Janice K. Brewer, Governor Thomas J. Betlach, Director · 2016. 9. 9. · Janice K. Brewer, Governor Thomas J. Betlach, Director 801 East Jefferson, Phoenix, AZ 85034 PO Box 25520,

Janice K. Brewer, Governor Thomas J. Betlach, Director 801 East Jefferson, Phoenix, AZ 85034 PO Box 25520, Phoenix, AZ 85002 Phone: 602-417-4000 www.azahcccs.gov

Our first care is your health care ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

February 25, 2014 The Honorable Andy Biggs, President Arizona State Senate 1700 West Washington Phoenix, AZ 85007 The Honorable Andy Tobin, Speaker Arizona House of Representatives 1700 West Washington Phoenix, AZ 85007 SUBJECT: FY 2014 Appropriation Status Report for the Period Ended January 31, 2014 Dear President Biggs and Speaker Tobin: 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 January 31, 2014. Status Summary - As part of the FY 2015 budget request to the Governor’s Office of Strategic Planning and Budgeting, a FY 2014 rebase was prepared. AHCCCS is currently forecasting a FY 2014 Total Fund surplus of $32.3 million and a General Fund surplus of $59.2 million (not including the administrative adjustments described later in this letter). However, AHCCCS is experiencing many program changes and issues this fiscal year that have the potential to significantly decrease the projected surplus. They include:

• Impacts of the ACA on the existing caseload including woodwork of currently eligible but not enrolled members and streamlined redetermination requirements.

• Lifting of the enrollment freeze for the AHCCCS Care program effective January 1, 2014.

• Implementation of prior quarter coverage costs effective January 1, 2014. • Encounter and invoicing issues associated with the Prescription Drug Rebate Fund which

may impact the collections in that fund which are used as a state match source. • Potential Agency audit liabilities, which are detailed in the ASR.

Given these program changes and issues, for purposes of this report, projected annual expenditures equal the appropriations included in Laws 2013, First Special Session, Chapter 1. The current appropriations and projected annual expenditures now include $416,516,000 in total expenditure authority consisting of $74,964,400 in Hospital Assessment funding and $341,551,600 in federal expenditure authority for certain populations as appropriated by Laws 2013, First Special Session, Chapter 10, Section 50.

The Honorable Andy Biggs The Honorable Andy Tobin February 25, 2014 Page 2 The $59.2 million General Fund surplus consists of an administrative shortfall of $2.1 million associated with the historical underfunding of the Arizona Department of Administration Data Center requirements; a projected shortfall of $4.7 million in the ALTCS special line item; and a projected surplus of $66.0 million in the Acute Care services special line items. In December, AHCCCS administratively adjusted $126.7 million Total Fund ($40.6 million General Fund) of Fiscal Year 2013 date of service expenditures back to the Fiscal Year 2013 appropriation. This reduction to current year expenditures will allow for the shift of $40 million in General Fund from AHCCCS to the Arizona Department of Health Services as recommended by the Governor’s budget recommendation. The federal fund savings from this action will offset the projected federal funding shortfall due to increased federal spending associated with the 90% match for the ACA primary care rate increase and 100% federal match for the Indian Health Services uncompensated care waiver. Enrollment Update – January 2014 enrollment was 1,298,209 members, a 1,059 member increase over the prior month. Enrollment for February 2014 increased to 1,315,356 members, a 17,147 member increase. Childless Adult (Prop 204 Restoration) Enrollment December was the final month of the Childless Adult enrollment freeze. With the freeze lifted, childless adult enrollment increased 29,064 in January to 96,834 and another 34,798 in February to 131,632. Newly Eligible Adult Enrollment Beginning January 1, 2014 adults with income between 100-133% FPL are now eligible for Medicaid. This newly eligible population is funded with 100% federal funds until calendar year 2017. There were 1,369 new members enrolled in this category as of January 1, 2014, increasing by 1,674 members to 3,043 on February 1, 2014. KidsCare Enrollment Freeze and KidsCare II Impacts KidsCare and KidsCare II enrollment – The January 1, 2014 KidsCare enrollment was 42,684, which is comprised of 5,583 members in the state plan program and 37,101 members in the KidsCare II waiver program. In January, a significant portion of the KidsCare and KidsCare II populations were transferred to Medicaid based on the expanded eligibility to 133 percent of FPL. The remaining 2,290 KidsCare state plan members as of February 1, 2014, will continue enrollment in the frozen program. The KidsCare II program officially ended January 31, 2014. Those KidsCare II members who were not eligible for Medicaid were discontinued, but had their information sent to the Federally Facilitated Marketplace to determine eligibility for other federal programs. Tobacco Funds Revenue Update – Tobacco tax collections through January 2014 are $1.8 million less than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2014 appropriations. At

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Arizona Health Care Cost Containment System

Appropriation Status Report (ASR)

Fiscal Year 2014

Through January 31, 2014

Prepared by: Division of Business and Finance

Arizona Health Care Cost Containment SystemAppropriation Status Report

Table of Contents

• APPROPRIATED SOURCES AND USES OF FUNDS Page Summary of Appropriated Expenditures for SFY 2014 2 Appropriated Expenditures by Funding Source 3 Appropriated Revenue Received Detail Schedule 4

• FOOTNOTES 6

• CASELOAD AND EXPENDITURES BY RATE CODE 11

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

APPROPRIATION STATUS REPORT

APPROPRIATED SOURCES AND USES OF FUNDS

(A) (B) (A) - (B)EXPENDITURE PROJECTED

ANNUAL PLAN EXPENDITURES VARIANCE ANNUAL ANNUALIZEDAPPROPRIATION YTD YTD YTD EXPENDITURES VARIANCE

APPROPRIATIONS:

ADMINISTRATION

AHCCCS Operating Lump Sum 78,082,200$ 44,826,300$ 46,089,883$ (1,263,583)$ 78,082,200$ -$ AHCCCS Prop 204 Administration 8,831,800 4,515,000 4,475,414 39,587 8,831,800 - DES Eligibility 67,867,700 31,736,800 49,593,264 (17,856,464) 67,867,700 - DES Prop 204 Eligibility 25,354,100 22,177,700 11,561,785 10,615,915 25,354,100 -

TOTAL ADMINISTRATION 180,135,800 103,255,800 111,720,345 (8,464,545) 180,135,800 -

Traditional Medicaid Services 3,553,419,100 1,886,456,400 1,803,791,962 82,664,438 3,553,419,100 - Proposition 204 Services 1,433,525,400 596,770,400 536,868,785 59,901,615 1,433,525,400 - ACA Adult Expansion 65,931,900 3,164,700 859,900 2,304,800 65,931,900 - Children's Rehabilitative Services 152,350,000 85,777,900 81,122,873 4,655,027 152,350,000 - KidsCare Services 12,081,300 7,559,800 6,918,883 640,917 12,081,300 - KidsCare II 48,222,700 47,143,037 47,143,037 - 48,222,700 - ALTCS Services 1,271,574,100 722,968,500 710,092,962 12,875,538 1,271,574,100 - Disproportionate Share Payments 13,487,100 - - - 13,487,100 - Rural Hospitals 13,858,100 13,858,100 13,008,100 850,000 13,858,100 - Voluntary Political Subdivision Programs 659,808,100 452,799,279 452,799,279 - 659,808,100 -

TOTAL PROGRAMMATIC 7,224,257,800 3,816,498,116 3,652,605,782 163,892,334 7,224,257,800 -

TOTAL EXPENDITURES 7,404,393,600$ 3,919,753,916$ 3,764,326,127$ 155,427,789$ 7,404,393,600$ -$

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEMFY 2014 APPROPRIATION STATUS REPORT

For the Period Ending January 31, 2014SUMMARY OF APPROPRIATED EXPENDITURES

2

(A) (B) (A) - (B)EXPENDITURE PROJECTED

ANNUAL PLAN EXPENDITURES VARIANCE ANNUAL ANNUALIZEDAPPROPRIATION YTD YTD YTD EXPENDITURES VARIANCE

STATE - GENERAL FUND

Administrative Expenditures 54,182,700$ 31,130,600$ 32,388,625$ (1,258,025) 54,182,700$ -$ Proposition 204 - Administrative Expenditures 20,601,300 11,652,600 10,483,189 1,169,411 20,601,300 -

Programmatic ExpendituresTraditional Medicaid Services 863,439,000 482,895,400 449,673,554 33,221,846 863,439,000 - Proposition 204 Services 174,169,700 123,504,800 118,725,859 4,778,941 174,169,700 - Children's Rehabilitative Services 50,181,000 28,591,500 27,020,370 1,571,130 50,181,000 - KidsCare Services 2,549,700 1,601,500 1,449,889 151,611 2,549,700 - ALTCS Services 162,226,100 92,919,500 94,602,347 (1,682,847) 162,226,100 - DSH and Rural Hospitals 7,583,900 4,541,300 4,262,754 278,546 7,583,900 -

TOTAL GF EXPENDITURES 1,334,933,400 776,837,200 738,606,586 38,230,614 1,334,933,400 -

FEDERAL

Administrative Expenditures 90,553,900 44,730,200 62,419,509 (17,689,309) 90,553,900 - Proposition 204 - Administrative Expenditures 10,280,700 13,129,600 4,728,034 8,401,566 10,280,700 -

Programmatic ExpendituresTraditional Medicaid Services 2,347,140,900 1,203,317,900 1,207,778,772 (4,460,872) 2,347,140,900 - Proposition 204 Services 1,027,598,900 431,241,400 384,969,134 46,272,266 1,027,598,900 - ACA Adult Expansion 65,931,900 3,164,700 859,900 2,304,800 65,931,900 - Children's Rehabilitative Services 102,169,000 57,186,400 54,102,503 3,083,897 102,169,000 - KidsCare Services 8,619,300 5,312,400 4,801,201 511,199 8,619,300 - ALTCS Services and Nursing Facility Assessment 828,232,100 470,357,000 464,753,096 5,603,904 828,232,100 - DSH and Rural Hospitals 19,761,300 9,316,800 8,745,346 571,454 19,761,300 - Voluntary Political Subdivision Programs - See Note 5 438,256,700 304,289,358 304,289,358 - 438,256,700 - KidsCare II 37,772,000 36,830,448 36,830,448 - 37,772,000 -

TOTAL FEDERAL EXPENDITURES 4,976,316,700 2,578,876,205 2,534,277,301 44,598,905 4,976,316,700 -

COUNTY

Administrative Expenditures Proposition 204 - BNCF 3,303,900 1,910,500 825,975 1,084,525 3,303,900 - Programmatic Expenditures

Traditional Medicaid Services Acute Care 50,497,200 29,456,700 29,456,700 - 50,497,200 - ALTCS Services 244,696,100 140,156,500 136,011,359 4,145,141 244,696,100 -

TOTAL COUNTY EXPENDITURES 298,497,200 171,523,700 166,294,034 5,229,666 298,497,200 -

TOBACCO FUNDSProgrammatic Expenditures

Traditional Medicaid Services Acute Care - Medically Needy 37,389,300 22,177,500 22,643,488 (465,988) 37,389,300 - Proposition 204 Services - Emergency Health Services 18,320,100 10,909,100 10,701,223 207,877 18,320,100 - Proposition 204 Services - Proposition 204 Protection 38,472,300 22,819,900 22,472,569 347,331 38,472,300 - Proposition 204 Services - ATLSF 100,000,000 - - - 100,000,000 -

TOTAL TOBACCO EXPENDITURES 194,181,700 55,906,500 55,817,280 89,220 194,181,700 -

OTHERAdministrative Expenditures

HCG 1,097,200 634,500 787,941 (153,441) 1,097,200 - Prescription Drug Rebate Program 116,100 67,800 87,073 (19,273) 116,100 -

Programmatic ExpendituresAcute Care - Prescription Drug Rebate Program State Match 88,397,500 51,565,200 51,565,208 (8) 88,397,500 - Acute Care - Prescription Drug Rebate Program Federal Authority 166,318,500 97,019,300 42,070,745 54,948,555 166,318,500 - Long Term Care - Prescription Drug Rebate Program State Match 6,497,300 3,708,700 3,790,092 (81,392) 6,497,300 - Long Term Care - Prescription Drug Rebate Program Federal Authority 12,224,500 6,977,800 753,710 6,224,090 12,224,500 - Proposition 204 Services - Hospital Assessment 74,964,400 8,295,200 - 8,295,200 74,964,400 - Traditional Medicaid Services - TPL 194,700 - 575,944 (575,944) 194,700 - ALTCS Services - TPL - - 563,422 (563,422) - - ALTCS Services - Nursing Facility Assessment 17,698,000 8,849,000 9,618,937 (769,937) 17,698,000 - KidsCare Services Premiums 912,300 645,900 667,794 (21,894) 912,300 - Freedom to Work Premiums 42,000 24,400 27,551 (3,151) 42,000 - Voluntary Political Subdivision Programs - See Note 5 221,551,400 148,509,921 148,509,921 - 221,551,400 - KidsCare II 10,450,700 10,312,590 10,312,590 - 10,450,700 -

TOTAL OTHER EXPENDITURES 600,464,600 336,610,311 269,330,926 67,279,385 600,464,600 -

TOTAL

Administrative Expenditures 180,135,800 103,255,800 111,720,345 (8,464,545) 180,135,800 - Acute Care 5,952,683,700 3,093,529,616 2,942,512,820 151,016,797 5,952,683,700 - Long Term Care 1,271,574,100 722,968,500 710,092,962 12,875,538 1,271,574,100 - TOTAL EXPENDITURES 7,404,393,600$ 3,919,753,916$ 3,764,326,127$ 155,427,789$ 7,404,393,600$ -$


For the Period Ending January 31, 2014APPROPRIATED EXPENDITURES BY FUNDING SOURCE

3

BUDGET BUDGETYTD

GENERAL FUND:Traditional Medicaid Services & Administrative 975,386,600$ 547,158,800$ 513,345,303$ Proposition 204 Services & Administrative 194,771,000 135,157,400 128,983,086 KidsCare Services 2,549,700 1,601,500 1,449,889 ALTCS Services 162,226,100 92,919,500 94,602,347 TOTAL 1,334,933,400 776,837,200 738,380,625

FEDERAL:Acute & Administrative 4,139,465,300 2,103,206,805 2,153,635,242 KidsCare Services 8,619,300 5,312,400 5,812,240 ALTCS Services 828,232,100 470,357,000 466,853,123 TOTAL 4,976,316,700 2,578,876,205 2,626,300,605

COUNTY:Acute & Administrative 53,801,100 31,367,200 31,828,827 ALTCS Services 244,696,100 140,156,500 142,739,401 TOTAL 298,497,200 171,523,700 174,568,228

TOBACCO FUNDS:Traditional Medicaid Services 37,389,300 22,177,500 22,643,488 Proposition 204 Services 156,792,400 33,729,000 33,173,792 TOTAL 194,181,700 55,906,500 55,817,280

OTHER:Administrative 1,213,300 702,300 875,014 Acute Care - Prescription Drug Rebate Program 254,716,000 148,584,500 93,635,954 Long Term Care - Prescription Drug Rebate Program 18,721,800 10,686,500 4,543,801 Hospital Assessment 74,964,400 8,295,200 - ALTCS - Nursing Facility Assessment 17,698,000 8,849,000 8,445,923 Acute TPL - Note 1 194,700 - 575,944 LTC TPL - Note 1 - - 563,422 KidsCare TPL - Note 1 - - 1,921 Member Premiums - CHIP 912,300 645,900 382,448 Member Premiums - Freedom to Work 42,000 24,400 27,551 Voluntary Political Subdivision - State Match 232,002,100 158,822,511 146,607,963 TOTAL 600,464,600 336,610,311 255,659,941

TOTAL REVENUE 7,404,393,600$ 3,919,753,916$ 3,850,726,679$

RECEIPTSYTD


APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULEFor the Period Ending January 31, 2014

4

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEMARIZONA HEALTH CARE COST CONTAINMENT SYSTEM


FOOTNOTES

Note 1: Third Party Liability Collections: January 2014 January 2013 July 1, 2013 July 1, 2012 Gross Collections: January 31, 2014 January 31, 2013 Acute 707,824$ 1,082,174$ 5,338,370$ 4,485,193$ LTC 254,564 643,455 2,321,809 3,307,395 KidsCare 1,531 - 10,612 27,461

Total TPL Collections 963,919$ 1,725,629$ 7,670,791$ 7,820,049$

AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets: Acute 74,577$ 185,340$ 575,944$ 743,769$ LTC 59,340 149,101 563,422 766,179 KidsCare 159 - 1,921 4,650

Total Expenditure Offsets 134,076$ 334,441$ 1,141,287$ 1,514,598$

FY 14 TotalNote 2: Authorized Positions 1,032.2

Actual Positions as of January 31, 2014 941.4


For the Period Ending January 31, 2014

6

Note 3: Intergovernmental Service Agreement - State of Hawaii:

Beginning Balance July 1, 2013 2,060,050$

Revenues 3,777,880 Transfers-In 147,250 Total Revenues 3,925,130

Expenditures 3,341,567 Transfers-out 519,180 Total Expenditures 3,860,747

Ending Balance January 31, 2014 2,124,433$

Note 4:

Description Amount

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



Summary of HHS Office of Inspector General Questioned Costs and CMS Deferrals and Disallowances Liabilities.

