

0.00

28,201.71

6,460,618.25

8700	SSI DISABLED FREEDO M	0.00	0.00	0.00	61.65	36.81	95.62	36.81	1,290.05	966.68	36.81	47.46	1,460.67	
8710	SSI DISABLED FREEDO M	0.00	2,178.61	0.00	0.00	13,816.87	0.00	0.00	0.00	6,421.98	1,707.22	44.47	0.00	
8720	SSI DISABLED FREEDO	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	2,178.61	0.00	61.65	13,853.68	95.62	36.81	1,290.05	7,388.66	1,744.03	91.93	1,460.67	

689,215.77	447,049.28	414,228.06	523,522.32	465,787.35	469,844.22	477,417.05	541,469.72	643,505.29	370,401.63	

M

TOTAL:

646,451.11

771,726.45

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	19,435.74	28,348.02	40,057.83	35,077.29	35,714.00		349,774.67		
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		
	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	19,435.74	28,348.02	40,057.83	35,077.29	35,714.00		349,774.67		

SUBTOTAL:

TOTAL:	22,473.97	26,318.07	47,874.45	20,739.53	22,793.94	31,172.34	19,769.49	19,435.74	28,348.02	40,057.83	35,077.29	35,714.00		349,774.67		

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	0.00	0.00	54.51	0.00	0.00	0.00	14.54	1,306.08	0.00	0.00	-1,306.08	0.00		69.05		
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		
	0.00	0.00	54.51	0.00	0.00	0.00	14.54	1,306.08	0.00	0.00	-1,306.08	0.00		69.05		

SUBTOTAL:

69.05

0.00	0.00	54.51	0.00	0.00	0.00	14.54	1,306.08	0.00	0.00	-1,306.08	0.00	

TOTAL:

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
5510	SOBRA FPS FEMALE W IT	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
8020	QMB ONLY	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	315,568.31	500,143.03	389,444.78	369,519.74	538,763.44		4,389,361.37		
8040	SLMB	0.00	0.00	0.00	0.00	0.00	0.00	0.00	22.47	0.00	0.00	-13.21	0.00		9.26		
8050	QI1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	149.96	0.00	0.00		149.96		
	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	315,590.78	500,143.03	389,594.74	369,506.53	538,763.44		4,389,520.59		

SUBTOTAL:

TOTAL:	270,941.80	185,031.50	445,748.41	353,754.91	251,421.53	511,951.66	257,072.26	315,590.78	500,143.03	389,594.74	369,506.53	538,763.44		4,389,520.59		

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

13AD

MARICOPA ADULT INM
AT

SUBTOTAL:

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

1006	TANF 21-44 MALE WITH	46.42	188.36	166.12	101.73	229.42	48.01	0.00	0.00	0.00	0.00	0.00	-102.38	
1007	TANF 21-44 FEMALE WI	286.14	1,871.10	104.02	503.75	0.00	0.00	113.90	70.29	1,456.73	4.26	372.75	95.82	
1008	TANF 45-64 M & F WIT	963.94	990.67	2,333.71	726.40	204.34	1,533.87	0.00	96.42	96.08	0.00	173.55	127.25	
1009	TANF 65+ M & F WITH	15.97	66.51	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	14,101.84	25,301.91	30,300.16	178,822.23	20,727.64	74,856.12	34,313.55	83,860.40	29,081.54	37,405.10	76,083.54	103,015.62	
1012	TANF 01-05 M & F NON	16,538.91	9,600.05	8,669.16	18,344.02	3,875.07	16,616.29	8,596.17	11,578.05	10,855.28	8,330.40	931.42	1,808.21	
1013	TANF 06-13 M & F NON	6,436.73	7,171.95	14,303.13	4,999.12	7,077.73	5,741.50	1,318.35	1,001.01	627.70	5,090.38	705.45	1,183.59	
1014	TANF 14-20 MALE NON-	1,257.04	3,493.94	1,522.66	776.75	1,794.11	320.53	286.55	742.46	267.38	256.45	312.17	0.00	
1015	TANF 14-20 FEMALE N O	3,520.43	4,447.58	5,020.50	8,102.17	4,452.11	9,382.50	6,249.18	8,922.12	6,905.45	2,096.02	10,167.52	9,496.42	
1016	TANF 21-44 MALE NON-	24,274.51	27,434.69	45,477.46	88,415.76	9,738.08	28,789.89	85,091.79	31,412.32	110,675.29	28,537.60	31,705.95	62,100.53	
1017	TANF 21-44 FEMALE N O	122,776.63	149,984.88	198,163.63	154,340.59	107,095.16	99,397.82	87,007.19	116,787.64	164,332.19	91,485.31	120,549.62	157,894.95	
1018	TANF 45-64 M & F NON	44,637.53	34,488.13	37,346.87	40,804.81	32,291.49	49,057.57	51,649.62	69,573.56	60,779.61	24,241.45	28,594.72	69,623.57	
1019	TANF 65+ M & F NON-M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
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	
1028	TANF 45-64 M & F WIT	0.00	2,013.78	1,713.94	22.74	132.86	15.79	0.00	0.00	73.95	0.00	1,331.23	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	
2100	SSI AGED WITH MEDIC A	8,786.84	9,235.08	13,562.46	4,876.58	4,017.94	1,926.23	480.64	1,608.57	3,475.77	1,525.04	3,486.38	2,028.09	
2110	SSI AGED NON-MEDICA R	267.22	1,844.32	1,193.89	206.73	207.49	3,138.04	0.00	0.00	278.42	1,712.20	14.78	254.71	
2120	SSI AGED WITH QMB	5,639.69	5,409.53	7,747.96	8,330.00	3,535.97	10,351.60	4,741.69	6,240.10	9,235.80	7,675.38	13,268.34	11,355.06	
2200	SSI DISABLED WITH M E	21,233.51	3,529.27	27,584.81	6,512.83	4,472.52	8,071.02	2,754.21	7,716.73	6,449.52	6,597.97	9,258.74	7,425.82	
2210	SSI DISABLED NON-ME	231,778.99	342,969.11	271,027.04	176,793.76	210,239.42	204,543.74	177,331.11	196,420.41	252,320.07	159,265.26	183,202.92	224,698.07	
2220	SSI DISABLED WITH Q M	31,844.13	34,580.97	45,422.53	27,354.81	19,197.99	51,044.87	26,387.05	49,741.49	52,592.80	29,049.85	37,565.92	45,048.88	
2300	SSI BLIND WITH MEDIC	0.00	530.71	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2310	SSI BLIND NON-MEDIC A	1,267.01	342.49	390.50	653.66	984.10	2,563.68	1,883.94	0.00	561.96	857.34	8,733.77	13,176.03	
2320	SSI BLIND WITH QMB	222.46	193.39	118.72	208.81	92.93	70.22	-24.30	0.00	0.00	583.37	56.25	339.30	
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	
4304	SOBRA CHILD 14-20 MA	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
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	
4311	SOBRA CHILD <1 M & F	99,444.46	34,799.65	70,959.07	70,572.82	252,132.06	70,672.39	98,949.20	146,993.00	99,520.37	80,613.83	284,461.20	251,365.80	
4312	SOBRA CHILD 01-05 M	37,985.34	18,128.44	50,244.41	32,655.05	36,957.52	60,885.81	29,395.94	175,445.37	85,220.46	50,899.64	75,158.96	45,753.21	
4313	SOBRA CHILD 06-13 M	20,935.84	28,886.52	38,212.84	34,130.76	44,076.50	65,842.47	27,330.41	40,338.93	52,942.41	20,420.44	40,636.15	46,258.46	
4314	SOBRA CHILD 14-20 MA	36,910.73	21,260.73	9,048.41	10,576.23	10,522.89	23,738.76	4,567.14	15,257.76	36,080.81	7,544.09	4,343.40	16,395.70	