Schedule of Outstanding LiabilitiesAs of January 31, 2014

Type

Of the $2,124,433 ending balance, $933,468 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through February 2014.

7

Note 5:

State Match Federal Total

DSH Voluntary 6,301,903$ 12,309,751$ 18,611,653$ GME Voluntary - - - Safety Net Care Pool 58,697,017 125,897,836 184,594,853 City of Phoenix Hospital Assessment - SNCP 74,530,842 146,882,276 221,413,118

Subtotal Voluntary Political Subdivision - Hospital 139,529,762$ 285,089,862$ 424,619,625$

City of Phoenix Hospital Assessment - Coverage Expansion 8,980,159 19,199,495 28,179,654

Total Voluntary Political Subdivision Program Expenditures 148,509,921$ 304,289,358$ 452,799,279$

Note 6:

Original RevisedAppropriation Increase Appropriation

DSH Voluntary 28,457,100$ 14,860,900 43,318,000$ GME Voluntary 160,184,900 26,305,200 186,490,100 Safety Net Care Pool 166,000,000 264,000,000 430,000,000

Subtotal Voluntary Political Subdivision Programs 354,642,000$ 305,166,100$ 659,808,100$

KidsCare II 26,825,700 21,397,000 48,222,700 Nursing Facility Assessment * 51,567,500 - 51,567,500

Total Voluntary Appropriations 433,035,200$ 326,563,100$ 759,598,300$

* The Nursing Facility Assessment amount is included as expenditure authority in the ALTCS annual appropriation total.

Note 7: Beginning October 1, 2013, AHCCCS implemented an integrated model for certain CRS members where all care is coordinated under one health plan. However, the behavioral health care component is not included in the expenditures in the AHCCCS Appropriations Status Report. As of January 31, 2014, $5,335,009 Total Fund ($1,748,282 General Fund) of behavioral health services were paid to the integrated contractor.

Laws 2013, First Special Session, Chapter 1, Section 9 provides that any voluntary political subdivision monies received are appropriated to the administration. The following schedule reconciles the initial total fund expenditure authority to the current amount.



Summary of Voluntary Political Subdivision Contribution Expenditures.As of January 31, 2014

Expenditures

8

Note 8:

General AHCCCS ALTCS TotalFund Fund Fund Fund

Traditional Medicaid Services 33,798,296$ 66,468,379$ -$ 100,266,675$ Proposition 204 Services 5,970,141 11,671,072 - 17,641,214 Children's Rehabilitative Services 882,461 1,746,675 - 2,629,137 Long Term Care - - 6,139,779 6,139,779

Total 40,650,899$ 79,886,126$ 6,139,779$ 126,676,804$



FY 2013 YTD January 31, 2014

The following is a summary of a $126,676,804 Total Fund ($40,650,899 General Fund) administrative adjustment transaction processed in December 2013 transferring expenditures with dates of service prior to June 30, 2013 previously recorded in Fiscal Year 2014 back to Fiscal Year 2013.

9

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEMARIZONA HEALTH CARE COST CONTAINMENT SYSTEM


CASELOAD AND EXPENDITURES BY RATE CODE

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

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEMEXPENDITURE SUMMARYFor the Period Ending January 31, 2014

TOTAL

TITLE XIX TRADITIONALCAPITATION - ACUTE 200,449,004 199,644,742 200,643,455 205,772,353 202,658,292 203,214,634 200,852,988 0 0 0 0 0 1,413,235,468

CAPITATION - CHILD EXPANSION 0 0 0 0 0 0 896,162 0 0 0 0 0 896,162

CAPITATION - RURAL HOSPITAL 0 0 0 0 0 0 9,192,729 0 0 0 0 0 9,192,729

CAPITATION - LTC 158,655,252 168,402,215 159,900,180 164,798,306 180,403,126 165,594,367 165,792,868 0 0 0 0 0 1,163,546,315

MENTAL HEALTH - CHILD 22,591,491 22,565,423 22,740,340 20,500,274 20,465,697 20,280,579 20,027,813 0 0 0 0 0 149,171,617

MENTAL HEALTH - ADULT 22,354,793 22,375,207 22,519,813 23,491,108 23,509,031 23,370,730 22,268,509 0 0 0 0 0 159,889,191

MENTAL HEALTH - GENERAL 12,683,652 12,695,235 12,777,281 12,753,054 12,762,784 12,660,723 12,565,662 0 0 0 0 0 88,898,391

MENTAL HEALTH - CMDP 13,387,362 13,436,184 13,559,736 14,783,798 14,979,999 15,068,700 15,175,669 0 0 0 0 0 100,391,448

CHILDREN'S REHAB SERVICES 8,851,077 8,876,300 8,850,776 12,018,118 6,652,247 0 3,330,353 0 0 0 0 0 48,578,871

FEE FOR SERVICE - ACUTE 43,496,880 37,262,084 37,216,880 44,705,271 33,472,195 39,396,728 31,996,401 0 0 0 0 0 267,546,439

FEE FOR SERVICE - CHILD EXPAN 0 0 0 0 0 0 17,829 0 0 0 0 0 17,829

EMERGENCY SERVICES - FEDERAL 7,399,807 6,516,975 5,806,452 7,455,773 5,955,070 6,979,018 4,620,071 0 0 0 0 0 44,733,166

FFS - FAMILY PLANNING 5,892 6,487 6,416 7,060 6,742 5,463 2,310 0 0 0 0 0 40,369

FFS MEDICAID IN PUBLIC SCHOOLS 970,555 218,211 104,569 468,389 389,220 571,602 607,853 0 0 0 0 0 3,330,400

QMB - FEE FOR SERVICE 226,696 369,590 185,145 269,661 235,565 192,484 264,177 0 0 0 0 0 1,743,318

PINAL COUNTY INMATES FFS 0 0 0 8,570 0 846 4,409 0 0 0 0 0 13,825

COCONINO COUNTY INMATES FFS 1,030 0 0 0 0 0 0 0 0 0 0 0 1,030

COCHISE COUNTY INMATES FFS 0 0 0 0 2 0 0 0 0 0 0 0 2

PIMA COUNTY INMATES FFS 1,048 5,823 5,261 2,869 917 3,746 2,873 0 0 0 0 0 22,538

FEE FOR SERVICE - LTC 10,485,326 8,959,217 9,328,364 10,675,242 8,452,759 10,115,761 9,069,758 0 0 0 0 0 67,086,426

LFFS MEDICAID IN PUBLIC SCHOOLS 1,709,095 560,146 204,506 826,877 569,725 976,791 1,209,131 0 0 0 0 0 6,056,271

REINSURANCE - ACUTE 9,455,316 6,508,242 11,837,298 10,628,911 10,662,231 12,094,180 8,116,469 0 0 0 0 0 69,302,646

REINSURANCE - LTC 4,057,738 4,339,447 5,609,462 4,026,724 3,970,224 4,482,337 1,684,031 0 0 0 0 0 28,169,964

SMIB - ACUTE 9,504,102 9,515,816 9,598,066 9,607,827 9,623,371 9,739,723 9,680,246 0 0 0 0 0 67,269,151

HIB - ACUTE 261,627 262,915 260,425 272,703 270,459 267,181 257,157 0 0 0 0 0 1,852,467

Q1 1,643,501 1,657,884 1,654,489 1,672,478 1,692,056 1,686,914 1,678,035 0 0 0 0 0 11,685,356

SMIB - LTC 2,715,365 2,719,103 2,738,494 2,743,917 2,746,049 2,763,811 2,764,065 0 0 0 0 0 19,190,805

HIB - LTC 269,497 273,070 272,136 281,118 278,161 279,927 274,240 0 0 0 0 0 1,928,149

531,176,104 527,170,317 525,819,545 547,770,402 539,755,923 529,746,245 522,351,807 0 0 0 0 0SUBTOTAL 3,723,790,342

TITLE XIX PROP 204CAPITATION - ACUTE 60,227,970 59,864,693 59,274,299 59,603,463 58,448,318 57,576,274 98,730,216 0 0 0 0 0 453,725,234

CAPITATION - RURAL HOSPITAL 0 0 0 0 0 0 3,213,545 0 0 0 0 0 3,213,545

MENTAL HEALTH - CHILD 257,893 257,463 260,124 239,439 237,794 239,285 225,948 0 0 0 0 0 1,717,947

MENTAL HEALTH - ADULT 16,699,322 16,574,121 16,595,855 17,288,291 17,155,792 17,025,222 18,635,612 0 0 0 0 0 119,974,214

MENTAL HEALTH - GENERAL 9,474,854 9,403,817 9,416,148 9,385,615 9,313,683 9,223,066 10,515,693 0 0 0 0 0 66,732,876

MENTAL HEALTH - CMDP 996 996 996 1,108 1,108 1,113 1,126 0 0 0 0 0 7,446

11


ARIZONA HEALTH CARE COST CONTAINMENT SYSTEMEXPENDITURE SUMMARYFor the Period Ending January 31, 2014

TOTAL

CHILDREN'S REHAB SERVICES 216,773 223,793 225,808 229,332 29,941 0 16,546 0 0 0 0 0 942,194

FEE FOR SERVICE - ACUTE 12,157,358 10,471,712 10,820,094 11,762,694 8,895,282 10,378,646 9,048,138 0 0 0 0 0 73,533,924

EMERGENCY SERVICES - FEDERAL 1,237,456 1,284,836 1,085,038 1,096,922 943,325 1,132,703 854,356 0 0 0 0 0 7,634,636

FFS MEDICAID IN PUBLIC SCHOOLS 8,486 1,411 1,133 5,192 3,182 4,987 4,743 0 0 0 0 0 29,135

INPATIENT INMATES FFS 0 0 -323 0 0 0 0 0 0 0 0 0 -323

PIMA COUNTY INMATES FFS 0 0 0 0 0 0 1,013 0 0 0 0 0 1,013

PINAL COUNTY INMATES FFS 43 4,240 9,286 1,194 0 0 0 0 0 0 0 0 14,763

REINSURANCE - ACUTE 1,769,509 1,327,774 1,906,059 2,008,985 1,140,886 1,096,849 980,130 0 0 0 0 0 10,230,193

SMIB - ACUTE 3,788,779 3,832,781 3,846,627 3,898,048 3,892,919 3,845,556 3,852,372 0 0 0 0 0 26,957,080

HIB - ACUTE 1,610 2,492 2,051 2,051 2,051 2,051 1,981 0 0 0 0 0 14,287

105,841,050 103,250,128 103,443,197 105,522,335 100,064,283 100,525,752 146,081,419 0 0 0 0 0SUBTOTAL 764,728,163

TITLE XIX ACA ADULT EXPANSIONCAPITATION - NEWLY ELIGIBLE 0 0 0 0 0 0 1,057,213 0 0 0 0 0 1,057,213

FEE FOR SERVICE - NEWLY ELIG 0 0 0 0 0 0 31,566 0 0 0 0 0 31,566

0 0 0 0 0 0 1,088,779 0 0 0 0 0SUBTOTAL 1,088,779

TOTAL TITLE XIX 637,017,154 630,420,444 629,262,741 653,292,736 639,820,206 630,271,997 669,522,005 0 0 0 0 0 4,489,607,284

TITLE XXI KIDSCAREKidsCare - CAPITATION 5,574,070 5,580,461 5,699,832 6,321,867 6,527,983 6,220,402 4,676,406 0 0 0 0 0 40,601,022

KidsCare - FEE FOR SERVICE 136,548 165,279 164,031 261,413 155,848 177,265 124,301 0 0 0 0 0 1,184,685

KidsCare - MENTAL HEALTH 1,186,857 1,178,398 1,214,076 1,635,249 1,762,333 1,697,021 1,560,489 0 0 0 0 0 10,234,423

KidsCare - REINSURANCE 133,945 120,710 134,819 157,077 123,186 306,693 130,153 0 0 0 0 0 1,106,584

KidsCare - CHILD REHAB SERVICES 326,763 335,153 347,219 366,299 24,819 0 11,819 0 0 0 0 0 1,412,072

7,358,181 7,380,002 7,559,977 8,741,906 8,594,170 8,401,381 6,503,169 0 0 0 0 0TOTAL TITLE XXI 54,538,785

GRAND TOTAL 644,375,335 637,800,446 636,822,718 662,034,642 648,414,375 638,673,377 676,025,174 0 0 0 0 0 4,544,146,069

12

ACUTE CAPITATION - AMOUNTSFor The Period Ending January 31, 2014

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

1003 TANF 06-13 M & F WIT 229.49 229.49 229.49 212.12 212.12 212.12 212.12 0.00 0.00 0.00 0.00 0.00 1,536.95

1004 TANF 14-20 MALE WITH 58.87 140.38 140.38 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 339.63

1005 TANF 14-20 FEMALE WI 668.89 668.89 433.39 197.56 197.56 938.78 938.91 0.00 0.00 0.00 0.00 0.00 4,043.98

1006 TANF 21-44 MALE WITH 15,719.67 15,772.84 14,036.35 13,760.49 14,967.24 14,786.16 14,492.21 0.00 0.00 0.00 0.00 0.00 103,534.96

1007 TANF 21-44 FEMALE WI 57,047.15 56,596.85 59,660.46 61,087.18 61,067.52 61,395.14 59,154.82 0.00 0.00 0.00 0.00 0.00 416,009.12

1008 TANF 45-64 M & F WIT 60,182.52 61,150.65 58,021.63 59,138.19 58,478.63 59,189.35 59,792.37 0.00 0.00 0.00 0.00 0.00 415,953.34

1009 TANF 65+ M & F WITH 11,071.32 12,871.11 12,889.96 15,692.00 17,395.38 17,341.63 17,578.52 0.00 0.00 0.00 0.00 0.00 104,839.92

100D TANF 14-20 MALE WITH 94.86 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 94.86

100F TANF 21-44 MALE WITH 560.82 1,044.15 47.11 385.42 255.11 614.85 1,576.36 0.00 0.00 0.00 0.00 0.00 4,483.82

100G TANF 21-44 FEMALE WI 1,553.35 1,744.88 1,332.76 1,602.73 1,008.56 557.42 2,138.75 0.00 0.00 0.00 0.00 0.00 9,938.45

100H TANF 44-64 M & F WIT 1,817.05 269.79 601.44 657.09 0.00 2,636.61 812.71 0.00 0.00 0.00 0.00 0.00 6,794.69

100J TANF 65+ M & F WITH 10.97 0.00 0.00 14.14 204.62 0.00 0.00 0.00 0.00 0.00 0.00 0.00 229.73

1011 TANF <1 M & F NON-ME 7,229,363.76 7,172,332.93 7,221,252.73 6,838,376.22 6,783,587.52 6,821,075.50 6,677,906.27 0.00 0.00 0.00 0.00 0.00 48,743,894.93

1012 TANF 01-05 M & F NON 8,894,587.91 8,845,596.20 8,789,976.35 9,355,258.58 9,243,240.98 9,004,688.94 8,831,181.45 0.00 0.00 0.00 0.00 0.00 62,964,530.41

1013 TANF 06-13 M & F NON 12,865,660.76 12,938,207.36 12,976,296.37 13,868,384.81 13,776,360.26 13,584,106.02 13,456,544.43 0.00 0.00 0.00 0.00 0.00 93,465,560.01

1014 TANF 14-20 MALE NON- 3,475,265.44 3,509,672.68 3,516,967.04 3,907,946.35 3,902,882.55 3,881,123.18 3,871,326.90 0.00 0.00 0.00 0.00 0.00 26,065,184.14

1015 TANF 14-20 FEMALE NO

6,613,144.57 6,621,350.58 6,630,564.18 7,094,196.36 7,091,596.16 7,050,112.28 6,997,954.10 0.00 0.00 0.00 0.00 0.00 48,098,918.23

1016 TANF 21-44 MALE NON- 2,985,909.18 2,981,450.26 2,975,153.18 3,023,836.44 2,986,944.66 2,924,443.51 2,869,933.99 0.00 0.00 0.00 0.00 0.00 20,747,671.22


19,346,230.92 19,466,656.56 19,506,993.46 19,862,448.93 19,655,467.85 19,301,912.30 18,880,696.48 0.00 0.00 0.00 0.00 0.00 136,020,406.50

1018 TANF 45-64 M & F NON 6,305,591.04 6,362,825.58 6,357,277.70 6,543,669.07 6,505,980.76 6,432,193.06 6,417,775.73 0.00 0.00 0.00 0.00 0.00 44,925,312.94

1019 TANF 65+ M & F NON-M 14,620.05 15,771.28 16,549.51 18,404.67 16,185.99 14,085.73 14,371.30 0.00 0.00 0.00 0.00 0.00 109,988.53

101A TANF < 1 M & F NON-M 384,054.68 383,675.61 381,720.76 446,521.01 376,551.35 410,119.92 460,083.02 0.00 0.00 0.00 0.00 0.00 2,842,726.35

101B TANF 01-05 M & F NON 186,694.63 204,841.58 182,955.74 182,832.50 156,685.10 164,583.04 199,342.69 0.00 0.00 0.00 0.00 0.00 1,277,935.28

101C TANF 06-13 M & F NON 213,681.11 231,132.76 220,319.67 200,601.09 177,718.75 192,557.08 239,775.68 0.00 0.00 0.00 0.00 0.00 1,475,786.14