677.68	
4,878.76	
7,246.23	
82.48	
707,869.65	
115,743.03	
55,656.64	
11,030.04	
78,762.00	
573,653.87	
1,569,815.61	
543,088.93	
0.00	
0.00	
0.00	
5,304.29	
0.00	
55,009.62	
9,117.80	
93,531.12	
111,606.95	
2,630,589.90	
449,831.29	
530.71	
31,414.48	
1,861.15	
0.00	
0.00	
0.00	
1,560,483.85	
698,730.15	
460,011.73	
196,246.65	

D

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4315	SOBRA CHILD 14-20 FE	7,807.11	22,781.32	26,164.00	49,311.09	32,388.98	22,462.76	25,449.12	35,183.29	35,745.28	26,779.94	19,214.82	25,269.95		328,557.66		
5007	SOBRA PREG 21-44 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	49.35	139.79		189.14		
5013	SOBRA PREG 09-13 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	318.29	0.00		318.29		
5015	SOBRA PREG 14-20 FE M	19,583.10	16,174.12	18,249.56	19,803.43	28,709.84	38,838.71	33,355.08	25,221.76	16,010.44	26,586.00	10,992.09	22,464.19		275,988.32		
5017	SOBRA PREG 21-44 FE	50,370.25	73,392.58	98,242.24	99,306.65	73,113.89	108,947.96	91,772.55	117,925.86	123,974.82	72,169.26	101,333.03	108,791.97		1,119,341.06		
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	108.39	0.00		108.39		
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	57.17		57.17		
5028	SOBRA PREG 45-64 FE M	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	57.17	57.17	0.00	114.34		228.68		
	808,932.77	881,111.78	1,023,289.80	1,037,253.28	908,268.05	958,858.15	799,000.08	1,142,137.54	1,159,617.30	689,783.75	1,063,130.70	1,226,180.12		11,697,563.32		

M

M

SUBTOTAL:

0.00

0.00

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

1103	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	
1104	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	
1106	TANF EXPANDED 21-44	0.00	414.69	0.00	0.00	-2,606.36	0.00	181.95	24.92	562.25	309.39	2,113.54	970.85	
1107	TANF EXPANDED 21-44	1,241.25	491.94	2,444.85	1,158.04	613.86	2,048.94	316.38	1,453.25	906.70	1,290.59	1,186.07	536.90	
1108	TANF EXPANDED 45-64	1,825.46	2,238.26	622.19	467.69	2,209.12	6,622.48	1,461.53	1,269.77	2,812.65	3,062.56	2,161.31	1,545.27	
1109	TANF EXPANDED 65+	1,249.86	53.73	663.23	32.04	433.73	1,330.06	324.00	138.41	4.98	956.87	618.44	995.43	
1111	TANF EXPANDED <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	
1112	TANF EXPANDED 01-05	0.00	0.00	169.40	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
1113	TANF EXPANDED 06-13	15.00	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	506.37	0.00	0.00	271.22	0.00	155.37	5,416.82	0.00	0.00	189.76	0.00	
1115	TANF EXPANDED 14-20	0.00	0.00	0.00	0.00	53.99	0.00	0.00	1,316.97	0.00	2,641.49	627.45	409.48	
1116	TANF EXPANDED 21-44	7,020.19	10,188.24	39,666.55	3,815.71	20,026.14	8,013.62	7,283.17	8,831.96	58,286.70	19,690.12	30,453.33	23,742.12	
1117	TANF EXPANDED 21-44	29,232.13	26,262.11	33,390.49	26,291.09	53,340.49	32,354.21	46,315.17	57,426.54	46,389.10	56,466.01	22,640.55	53,618.78	
1118	TANF EXPANDED 45-64	7,699.38	15,070.15	15,381.52	14,385.88	14,008.71	17,783.01	23,453.79	39,485.25	39,783.92	19,961.73	27,719.42	21,778.05	
1119	TANF EXPANDED 65+
M&	0.00	1,058.40	0.00	0.00	0.00	310.53	0.00	0.00	0.00	0.00	0.00	0.00	
1126	TANF EXPANDED 21-44	173.16	204.04	268.33	0.00	105.51	394.56	57.30	2,153.33	878.20	0.00	0.00	107.93	
1127	TANF EXPANDED 21-44	89.09	21.69	48.01	58.18	21.69	48.01	0.00	91.29	261.46	659.83	15.74	82.56	
1128	TANF EXPANDED 45-64	612.96	79.99	1,202.50	0.00	647.39	1,664.73	0.00	1,336.58	2,228.79	30.83	1,424.65	1,113.67	
1129	TANF EXPANDED 65+
M&	0.00	0.00	0.00	0.00	0.00	81.70	0.00	0.00	0.00	4.95	197.14	1,084.14	
2400	SSI AGED EXPANDED WI	174.66	70.14	1,351.38	245.08	1,187.78	146.02	0.00	0.00	-44.50	0.00	341.23	0.00	
2410	SSI AGED EXPANDED NO	504.00	193.90	3,907.14	0.00	360.04	44.31	0.00	355.10	0.00	0.00	0.00	0.00	
2420	SSI AGED EXPANDED WI	3,538.39	5,601.99	9,609.73	6,111.76	4,987.34	12,361.60	7,977.92	15,779.52	27,250.10	23,514.11	9,197.31	8,452.70	
2600	SSI DISABLED EXPAND E	170.31	695.50	498.27	5,168.66	108.02	80.25	1,527.12	247.27	736.84	1,346.13	1,554.04	263.31	
2610	SSI DISABLED EXPAND	13,636.52	8,325.86	26,011.62	1,009.53	583.66	720.17	2,476.55	1,039.57	1,032.31	427.01	2,996.23	1,174.27	

0.00	
0.00	
1,971.23	
13,688.77	
26,298.29	
6,800.78	
0.00	
169.40	
15.00	
6,539.54	
5,049.38	
237,017.85	
483,726.67	
256,510.81	
1,368.93	
4,342.36	
1,397.55	
10,342.09	
1,367.93	
3,471.79	
5,364.49	
134,382.47	
12,395.72	
59,433.30	

M&

E

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016

RATE CODE	DESCRIPTION

2620

SSI DISABLED EXPAND
E

SUBTOTAL:

JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
4,285.83	11,263.10	11,272.83	7,319.43	5,081.88	20,081.95	9,392.05	10,511.78	12,169.11	9,199.73	8,152.95	18,375.57	127,106.21	
71,468.19	82,740.10	146,508.04	66,063.09	101,434.21	104,086.15	100,922.30	146,878.33	193,258.61	139,561.35	111,589.16	134,251.03	1,398,760.56	

3308	AHC CARE M&F 45-64 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	
3316	AHC CARE MALE 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	
3317	AHC CARE FEMALE 21- 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	
3318	AHC CARE M&F 45-64 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	
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	

3400	MED ELIGIBILITY W/ 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	
3410	MED ELIGIBILITY NON-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3608	AHC CARE/MI M&F 45-6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3614	AHC CARE/MI MALE 14-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3615	AHC CARE/MI FEMALE 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	
3616	AHC CARE/MI MALE 21-	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3617	AHC CARE/MI FEMALE 2	0.00	0.00	-84.11	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3618	AHC CARE/MI M&F 45-6	0.00	0.00	-123.34	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
SUBTOTAL:	0.00	0.00	-207.45	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	
0.00	
0.00	
-84.11	
-123.34	
-207.45	

3506	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	257.39	536.53	221.46	263.69	15.74	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	2,553.86	0.00	105.51	131.56	380.07	27.35	62.40	0.00	92.34	0.00	
3509	ADULT 40-100% M&F 65	0.00	43.83	0.00	0.00	21.82	25.70	0.00	0.00	0.00	0.00	0.00	92.13	
3514	ADULT 40-100% MALE 1	0.00	3,215.37	0.00	0.00	0.00	13,222.08	381.09	0.00	501.26	591.32	293.02	252.04	
3515	ADULT 40-100% FEMAL E	911.05	84.70	1,203.19	1,329.48	45.31	790.15	224.84	155.67	249.15	529.25	2,847.80	603.59	
3516	ADULT 40-100% MALE 2	31,925.03	31,046.31	93,315.47	49,847.53	28,052.89	39,983.33	166,909.20	53,183.84	146,546.98	31,522.14	42,504.39	26,587.62	
3517	ADULT 40-100% FEMAL	12,294.00	3,333.58	14,103.28	9,486.39	17,241.16	6,694.26	9,776.39	16,322.61	49,510.70	11,406.07	11,207.27	14,498.19	
3518	ADULT 40-100% M&F 45	65,376.33	62,636.67	86,530.21	62,232.60	77,425.47	99,438.77	136,171.18	94,223.08	69,012.14	31,947.34	100,669.36	80,709.01	
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	57.17	0.00	0.00	
3526	ADULT 40-100% MALE 2	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3527	ADULT 40-100% FEMAL E	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3528	ADULT 40-100% M&F 45	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3529	ADULT 40-100% M&F 65	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3705	ADULT <40% EXP FEM AL	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	9.16	0.00	5.33	
3707	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	246.62	0.00	1,361.40	109.80	0.00	0.00	0.00	0.00	
3708	ADULT <40% EXP M&F	1,741.29	1,260.00	0.00	170.39	48.25	139.91	126.40	0.00	0.00	0.00	591.66	316.99	
3709	ADULT <40% EXP M&F	0.00	0.00	0.00	0.00	0.00	0.00	-224.42	0.00	0.00	0.00	0.00	0.00	

1,294.81	
0.00	
3,353.09	
183.48	
18,456.18	
8,974.18	
741,424.73	
175,873.90	
966,372.16	
57.17	
0.00	
0.00	
0.00	
0.00	
0.00	
14.49	
1,717.82	
4,394.89	
-224.42	

E

4

6

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
3714	ADULT <40% EXP MALE	7,292.84	12,081.73	19,979.50	3,571.18	6,165.38	11,600.06	1,839.57	21,101.83	4,513.44	1,928.48	8,987.34	42,309.74		141,371.09		
3715	ADULT <40% EXP FEM AL	4,451.72	328.62	16,586.75	12,371.04	3,512.57	6,007.85	5,785.32	14,507.32	10,027.92	3,981.55	1,542.37	2,804.01		81,907.04		
3716	ADULT <40% EXP MALE	136,455.42	205,325.04	266,134.03	102,321.13	255,550.69	161,837.89	126,535.96	200,353.43	354,171.45	141,946.79	142,644.33	127,595.31		2,220,871.47		
3717	ADULT <40% EXP FEM AL	94,474.99	126,480.57	88,278.29	77,117.72	75,243.41	61,658.54	113,024.70	85,873.98	76,008.50	72,238.22	63,398.12	113,988.74		1,047,785.78		
3718	ADULT <40% EXP M&F	181,612.85	129,721.57	241,985.31	168,543.69	210,132.57	273,111.36	172,306.98	297,742.35	316,208.36	108,374.36	137,058.23	825,006.66		3,061,804.29		
3719	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3726	ADULT <40% EXP MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3727	ADULT <40% EXP FEM AL	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
3728	ADULT <40% EXP M&F 4	0.00	1,260.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		1,260.00		
3729	ADULT <40% EXP M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
	536,535.52	576,817.99	830,669.89	486,991.15	673,791.65	674,641.46	734,856.07	784,137.79	1,027,033.76	404,795.54	511,851.97	1,234,769.36		8,476,892.15		

4

SUBTOTAL:

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	627.65	95.99	385.35	0.00	0.00	0.00	0.00	-1,216.00	0.00	18.35	20.56	228.64	
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	697.18	0.00	0.00	182.55	87.98	0.00	476.85	0.00	42.72	
3915	NEWLY ELIGIBLE FEMA L	303.87	213.29	165.29	178.10	3,617.10	0.00	0.00	0.00	565.34	216.70	2,633.83	569.77	
3916	NEWLY ELIGIBLE MALE	2,249.16	5,021.93	10,459.28	5,204.43	5,186.22	7,082.88	5,342.73	4,706.53	4,710.97	5,075.74	4,589.32	8,017.54	
3917	NEWLY ELIGIBLE FEMA L	2,574.73	5,949.64	7,868.75	10,984.25	13,427.45	10,371.16	4,670.18	16,876.09	29,294.65	42,577.88	14,084.08	27,635.00	
3918	NEWLY ELIGIBLE M&F 4	51,923.13	16,392.55	23,221.63	35,300.47	24,728.16	50,480.40	45,409.67	44,455.79	44,508.33	42,246.68	22,177.31	22,753.48	
3919	NEWLY ELIGIBLE M&F 6	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3926	NEWLY ELIGIBLE MALE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
3928	NEWLY ELIGIBLE M&F	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	57,678.54	27,673.40	42,100.30	52,364.43	46,958.93	67,934.44	55,605.13	64,910.39	79,079.29	90,612.20	43,505.10	59,247.15	

0.00	
0.00	
160.54	
0.00	
1,487.28	
8,463.29	
67,646.73	
186,313.86	
423,597.60	
0.00	
0.00	
0.00	
687,669.30	

4

4
SUBTOTAL:

4412	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	
4413	SOBRA 100-133% M&F
6	920.33	606.76	51.87	3,005.28	2,948.59	9,142.94	2,684.28	4,211.66	10,149.38	3,254.06	2,438.14	6,339.47	
4414	SOBRA 100-133% MALE	0.00	0.00	307.68	188.97	4,687.80	1,065.11	1,022.44	787.94	405.91	117.61	611.65	1,421.08	
4415	SOBRA 100-133% FEMA	589.03	196.50	0.00	4,003.47	2,355.99	5,473.69	1,606.27	1,572.40	2,865.83	3,038.92	313.69	486.39	
	1,509.36	803.26	359.55	7,197.72	9,992.38	15,681.74	5,312.99	6,572.00	13,421.12	6,410.59	3,363.48	8,246.94	