101D TANF 14-20 MALE NON- 122,752.22 128,106.00 122,670.20 119,659.66 94,744.33 114,855.25 149,125.81 0.00 0.00 0.00 0.00 0.00 851,913.47

101E TANF 14-20 FEMALE NO

193,842.10 204,175.00 202,384.36 191,189.26 164,347.41 163,985.58 224,235.13 0.00 0.00 0.00 0.00 0.00 1,344,158.84

101F TANF 21-44 MALE NON- 158,274.41 176,975.17 163,536.14 165,111.18 134,633.51 136,198.08 187,902.53 0.00 0.00 0.00 0.00 0.00 1,122,631.02

101G TANF 21-44 FEMALE NO

664,817.99 737,283.34 641,501.97 623,020.77 570,175.98 574,343.09 721,687.30 0.00 0.00 0.00 0.00 0.00 4,532,830.44

101H TANF 44-64 M & F NON 163,531.38 173,330.91 167,571.39 186,411.74 177,533.65 187,345.19 271,260.69 0.00 0.00 0.00 0.00 0.00 1,326,984.95

101J TANF 65+ N & F NON-M 161.67 2,304.62 1,597.79 479.98 0.00 84.87 1,167.01 0.00 0.00 0.00 0.00 0.00 5,795.94

1026 TANF 21-44 MALE WITH 654.61 654.61 389.79 418.99 271.80 145.80 36.62 0.00 0.00 0.00 0.00 0.00 2,572.22

1027 TANF 21-44 FEMALE WI 1,722.84 1,345.77 1,227.06 1,440.00 2,202.84 2,651.69 3,232.71 0.00 0.00 0.00 0.00 0.00 13,822.91

1028 TANF 45-64 M & F WIT 4,955.23 4,241.67 4,670.86 4,459.41 4,712.11 3,551.35 4,338.26 0.00 0.00 0.00 0.00 0.00 30,928.89

1029 TANF 65+ M & F WITH 0.00 0.00 374.27 379.15 379.04 379.04 691.49 0.00 0.00 0.00 0.00 0.00 2,202.99

102F TANF 21-44 MALE WITH 0.00 0.00 0.00 0.00 0.00 0.00 256.26 0.00 0.00 0.00 0.00 0.00 256.26

102G TANF 21-44 FEMALE WI 0.00 0.00 0.00 0.00 144.41 103.29 0.00 0.00 0.00 0.00 0.00 0.00 247.70

13



102H TANF 44-64 M & F WIT 95.27 58.07 27.36 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 180.70

2100 SSI AGED WITH MEDICA

549,289.58 546,902.63 551,500.06 558,098.44 570,980.82 583,835.82 599,178.98 0.00 0.00 0.00 0.00 0.00 3,959,786.33

210Z SSI AGED WITH MEDICA

18,261.09 18,275.74 24,819.16 28,829.02 17,691.25 19,182.44 22,188.28 0.00 0.00 0.00 0.00 0.00 149,246.98

2110 SSI AGED NON-MEDICAR

3,786,149.56 3,800,856.32 3,806,441.52 3,912,882.08 3,956,740.74 3,955,142.06 3,991,212.81 0.00 0.00 0.00 0.00 0.00 27,209,425.09

211Z SSI AGED NON-MEDICAR

92,237.69 82,118.56 89,857.17 96,868.20 119,886.60 98,219.23 166,920.54 0.00 0.00 0.00 0.00 0.00 746,107.99

2120 SSI AGED WITH QMB 2,623,428.50 2,632,215.71 2,635,975.40 2,692,672.44 2,686,807.71 2,683,490.78 2,685,198.80 0.00 0.00 0.00 0.00 0.00 18,639,789.34

212Z SSI AGED WITH QMB PP

8,554.29 9,953.21 9,574.87 7,751.74 5,331.91 7,849.04 11,642.66 0.00 0.00 0.00 0.00 0.00 60,657.72

2200 SSI DISABLED WITH ME

489,792.37 494,327.71 493,661.64 500,811.09 525,363.57 544,599.95 555,110.76 0.00 0.00 0.00 0.00 0.00 3,603,667.09

220Z SSI DISABLED WITH ME

37,298.53 34,435.49 29,491.24 32,318.02 24,272.69 23,957.63 26,550.03 0.00 0.00 0.00 0.00 0.00 208,323.63

2210 SSI DISABLED NON-MED

42,831,519.12 42,949,504.06 43,075,272.73 44,431,098.91 44,290,308.53 44,398,987.93 44,278,631.98 0.00 0.00 0.00 0.00 0.00 306,255,323.26

221Z SSI DISABLED NON-MED

1,181,855.92 1,231,722.61 1,070,534.27 1,105,561.10 1,018,127.59 1,017,875.48 1,018,198.79 0.00 0.00 0.00 0.00 0.00 7,643,875.76

2220 SSI DISABLED WITH QM

3,654,245.57 3,665,758.22 3,675,070.60 3,735,310.69 3,721,739.15 3,717,148.04 3,706,560.55 0.00 0.00 0.00 0.00 0.00 25,875,832.82

222Z SSI DISABLED WITH QM

3,177.35 1,709.34 2,341.28 1,900.55 4,292.79 2,654.41 1,049.84 0.00 0.00 0.00 0.00 0.00 17,125.56

2300 SSI BLIND WITH MEDIC 2,793.69 2,793.69 2,793.69 2,939.04 3,779.55 4,005.56 4,005.56 0.00 0.00 0.00 0.00 0.00 23,110.78

230Z SSI BLIND WITH MEDIC 0.00 0.00 0.00 1,017.27 0.00 0.00 332.99 0.00 0.00 0.00 0.00 0.00 1,350.26

2310 SSI BLIND NON-MEDICA

301,691.09 301,196.54 301,393.83 312,986.11 320,313.22 313,126.34 311,486.42 0.00 0.00 0.00 0.00 0.00 2,162,193.55

231Z SSI BLIND NON-MEDICA

8,838.50 8,140.91 7,472.75 5,127.07 1,039.93 3,603.76 11,076.42 0.00 0.00 0.00 0.00 0.00 45,299.34

2320 SSI BLIND WITH QMB 29,653.61 29,566.84 29,887.45 30,152.87 30,089.42 30,286.51 29,991.25 0.00 0.00 0.00 0.00 0.00 209,627.95

232Z SSI BLIND WITH QMB P 0.00 0.00 0.00 0.00 5.93 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.93

4303 SOBRA CHILD 06-13 M 0.00 55.37 107.28 102.73 102.73 102.73 102.73 0.00 0.00 0.00 0.00 0.00 573.57

4304 SOBRA CHILD 14-20 MA 0.00 122.68 122.68 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 245.36

4305 SOBRA CHILD 14-20 FE 235.50 235.50 235.50 741.22 741.22 741.22 741.22 0.00 0.00 0.00 0.00 0.00 3,671.38

430C SOBRA CHILD 06-13 M 0.00 27.89 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 27.89

4311 SOBRA CHILD <1 M & F 15,751,099.36 15,616,391.80 15,612,057.76 14,744,869.22 14,616,612.35 14,702,157.94 14,501,001.22 0.00 0.00 0.00 0.00 0.00 105,544,189.65

4312 SOBRA CHILD 01-05 M 9,982,539.92 10,053,648.98 10,052,460.91 10,769,308.69 10,631,951.86 10,503,747.34 10,396,270.14 0.00 0.00 0.00 0.00 0.00 72,389,927.84

4313 SOBRA CHILD 06-13 M 12,539,105.25 12,625,970.92 12,725,260.75 13,793,496.18 13,739,101.77 13,624,722.38 13,498,595.24 0.00 0.00 0.00 0.00 0.00 92,546,252.49

4314 SOBRA CHILD 14-20 MA 4,344,662.86 4,372,584.69 4,381,679.31 4,781,270.38 4,726,213.37 4,665,944.50 4,595,864.35 0.00 0.00 0.00 0.00 0.00 31,868,219.46

4315 SOBRA CHILD 14-20 FE 6,615,405.98 6,675,192.86 6,705,750.70 7,225,593.30 7,133,739.15 6,974,776.03 6,833,747.56 0.00 0.00 0.00 0.00 0.00 48,164,205.58

431A SOBRA CHILD < 1 M & 534,715.97 638,359.56 482,802.70 575,909.29 538,764.00 505,413.39 694,068.41 0.00 0.00 0.00 0.00 0.00 3,970,033.32

431B SOBRA CHILD 01-05 M 250,169.54 266,484.95 240,527.79 254,668.09 204,351.99 213,661.10 260,937.11 0.00 0.00 0.00 0.00 0.00 1,690,800.57

431C SOBRA CHILD 6-13 M&F

234,679.10 273,433.77 240,520.22 246,443.60 197,965.17 204,692.36 258,469.66 0.00 0.00 0.00 0.00 0.00 1,656,203.88

431D SOBRA CHILD 14-20 MA 181,081.54 209,779.18 177,075.73 188,085.49 153,797.71 159,714.10 190,574.87 0.00 0.00 0.00 0.00 0.00 1,260,108.62

431E SOBRA CHILD 14-20 FE 207,479.27 242,222.75 207,315.16 215,087.78 183,092.30 179,881.69 235,013.44 0.00 0.00 0.00 0.00 0.00 1,470,092.39

5007 SOBRA PREG 21-44 FEM

13,046.72 10,862.92 11,672.57 12,261.48 11,931.31 11,853.93 10,392.32 0.00 0.00 0.00 0.00 0.00 82,021.25


378.10 378.10 0.00 348.74 348.74 348.74 348.74 0.00 0.00 0.00 0.00 0.00 2,151.16

500G SOBRA PREG 21-44 FEM

676.46 554.85 510.15 320.24 356.42 668.63 477.50 0.00 0.00 0.00 0.00 0.00 3,564.25

14




0.00 86.38 195.48 186.22 163.45 288.01 121.85 0.00 0.00 0.00 0.00 0.00 1,041.39


802,733.04 815,293.71 828,493.81 840,526.11 801,056.76 782,117.38 757,449.57 0.00 0.00 0.00 0.00 0.00 5,627,670.38


2,628,666.11 2,688,219.10 2,669,378.45 2,723,820.00 2,669,317.82 2,593,854.18 2,554,125.61 0.00 0.00 0.00 0.00 0.00 18,527,381.27


6,392.12 6,694.71 5,595.68 6,286.61 6,045.35 7,786.66 7,010.02 0.00 0.00 0.00 0.00 0.00 45,811.15

501C SOBRA PREG 09-13 FEM

0.00 0.00 0.00 0.00 69.98 0.00 0.00 0.00 0.00 0.00 0.00 0.00 69.98

501E SOBRA PREG 14-20 FEM

78,722.28 85,364.79 73,449.38 74,433.21 65,933.87 68,539.99 86,726.83 0.00 0.00 0.00 0.00 0.00 533,170.35


263,114.76 285,922.40 236,919.23 259,703.61 205,264.23 227,860.52 262,304.88 0.00 0.00 0.00 0.00 0.00 1,741,089.63

501H SOBRA PREG 45-64 FEM

229.50 273.63 182.42 773.07 190.00 1,243.01 348.60 0.00 0.00 0.00 0.00 0.00 3,240.23


1,323.91 1,156.48 972.94 954.12 488.61 488.61 647.98 0.00 0.00 0.00 0.00 0.00 6,032.65


0.00 0.00 0.00 0.00 0.00 0.00 245.08 0.00 0.00 0.00 0.00 0.00 245.08

5500 SOBRA FPS FEMALE WIT

28.12 28.12 13.37 13.09 13.09 0.00 0.00 0.00 0.00 0.00 0.00 0.00 95.79


65,325.95 66,257.69 67,842.91 63,357.10 63,229.25 59,501.29 -1,028.65 0.00 0.00 0.00 0.00 0.00 384,485.54

180,095,224.55SUBTOTAL: 181,057,558.93 180,756,601.39 187,022,677.30 185,223,747.65 184,016,386.56 183,201,415.56 0.00 0.00 0.00 0.00 0.00 1,281,373,611.94

9910 TANF & SOBRA CHILDRE

6,929,861.65 6,196,671.66 7,076,713.78 6,133,795.64 6,127,043.86 6,416,920.72 5,885,004.32 0.00 0.00 0.00 0.00 0.00 44,766,011.63

9920 SSI W/MEDICARE KICK 103,541.97 48,730.97 78,449.46 77,918.61 102,011.95 52,692.84 54,639.33 0.00 0.00 0.00 0.00 0.00 517,985.13

9921 SSI W/O MEDICARE KIC 303,856.04 224,059.46 268,408.85 232,732.22 259,855.55 239,119.33 221,938.98 0.00 0.00 0.00 0.00 0.00 1,749,970.43

9950 S.O.B.R.A. KICK PAYM 12,521,985.84 11,622,011.11 11,957,674.26 11,783,996.42 10,447,421.08 11,974,472.50 10,988,142.89 0.00 0.00 0.00 0.00 0.00 81,295,704.10

19,859,245.50SUBTOTAL: 18,091,473.20 19,381,246.35 18,228,442.89 16,936,332.44 18,683,205.39 17,149,725.52 0.00 0.00 0.00 0.00 0.00 128,329,671.29

3100 TRANSPLANT OPTION 1

49.50 16.50 33.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 99.00

49.50SUBTOTAL: 16.50 33.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 99.00

1106 TANF EXPANDED 21-44 114,545.83 116,511.09 115,995.29 117,141.14 114,311.09 111,292.82 110,348.96 0.00 0.00 0.00 0.00 0.00 800,146.22

1107 TANF EXPANDED 21-44 390,141.49 385,661.09 387,179.50 393,923.57 386,337.02 380,071.34 379,156.52 0.00 0.00 0.00 0.00 0.00 2,702,470.53

1108 TANF EXPANDED 45-64 825,708.66 830,415.55 832,501.32 861,478.13 866,368.38 877,103.04 877,141.91 0.00 0.00 0.00 0.00 0.00 5,970,716.99

1109 TANF EXPANDED 65+ M&

236,943.44 245,366.87 251,184.34 261,771.62 264,829.68 262,773.35 267,975.99 0.00 0.00 0.00 0.00 0.00 1,790,845.29

110F TANF EXPANDED 21-44 3,221.70 3,255.18 2,587.94 1,692.01 3,040.69 1,539.55 4,453.55 0.00 0.00 0.00 0.00 0.00 19,790.62

110G TANF EXPANDED 21-44 6,745.15 6,151.22 6,213.39 9,761.25 9,201.49 8,706.55 7,962.85 0.00 0.00 0.00 0.00 0.00 54,741.90

110H TANF EXPANDED 45-64 12,437.36 12,306.24 8,984.37 19,626.70 15,546.66 15,643.13 18,334.07 0.00 0.00 0.00 0.00 0.00 102,878.53

110J TANF EXPANDED 65+ M&

3,190.00 3,278.19 3,102.72 4,182.95 4,017.38 3,891.84 8,145.07 0.00 0.00 0.00 0.00 0.00 29,808.15

1111 TANF EXPANDED <1 M&F

13,190.95 14,844.65 13,814.75 10,799.40 12,462.12 12,968.43 11,092.49 0.00 0.00 0.00 0.00 0.00 89,172.79

1112 TANF EXPANDED 01-05 87,801.37 92,960.25 90,741.40 99,632.12 97,449.34 95,152.71 93,775.09 0.00 0.00 0.00 0.00 0.00 657,512.28

1113 TANF EXPANDED 06-13 352,727.49 355,959.65 358,089.99 396,493.28 398,159.13 400,117.21 371,884.40 0.00 0.00 0.00 0.00 0.00 2,633,431.15

1114 TANF EXPANDED 14-20 237,225.71 231,321.91 229,143.57 255,296.26 254,413.33 253,486.04 237,664.00 0.00 0.00 0.00 0.00 0.00 1,698,550.82

1115 TANF EXPANDED 14-20 685,892.98 674,647.04 651,782.28 690,370.95 682,615.62 678,290.77 645,688.63 0.00 0.00 0.00 0.00 0.00 4,709,288.27

1116 TANF EXPANDED 21-44 3,596,738.30 3,607,329.47 3,582,021.65 3,600,630.38 3,535,788.08 3,468,891.81 3,407,902.81 0.00 0.00 0.00 0.00 0.00 24,799,302.50

1117 TANF EXPANDED 21-44 11,922,197.74 11,981,136.06 12,040,903.83 12,351,369.11 12,211,059.59 12,084,149.19 11,915,262.29 0.00 0.00 0.00 0.00 0.00 84,506,077.81

15



1118 TANF EXPANDED 45-64 6,442,725.68 6,480,677.55 6,515,377.77 6,767,104.82 6,698,278.73 6,660,753.95 6,655,032.55 0.00 0.00 0.00 0.00 0.00 46,219,951.05


14,589.85 15,138.21 16,023.30 14,011.68 12,444.34 16,372.97 18,020.16 0.00 0.00 0.00 0.00 0.00 106,600.51

111A TANF EXPANDED <1 M&F

480.75 4,860.15 413.16 1,076.20 3,576.69 1,765.14 3,930.26 0.00 0.00 0.00 0.00 0.00 16,102.35

111B TANF EXPANDED 01-05 3,458.59 2,030.04 3,166.04 2,262.58 1,960.43 1,824.21 2,720.86 0.00 0.00 0.00 0.00 0.00 17,422.75