0.00	
45,752.76	
10,616.19	
22,502.18	
78,871.13	

1

L
SUBTOTAL:

4517	BC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4518	BC PATIENT FEMALE 4 5	10.17	15.64	0.00	0.00	15.64	0.00	0.00	66.89	0.00	0.00	15.42	0.00	
4519	BC PATIENT FEMALE 6 5	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4617	CC PATIENT FEMALE 2 1	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
4618	CC PATIENT FEMALE 4	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	

0.00	
123.76	
0.00	
0.00	
0.00	

5

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERV
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
	10.17	15.64	0.00	0.00	15.64	0.00	0.00	66.89	0.00	0.00	15.42	0.00		123.76		

SUBTOTAL:

1,240.60

0.00

0.00

1,240.60

22,340,913.37

8700	SSI DISABLED FREEDO M	0.00	22.70	0.00	274.10	91.00	262.32	10.12	0.00	0.00	324.99	247.96	7.41	
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	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	22.70	0.00	274.10	91.00	262.32	10.12	0.00	0.00	324.99	247.96	7.41	

2,042,720.13	1,650,143.77	1,740,551.86	1,821,464.26	1,695,706.69	2,144,702.94	2,472,410.08	1,331,488.42	1,733,703.79	2,662,702.01	

M

TOTAL:

1,476,134.55

1,569,184.87

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SER
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	350.00	0.00	350.00	0.00	0.00	0.00	0.00	0.00	0.00	368.00	0.00		1,068.00		
2100	SSI AGED WITH MEDIC A	106,605.75	138,772.37	243,060.06	109,396.22	86,575.09	110,463.52	87,654.44	143,745.18	106,223.61	176,974.54	131,366.18	144,430.52		1,585,267.48		
2110	SSI AGED NON-MEDICA R	26,434.90	13,763.26	31,784.99	27,506.02	11,008.01	20,476.11	15,801.28	35,485.17	47,163.43	24,189.70	24,557.57	79,605.44		357,775.88		
2120	SSI AGED WITH QMB	121,926.99	174,038.05	225,195.50	122,450.70	94,459.04	143,149.01	108,417.25	127,249.33	132,429.19	181,919.62	192,616.02	172,561.65		1,796,412.35		
2200	SSI DISABLED WITH M	45,476.20	32,686.17	56,715.55	29,618.96	25,027.91	41,363.82	24,516.31	25,071.19	28,005.89	40,283.81	45,971.28	38,782.37		433,519.46		
2210	SSI DISABLED NON-ME D	688,624.66	871,046.82	795,795.36	508,232.84	646,246.26	763,839.63	495,448.90	797,805.28	649,141.58	704,622.90	741,206.90	978,084.38		8,640,095.51		
2220	SSI DISABLED WITH Q	48,687.58	68,819.71	112,495.22	51,083.18	51,662.77	56,329.19	40,683.06	55,679.68	57,484.17	65,696.57	73,507.53	70,500.31		752,628.97		
2300	SSI BLIND WITH MEDIC	74.93	0.00	59.40	59.40	0.00	32.09	0.00	0.00	0.00	0.00	0.00	0.00		225.82		
2310	SSI BLIND NON-MEDIC A	8,400.00	7,019.66	6,650.00	5,950.00	2,407.81	8,076.38	7,009.55	5,745.60	5,363.93	7,280.00	7,962.00	11,167.32		83,032.25		
2320	SSI BLIND WITH QMB	431.94	428.25	416.46	71.62	789.22	833.02	421.52	274.18	191.34	736.00	1,545.26	443.05		6,581.86		
	1,046,662.95	1,306,924.29	1,472,172.54	854,718.94	918,176.11	1,144,562.77	779,952.31	1,191,055.61	1,026,003.14	1,201,703.14	1,219,100.74	1,495,575.04		13,656,607.58		

E

M

SUBTOTAL:

8710	SSI DISABLED FREEDO M	0.00	0.00	7.35	0.00	99.53	0.00	0.00	0.00	0.00	0.00	0.00	332.51	
8720	SSI DISABLED FREEDO	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	7.35	0.00	99.53	0.00	0.00	0.00	0.00	0.00	0.00	332.51	

439.39	
0.00	
439.39	

M
SUBTOTAL:

TOTAL:	1,046,662.95	1,306,924.29	1,472,179.89	854,718.94	918,275.64	1,144,562.77	779,952.31	1,191,055.61	1,026,003.14	1,201,703.14	1,219,100.74	1,495,907.55		13,657,046.97		

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMER
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	1,685,117.40	1,915,799.87	2,681,450.39	1,999,482.31	2,206,654.38	2,521,199.26	1,971,919.68	2,053,589.56	2,482,402.80	2,002,232.73	2,057,786.95	2,454,484.99		26,032,120.32		
2110	SSI AGED NON-MEDICA R	134,210.18	86,635.19	183,540.43	121,497.09	95,581.49	106,014.38	109,241.83	92,529.35	115,438.69	96,169.75	108,703.84	116,208.08		1,365,770.30		
2120	SSI AGED WITH QMB	2,732,315.87	2,691,509.27	3,869,487.21	2,806,461.70	3,006,316.90	3,483,453.49	2,966,589.34	2,913,764.31	3,487,725.23	2,863,327.97	2,977,479.88	3,445,403.73		37,243,834.90		
2200	SSI DISABLED WITH M	484,829.08	429,355.23	623,488.25	496,865.31	514,028.21	644,163.05	445,334.53	555,686.95	542,999.94	556,486.40	570,871.64	559,894.16		6,424,002.75		
2210	SSI DISABLED NON-ME D	1,738,486.52	1,802,598.11	2,237,418.61	1,856,867.73	1,821,700.40	2,248,380.45	1,960,119.55	1,762,751.80	2,202,913.44	2,150,461.81	2,022,184.53	2,260,214.05		24,064,097.00		
2220	SSI DISABLED WITH Q	585,872.48	620,560.01	851,203.88	615,551.90	612,586.36	832,248.41	699,418.83	675,434.25	843,309.26	667,418.48	694,378.07	828,808.79		8,526,790.72		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	7,740.32	7,420.92	10,075.82	6,388.81	10,469.71	3,611.59	6,315.84	5,273.47	12,748.95	9,261.88	9,125.44	10,088.96		98,521.71		
2320	SSI BLIND WITH QMB	4,994.88	7,132.53	7,260.58	5,253.26	5,833.93	6,424.90	7,449.06	5,835.69	7,493.66	6,103.94	6,213.19	8,113.27		78,108.89		
	7,373,566.73	7,561,011.13	10,463,925.17	7,908,368.11	8,273,171.38	9,845,495.53	8,166,388.66	8,064,865.38	9,695,031.97	8,351,462.96	8,446,743.54	9,683,216.03		103,833,246.59		

E

M

SUBTOTAL:

8710	SSI DISABLED FREEDO M	0.00	1,877.34	5,037.06	2,637.12	0.00	2,709.12	2,578.56	5,483.52	2,578.56	2,774.40	2,643.84	2,741.76	
8720	SSI DISABLED FREEDO	1,712.52	2,990.88	4,148.64	2,052.00	2,056.32	4,112.64	2,741.76	2,741.76	3,427.20	2,741.76	2,741.76	3,427.20	
	1,712.52	4,868.22	9,185.70	4,689.12	2,056.32	6,821.76	5,320.32	8,225.28	6,005.76	5,516.16	5,385.60	6,168.96	

31,061.28	
34,894.44	
65,955.72	

M
SUBTOTAL:

103,899,202.31

7,375,279.25	7,565,879.35	10,473,110.87	7,913,057.23	8,275,227.70	9,852,317.29	8,171,708.98	8,073,090.66	9,701,037.73	8,356,979.12	8,452,129.14	9,689,384.99	

TOTAL:

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICES
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	57,961.58	35,627.77	43,341.81	22,249.92	35,336.54	18,733.95	43,788.71	42,146.50	28,592.89	30,062.43	26,123.45	37,621.56		421,587.11		
2110	SSI AGED NON-MEDICA R	16,433.83	946.68	83,538.56	8,338.74	936.50	2,605.51	0.00	20,403.46	0.00	35,545.96	59.50	154.53		168,963.27		
2120	SSI AGED WITH QMB	443.59	1,507.61	18.05	566.68	28.46	76.41	312.29	12.87	2,062.75	4,839.65	7,052.25	1,195.87		18,116.48		
2200	SSI DISABLED WITH M	11,220.75	6,502.00	26,013.79	7,482.95	9,714.19	1,405.20	16,547.58	1,364.39	4,430.82	24,058.22	18,479.74	11,853.42		139,073.05		
2210	SSI DISABLED NON-ME D	26,834.51	19,004.26	28,589.63	10,783.29	71,004.32	45,428.28	10,585.96	170.30	50,760.97	38,195.51	47,165.23	98,217.66		446,739.92		
2220	SSI DISABLED WITH Q	2,359.28	722.71	6,308.23	1,497.53	1,372.98	2,162.54	215.93	1,994.88	1,570.30	7.48	802.18	1,009.00		20,023.04		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	6,656.83	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		6,656.83		
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		
	121,910.37	64,311.03	187,810.07	50,919.11	118,392.99	70,411.89	71,450.47	66,092.40	87,417.73	132,709.25	99,682.35	150,052.04		1,221,159.70		

E

M

SUBTOTAL:

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	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:

TOTAL:	121,910.37	64,311.03	187,810.07	50,919.11	118,392.99	70,411.89	71,450.47	66,092.40	87,417.73	132,709.25	99,682.35	150,052.04		1,221,159.70		

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRV
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
1010	TANF NON-MEDICARE	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2100	SSI AGED WITH MEDIC A	17,791.38	16,157.36	33,799.85	22,186.80	28,584.66	11,004.95	44,168.26	27,967.84	21,732.02	19,672.68	15,852.13	38,807.19		297,725.12		
2110	SSI AGED NON-MEDICA R	68.35	0.00	655.42	0.00	206.68	50.89	0.00	0.00	2,122.27	35.87	50.89	4,510.92		7,701.29		
2120	SSI AGED WITH QMB	12,713.06	10,199.58	16,135.95	9,872.20	12,567.92	15,770.42	14,838.78	15,840.80	19,040.34	12,224.10	10,367.80	12,161.55		161,732.50		
2200	SSI DISABLED WITH M	1,998.01	5,671.10	17,991.36	2,677.54	3,446.03	8,612.53	11,085.27	10,507.32	7,029.28	7,487.38	4,133.42	24,482.19		105,121.43		
2210	SSI DISABLED NON-ME D	39,207.69	57,526.26	37,706.14	98,519.59	47,761.48	76,557.96	49,875.46	60,565.37	118,494.07	20,028.68	46,506.00	55,083.55		707,832.25		
2220	SSI DISABLED WITH Q	2,612.76	3,357.96	4,743.41	3,725.64	6,845.49	13,692.39	6,072.55	3,415.05	9,910.87	6,107.77	5,949.25	7,323.05		73,756.19		
2300	SSI BLIND WITH MEDIC	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2310	SSI BLIND NON-MEDIC A	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		0.00		
2320	SSI BLIND WITH QMB	36.96	218.14	48.21	37.14	48.21	48.21	48.21	37.14	105.21	0.00	0.00	57.17		684.60		
	74,428.21	93,130.40	111,080.34	137,018.91	99,460.47	125,737.35	126,088.53	118,333.52	178,434.06	65,556.48	82,859.49	142,425.62		1,354,553.38		

E

M

SUBTOTAL:

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	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
	0.00	0.00	0.00	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:

1,354,553.38

74,428.21	93,130.40	111,080.34	137,018.91	99,460.47	125,737.35	126,088.53	118,333.52	178,434.06	65,556.48	82,859.49	142,425.62	

TOTAL:

KidsCare - CAPITATION AMOUNTS
For The Period Ending June 30, 2016

N
SUBTOTAL:

183,782.09

170,408.91

173,185.84

164,735.13

157,227.01

237,286.25

145,035.95

134,596.32

138,960.53

125,403.43

119,709.56

113,266.21

1,863,597.23

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	1,007.22	1,007.22	833.38	959.01	959.01	2,143.00	479.18	479.18	911.99	958.36	958.36	479.18	11,175.09	

6012	C
KIDS 1-5 M & F NON-M	
220.96	
220.96	
220.96	
223.26	
223.26	
544.33	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
1,653.73	
6013	KIDS 6-13 M & F NON-	58,022.76	55,071.22	54,144.19	51,905.62	50,587.41	81,247.87	46,353.98	44,050.29	41,851.79	39,485.08	38,911.51	35,061.23	596,692.95	
6014	KIDS 14-19 MALE NON-	49,755.46	44,451.13	44,464.06	45,078.81	41,422.38	59,062.76	40,125.21	36,864.12	37,371.18	35,442.31	33,916.58	33,251.17	501,205.17	
6015	KIDS 14-19 FEMALE NO	74,775.69	69,658.38	67,362.69	66,568.43	64,034.95	94,288.29	58,077.58	53,202.73	52,590.24	49,517.68	45,923.11	44,474.63	740,474.40	
9960	KIDSCARE KICK PAYME	0.00	0.00	6,160.56	0.00	0.00	0.00	0.00	0.00	6,235.33	0.00	0.00	0.00	12,395.89	

TOTAL:	183,782.09	170,408.91	173,185.84	164,735.13	157,227.01	237,286.25	145,035.95	134,596.32	138,960.53	125,403.43	119,709.56	113,266.21		1,863,597.23		

KidsCare - CAPITATION MEMBER MONTHS
For The Period Ending June 30, 2016

993.61	932.52	910.22	883.58	836.18	816.75	763.37	720.42	704.92	663.35	632.44	590.32	