111C TANF EXPANDED 06-13 6,300.99 9,818.43 8,143.36 6,804.38 6,376.52 5,483.85 5,513.67 0.00 0.00 0.00 0.00 0.00 48,441.20

111D TANF EXPANDED 14-20 11,255.55 14,288.68 13,785.70 15,227.24 11,873.90 10,767.68 13,279.62 0.00 0.00 0.00 0.00 0.00 90,478.37

111E TANF EXPANDED 14-20 27,380.04 27,925.74 26,816.30 22,331.24 28,125.79 25,001.56 27,170.87 0.00 0.00 0.00 0.00 0.00 184,751.54

111F TANF EXPANDED 21-44 196,868.92 223,313.95 183,720.82 209,156.06 165,592.12 166,116.77 230,873.59 0.00 0.00 0.00 0.00 0.00 1,375,642.23

111G TANF EXPANDED 21-44 482,080.11 548,456.73 475,495.43 499,697.11 414,269.81 411,990.90 514,020.58 0.00 0.00 0.00 0.00 0.00 3,346,010.67

111H TANF EXPANDED 45-64 222,372.79 225,665.96 205,338.62 237,179.56 196,927.32 241,850.18 310,622.01 0.00 0.00 0.00 0.00 0.00 1,639,956.44


2,625.71 2,246.98 3,934.35 1,719.49 1,244.43 2,195.40 2,180.32 0.00 0.00 0.00 0.00 0.00 16,146.68

1126 TANF EXPANDED 21-44 5,518.39 4,840.44 4,641.20 4,651.44 4,456.36 4,174.03 4,460.29 0.00 0.00 0.00 0.00 0.00 32,742.15

1127 TANF EXPANDED 21-44 12,331.81 12,882.19 13,614.69 13,397.39 14,122.42 14,064.32 13,566.03 0.00 0.00 0.00 0.00 0.00 93,978.85

1128 TANF EXPANDED 45-64 42,996.48 44,101.60 41,052.14 43,120.79 44,908.75 43,607.52 46,883.85 0.00 0.00 0.00 0.00 0.00 306,671.13


13,233.28 13,999.62 15,688.82 16,661.28 17,372.82 18,034.58 15,801.44 0.00 0.00 0.00 0.00 0.00 110,791.84

112F TANF EXPANDED 21-44 133.52 231.88 0.00 0.00 97.93 0.00 113.81 0.00 0.00 0.00 0.00 0.00 577.14

112G TANF EXPANDED 21-44 62.34 0.00 456.42 116.48 114.44 12.38 86.67 0.00 0.00 0.00 0.00 0.00 848.73

112H TANF EXPANDED 45-64 291.28 1,231.29 355.72 420.21 508.16 344.95 726.56 0.00 0.00 0.00 0.00 0.00 3,878.17


406.03 662.23 0.00 10.07 438.47 1,165.65 1,788.46 0.00 0.00 0.00 0.00 0.00 4,470.91

2400 SSI AGED EXPANDED WI

52,467.34 47,201.38 47,426.56 51,167.32 59,606.60 70,133.60 85,815.46 0.00 0.00 0.00 0.00 0.00 413,818.26

240Z SSI AGED EXPANDED WI

27,185.22 25,797.21 24,262.12 25,468.06 17,517.76 20,822.53 23,306.22 0.00 0.00 0.00 0.00 0.00 164,359.12

2410 SSI AGED EXPANDED NO

844,945.61 850,929.40 836,959.14 858,987.48 865,464.12 876,425.84 892,855.75 0.00 0.00 0.00 0.00 0.00 6,026,567.34

241Z SSI AGED EXPANDED NO

34,135.96 36,734.45 37,136.78 46,393.52 51,025.32 59,963.02 63,105.41 0.00 0.00 0.00 0.00 0.00 328,494.46


2,853,407.43 2,867,210.64 2,879,889.85 2,917,577.12 2,916,773.86 2,906,129.43 2,902,273.04 0.00 0.00 0.00 0.00 0.00 20,243,261.37


18,145.67 16,774.10 18,273.40 16,597.26 13,889.93 15,298.66 21,841.49 0.00 0.00 0.00 0.00 0.00 120,820.51

2500 SSI BLIND EXPANDED W

0.00 146.63 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 146.63

250Z SSI BLIND EXPANDED W

0.00 334.79 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 334.79


1,521.14 1,521.14 1,819.04 1,668.31 1,668.31 1,668.31 1,668.31 0.00 0.00 0.00 0.00 0.00 11,534.56

2600 SSI DISABLED EXPANDE

48,867.65 50,790.49 50,729.49 55,458.20 75,094.10 86,813.61 93,503.54 0.00 0.00 0.00 0.00 0.00 461,257.08

260Z SSI DISABLED EXPANDE

23,123.22 25,553.51 29,596.99 27,007.45 15,819.07 21,354.01 15,900.79 0.00 0.00 0.00 0.00 0.00 158,355.04


1,734,839.36 1,661,828.10 1,585,213.64 1,573,850.34 1,566,048.85 1,526,163.42 1,470,296.41 0.00 0.00 0.00 0.00 0.00 11,118,240.12


78,255.95 54,348.81 66,554.57 83,926.38 63,087.92 67,803.53 54,429.06 0.00 0.00 0.00 0.00 0.00 468,406.22


1,235,336.35 1,244,504.22 1,262,854.58 1,281,807.41 1,269,871.30 1,268,847.18 1,263,786.10 0.00 0.00 0.00 0.00 0.00 8,827,007.14


5,108.60 3,113.02 3,343.19 3,598.16 3,365.20 5,513.78 2,164.34 0.00 0.00 0.00 0.00 0.00 26,206.29

32,931,159.78SUBTOTAL: 33,080,304.02 32,946,329.53 33,872,623.90 33,397,521.37 33,206,540.74 33,114,526.15 0.00 0.00 0.00 0.00 0.00 232,549,005.49

16



9911 SB PAYMENT FOR TANF

388,880.64 323,125.27 383,421.57 401,947.72 297,380.54 294,569.51 394,221.71 0.00 0.00 0.00 0.00 0.00 2,483,546.96

9922 SB PAYMENT FOR SSI E

0.00 12,334.94 12,334.94 12,263.97 17,658.30 6,169.00 6,094.97 0.00 0.00 0.00 0.00 0.00 66,856.12


35,937.06 0.00 6,167.47 17,505.12 0.00 11,405.17 0.00 0.00 0.00 0.00 0.00 0.00 71,014.82

424,817.70SUBTOTAL: 335,460.21 401,923.98 431,716.81 315,038.84 312,143.68 400,316.68 0.00 0.00 0.00 0.00 0.00 2,621,417.90

3306 AHC CARE MALE 21-44 2,960.40 3,347.06 3,347.06 2,923.13 2,923.13 2,504.12 0.00 0.00 0.00 0.00 0.00 0.00 18,004.90

3307 AHC CARE FEMALE 21-4

1,257.77 1,707.21 1,707.21 1,555.27 1,158.89 1,158.89 0.00 0.00 0.00 0.00 0.00 0.00 8,545.24

3308 AHC CARE M&F 45-64 W

5,027.82 6,016.03 7,148.72 7,114.94 7,876.37 8,239.46 0.00 0.00 0.00 0.00 0.00 0.00 41,423.34

3309 AHC CARE M&F 65+ W/ 4,317.99 4,572.03 4,317.99 4,204.31 4,204.31 3,883.48 0.00 0.00 0.00 0.00 0.00 0.00 25,500.11

330H AHC CARE M&F 45-64 W

221.65 1,734.04 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,955.69

330J AHC CARE M&F 65+ W/ 0.00 295.54 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 295.54

3314 AHC CARE MALE 14-20 332,188.78 340,390.25 341,743.37 337,864.51 334,267.10 333,268.97 437.25 0.00 0.00 0.00 0.00 0.00 2,020,160.23


438,080.65 437,684.71 455,760.06 468,459.58 455,087.38 456,526.58 1,650.42 0.00 0.00 0.00 0.00 0.00 2,713,249.38

3316 AHC CARE MALE 21-44 972,742.19 972,794.09 972,994.16 937,439.97 920,245.82 886,615.06 10,432.39 0.00 0.00 0.00 0.00 0.00 5,673,263.68


1,090,808.57 1,083,767.00 1,080,263.97 1,064,488.25 1,048,674.46 1,018,430.29 7,259.24 0.00 0.00 0.00 0.00 0.00 6,393,691.78

3318 AHC CARE M&F 45-64 N 3,656,481.60 3,586,234.80 3,543,866.55 3,431,299.90 3,331,111.89 3,255,241.48 20,475.52 0.00 0.00 0.00 0.00 0.00 20,824,711.74

331D AHC CARE MALE 14-20 8,316.84 5,432.79 1,579.92 4,864.13 1,171.93 1,240.74 0.00 0.00 0.00 0.00 0.00 0.00 22,606.35

331E AHC CARE FEMALE 14-2

1,798.18 4,778.10 4,690.91 4,663.41 3,702.95 4,843.55 0.00 0.00 0.00 0.00 0.00 0.00 24,477.10

331F AHC CARE MALE 21-44 18,457.34 22,447.39 15,175.12 15,558.47 8,141.48 6,924.27 4,381.16 0.00 0.00 0.00 0.00 0.00 91,085.23

331G AHC CARE FEMALE 21-4

21,922.59 26,581.88 25,429.57 14,854.02 5,079.53 8,145.65 3,212.49 0.00 0.00 0.00 0.00 0.00 105,225.73

331H AHC CARE M&F 45-64 N 36,348.08 32,654.00 12,107.09 17,270.39 29,877.01 15,348.92 10,995.38 0.00 0.00 0.00 0.00 0.00 154,600.87

3326 AHC CARE MALE 21-44 3,112.10 2,782.29 2,782.29 3,165.44 3,165.44 2,765.55 0.00 0.00 0.00 0.00 0.00 0.00 17,773.11


329.81 329.81 769.36 750.54 750.54 750.54 0.00 0.00 0.00 0.00 0.00 0.00 3,680.60


6,888.94 7,218.75 6,041.50 4,297.67 4,949.54 4,949.54 0.00 0.00 0.00 0.00 0.00 0.00 34,345.94

3329 AHC CARE M&F 65+ W/ 1,228.47 2,164.76 2,445.94 2,357.40 2,357.40 2,357.40 0.00 0.00 0.00 0.00 0.00 0.00 12,911.37

332J AHC CARE M&F 65+ W/ 0.00 790.58 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 790.58

6,602,489.77SUBTOTAL: 6,543,723.11 6,482,170.79 6,323,131.33 6,164,745.17 6,013,194.49 58,843.85 0.00 0.00 0.00 0.00 0.00 38,188,298.51

9933 SB PAYMENT FOR AHCCS

24,669.88 18,701.28 12,334.94 29,951.87 18,507.00 36,166.60 0.00 0.00 0.00 0.00 0.00 0.00 140,331.57

24,669.88SUBTOTAL: 18,701.28 12,334.94 29,951.87 18,507.00 36,166.60 0.00 0.00 0.00 0.00 0.00 0.00 140,331.57

3606 AHC CARE/MI MALE 21- 2,853.77 2,467.11 2,808.54 3,039.98 3,112.44 2,984.52 393.93 0.00 0.00 0.00 0.00 0.00 17,660.29

3607 AHC CARE/MI FEMALE 2

789.45 789.45 1,603.96 1,247.23 1,660.75 2,078.19 0.00 0.00 0.00 0.00 0.00 0.00 8,169.03

3608 AHC CARE/MI M&F 45-6 6,259.29 5,431.18 5,446.07 5,788.24 4,638.02 3,784.92 0.00 0.00 0.00 0.00 0.00 0.00 31,347.72

3609 AHC CARE/MI M&F 65+ 0.00 0.00 0.00 345.20 345.20 345.20 0.00 0.00 0.00 0.00 0.00 0.00 1,035.60

360F AHC CARE/MI MALE 21- 0.00 0.00 0.00 0.00 0.00 0.00 8,614.70 0.00 0.00 0.00 0.00 0.00 8,614.70

360G AHC CARE/MI FEMALE 2

0.00 0.00 0.00 0.00 0.00 0.00 11,892.14 0.00 0.00 0.00 0.00 0.00 11,892.14

360H AHC CARE/MI M&F 45-6 0.00 0.00 0.00 0.00 0.00 0.00 17,659.38 0.00 0.00 0.00 0.00 0.00 17,659.38

17



3611 AHC CARE/MI M&F < 1 0.00 61.51 381.38 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 442.89

3614 AHC CARE/MI MALE 14- 2,321,919.56 2,288,485.88 2,283,202.62 2,328,556.29 2,340,119.25 2,324,542.94 3,438.98 0.00 0.00 0.00 0.00 0.00 13,890,265.52


2,129,041.00 2,119,294.99 2,116,949.81 2,157,124.22 2,163,282.30 2,162,558.97 2,574.70 0.00 0.00 0.00 0.00 0.00 12,850,825.99

3616 AHC CARE/MI MALE 21- 4,047,739.76 3,916,262.18 3,769,290.17 3,611,597.92 3,509,074.74 3,348,586.94 30,690.14 0.00 0.00 0.00 0.00 0.00 22,233,241.85


2,983,197.35 2,974,524.33 2,917,348.07 2,835,347.35 2,755,670.65 2,684,847.78 20,195.12 0.00 0.00 0.00 0.00 0.00 17,171,130.65

3618 AHC CARE/MI M&F 45-6 8,474,077.72 8,305,287.84 8,100,218.81 7,757,445.62 7,581,620.01 7,323,288.64 35,176.64 0.00 0.00 0.00 0.00 0.00 47,577,115.28

3619 AHC CARE/MI M&F 65+ 341.43 341.43 341.43 320.83 320.83 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,665.95

361A AHC CARE/MI M&F < 1 0.00 640.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 640.33

361D AHC CARE/MI MALE 14- 29,997.48 24,308.13 32,713.89 30,399.93 17,313.03 20,769.67 107,747.71 0.00 0.00 0.00 0.00 0.00 263,249.84

361E AHC CARE/MI FEMALE 1

22,205.28 38,123.45 24,765.29 14,517.34 12,747.04 14,299.29 56,917.08 0.00 0.00 0.00 0.00 0.00 183,574.77

361F AHC CARE/MI MALE 21- 26,794.10 37,524.74 35,111.22 28,123.97 18,748.60 17,532.31 1,968,759.45 0.00 0.00 0.00 0.00 0.00 2,132,594.39


20,633.01 24,469.25 22,032.35 19,792.97 11,672.68 10,897.97 1,374,285.08 0.00 0.00 0.00 0.00 0.00 1,483,783.31

361H AHC CARE/MI M&F 45-6 31,438.41 53,879.26 27,438.83 36,585.86 36,187.88 39,818.67 6,034,783.07 0.00 0.00 0.00 0.00 0.00 6,260,131.98

361J AHC CARE/MI M&F 65+ 0.00 3,053.88 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,053.88

3628 AHC CARE/MI M&F 45-6 727.90 727.90 727.90 734.35 734.35 869.82 0.00 0.00 0.00 0.00 0.00 0.00 4,522.22


0.00 0.00 0.00 0.00 0.00 0.00 1,526.94 0.00 0.00 0.00 0.00 0.00 1,526.94

20,098,015.51SUBTOTAL: 19,795,672.84 19,340,380.34 18,830,967.30 18,457,247.77 17,957,205.83 9,674,655.06 0.00 0.00 0.00 0.00 0.00 124,154,144.65

9936 SB PAYMENT FOR AHCC

146,816.89 90,831.20 91,159.84 115,071.98 95,258.22 70,426.87 0.00 0.00 0.00 0.00 0.00 0.00 609,565.00

146,816.89SUBTOTAL: 90,831.20 91,159.84 115,071.98 95,258.22 70,426.87 0.00 0.00 0.00 0.00 0.00 0.00 609,565.00

3506 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 9,779.72 0.00 0.00 0.00 0.00 0.00 9,779.72

3507 ADULT 40-100% FEMALE

0.00 0.00 0.00 0.00 0.00 0.00 5,414.76 0.00 0.00 0.00 0.00 0.00 5,414.76

3508 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 62,865.06 0.00 0.00 0.00 0.00 0.00 62,865.06

3509 ADULT 40-100% M&F 65 0.00 0.00 0.00 0.00 0.00 0.00 4,397.55 0.00 0.00 0.00 0.00 0.00 4,397.55

350F ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 6,590.67 0.00 0.00 0.00 0.00 0.00 6,590.67

350G ADULT 40-100% FEMALE

0.00 0.00 0.00 0.00 0.00 0.00 5,171.59 0.00 0.00 0.00 0.00 0.00 5,171.59

350H ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 32,222.39 0.00 0.00 0.00 0.00 0.00 32,222.39

3514 ADULT 40-100% MALE 1 0.00 0.00 0.00 0.00 0.00 0.00 417,678.62 0.00 0.00 0.00 0.00 0.00 417,678.62


0.00 0.00 0.00 0.00 0.00 0.00 579,792.86 0.00 0.00 0.00 0.00 0.00 579,792.86

3516 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 -425.05 1,728,451.08 0.00 0.00 0.00 0.00 0.00 1,728,026.03


0.00 0.00 0.00 0.00 0.00 -425.05 1,781,937.35 0.00 0.00 0.00 0.00 0.00 1,781,512.30