RATE	CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI	2.00	2.00	1.66	2.00	2.00	2.00	1.00	1.00	1.90	2.00	2.00	1.00	20.56	

6012	C
KIDS 1-5 M & F NON-M	
2.00	
2.00	
2.00	
2.00	
2.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
0.00	
10.00	
6013	KIDS 6-13 M & F NON-	456.25	434.86	420.34	395.88	383.89	368.99	348.57	328.13	314.83	293.41	287.87	260.00	4,293.02	
6014	KIDS 14-19 MALE NON-	258.56	236.67	237.23	242.85	218.16	218.83	207.34	199.29	198.00	190.63	180.96	176.83	2,565.35	
6015	KIDS 14-19 FEMALE NO	274.80	256.99	247.99	240.85	230.13	226.93	206.46	192.00	189.19	177.31	161.61	152.49	2,556.75	
9960	KIDSCARE KICK PAYME N	0.00	0.00	1.00	0.00	0.00	0.00	0.00	0.00	1.00	0.00	0.00	0.00	2.00	
SUBTOTAL:	993.61	932.52	910.22	883.58	836.18	816.75	763.37	720.42	704.92	663.35	632.44	590.32		9,447.68	
															
TOTAL:														9,447.68	

KidsCare - MENTAL HEALTH CAPITATION AMOUNTS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	75.10	75.10	37.55	82.84	82.84	125.24	41.42	41.42	41.42	82.84	82.84	41.42		810.03		
6012	KIDS 1-5 M & F NON-M	75.10	75.10	75.10	82.84	82.84	101.76	0.00	0.00	0.00	0.00	0.00	0.00		492.74		
6013	KIDS 6-13 M & F NON-	16,709.75	16,146.50	15,620.80	15,698.18	15,532.50	19,008.02	14,165.64	13,254.40	12,674.52	11,639.02	11,183.40	10,520.68		172,153.41		
6014	KIDS 14-19 MALE NON-	9,776.08	8,979.83	9,075.34	10,574.10	9,401.08	11,247.46	8,858.20	8,661.96	8,476.58	8,171.36	7,582.64	7,329.70		108,134.33		
6015	KIDS 14-19 FEMALE NO	10,772.21	10,088.61	9,721.39	10,393.14	10,092.34	11,969.04	9,002.16	8,417.86	8,335.02	7,720.16	6,671.40	6,444.60		109,627.93		
SUBTOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	35,191.60	42,451.52	32,067.42	30,375.64	29,527.54	27,613.38	25,520.28	24,336.40		391,218.44		

TOTAL:	37,408.24	35,365.14	34,530.18	36,831.10	35,191.60	42,451.52	32,067.42	30,375.64	29,527.54	27,613.38	25,520.28	24,336.40		391,218.44		

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHS
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6011	KIDS <1M&F NON MEDI C	2.00	2.00	1.00	2.00	2.00	2.00	1.00	1.00	1.00	2.00	2.00	1.00		19.00		
6012	KIDS 1-5 M & F NON-M	2.00	2.00	2.00	2.00	2.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		10.00		
6013	KIDS 6-13 M & F NON-	445.00	430.00	416.00	379.00	375.00	359.00	342.00	320.00	306.00	281.00	270.00	254.00		4,177.00		
6014	KIDS 14-19 MALE NON-	248.00	229.00	230.00	235.00	210.00	211.00	198.00	194.00	191.00	184.00	172.00	167.00		2,469.00		
6015	KIDS 14-19 FEMALE NO	271.00	255.00	245.00	231.00	223.00	220.00	200.00	187.00	185.00	172.00	150.00	146.00		2,485.00		
SUBTOTAL:	968.00	918.00	894.00	849.00	812.00	792.00	741.00	702.00	683.00	639.00	594.00	568.00		9,160.00		

TOTAL:

968.00

9,160.00

918.00	894.00	849.00	812.00	792.00	741.00	702.00	683.00	639.00	594.00	568.00

KidsCare - FEE FOR SERVICE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6012	KIDS 1-5 M & F NON-M	-357.10	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00		-357.10		
6013	KIDS 6-13 M & F NON-	364.77	362.20	318.01	1,505.26	72.88	323.60	0.00	0.00	93.55	30.89	89.77	158.40		3,319.33		
6014	KIDS 14-19 MALE NON-	-652.26	85.01	0.00	96.20	0.00	0.00	0.00	0.00	15.43	0.00	0.00	0.00		-455.62		
6015	KIDS 14-19 FEMALE NO	-174.33	326.70	118.31	203.32	331.61	11.19	15.43	139.88	120.75	85.89	116.13	94.19		1,389.07		
	-818.92	773.91	436.32	1,804.78	404.49	334.79	15.43	139.88	229.73	116.78	205.90	252.59		3,895.68		

SUBTOTAL:

TOTAL:	-818.92	773.91	436.32	1,804.78	404.49	334.79	15.43	139.88	229.73	116.78	205.90	252.59		3,895.68		

KidsCare - REINSURANCE
For The Period Ending June 30, 2016	
RATE CODE	DESCRIPTION	JULY	AUGUST	SEPTEMBER	OCTOBER	NOVEMBER	DECEMBER	JANUARY	FEBRUARY	MARCH	APRIL	MAY	JUNE	TOTAL	
6013	KIDS 6-13 M & F NON-	161.54	203.93	36,712.84	0.01	0.00	-0.01	0.00	0.00	0.00	0.00	0.00	0.00		37,078.31		
6014	KIDS 14-19 MALE NON-	0.00	29,016.36	29,093.10	36,857.22	90,654.13	25,128.40	85.90	25,621.74	104,593.60	52,988.75	38,284.93	35.11		432,359.24		
6015	KIDS 14-19 FEMALE NO	0.00	1,274.86	5,182.91	20,265.16	13,172.36	268.82	0.00	0.00	0.00	0.00	0.00	0.00		40,164.11		
	161.54	30,495.15	70,988.85	57,122.39	103,826.49	25,397.21	85.90	25,621.74	104,593.60	52,988.75	38,284.93	35.11		509,601.66		

SUBTOTAL:

TOTAL:

161.54

30,495.15	70,988.85	57,122.39	103,826.49	25,397.21	85.90	25,621.74	104,593.60	52,988.75	38,284.93	35.11	509,601.66