3518 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 -2,330.39 5,088,801.35 0.00 0.00 0.00 0.00 0.00 5,086,470.96

3519 ADULT 40-100% M&F 65 0.00 0.00 0.00 0.00 0.00 0.00 53.99 0.00 0.00 0.00 0.00 0.00 53.99

351D ADULT 40-100% MALE 1 0.00 0.00 0.00 0.00 0.00 0.00 71,682.36 0.00 0.00 0.00 0.00 0.00 71,682.36

351E ADULT 40-100% FEMALE

0.00 0.00 0.00 0.00 0.00 0.00 89,380.55 0.00 0.00 0.00 0.00 0.00 89,380.55

351F ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 657,846.27 0.00 0.00 0.00 0.00 0.00 657,846.27

18




0.00 0.00 0.00 0.00 0.00 0.00 604,214.52 0.00 0.00 0.00 0.00 0.00 604,214.52

351H ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 1,285,644.17 0.00 0.00 0.00 0.00 0.00 1,285,644.17

351J ADULT 40-100% M&F 65 0.00 0.00 0.00 0.00 0.00 0.00 607.13 0.00 0.00 0.00 0.00 0.00 607.13

3526 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 2,832.20 0.00 0.00 0.00 0.00 0.00 2,832.20


0.00 0.00 0.00 0.00 0.00 0.00 1,783.60 0.00 0.00 0.00 0.00 0.00 1,783.60

3528 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 10,382.83 0.00 0.00 0.00 0.00 0.00 10,382.83

3529 ADULT 40-100% M&F 65 0.00 0.00 0.00 0.00 0.00 0.00 2,405.30 0.00 0.00 0.00 0.00 0.00 2,405.30

352F ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 1,519.34 0.00 0.00 0.00 0.00 0.00 1,519.34


0.00 0.00 0.00 0.00 0.00 0.00 380.83 0.00 0.00 0.00 0.00 0.00 380.83

352H ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 3,290.39 0.00 0.00 0.00 0.00 0.00 3,290.39

3706 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 15,106.06 0.00 0.00 0.00 0.00 0.00 15,106.06

3707 ADULT <40% EXP FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 9,958.00 0.00 0.00 0.00 0.00 0.00 9,958.00

3708 ADULT <40% EXP M&F 4

0.00 0.00 0.00 0.00 0.00 0.00 34,499.72 0.00 0.00 0.00 0.00 0.00 34,499.72


0.00 0.00 0.00 0.00 0.00 0.00 353.40 0.00 0.00 0.00 0.00 0.00 353.40

370F ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 9,827.12 0.00 0.00 0.00 0.00 0.00 9,827.12

370G ADULT <40% EXP FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 3,721.35 0.00 0.00 0.00 0.00 0.00 3,721.35

370H ADULT <40% EXP M&F 4

0.00 0.00 0.00 0.00 0.00 0.00 11,701.59 0.00 0.00 0.00 0.00 0.00 11,701.59

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 -1,198.51 2,972,324.03 0.00 0.00 0.00 0.00 0.00 2,971,125.52


0.00 0.00 0.00 0.00 0.00 0.00 2,656,441.38 0.00 0.00 0.00 0.00 0.00 2,656,441.38

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 -5,190.88 8,574,644.03 0.00 0.00 0.00 0.00 0.00 8,569,453.15


0.00 0.00 0.00 0.00 0.00 -3,794.52 5,676,671.86 0.00 0.00 0.00 0.00 0.00 5,672,877.34


0.00 0.00 0.00 0.00 0.00 -6,039.36 13,380,709.08 0.00 0.00 0.00 0.00 0.00 13,374,669.72


0.00 0.00 0.00 0.00 0.00 0.00 6,655.49 0.00 0.00 0.00 0.00 0.00 6,655.49

371D ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 438,685.25 0.00 0.00 0.00 0.00 0.00 438,685.25

371E ADULT <40% EXP FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 351,627.49 0.00 0.00 0.00 0.00 0.00 351,627.49

371F ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 3,058,608.00 0.00 0.00 0.00 0.00 0.00 3,058,608.00


0.00 0.00 0.00 0.00 0.00 0.00 1,899,038.39 0.00 0.00 0.00 0.00 0.00 1,899,038.39


0.00 0.00 0.00 0.00 0.00 0.00 3,829,076.55 0.00 0.00 0.00 0.00 0.00 3,829,076.55

371J ADULT <40% EXP M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 3,550.11 0.00 0.00 0.00 0.00 0.00 3,550.11


0.00 0.00 0.00 0.00 0.00 0.00 3,386.20 0.00 0.00 0.00 0.00 0.00 3,386.20


0.00 0.00 0.00 0.00 0.00 0.00 611.11 0.00 0.00 0.00 0.00 0.00 611.11

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 -19,403.76 55,392,322.69 0.00 0.00 0.00 0.00 0.00 55,372,918.93

9935 BIRTH SUPP PAYMENT A

0.00 0.00 0.00 0.00 0.00 0.00 36,701.20 0.00 0.00 0.00 0.00 0.00 36,701.20


0.00 0.00 0.00 0.00 0.00 0.00 52,850.47 0.00 0.00 0.00 0.00 0.00 52,850.47

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 89,551.67 0.00 0.00 0.00 0.00 0.00 89,551.67

19



4515 BC PATIENT FEMALE 14

0.00 0.00 0.00 213.09 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 213.09


7,558.40 8,016.13 8,135.22 8,796.19 8,660.81 9,265.35 9,434.51 0.00 0.00 0.00 0.00 0.00 59,866.61


104,195.46 108,389.01 114,046.23 117,680.62 114,897.04 119,853.53 123,410.17 0.00 0.00 0.00 0.00 0.00 802,472.06


0.00 362.20 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 362.20

451E BC PATIENT FEMALE 14

0.00 0.00 0.00 677.76 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 677.76

451G BC PATIENT FEMALE 21

721.91 613.60 708.69 380.84 376.87 0.00 643.86 0.00 0.00 0.00 0.00 0.00 3,445.77

451H BC PATIENT FEMALE 45

5,088.82 4,373.78 4,654.41 8,474.87 7,710.35 5,312.44 8,703.05 0.00 0.00 0.00 0.00 0.00 44,317.72

451J BC PATIENT FEMALE 65

0.00 10.97 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.97

4617 CC PATIENT FEMALE 21

6,630.84 6,647.15 7,545.69 8,526.92 7,558.86 8,323.07 8,217.94 0.00 0.00 0.00 0.00 0.00 53,450.47


7,847.28 8,101.14 8,689.62 9,256.41 8,969.23 11,362.08 12,917.53 0.00 0.00 0.00 0.00 0.00 67,143.29

461G CC PATIENT FEMALE 21

438.24 649.48 775.89 1,189.24 217.37 1,054.28 194.44 0.00 0.00 0.00 0.00 0.00 4,518.94

461H CC PATIENT FEMALE 45

849.85 1,027.37 218.90 694.30 3,407.64 2,729.83 2,429.78 0.00 0.00 0.00 0.00 0.00 11,357.67

133,330.80SUBTOTAL: 138,190.83 144,774.65 155,890.24 151,798.17 157,900.58 165,951.28 0.00 0.00 0.00 0.00 0.00 1,047,836.55

8600 SSI BLIND FREEDOM/WO

0.00 0.00 0.00 0.00 57.72 157.41 157.41 0.00 0.00 0.00 0.00 0.00 372.54

860Z SSI BLIND FREEDOM/WO

0.00 0.00 0.00 0.00 167.73 0.00 0.00 0.00 0.00 0.00 0.00 0.00 167.73

8700 SSI DISABLED FREEDOM

179,495.41 179,492.64 180,816.82 178,635.06 178,907.57 180,359.71 176,042.46 0.00 0.00 0.00 0.00 0.00 1,253,749.67

870Z SSI DISABLED FREEDOM

4,403.97 3,766.99 3,809.08 3,338.10 2,391.15 1,923.57 2,452.63 0.00 0.00 0.00 0.00 0.00 22,085.49


146,143.09 141,607.27 141,765.54 147,924.01 139,802.86 136,559.57 128,380.07 0.00 0.00 0.00 0.00 0.00 982,182.41


7,016.29 8,708.37 11,183.50 13,245.98 3,315.63 16,660.96 6,991.57 0.00 0.00 0.00 0.00 0.00 67,122.30


23,685.96 23,063.44 23,007.15 22,199.56 21,723.02 21,003.14 21,865.38 0.00 0.00 0.00 0.00 0.00 156,547.65


409.07 864.01 217.50 0.00 47.92 477.02 5.65 0.00 0.00 0.00 0.00 0.00 2,021.17

361,153.79SUBTOTAL: 357,502.72 360,799.59 365,342.71 346,413.60 357,141.38 335,895.17 0.00 0.00 0.00 0.00 0.00 2,484,248.96

260,676,973.67 TOTAL: 259,509,434.84 259,917,754.40 265,375,816.33 261,106,610.23 260,790,908.36 299,583,203.63 0.00 0.00 0.00 0.00 0.00 1,866,960,701.46

20

ACUTE CAPITATION - MEMBER MONTHSFor The Period Ending January 31, 2014


1003 TANF 06-13 M & F WIT 2.00 2.00 2.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 14.00

1004 TANF 14-20 MALE WITH 0.41 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.41

1005 TANF 14-20 FEMALE WI 3.00 3.00 2.00 1.00 1.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 14.00

1006 TANF 21-44 MALE WITH 108.59 107.22 95.69 93.49 101.42 100.30 97.19 0.00 0.00 0.00 0.00 0.00 703.90

1007 TANF 21-44 FEMALE WI 246.91 245.28 259.30 260.73 261.07 263.13 253.31 0.00 0.00 0.00 0.00 0.00 1,789.73

1008 TANF 45-64 M & F WIT 157.41 161.11 152.19 150.37 149.00 150.86 152.11 0.00 0.00 0.00 0.00 0.00 1,073.05

1009 TANF 65+ M & F WITH 29.96 35.00 35.00 40.96 45.53 46.00 47.00 0.00 0.00 0.00 0.00 0.00 279.45

100D TANF 14-20 MALE WITH 0.58 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.58

100F TANF 21-44 MALE WITH 3.69 6.43 0.30 2.33 1.52 3.65 9.57 0.00 0.00 0.00 0.00 0.00 27.49

100G TANF 21-44 FEMALE WI 7.92 9.03 6.98 8.09 5.27 2.87 10.87 0.00 0.00 0.00 0.00 0.00 51.03

100H TANF 44-64 M & F WIT 6.52 0.64 1.79 1.67 0.00 6.07 1.86 0.00 0.00 0.00 0.00 0.00 18.55

100J TANF 65+ M & F WITH 0.03 0.00 0.00 0.03 0.46 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.52

1011 TANF <1 M & F NON-ME 15,238.20 15,114.66 15,224.25 15,053.95 14,939.02 15,002.15 14,705.23 0.00 0.00 0.00 0.00 0.00 105,277.46

1012 TANF 01-05 M & F NON 84,689.71 84,306.29 83,822.21 82,961.92 81,790.89 79,754.24 78,383.31 0.00 0.00 0.00 0.00 0.00 575,708.57

1013 TANF 06-13 M & F NON 123,352.79 124,109.11 124,547.98 124,115.07 122,973.89 121,514.16 120,397.08 0.00 0.00 0.00 0.00 0.00 861,010.08

1014 TANF 14-20 MALE NON- 24,129.12 24,378.64 24,432.71 24,522.71 24,504.56 24,417.90 24,346.90 0.00 0.00 0.00 0.00 0.00 170,732.54


29,331.66 29,363.96 29,411.19 29,306.05 29,260.76 29,092.95 28,863.11 0.00 0.00 0.00 0.00 0.00 204,629.68

1016 TANF 21-44 MALE NON- 20,711.59 20,702.27 20,652.78 20,693.81 20,452.74 20,025.22 19,646.60 0.00 0.00 0.00 0.00 0.00 142,885.01


85,760.84 86,307.17 86,505.17 85,944.43 85,067.42 83,542.90 81,664.14 0.00 0.00 0.00 0.00 0.00 594,792.07

1018 TANF 45-64 M & F NON 16,639.58 16,795.72 16,775.26 16,701.88 16,620.32 16,441.31 16,414.09 0.00 0.00 0.00 0.00 0.00 116,388.16

1019 TANF 65+ M & F NON-M 38.41 41.48 43.68 46.41 40.98 35.80 36.33 0.00 0.00 0.00 0.00 0.00 283.09

101A TANF < 1 M & F NON-M 402.52 402.23 399.41 442.03 356.17 386.43 434.43 0.00 0.00 0.00 0.00 0.00 2,823.22

101B TANF 01-05 M & F NON 3,299.99 3,609.55 3,219.27 3,234.74 2,794.94 2,915.35 3,536.51 0.00 0.00 0.00 0.00 0.00 22,610.35

101C TANF 06-13 M & F NON 3,779.22 4,072.94 3,895.04 3,559.21 3,143.36 3,419.89 4,240.95 0.00 0.00 0.00 0.00 0.00 26,110.61

101D TANF 14-20 MALE NON- 783.18 808.84 786.56 738.27 573.39 695.12 894.48 0.00 0.00 0.00 0.00 0.00 5,279.84

101E TANF 14-20 FEMALE NO

1,029.01 1,086.66 1,080.16 995.06 846.03 841.56 1,144.91 0.00 0.00 0.00 0.00 0.00 7,023.39

101F TANF 21-44 MALE NON- 1,017.99 1,134.70 1,046.28 1,019.87 811.92 819.19 1,120.51 0.00 0.00 0.00 0.00 0.00 6,970.46

101G TANF 21-44 FEMALE NO

3,541.74 3,927.95 3,429.55 3,261.17 2,941.04 2,951.21 3,697.18 0.00 0.00 0.00 0.00 0.00 23,749.84

101H TANF 44-64 M & F NON 540.17 562.04 562.02 518.38 440.80 458.50 657.10 0.00 0.00 0.00 0.00 0.00 3,739.01

101J TANF 65+ N & F NON-M 0.57 7.90 5.44 1.40 0.00 0.19 2.62 0.00 0.00 0.00 0.00 0.00 18.12

1026 TANF 21-44 MALE WITH 5.00 5.00 3.00 3.00 2.00 1.00 0.29 0.00 0.00 0.00 0.00 0.00 19.29

1027 TANF 21-44 FEMALE WI 7.00 5.45 5.00 6.00 9.39 11.45 14.00 0.00 0.00 0.00 0.00 0.00 58.29

1028 TANF 45-64 M & F WIT 12.67 10.83 11.90 10.99 12.00 9.00 11.00 0.00 0.00 0.00 0.00 0.00 78.39

1029 TANF 65+ M & F WITH 0.00 0.00 1.00 0.99 1.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 5.99

102F TANF 21-44 MALE WITH 0.00 0.00 0.00 0.00 0.00 0.00 1.70 0.00 0.00 0.00 0.00 0.00 1.70

102G TANF 21-44 FEMALE WI 0.00 0.00 0.00 0.00 0.76 0.54 0.00 0.00 0.00 0.00 0.00 0.00 1.30

21



102H TANF 44-64 M & F WIT 0.32 0.16 0.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.58


3,832.71 3,815.81 3,840.36 3,857.25 3,948.25 4,036.19 4,147.15 0.00 0.00 0.00 0.00 0.00 27,477.72


153.28 153.34 205.20 247.68 165.87 190.33 237.61 0.00 0.00 0.00 0.00 0.00 1,353.31


5,177.76 5,199.05 5,200.22 5,187.74 5,247.45 5,243.20 5,290.82 0.00 0.00 0.00 0.00 0.00 36,546.24


254.76 226.92 250.03 230.26 272.42 206.35 359.22 0.00 0.00 0.00 0.00 0.00 1,799.96

2120 SSI AGED WITH QMB 18,696.99 18,761.55 18,792.57 18,895.86 18,851.06 18,826.70 18,836.86 0.00 0.00 0.00 0.00 0.00 131,661.59


71.93 81.90 80.54 73.92 56.66 84.42 125.05 0.00 0.00 0.00 0.00 0.00 574.42


3,492.79 3,523.22 3,520.71 3,535.81 3,711.25 3,841.57 3,902.82 0.00 0.00 0.00 0.00 0.00 25,528.17


313.43 291.80 250.89 286.34 227.61 237.07 261.09 0.00 0.00 0.00 0.00 0.00 1,868.23


58,351.48 58,504.87 58,649.24 58,766.52 58,584.17 58,736.87 58,579.29 0.00 0.00 0.00 0.00 0.00 410,172.44


3,266.78 3,386.00 2,927.69 2,899.10 2,522.72 2,448.21 2,360.34 0.00 0.00 0.00 0.00 0.00 19,810.84


26,236.10 26,318.19 26,376.26 26,464.83 26,378.93 26,345.42 26,278.39 0.00 0.00 0.00 0.00 0.00 184,398.12


26.34 15.34 19.21 17.84 39.25 25.13 11.28 0.00 0.00 0.00 0.00 0.00 154.39

2300 SSI BLIND WITH MEDIC 18.00 18.00 18.00 19.34 21.00 23.00 23.00 0.00 0.00 0.00 0.00 0.00 140.34

230Z SSI BLIND WITH MEDIC 0.00 0.00 0.00 8.64 0.00 0.00 3.00 0.00 0.00 0.00 0.00 0.00 11.64


412.81 412.78 412.91 415.54 425.81 417.03 414.22 0.00 0.00 0.00 0.00 0.00 2,911.10

231Z SSI BLIND NON-MEDICA

24.09 21.81 20.43 14.55 2.63 7.53 24.22 0.00 0.00 0.00 0.00 0.00 115.26

2320 SSI BLIND WITH QMB 207.65 207.04 209.78 209.98 210.01 211.24 208.99 0.00 0.00 0.00 0.00 0.00 1,464.69

232Z SSI BLIND WITH QMB P 0.00 0.00 0.00 0.00 0.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.06

4303 SOBRA CHILD 06-13 M 0.00 0.51 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 5.51

4304 SOBRA CHILD 14-20 MA 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00

4305 SOBRA CHILD 14-20 FE 1.00 1.00 1.00 1.00 1.00 1.00 0.99 0.00 0.00 0.00 0.00 0.00 6.99

430C SOBRA CHILD 06-13 M 0.00 0.48 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.48

4311 SOBRA CHILD <1 M & F 33,018.36 32,743.71 32,776.86 32,418.75 32,177.52 32,378.38 31,953.37 0.00 0.00 0.00 0.00 0.00 227,466.95

4312 SOBRA CHILD 01-05 M 92,523.97 93,052.40 92,953.72 92,558.62 91,377.08 90,301.15 88,608.21 0.00 0.00 0.00 0.00 0.00 641,375.15

4313 SOBRA CHILD 06-13 M 117,682.97 118,409.08 119,305.49 119,489.74 118,876.19 117,902.79 116,210.06 0.00 0.00 0.00 0.00 0.00 827,876.32

4314 SOBRA CHILD 14-20 MA 29,910.24 30,095.09 30,153.65 29,993.51 29,558.28 29,135.98 28,553.49 0.00 0.00 0.00 0.00 0.00 207,400.24

4315 SOBRA CHILD 14-20 FE 29,386.22 29,656.81 29,797.16 29,605.09 29,216.39 28,619.84 28,041.29 0.00 0.00 0.00 0.00 0.00 204,322.80

431A SOBRA CHILD < 1 M & 569.77 682.43 516.50 595.03 528.55 486.98 673.90 0.00 0.00 0.00 0.00 0.00 4,053.16

431B SOBRA CHILD 01-05 M 3,994.05 4,392.16 3,948.83 4,026.21 3,361.17 3,477.45 4,076.18 0.00 0.00 0.00 0.00 0.00 27,276.05

431C SOBRA CHILD 6-13 M&F

3,916.76 4,511.61 3,903.25 3,973.00 3,218.69 3,330.37 4,058.86 0.00 0.00 0.00 0.00 0.00 26,912.54

431D SOBRA CHILD 14-20 MA 1,118.24 1,263.67 1,072.69 1,111.32 901.67 929.48 1,089.15 0.00 0.00 0.00 0.00 0.00 7,486.22

431E SOBRA CHILD 14-20 FE 1,079.69 1,273.05 1,093.31 1,086.71 907.98 898.85 1,177.47 0.00 0.00 0.00 0.00 0.00 7,517.06


57.40 47.95 51.32 52.96 51.08 50.50 44.44 0.00 0.00 0.00 0.00 0.00 355.65


1.00 1.00 0.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 6.00


3.56 3.01 2.83 1.56 1.88 3.48 2.50 0.00 0.00 0.00 0.00 0.00 18.82

22




0.00 1.00 2.00 2.00 1.76 3.00 1.22 0.00 0.00 0.00 0.00 0.00 10.98


3,558.81 3,617.03 3,673.51 3,567.94 3,395.92 3,310.27 3,195.48 0.00 0.00 0.00 0.00 0.00 24,318.96


11,647.59 11,918.46 11,826.21 11,749.33 11,505.62 11,173.95 10,989.95 0.00 0.00 0.00 0.00 0.00 80,811.11


17.16 17.00 14.33 15.99 15.56 19.71 17.93 0.00 0.00 0.00 0.00 0.00 117.68

501C SOBRA PREG 09-13 FEM

0.00 0.00 0.00 0.00 1.23 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.23

501E SOBRA PREG 14-20 FEM

419.32 453.45 389.99 387.36 338.28 352.20 444.65 0.00 0.00 0.00 0.00 0.00 2,785.25


1,408.96 1,522.02 1,264.05 1,366.02 1,053.39 1,172.40 1,340.98 0.00 0.00 0.00 0.00 0.00 9,127.82

501H SOBRA PREG 45-64 FEM

0.83 1.00 0.66 1.99 0.43 3.25 1.05 0.00 0.00 0.00 0.00 0.00 9.21


6.00 5.00 4.00 4.00 2.00 2.00 2.66 0.00 0.00 0.00 0.00 0.00 25.66


0.00 0.00 0.00 0.00 0.00 0.00 1.32 0.00 0.00 0.00 0.00 0.00 1.32


2.00 2.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00


4,611.22 4,676.09 4,785.79 4,881.82 4,865.02 4,574.22 -79.00 0.00 0.00 0.00 0.00 0.00 28,315.16

870,350.32SUBTOTAL: 876,609.89 874,730.40 871,722.16 860,175.49 851,923.45 842,261.88 0.00 0.00 0.00 0.00 0.00 6,047,773.59

9910 TANF & SOBRA CHILDRE

1,139.00 1,019.00 1,162.00 1,033.00 1,034.00 1,083.00 993.00 0.00 0.00 0.00 0.00 0.00 7,463.00

9920 SSI W/MEDICARE KICK 17.00 8.00 13.00 13.00 17.00 9.00 9.00 0.00 0.00 0.00 0.00 0.00 86.00

9921 SSI W/O MEDICARE KIC 50.00 37.00 44.00 39.00 44.00 40.00 37.00 0.00 0.00 0.00 0.00 0.00 291.00

9950 S.O.B.R.A. KICK PAYM 2,053.00 1,909.00 1,964.00 1,982.00 1,765.00 2,018.00 1,852.00 0.00 0.00 0.00 0.00 0.00 13,543.00

3,259.00SUBTOTAL: 2,973.00 3,183.00 3,067.00 2,860.00 3,150.00 2,891.00 0.00 0.00 0.00 0.00 0.00 21,383.00


3.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00

3.00SUBTOTAL: 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00

1106 TANF EXPANDED 21-44 781.21 796.96 793.17 793.24 773.49 753.06 747.41 0.00 0.00 0.00 0.00 0.00 5,438.54

1107 TANF EXPANDED 21-44 1,707.59 1,685.71 1,692.31 1,686.19 1,652.85 1,626.02 1,621.95 0.00 0.00 0.00 0.00 0.00 11,672.62

1108 TANF EXPANDED 45-64 2,154.36 2,163.83 2,171.12 2,178.31 2,191.31 2,220.30 2,220.35 0.00 0.00 0.00 0.00 0.00 15,299.58


627.66 648.95 663.64 672.51 679.79 673.68 687.85 0.00 0.00 0.00 0.00 0.00 4,654.08

110F TANF EXPANDED 21-44 20.46 21.18 16.27 10.26 18.08 9.30 27.27 0.00 0.00 0.00 0.00 0.00 122.82

110G TANF EXPANDED 21-44 35.50 32.47 32.80 50.50 47.44 44.46 41.19 0.00 0.00 0.00 0.00 0.00 284.36

110H TANF EXPANDED 45-64 41.18 39.58 28.78 51.10 39.63 38.88 44.50 0.00 0.00 0.00 0.00 0.00 283.65


9.94 10.46 9.57 10.65 9.47 10.52 20.78 0.00 0.00 0.00 0.00 0.00 81.39


26.89 30.78 28.56 23.05 26.70 27.20 22.94 0.00 0.00 0.00 0.00 0.00 186.12

1112 TANF EXPANDED 01-05 853.52 901.39 879.74 881.30 853.44 845.86 808.67 0.00 0.00 0.00 0.00 0.00 6,023.92

1113 TANF EXPANDED 06-13 3,414.36 3,444.82 3,463.95 3,497.36 3,499.79 3,515.54 3,241.76 0.00 0.00 0.00 0.00 0.00 24,077.58

1114 TANF EXPANDED 14-20 1,653.45 1,613.57 1,600.91 1,635.34 1,615.04 1,608.15 1,513.82 0.00 0.00 0.00 0.00 0.00 11,240.28

1115 TANF EXPANDED 14-20 3,043.81 2,995.64 2,896.14 2,885.38 2,846.07 2,840.49 2,694.40 0.00 0.00 0.00 0.00 0.00 20,201.93

1116 TANF EXPANDED 21-44 25,174.04 25,242.42 25,082.51 24,857.46 24,401.53 23,936.06 23,461.00 0.00 0.00 0.00 0.00 0.00 172,155.02

1117 TANF EXPANDED 21-44 52,992.08 53,249.11 53,509.27 53,526.08 52,927.26 52,372.22 51,613.87 0.00 0.00 0.00 0.00 0.00 370,189.89

23



1118 TANF EXPANDED 45-64 17,126.60 17,235.01 17,330.56 17,381.57 17,189.37 17,086.98 17,053.49 0.00 0.00 0.00 0.00 0.00 120,403.58


38.66 40.99 43.56 36.07 31.69 41.93 45.29 0.00 0.00 0.00 0.00 0.00 278.19

111A TANF EXPANDED <1 M&F

0.51 5.09 0.43 0.92 3.24 1.63 3.95 0.00 0.00 0.00 0.00 0.00 15.77

111B TANF EXPANDED 01-05 61.36 35.56 56.24 40.22 34.88 32.13 49.09 0.00 0.00 0.00 0.00 0.00 309.48

111C TANF EXPANDED 06-13 110.74 172.51 142.78 121.02 112.90 96.34 99.96 0.00 0.00 0.00 0.00 0.00 856.25

111D TANF EXPANDED 14-20 72.52 92.23 87.97 94.05 71.44 64.96 79.64 0.00 0.00 0.00 0.00 0.00 562.81

111E TANF EXPANDED 14-20 148.16 147.53 142.46 116.20 145.41 129.84 137.39 0.00 0.00 0.00 0.00 0.00 966.99

111F TANF EXPANDED 21-44 1,273.15 1,434.37 1,190.10 1,300.86 1,003.37 1,005.29 1,386.31 0.00 0.00 0.00 0.00 0.00 8,593.45

111G TANF EXPANDED 21-44 2,576.50 2,934.62 2,546.23 2,616.05 2,136.55 2,117.62 2,636.52 0.00 0.00 0.00 0.00 0.00 17,564.09

111H TANF EXPANDED 45-64 730.32 740.40 673.38 662.20 493.91 600.15 777.84 0.00 0.00 0.00 0.00 0.00 4,678.20


8.23 6.91 11.36 4.88 3.29 5.01 5.61 0.00 0.00 0.00 0.00 0.00 45.29

1126 TANF EXPANDED 21-44 36.93 32.57 31.13 31.54 30.40 28.35 30.45 0.00 0.00 0.00 0.00 0.00 221.37

1127 TANF EXPANDED 21-44 54.70 57.00 60.45 58.36 61.40 61.04 58.54 0.00 0.00 0.00 0.00 0.00 411.49

1128 TANF EXPANDED 45-64 112.24 115.33 108.02 109.58 113.77 110.79 119.49 0.00 0.00 0.00 0.00 0.00 789.22


35.51 37.25 41.77 42.96 44.99 46.76 40.57 0.00 0.00 0.00 0.00 0.00 289.81

112F TANF EXPANDED 21-44 0.93 1.41 0.00 0.00 0.60 0.00 0.54 0.00 0.00 0.00 0.00 0.00 3.48

112G TANF EXPANDED 21-44 0.29 0.00 2.52 0.61 0.60 0.06 0.45 0.00 0.00 0.00 0.00 0.00 4.53

112H TANF EXPANDED 45-64 1.06 3.63 1.30 1.38 1.19 1.19 1.92 0.00 0.00 0.00 0.00 0.00 11.67


1.48 1.73 0.00 0.03 0.99 3.21 4.63 0.00 0.00 0.00 0.00 0.00 12.07


379.68 340.07 342.37 362.92 422.45 497.69 614.89 0.00 0.00 0.00 0.00 0.00 2,960.07


230.43 214.49 205.97 225.64 167.68 207.48 249.14 0.00 0.00 0.00 0.00 0.00 1,500.83


1,138.07 1,143.40 1,122.75 1,120.13 1,128.97 1,143.67 1,163.84 0.00 0.00 0.00 0.00 0.00 7,960.83

241Z SSI AGED EXPANDED NO

90.25 98.28 99.56 106.01 109.49 128.02 137.93 0.00 0.00 0.00 0.00 0.00 769.54


20,485.82 20,594.37 20,683.80 20,772.43 20,768.69 20,692.01 20,661.29 0.00 0.00 0.00 0.00 0.00 144,658.41


151.16 141.92 151.69 156.17 145.61 159.76 234.17 0.00 0.00 0.00 0.00 0.00 1,140.48


0.00 1.12 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.12

250Z SSI BLIND EXPANDED W

0.00 2.87 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.87


11.00 11.00 13.00 12.00 12.00 12.00 12.00 0.00 0.00 0.00 0.00 0.00 83.00


349.72 366.47 362.58 389.66 528.60 610.56 663.33 0.00 0.00 0.00 0.00 0.00 3,270.92


194.88 218.79 248.26 235.78 151.86 218.02 168.29 0.00 0.00 0.00 0.00 0.00 1,435.88


2,353.20 2,254.83 2,150.96 2,073.52 2,063.77 2,011.91 1,938.52 0.00 0.00 0.00 0.00 0.00 14,846.71


212.50 148.83 180.32 227.14 152.40 161.76 131.99 0.00 0.00 0.00 0.00 0.00 1,214.94


8,811.11 8,879.28 9,007.11 9,094.69 9,012.13 9,007.29 8,967.60 0.00 0.00 0.00 0.00 0.00 62,779.21


42.53 26.32 27.59 32.70 33.08 51.92 23.21 0.00 0.00 0.00 0.00 0.00 237.35

149,376.29SUBTOTAL: 150,413.05 149,934.96 150,186.02 147,758.61 146,857.11 146,265.64 0.00 0.00 0.00 0.00 0.00 1,040,791.68

24



9911 SB PAYMENT FOR TANF

64.00 53.00 63.00 67.00 50.00 49.00 66.00 0.00 0.00 0.00 0.00 0.00 412.00


0.00 2.00 2.00 2.00 3.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 11.00


6.00 0.00 1.00 3.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00

70.00SUBTOTAL: 55.00 66.00 72.00 53.00 52.00 67.00 0.00 0.00 0.00 0.00 0.00 435.00

3306 AHC CARE MALE 21-44 7.00 8.00 8.00 7.00 7.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 43.00


3.00 4.00 4.00 4.00 3.00 3.00 0.00 0.00 0.00 0.00 0.00 0.00 21.00


12.96 15.00 18.00 17.99 20.00 20.93 0.00 0.00 0.00 0.00 0.00 0.00 104.88

3309 AHC CARE M&F 65+ W/ 11.00 11.61 11.00 11.00 11.00 10.00 0.00 0.00 0.00 0.00 0.00 0.00 65.61

330H AHC CARE M&F 45-64 W

0.29 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.29

330J AHC CARE M&F 65+ W/ 0.00 0.38 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.38

3314 AHC CARE MALE 14-20 832.82 853.88 861.03 837.59 826.75 822.19 1.00 0.00 0.00 0.00 0.00 0.00 5,035.26


1,095.68 1,093.38 1,132.95 1,138.41 1,115.16 1,122.69 4.00 0.00 0.00 0.00 0.00 0.00 6,702.27

3316 AHC CARE MALE 21-44 2,428.49 2,422.17 2,423.21 2,377.53 2,336.63 2,248.55 26.11 0.00 0.00 0.00 0.00 0.00 14,262.69


2,721.73 2,699.17 2,691.91 2,703.18 2,664.58 2,587.87 17.99 0.00 0.00 0.00 0.00 0.00 16,086.43

3318 AHC CARE M&F 45-64 N 9,099.02 8,916.94 8,813.24 8,742.57 8,490.91 8,295.61 51.52 0.00 0.00 0.00 0.00 0.00 52,409.81

331D AHC CARE MALE 14-20 10.54 7.12 1.99 7.23 1.79 1.92 0.00 0.00 0.00 0.00 0.00 0.00 30.59

331E AHC CARE FEMALE 14-2

2.44 6.29 5.98 6.71 5.73 7.34 0.00 0.00 0.00 0.00 0.00 0.00 34.49

331F AHC CARE MALE 21-44 26.15 30.27 20.51 24.30 12.13 11.37 6.70 0.00 0.00 0.00 0.00 0.00 131.43

331G AHC CARE FEMALE 21-4

28.85 35.67 35.62 22.13 8.04 12.51 5.00 0.00 0.00 0.00 0.00 0.00 147.82

331H AHC CARE M&F 45-64 N 51.86 42.99 16.43 25.94 42.34 23.53 17.57 0.00 0.00 0.00 0.00 0.00 220.66

3326 AHC CARE MALE 21-44 8.00 7.00 7.00 8.00 8.00 7.00 0.00 0.00 0.00 0.00 0.00 0.00 45.00


1.00 1.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00


17.00 18.00 15.00 11.46 13.00 13.00 0.00 0.00 0.00 0.00 0.00 0.00 87.46

3329 AHC CARE M&F 65+ W/ 3.00 5.15 6.00 6.00 6.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 32.15

332J AHC CARE M&F 65+ W/ 0.00 1.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.06