6

4

110007  DES-DD - CAP MEMBER MONTHS
For The Period Ending June 30, 2016

RATE CODE

DESCRIPTION

JULY

AUGUST      SEPTEMBER

OCTOBER

NOVEMBER	DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

TOTAL

347,501.84

347,501.84

64.00

7,820.09

19.00

1,950.62

54.19

3,263.45

21,807.20

0.00

262,030.79

9.27

48,452.39

1.00

164.00

1,384.54

334.30

91.00

20.00

36.00

1000	TANF WITH MEDICARE	2.00	2.00	2.00	2.00	4.00	5.00	7.00	7.00	7.00	6.00	9.00	11.00	
1010	TANF NON-MEDICARE	643.15	641.57	646.12	649.50	648.46	646.64	649.79	655.10	651.45	661.37	664.14	662.80	
1020	TANF WITH QMB	1.00	1.00	1.00	1.00	1.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	
2100	SSI AGED WITH MEDICA	151.70	154.89	157.99	163.43	165.59	166.66	163.88	160.60	162.00	163.43	174.04	166.41	
2110	SSI AGED NON-MEDICAR	5.00	5.00	5.00	5.19	4.00	4.00	4.00	4.00	4.00	5.00	5.00	4.00	
2120	SSI AGED WITH QMB	272.31	272.62	271.31	271.53	273.47	273.79	269.17	269.00	268.17	273.30	274.58	274.20	
2200	SSI DISABLED WITH ME	1,753.65	1,745.73	1,754.42	1,769.90	1,793.19	1,805.13	1,821.01	1,828.18	1,838.54	1,874.85	1,878.03	1,944.57	
220Z	SSI DISABLED WITH 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	
2210	SSI DISABLED NON-MED	21,475.15	21,538.50	21,702.85	21,678.83	21,721.06	21,810.43	21,771.15	21,887.82	22,013.59	22,057.19	22,137.63	22,236.59	
221Z	SSI DISABLED NON-MED	0.03	0.00	0.00	0.03	0.00	0.64	0.00	0.00	4.35	4.22	0.00	0.00	
2220	SSI DISABLED WITH QM	3,977.48	3,986.67	4,014.73	4,014.04	4,014.92	4,010.25	4,042.00	4,051.30	4,066.29	4,076.82	4,103.05	4,094.84	
222Z	SSI DISABLED WITH QM	0.00	1.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	0.00	
2300	SSI BLIND WITH MEDIC	13.00	13.00	13.00	14.00	14.00	14.00	14.00	14.00	14.00	14.00	14.00	13.00	
2310	SSI BLIND NON-MEDICA	111.00	112.38	114.06	111.81	116.00	115.00	117.00	115.00	116.00	117.66	118.70	119.93	
2320	SSI BLIND WITH QMB	28.00	29.00	28.00	28.00	27.30	27.00	27.00	28.00	28.00	28.00	28.00	28.00	
8700	SSI DISABLED FREEDOM	7.00	7.00	7.00	7.00	7.00	7.00	7.00	7.00	8.00	9.00	9.00	9.00	
8710	SSI DISABLED FREEDOM	2.00	2.00	2.00	2.00	2.00	2.00	2.00	2.00	1.00	1.00	1.00	1.00	
8720	SSI DISABLED FREEDOM	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	3.00	
SUBTOTAL: TOTAL:	28,445.47	28,515.36	28,722.48	28,721.26	28,794.99	28,892.54	28,900.00	29,034.00	29,187.39	29,296.84	29,421.17	29,570.34	
	28,445.47	28,515.36	28,722.48	28,721.2	28,794.99	28,892.54	28,900.00	29,034.00	29,187.39	29,296.8	29,421.17	29,570.34	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EPD/DD EXPENDITURES
For the Period Ending June 30, 2016

EPD/DD CAPITATION-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TRIBAL	370,741.89	366,197.37	369,544.65	371,342.65	369,390.76	369,639.86	371,326.59	375,239.67	372,982.88	377,626.94	373,216.46	375,489.56	4,462,739.28	
EPD	84,945,196.47	97,607,756.74	86,404,566.22	86,818,575.78	99,193,232.58	87,521,696.46	86,043,306.40	98,880,037.83	86,041,307.17	85,586,531.41	98,900,409.02	86,260,385.67	1,084,203,001.75	
TOTAL AHCCCS LTC	85,315,938.36	97,973,954.11	86,774,110.87	87,189,918.43	99,562,623.34	87,891,336.32	86,414,632.99	99,255,277.50	86,414,290.05	85,964,158.35	99,273,625.48	86,635,875.23	1,088,665,741.03	
DES/DD	97,105,888.85	97,348,150.88	98,057,803.05	98,603,338.74	98,857,708.49	101,652,897.48	99,469,295.66	99,930,110.58	100,459,478.61	100,835,854.24	101,265,200.41	101,779,140.06	1,195,364,867.05	
TOTAL DES LTC	97,105,888.85	97,348,150.88	98,057,803.05	98,603,338.74	98,857,708.49	101,652,897.48	99,469,295.66	99,930,110.58	100,459,478.61	100,835,854.24	101,265,200.41	101,779,140.06	1,195,364,867.05	
TOTAL LTC - CAP	182,421,827.21	195,322,104.99	184,831,913.92	185,793,257.17	198,420,331.83	189,544,233.80	185,883,928.65	199,185,388.08	186,873,768.66	186,800,012.59	200,538,825.89	188,415,015.29	2,284,030,608.08	

EPD/DD FEE-FOR-SERVICE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	8,618,280.78
0.00	9,030,245.07
0.00	12,244,181.17
0.00	8,955,714.19
0.00	9,411,356.80
0.00	11,193,029.30
0.00	9,149,200.29
0.00	9,448,572.19
0.00	10,992,892.66
0.00	9,756,947.99
0.00	9,853,771.72
0.00	11,477,770.20
0.00	120,131,962.36
0.00	
	0.00	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	8,618,280.78	9,030,245.07	12,244,181.17	8,955,714.19	9,411,356.80	11,193,029.30	9,149,200.29	9,448,572.19	10,992,892.66	9,756,947.99	9,853,771.72	11,477,770.20	120,131,962.36	

EPD/DD REINSURANCE - LTC	

TOTAL AHCCCS LTC DES/DD
TOTAL DES LTC	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
	3,670,305.62
375,457.62	3,513,547.75
326,085.82	4,248,800.50
792,734.80	3,640,983.44
709,764.46	5,239,547.36
616,786.74	3,396,112.43
373,282.71	2,918,684.38
255,643.16	1,941,692.74
496,962.44	2,187,299.24
457,882.59	2,136,870.97
248,611.72	2,726,642.76
506,969.78	3,511,561.87
362,694.41	39,132,049.06
5,522,876.25	
	375,457.62	326,085.82	792,734.80	709,764.46	616,786.74	373,282.71	255,643.16	496,962.44	457,882.59	248,611.72	506,969.78	362,694.41	5,522,876.25	
TOTAL LTC - REIN	4,045,763.24	3,839,633.57	5,041,535.30	4,350,747.90	5,856,334.10	3,769,395.14	3,174,327.54	2,438,655.18	2,645,181.83	2,385,482.69	3,233,612.54	3,874,256.28	44,654,925.31	

EPD/DD SMIB/HIB-LTC	
	JUL	AUG	SEP	OCT	NOV	DEC	JAN	FEB	MAR	APR	MAY	JUN	TOTAL	
TOTAL SMIB/HIB LTC	3,116,250.30	3,135,587.40	3,128,183.70	3,118,231.90	3,139,674.00	3,156,287.10	3,604,498.00	3,581,856.00	3,624,590.50	3,537,088.30	3,598,185.80	3,623,850.50	40,364,283.50	

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.

CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTS
For the Period Ending June 30, 2016

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

TOTAL

Friday, July 08, 2016

010115	CRS FULLY INTEGRATED PLAN - CAP	13,474,971.60	13,492,632.75	13,576,771.54	13,943,462.74	13,889,830.86	19,864,340.45	14,238,273.42	14,161,860.04	14,223,154.37	14,156,915.89	14,144,609.13	14,069,050.32	173,235,873.11	
010145	CRS ACUTE SEMI INTEGRATED - CAP	122,251.86	115,316.41	116,070.08	130,768.30	127,797.18	190,317.07	138,461.10	145,302.07	144,121.20	154,143.83	147,585.85	145,170.49	1,677,305.44	
999125	CRS SEMI INTEGRATED PLAN - CAP	3,253,162.92	3,256,188.18	3,258,709.23	4,767,213.72	4,765,739.40	4,794,488.64	4,916,352.00	4,920,883.20	4,913,331.20	4,920,128.00	4,939,008.00	4,959,398.40	53,664,602.89	
999135	CRS ONLY PLAN - CAP	476,979.36	481,148.76	485,318.16	546,356.40	545,428.80	542,646.00	556,799.04	547,733.76	549,642.24	548,210.88	551,550.72	548,210.88	6,380,025.00	
	17,327,365.74	17,345,286.10	17,436,869.01	19,387,801.16	19,328,796.24	25,391,792.16	19,849,885.56	19,775,779.07	19,830,249.01	19,779,398.60	19,782,753.70	19,721,830.09	234,957,806.44	

Subtotal

999155	CRS REINSURANCE ONLY	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	934,360.25	2,963,907.95	189,912.38	3,233,117.99	1,312,151.22	1,912,964.11	1,817,804.74	1,824,544.87	21,753,325.24	
	2,189,497.55	1,498,470.16	1,869,622.81	2,006,971.21	934,360.25	2,963,907.95	189,912.38	3,233,117.99	1,312,151.22	1,912,964.11	1,817,804.74	1,824,544.87	21,753,325.24	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC CAP	29,112.95	25,266.88	26,056.47	28,258.30	28,258.30	49,375.16	27,578.53	23,263.52	23,263.52	22,432.68	22,941.90	23,235.83	329,044.04	
	29,112.95	25,266.88	26,056.47	28,258.30	28,258.30	49,375.16	27,578.53	23,263.52	23,263.52	22,432.68	22,941.90	23,235.83	329,044.04	

Subtotal

19,545,976.24	18,869,023.14	19,332,548.29	21,423,030.67	20,291,414.79	28,405,075.27	20,067,376.47	23,032,160.58	21,165,663.75	21,714,795.39	21,623,500.34	21,569,610.79	257,040,175.72	

GRAND TOTAL

CRS INTEGRATED HEALTH PLANS - MEMBER MONTHS
For the Period Ending June 30, 2016

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

TOTAL

Friday, July 08, 2016

010115	CRS FULLY INTEGRATED PLAN - MM	17,063.13	17,085.46	17,193.00	17,270.81	17,202.37	17,268.27	17,137.32	17,043.20	17,117.52	17,037.71	17,022.37	16,931.25	205,372.41	
010145	CRS ACUTE SEMI INTEGRATED - MM	174.03	164.14	165.24	168.21	164.43	179.03	172.82	181.83	180.00	193.70	184.18	181.18	2,108.79	
999125	CRS SEMI INTEGRATED PLAN - MM	6,452.00	6,458.00	6,463.00	6,467.00	6,465.00	6,504.00	6,510.00	6,516.00	6,506.00	6,515.00	6,540.00	6,567.00	77,963.00	
999135	CRS ONLY PLAN - MM	1,144.00	1,154.00	1,164.00	1,178.00	1,176.00	1,170.00	1,167.00	1,148.00	1,152.00	1,149.00	1,156.00	1,149.00	13,907.00	
	24,833.16	24,861.60	24,985.24	25,084.02	25,007.80	25,121.30	24,987.14	24,889.03	24,955.52	24,895.41	24,902.55	24,828.43	299,351.20	

Subtotal

010115	CRS FULLY INTEGRATED PLAN - KC MM	36.87	32.00	33.00	34.99	35.00	32.93	33.19	28.00	28.00	27.00	27.61	27.96	376.55	
	36.87	32.00	33.00	34.99	35.00	32.93	33.19	28.00	28.00	27.00	27.61	27.96	376.55	

Subtotal

24,870.03	24,893.60	25,018.24	25,119.01	25,042.80	25,154.23	25,020.33	24,917.03	24,983.52	24,922.41	24,930.16	24,856.39	299,727.75	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - CAPITATION AMOUNTS
For the Period Ending June 30, 2016

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

TOTAL

Friday, July 08, 2016

010700	HEALTH CHOICE INTEGRATED - CAP	0.00	0.00	-1,518.09	8,509,580.12	8,451,274.03	8,462,710.24	8,392,913.99	8,306,683.94	8,299,374.31	8,314,349.07	8,278,706.44	8,337,185.67	75,351,259.72	
010725	CENPATICO INTEGRATED - CAP	0.00	0.00	18,507.72	21,037,755.17	20,895,096.45	20,870,006.63	20,650,744.57	20,514,578.77	20,420,411.06	20,100,652.09	20,025,021.70	20,139,411.69	184,672,185.85	
078999	MERCY MARICOPA INTEGRATED - CAP	47,152,827.77	47,326,614.65	47,809,819.28	44,365,579.73	44,294,160.01	45,020,020.63	44,903,579.02	44,581,909.48	44,898,393.66	44,399,729.00	44,325,789.11	44,674,864.99	543,753,287.33	
	47,152,827.77	47,326,614.65	47,826,808.91	73,912,915.02	73,640,530.49	74,352,737.50	73,947,237.58	73,403,172.19	73,618,179.03	72,814,730.16	72,629,517.25	73,151,462.35	803,776,732.90	

Subtotal

47,152,827.77	47,326,614.65	47,826,808.91	73,912,915.02	73,640,530.49	74,352,737.50	73,947,237.58	73,403,172.19	73,618,179.03	72,814,730.16	72,629,517.25	73,151,462.35	803,776,732.90	

GRAND TOTAL

BHS INTEGRATED HEALTH PLAN - MEMBER MONTHS
For the Period Ending June 30, 2016

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

TOTAL

Friday, July 08, 2016

010700	HEALTH CHOICE INTEGRATED - MM	0.00	0.00	-1.00	5,604.33	5,566.18	5,573.46	5,527.22	5,470.36	5,465.61	5,475.75	5,451.85	5,491.07	49,624.83	
010725	CENPATICO INTEGRATED - MM	0.00	0.00	12.00	13,638.68	13,546.91	13,530.10	13,387.94	13,298.98	13,238.06	13,031.26	12,981.07	13,056.91	119,721.91	
078999	MERCY MARICOPA INTEGRATED - MM	19,430.16	19,501.43	19,702.99	19,787.96	19,758.81	20,073.60	20,020.25	19,884.25	20,022.32	19,801.82	19,767.18	19,926.80	237,677.57	
	19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	39,177.16	38,935.41	38,653.59	38,725.99	38,308.83	38,200.10	38,474.78	407,024.31	

Subtotal

19,430.16	19,501.43	19,713.99	39,030.97	38,871.90	39,177.16	38,935.41	38,653.59	38,725.99	38,308.83	38,200.10	38,474.78	407,024.31	

GRAND TOTAL