16,360.83SUBTOTAL: 16,181.08 16,073.87 15,953.04 15,574.06 15,201.51 129.89 0.00 0.00 0.00 0.00 0.00 95,474.28

9933 SB PAYMENT FOR AHCCS

4.00 3.00 2.00 5.00 3.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 23.00

4.00SUBTOTAL: 3.00 2.00 5.00 3.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 23.00

3606 AHC CARE/MI MALE 21- 7.00 6.00 7.00 7.77 8.00 7.64 0.93 0.00 0.00 0.00 0.00 0.00 44.34


2.00 2.00 4.00 3.00 4.00 5.00 0.00 0.00 0.00 0.00 0.00 0.00 20.00

3608 AHC CARE/MI M&F 45-6 16.00 14.00 14.00 14.96 12.00 10.00 0.00 0.00 0.00 0.00 0.00 0.00 80.96

3609 AHC CARE/MI M&F 65+ 0.00 0.00 0.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00

360F AHC CARE/MI MALE 21- 0.00 0.00 0.00 0.00 0.00 0.00 13.06 0.00 0.00 0.00 0.00 0.00 13.06


0.00 0.00 0.00 0.00 0.00 0.00 16.00 0.00 0.00 0.00 0.00 0.00 16.00

360H AHC CARE/MI M&F 45-6 0.00 0.00 0.00 0.00 0.00 0.00 25.00 0.00 0.00 0.00 0.00 0.00 25.00

25



3611 AHC CARE/MI M&F < 1 0.00 0.16 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.16

3614 AHC CARE/MI MALE 14- 5,799.31 5,715.96 5,702.42 5,763.55 5,798.60 5,762.88 8.09 0.00 0.00 0.00 0.00 0.00 34,550.81


5,320.95 5,289.63 5,291.23 5,332.76 5,337.36 5,333.17 6.25 0.00 0.00 0.00 0.00 0.00 31,911.35

3616 AHC CARE/MI MALE 21- 10,115.71 9,781.06 9,411.68 9,140.38 8,873.26 8,464.38 77.29 0.00 0.00 0.00 0.00 0.00 55,863.76


7,425.57 7,403.23 7,259.56 7,180.96 6,982.93 6,802.88 49.95 0.00 0.00 0.00 0.00 0.00 43,105.08

3618 AHC CARE/MI M&F 45-6 21,027.21 20,607.11 20,091.43 19,634.08 19,188.72 18,537.28 87.46 0.00 0.00 0.00 0.00 0.00 119,173.29

3619 AHC CARE/MI M&F 65+ 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00

361A AHC CARE/MI M&F < 1 0.00 0.83 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.83

361D AHC CARE/MI MALE 14- 40.58 34.83 44.75 43.17 25.36 31.65 155.25 0.00 0.00 0.00 0.00 0.00 375.59

361E AHC CARE/MI FEMALE 1

28.30 50.90 34.25 22.64 20.43 20.88 81.00 0.00 0.00 0.00 0.00 0.00 258.40

361F AHC CARE/MI MALE 21- 36.07 53.75 50.03 39.33 27.51 26.39 2,835.96 0.00 0.00 0.00 0.00 0.00 3,069.04


28.18 32.77 29.91 30.27 17.48 16.88 1,961.82 0.00 0.00 0.00 0.00 0.00 2,117.31

361H AHC CARE/MI M&F 45-6 41.45 78.74 38.26 50.50 51.84 57.91 8,538.02 0.00 0.00 0.00 0.00 0.00 8,856.72

361J AHC CARE/MI M&F 65+ 0.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00

3628 AHC CARE/MI M&F 45-6 2.00 2.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00


0.00 0.00 0.00 0.00 0.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 2.00

49,891.33SUBTOTAL: 49,077.97 47,982.52 47,267.37 46,351.49 45,079.94 13,858.08 0.00 0.00 0.00 0.00 0.00 299,508.70

9936 SB PAYMENT FOR AHCC

24.00 15.00 15.00 19.00 16.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 101.00

24.00SUBTOTAL: 15.00 15.00 19.00 16.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 101.00

3506 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 23.41 0.00 0.00 0.00 0.00 0.00 23.41


0.00 0.00 0.00 0.00 0.00 0.00 13.58 0.00 0.00 0.00 0.00 0.00 13.58

3508 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 156.63 0.00 0.00 0.00 0.00 0.00 156.63

3509 ADULT 40-100% M&F 65 0.00 0.00 0.00 0.00 0.00 0.00 11.00 0.00 0.00 0.00 0.00 0.00 11.00

350F ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 9.41 0.00 0.00 0.00 0.00 0.00 9.41


0.00 0.00 0.00 0.00 0.00 0.00 7.30 0.00 0.00 0.00 0.00 0.00 7.30

350H ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 48.56 0.00 0.00 0.00 0.00 0.00 48.56

3514 ADULT 40-100% MALE 1 0.00 0.00 0.00 0.00 0.00 0.00 1,043.16 0.00 0.00 0.00 0.00 0.00 1,043.16


0.00 0.00 0.00 0.00 0.00 0.00 1,430.85 0.00 0.00 0.00 0.00 0.00 1,430.85

3516 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 -1.00 4,315.21 0.00 0.00 0.00 0.00 0.00 4,314.21


0.00 0.00 0.00 0.00 0.00 -1.00 4,447.71 0.00 0.00 0.00 0.00 0.00 4,446.71

3518 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 -6.00 12,709.58 0.00 0.00 0.00 0.00 0.00 12,703.58

3519 ADULT 40-100% M&F 65 0.00 0.00 0.00 0.00 0.00 0.00 0.12 0.00 0.00 0.00 0.00 0.00 0.12

351D ADULT 40-100% MALE 1 0.00 0.00 0.00 0.00 0.00 0.00 109.20 0.00 0.00 0.00 0.00 0.00 109.20

351E ADULT 40-100% FEMALE

0.00 0.00 0.00 0.00 0.00 0.00 134.58 0.00 0.00 0.00 0.00 0.00 134.58

351F ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 993.57 0.00 0.00 0.00 0.00 0.00 993.57

26




0.00 0.00 0.00 0.00 0.00 0.00 912.53 0.00 0.00 0.00 0.00 0.00 912.53

351H ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 1,917.83 0.00 0.00 0.00 0.00 0.00 1,917.83

351J ADULT 40-100% M&F 65 0.00 0.00 0.00 0.00 0.00 0.00 0.87 0.00 0.00 0.00 0.00 0.00 0.87

3526 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 7.02 0.00 0.00 0.00 0.00 0.00 7.02


0.00 0.00 0.00 0.00 0.00 0.00 4.44 0.00 0.00 0.00 0.00 0.00 4.44

3528 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 26.17 0.00 0.00 0.00 0.00 0.00 26.17

3529 ADULT 40-100% M&F 65 0.00 0.00 0.00 0.00 0.00 0.00 6.00 0.00 0.00 0.00 0.00 0.00 6.00

352F ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 1.95 0.00 0.00 0.00 0.00 0.00 1.95


0.00 0.00 0.00 0.00 0.00 0.00 0.54 0.00 0.00 0.00 0.00 0.00 0.54

352H ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 4.74 0.00 0.00 0.00 0.00 0.00 4.74

3706 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 36.97 0.00 0.00 0.00 0.00 0.00 36.97


0.00 0.00 0.00 0.00 0.00 0.00 23.72 0.00 0.00 0.00 0.00 0.00 23.72


0.00 0.00 0.00 0.00 0.00 0.00 84.57 0.00 0.00 0.00 0.00 0.00 84.57


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

370F ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 14.22 0.00 0.00 0.00 0.00 0.00 14.22


0.00 0.00 0.00 0.00 0.00 0.00 5.15 0.00 0.00 0.00 0.00 0.00 5.15


0.00 0.00 0.00 0.00 0.00 0.00 17.52 0.00 0.00 0.00 0.00 0.00 17.52

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 -3.00 7,375.62 0.00 0.00 0.00 0.00 0.00 7,372.62


0.00 0.00 0.00 0.00 0.00 0.00 6,593.03 0.00 0.00 0.00 0.00 0.00 6,593.03

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 -13.00 21,282.74 0.00 0.00 0.00 0.00 0.00 21,269.74


0.00 0.00 0.00 0.00 0.00 -10.00 14,086.15 0.00 0.00 0.00 0.00 0.00 14,076.15


0.00 0.00 0.00 0.00 0.00 -15.00 33,179.34 0.00 0.00 0.00 0.00 0.00 33,164.34


0.00 0.00 0.00 0.00 0.00 0.00 15.78 0.00 0.00 0.00 0.00 0.00 15.78

371D ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 652.62 0.00 0.00 0.00 0.00 0.00 652.62

371E ADULT <40% EXP FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 522.01 0.00 0.00 0.00 0.00 0.00 522.01

371F ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 4,581.65 0.00 0.00 0.00 0.00 0.00 4,581.65


0.00 0.00 0.00 0.00 0.00 0.00 2,839.04 0.00 0.00 0.00 0.00 0.00 2,839.04


0.00 0.00 0.00 0.00 0.00 0.00 5,687.70 0.00 0.00 0.00 0.00 0.00 5,687.70

371J ADULT <40% EXP M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 5.18 0.00 0.00 0.00 0.00 0.00 5.18


0.00 0.00 0.00 0.00 0.00 0.00 7.97 0.00 0.00 0.00 0.00 0.00 7.97


0.00 0.00 0.00 0.00 0.00 0.00 0.99 0.00 0.00 0.00 0.00 0.00 0.99

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 -49.00 125,348.93 0.00 0.00 0.00 0.00 0.00 125,299.93


0.00 0.00 0.00 0.00 0.00 0.00 6.00 0.00 0.00 0.00 0.00 0.00 6.00


0.00 0.00 0.00 0.00 0.00 0.00 9.00 0.00 0.00 0.00 0.00 0.00 9.00

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 15.00 0.00 0.00 0.00 0.00 0.00 15.00

27




0.00 0.00 0.00 1.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.03


33.15 35.40 36.32 37.99 37.39 40.00 40.62 0.00 0.00 0.00 0.00 0.00 260.87


268.67 279.09 294.48 301.17 294.57 307.25 316.27 0.00 0.00 0.00 0.00 0.00 2,061.50


0.00 0.96 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.96

451E BC PATIENT FEMALE 14

0.00 0.00 0.00 3.96 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.96

451G BC PATIENT FEMALE 21

3.79 3.55 3.65 1.99 1.79 0.00 3.35 0.00 0.00 0.00 0.00 0.00 18.12

451H BC PATIENT FEMALE 45

14.20 12.76 15.04 22.90 20.30 12.95 19.58 0.00 0.00 0.00 0.00 0.00 117.73

451J BC PATIENT FEMALE 65

0.00 0.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.03


28.03 28.31 32.05 35.89 31.96 35.44 34.96 0.00 0.00 0.00 0.00 0.00 226.64


19.96 20.64 22.20 23.18 22.78 28.76 32.53 0.00 0.00 0.00 0.00 0.00 170.05

461G CC PATIENT FEMALE 21

1.96 3.66 3.92 6.01 1.02 5.54 1.03 0.00 0.00 0.00 0.00 0.00 23.14

461H CC PATIENT FEMALE 45

2.03 3.34 0.80 1.80 7.96 6.20 5.44 0.00 0.00 0.00 0.00 0.00 27.57

371.79SUBTOTAL: 387.74 408.46 435.92 417.77 436.14 453.78 0.00 0.00 0.00 0.00 0.00 2,911.60


0.00 0.00 0.00 0.00 0.36 1.00 1.00 0.00 0.00 0.00 0.00 0.00 2.36

860Z SSI BLIND FREEDOM/WO

0.00 0.00 0.00 0.00 1.63 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.63


1,219.57 1,219.65 1,231.01 1,237.86 1,238.15 1,248.38 1,218.33 0.00 0.00 0.00 0.00 0.00 8,612.95


38.00 31.17 30.89 30.75 23.77 20.31 25.67 0.00 0.00 0.00 0.00 0.00 200.56


195.76 189.11 189.33 194.26 183.66 179.32 168.47 0.00 0.00 0.00 0.00 0.00 1,299.91


19.14 24.80 30.37 34.63 7.32 37.96 14.39 0.00 0.00 0.00 0.00 0.00 168.61


167.22 162.89 162.13 157.00 154.53 149.34 155.93 0.00 0.00 0.00 0.00 0.00 1,109.04


3.75 7.08 1.60 0.00 0.46 4.64 0.06 0.00 0.00 0.00 0.00 0.00 17.59

1,643.44SUBTOTAL: 1,634.70 1,645.33 1,654.50 1,609.88 1,640.95 1,583.85 0.00 0.00 0.00 0.00 0.00 11,412.65

1,091,354.00 TOTAL: 1,097,351.43 1,094,043.54 1,090,382.01 1,074,819.30 1,064,310.10 1,132,875.05 0.00 0.00 0.00 0.00 0.00 7,645,135.43

28

NEWLY ELIGIBLE ADULTS - CAPITATION AMOUNTSFor The Period Ending January 31, 2014


3906 NEWLY ELIGIBLE MALE 0.00 0.00 0.00 0.00 0.00 0.00 3,432.73 0.00 0.00 0.00 0.00 0.00 3,432.73

3907 NEWLY ELIGIBLE FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 3,762.96 0.00 0.00 0.00 0.00 0.00 3,762.96

3908 NEWLY ELIGIBLE M&F 4

0.00 0.00 0.00 0.00 0.00 0.00 30,835.35 0.00 0.00 0.00 0.00 0.00 30,835.35


0.00 0.00 0.00 0.00 0.00 0.00 166.33 0.00 0.00 0.00 0.00 0.00 166.33

390F NEWLY ELIGIBLE MALE 0.00 0.00 0.00 0.00 0.00 0.00 5,005.45 0.00 0.00 0.00 0.00 0.00 5,005.45

390G NEWLY ELIGIBLE FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 3,959.71 0.00 0.00 0.00 0.00 0.00 3,959.71

390H NEWLY ELIGIBLE M&F 4

0.00 0.00 0.00 0.00 0.00 0.00 38,615.18 0.00 0.00 0.00 0.00 0.00 38,615.18



0.00 0.00 0.00 0.00 0.00 0.00 24,775.85 0.00 0.00 0.00 0.00 0.00 24,775.85



0.00 0.00 0.00 0.00 0.00 0.00 105,018.68 0.00 0.00 0.00 0.00 0.00 105,018.68


0.00 0.00 0.00 0.00 0.00 0.00 370,339.86 0.00 0.00 0.00 0.00 0.00 370,339.86


0.00 0.00 0.00 0.00 0.00 0.00 78.28 0.00 0.00 0.00 0.00 0.00 78.28

391D NEWLY ELIGIBLE MALE 0.00 0.00 0.00 0.00 0.00 0.00 14,483.80 0.00 0.00 0.00 0.00 0.00 14,483.80

391E NEWLY ELIGIBLE FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 16,593.92 0.00 0.00 0.00 0.00 0.00 16,593.92

391F NEWLY ELIGIBLE MALE 0.00 0.00 0.00 0.00 0.00 0.00 54,057.17 0.00 0.00 0.00 0.00 0.00 54,057.17


0.00 0.00 0.00 0.00 0.00 0.00 59,473.12 0.00 0.00 0.00 0.00 0.00 59,473.12


0.00 0.00 0.00 0.00 0.00 0.00 181,161.36 0.00 0.00 0.00 0.00 0.00 181,161.36

391J NEWLY ELIGIBLE M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 586.64 0.00 0.00 0.00 0.00 0.00 586.64

3926 NEWLY ELIGIBLE MALE 0.00 0.00 0.00 0.00 0.00 0.00 40.63 0.00 0.00 0.00 0.00 0.00 40.63


0.00 0.00 0.00 0.00 0.00 0.00 39.14 0.00 0.00 0.00 0.00 0.00 39.14


0.00 0.00 0.00 0.00 0.00 0.00 158.16 0.00 0.00 0.00 0.00 0.00 158.16

392F NEWLY ELIGIBLE MALE 0.00 0.00 0.00 0.00 0.00 0.00 362.33 0.00 0.00 0.00 0.00 0.00 362.33


0.00 0.00 0.00 0.00 0.00 0.00 293.32 0.00 0.00 0.00 0.00 0.00 293.32


0.00 0.00 0.00 0.00 0.00 0.00 437.65 0.00 0.00 0.00 0.00 0.00 437.65

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 1,057,213.16 0.00 0.00 0.00 0.00 0.00 1,057,213.16

0.00 TOTAL: 0.00 0.00 0.00 0.00 0.00 1,057,213.16 0.00 0.00 0.00 0.00 0.00 1,057,213.16

29

NEWLY ELIGIBLE ADULTS - MEMBER MONTHSFor The Period Ending January 31, 2014




0.00 0.00 0.00 0.00 0.00 0.00 12.81 0.00 0.00 0.00 0.00 0.00 12.81


0.00 0.00 0.00 0.00 0.00 0.00 102.61 0.00 0.00 0.00 0.00 0.00 102.61


0.00 0.00 0.00 0.00 0.00 0.00 0.54 0.00 0.00 0.00 0.00 0.00 0.54



0.00 0.00 0.00 0.00 0.00 0.00 12.03 0.00 0.00 0.00 0.00 0.00 12.03


0.00 0.00 0.00 0.00 0.00 0.00 116.22 0.00 0.00 0.00 0.00 0.00 116.22



0.00 0.00 0.00 0.00 0.00 0.00 83.96 0.00 0.00 0.00 0.00 0.00 83.96



0.00 0.00 0.00 0.00 0.00 0.00 355.03 0.00 0.00 0.00 0.00 0.00 355.03


0.00 0.00 0.00 0.00 0.00 0.00 1,249.08 0.00 0.00 0.00 0.00 0.00 1,249.08


0.00 0.00 0.00 0.00 0.00 0.00 0.24 0.00 0.00 0.00 0.00 0.00 0.24

391D NEWLY ELIGIBLE MALE 0.00 0.00 0.00 0.00 0.00 0.00 44.21 0.00 0.00 0.00 0.00 0.00 44.21

391E NEWLY ELIGIBLE FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 49.53 0.00 0.00 0.00 0.00 0.00 49.53



0.00 0.00 0.00 0.00 0.00 0.00 179.53 0.00 0.00 0.00 0.00 0.00 179.53


0.00 0.00 0.00 0.00 0.00 0.00 540.56 0.00 0.00 0.00 0.00 0.00 540.56

391J NEWLY ELIGIBLE M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 1.74 0.00 0.00 0.00 0.00 0.00 1.74



0.00 0.00 0.00 0.00 0.00 0.00 0.12 0.00 0.00 0.00 0.00 0.00 0.12


0.00 0.00 0.00 0.00 0.00 0.00 0.60 0.00 0.00 0.00 0.00 0.00 0.60



0.00 0.00 0.00 0.00 0.00 0.00 0.87 0.00 0.00 0.00 0.00 0.00 0.87


0.00 0.00 0.00 0.00 0.00 0.00 1.38 0.00 0.00 0.00 0.00 0.00 1.38

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 3,426.48 0.00 0.00 0.00 0.00 0.00 3,426.48

0.00 TOTAL: 0.00 0.00 0.00 0.00 0.00 3,426.48 0.00 0.00 0.00 0.00 0.00 3,426.48

30

CHILD EXPANSION - CAPITATION AMOUNTSFor The Period Ending January 31, 2014


4413 SOBRA 100-133% M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 444,623.51 0.00 0.00 0.00 0.00 0.00 444,623.51

4414 SOBRA 100-133% MALE 0.00 0.00 0.00 0.00 0.00 0.00 172,294.40 0.00 0.00 0.00 0.00 0.00 172,294.40

4415 SOBRA 100-133% FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 275,251.03 0.00 0.00 0.00 0.00 0.00 275,251.03

441C SOBRA 100-133% M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 1,351.38 0.00 0.00 0.00 0.00 0.00 1,351.38

441D SOBRA 100-133% MALE 0.00 0.00 0.00 0.00 0.00 0.00 1,167.90 0.00 0.00 0.00 0.00 0.00 1,167.90

441E SOBRA 100-133% FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 1,473.60 0.00 0.00 0.00 0.00 0.00 1,473.60

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 896,161.82 0.00 0.00 0.00 0.00 0.00 896,161.82

0.00 TOTAL: 0.00 0.00 0.00 0.00 0.00 896,161.82 0.00 0.00 0.00 0.00 0.00 896,161.82

31

CHILD EXPANSION - MEMBER MONTHSFor The Period Ending January 31, 2014


4413 SOBRA 100-133% M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 4,529.84 0.00 0.00 0.00 0.00 0.00 4,529.84

4414 SOBRA 100-133% MALE 0.00 0.00 0.00 0.00 0.00 0.00 1,186.64 0.00 0.00 0.00 0.00 0.00 1,186.64


0.00 0.00 0.00 0.00 0.00 0.00 1,183.47 0.00 0.00 0.00 0.00 0.00 1,183.47

441C SOBRA 100-133% M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 23.72 0.00 0.00 0.00 0.00 0.00 23.72

441D SOBRA 100-133% MALE 0.00 0.00 0.00 0.00 0.00 0.00 6.83 0.00 0.00 0.00 0.00 0.00 6.83

441E SOBRA 100-133% FEMAL

0.00 0.00 0.00 0.00 0.00 0.00 7.24 0.00 0.00 0.00 0.00 0.00 7.24

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 6,937.74 0.00 0.00 0.00 0.00 0.00 6,937.74

0.00 TOTAL: 0.00 0.00 0.00 0.00 0.00 6,937.74 0.00 0.00 0.00 0.00 0.00 6,937.74

32

ACUTE CAPITATION RURAL HOSPITAL - AMOUNTSFor The Period Ending January 31, 2014


9810 RURAL HOSP PMT TACI 0.00 0.00 0.00 0.00 0.00 0.00 1,894,781.14 0.00 0.00 0.00 0.00 0.00 1,894,781.14

9812 RURAL HOSP PMT TACS

0.00 0.00 0.00 0.00 0.00 0.00 963,064.15 0.00 0.00 0.00 0.00 0.00 963,064.15

9814 RURAL HOSP PMT MALE

0.00 0.00 0.00 0.00 0.00 0.00 406.29 0.00 0.00 0.00 0.00 0.00 406.29

9816 RURAL HOSP PMT FMAL

0.00 0.00 0.00 0.00 0.00 0.00 3,994,909.10 0.00 0.00 0.00 0.00 0.00 3,994,909.10

9818 RURAL HOSP PMT ADLT

0.00 0.00 0.00 0.00 0.00 0.00 149.15 0.00 0.00 0.00 0.00 0.00 149.15

9820 RURAL HOSP PMT SSI W

0.00 0.00 0.00 0.00 0.00 0.00 302,005.78 0.00 0.00 0.00 0.00 0.00 302,005.78


0.00 0.00 0.00 0.00 0.00 0.00 2,023,067.66 0.00 0.00 0.00 0.00 0.00 2,023,067.66

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 9,178,383.27 0.00 0.00 0.00 0.00 0.00 9,178,383.27

9811 RURAL HOSP PMT TACI 0.00 0.00 0.00 0.00 0.00 0.00 1,450.38 0.00 0.00 0.00 0.00 0.00 1,450.38


0.00 0.00 0.00 0.00 0.00 0.00 11,526.60 0.00 0.00 0.00 0.00 0.00 11,526.60


0.00 0.00 0.00 0.00 0.00 0.00 1,504,759.33 0.00 0.00 0.00 0.00 0.00 1,504,759.33

9822 RURAL HOSP PMT FORS

0.00 0.00 0.00 0.00 0.00 0.00 191,675.34 0.00 0.00 0.00 0.00 0.00 191,675.34


0.00 0.00 0.00 0.00 0.00 0.00 125,461.23 0.00 0.00 0.00 0.00 0.00 125,461.23

9833 RURAL HOSP PMT FORA

0.00 0.00 0.00 0.00 0.00 0.00 377,196.04 0.00 0.00 0.00 0.00 0.00 377,196.04

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 2,212,068.92 0.00 0.00 0.00 0.00 0.00 2,212,068.92


0.00 0.00 0.00 0.00 0.00 0.00 1,001,475.85 0.00 0.00 0.00 0.00 0.00 1,001,475.85

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 1,001,475.85 0.00 0.00 0.00 0.00 0.00 1,001,475.85

9845 RURAL HOSP PMT FORB

0.00 0.00 0.00 0.00 0.00 0.00 966.27 0.00 0.00 0.00 0.00 0.00 966.27

9846 RURAL HOSP PMT FORC

0.00 0.00 0.00 0.00 0.00 0.00 1,918.40 0.00 0.00 0.00 0.00 0.00 1,918.40

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 2,884.67 0.00 0.00 0.00 0.00 0.00 2,884.67

9887 RH PAYMENT FREEDOM T

0.00 0.00 0.00 0.00 0.00 0.00 11,461.01 0.00 0.00 0.00 0.00 0.00 11,461.01

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 11,461.01 0.00 0.00 0.00 0.00 0.00 11,461.01

0.00 TOTAL: 0.00 0.00 0.00 0.00 0.00 12,406,273.72 0.00 0.00 0.00 0.00 0.00 12,406,273.72

33

ACUTE CAPITATION RURAL HOSPITAL - MEMBER MONTHSFor The Period Ending January 31, 2014


9810 RURAL HOSP PMT TACI 0.00 0.00 0.00 0.00 0.00 0.00 212.04 0.00 0.00 0.00 0.00 0.00 212.04


0.00 0.00 0.00 0.00 0.00 0.00 2,003.79 0.00 0.00 0.00 0.00 0.00 2,003.79

9814 RURAL HOSP PMT MALE

0.00 0.00 0.00 0.00 0.00 0.00 0.18 0.00 0.00 0.00 0.00 0.00 0.18


0.00 0.00 0.00 0.00 0.00 0.00 872.97 0.00 0.00 0.00 0.00 0.00 872.97

9818 RURAL HOSP PMT ADLT

0.00 0.00 0.00 0.00 0.00 0.00 0.03 0.00 0.00 0.00 0.00 0.00 0.03


0.00 0.00 0.00 0.00 0.00 0.00 353.19 0.00 0.00 0.00 0.00 0.00 353.19


0.00 0.00 0.00 0.00 0.00 0.00 358.32 0.00 0.00 0.00 0.00 0.00 358.32

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 3,800.52 0.00 0.00 0.00 0.00 0.00 3,800.52

9811 RURAL HOSP PMT TACI 0.00 0.00 0.00 0.00 0.00 0.00 0.12 0.00 0.00 0.00 0.00 0.00 0.12


0.00 0.00 0.00 0.00 0.00 0.00 23.67 0.00 0.00 0.00 0.00 0.00 23.67


0.00 0.00 0.00 0.00 0.00 0.00 322.86 0.00 0.00 0.00 0.00 0.00 322.86


0.00 0.00 0.00 0.00 0.00 0.00 222.27 0.00 0.00 0.00 0.00 0.00 222.27


0.00 0.00 0.00 0.00 0.00 0.00 21.78 0.00 0.00 0.00 0.00 0.00 21.78


0.00 0.00 0.00 0.00 0.00 0.00 114.00 0.00 0.00 0.00 0.00 0.00 114.00

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 704.70 0.00 0.00 0.00 0.00 0.00 704.70


0.00 0.00 0.00 0.00 0.00 0.00 304.32 0.00 0.00 0.00 0.00 0.00 304.32

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 304.32 0.00 0.00 0.00 0.00 0.00 304.32

9845 RURAL HOSP PMT FORB

0.00 0.00 0.00 0.00 0.00 0.00 0.21 0.00 0.00 0.00 0.00 0.00 0.21

9846 RURAL HOSP PMT FORC

0.00 0.00 0.00 0.00 0.00 0.00 0.39 0.00 0.00 0.00 0.00 0.00 0.39

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 0.60 0.00 0.00 0.00 0.00 0.00 0.60

9887 RH PAYMENT FREEDOM T

0.00 0.00 0.00 0.00 0.00 0.00 7.53 0.00 0.00 0.00 0.00 0.00 7.53

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 7.53 0.00 0.00 0.00 0.00 0.00 7.53

0.00 TOTAL: 0.00 0.00 0.00 0.00 0.00 4,817.67 0.00 0.00 0.00 0.00 0.00 4,817.67

34

LONG TERM CARE CAPITATION - AMOUNTSFor The Period Ending January 31, 2014


1000 TANF WITH MEDICARE 3,112.04 3,112.04 3,112.04 3,181.77 6,360.34 6,144.34 6,144.34 0.00 0.00 0.00 0.00 0.00 31,166.91

1010 TANF NON-MEDICARE 1,854,169.13 1,874,874.26 1,900,762.04 1,941,266.06 2,072,344.35 1,971,720.88 1,967,193.32 0.00 0.00 0.00 0.00 0.00 13,582,330.04

101Z TANF ALTCS NON-MEDIC

0.00 0.00 0.00 0.00 0.00 0.00 513.19 0.00 0.00 0.00 0.00 0.00 513.19

1020 TANF WITH QMB 9,336.12 9,336.12 9,336.12 9,545.31 10,193.31 9,545.31 9,545.31 0.00 0.00 0.00 0.00 0.00 66,837.60


28,840,530.95 32,762,047.29 29,163,709.75 30,026,161.57 34,183,173.86 30,399,672.88 30,295,914.25 0.00 0.00 0.00 0.00 0.00 215,671,210.55


655,264.14 625,858.27 536,994.55 655,957.13 563,773.55 617,885.96 680,076.33 0.00 0.00 0.00 0.00 0.00 4,335,809.93


2,457,323.93 2,668,274.16 2,490,415.59 2,593,358.63 2,834,493.83 2,564,025.31 2,572,273.32 0.00 0.00 0.00 0.00 0.00 18,180,164.77


12,376.15 11,342.15 18,035.71 24,114.49 18,495.09 17,345.85 16,390.30 0.00 0.00 0.00 0.00 0.00 118,099.74

2120 SSI AGED WITH QMB 16,671,987.89 18,798,662.22 16,825,368.24 17,363,655.60 19,459,131.40 17,185,158.63 16,976,072.66 0.00 0.00 0.00 0.00 0.00 123,280,036.64


13,339.59 9,870.91 13,278.42 7,454.18 6,754.84 14,558.81 13,627.52 0.00 0.00 0.00 0.00 0.00 78,884.27


12,799,580.27 13,941,990.86 12,921,186.37 13,338,880.17 14,840,737.89 13,534,047.54 13,615,348.02 0.00 0.00 0.00 0.00 0.00 94,991,771.12


66,341.65 98,001.14 71,177.37 73,535.12 79,547.95 90,049.82 109,310.77 0.00 0.00 0.00 0.00 0.00 587,963.82


75,858,615.68 77,180,087.23 76,355,440.34 78,605,474.98 84,400,892.93 79,207,978.43 79,534,245.47 0.00 0.00 0.00 0.00 0.00 551,142,735.06


57,275.78 85,412.51 66,651.29 138,783.20 93,732.30 53,687.57 105,185.24 0.00 0.00 0.00 0.00 0.00 600,727.89


18,592,614.98 19,548,555.32 18,769,120.73 19,238,432.03 20,996,895.25 19,119,304.75 19,079,202.53 0.00 0.00 0.00 0.00 0.00 135,344,125.59


1,006.88 1,849.75 443.79 4,233.67 0.00 716.12 5,800.75 0.00 0.00 0.00 0.00 0.00 14,050.96



406,569.94 415,923.42 409,474.51 427,886.96 463,342.38 453,976.29 449,450.25 0.00 0.00 0.00 0.00 0.00 3,026,623.75


158,483,808.20SUBTOTAL: 168,219,190.79 159,732,654.83 164,627,183.73 180,220,035.75 165,425,716.77 165,624,217.40 0.00 0.00 0.00 0.00 0.00 1,162,332,807.47


63,782.01 63,957.79 55,292.39 59,747.02 63,245.09 60,312.12 60,312.12 0.00 0.00 0.00 0.00 0.00 426,648.54


95,395.71 106,024.59 99,965.85 98,929.74 106,047.68 95,747.97 95,747.97 0.00 0.00 0.00 0.00 0.00 697,859.51


12,266.49 13,041.93 12,266.49 12,445.56 13,797.96 12,590.52 12,590.52 0.00 0.00 0.00 0.00 0.00 88,999.47

171,444.21SUBTOTAL: 183,024.31 167,524.73 171,122.32 183,090.73 168,650.61 168,650.61 0.00 0.00 0.00 0.00 0.00 1,213,507.52

158,655,252.41 TOTAL: 168,402,215.10 159,900,179.56 164,798,306.05 180,403,126.48 165,594,367.38 165,792,868.01 0.00 0.00 0.00 0.00 0.00 1,163,546,314.99

35

LONG TERM CARE MEMBER MONTHSFor The Period Ending January 31, 2014


1000 TANF WITH MEDICARE 1.00 1.00 1.00 1.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 10.00

1010 TANF NON-MEDICARE 592.61 597.40 607.11 606.55 607.18 616.23 615.14 0.00 0.00 0.00 0.00 0.00 4,242.22

101Z TANF ALTCS NON-MEDIC

0.00 0.00 0.00 0.00 0.00 0.00 0.16 0.00 0.00 0.00 0.00 0.00 0.16

1020 TANF WITH QMB 3.00 3.00 3.00 3.00 3.00 3.00 3.00 0.00 0.00 0.00 0.00 0.00 21.00


11,129.68 11,150.35 11,218.59 11,208.03 11,298.68 11,347.72 11,317.14 0.00 0.00 0.00 0.00 0.00 78,670.19


764.59 728.87 626.88 756.00 642.09 693.34 760.88 0.00 0.00 0.00 0.00 0.00 4,972.65


604.26 602.69 610.21 606.36 602.29 603.46 608.33 0.00 0.00 0.00 0.00 0.00 4,237.60


14.56 13.17 20.98 28.28 21.62 19.33 18.42 0.00 0.00 0.00 0.00 0.00 136.36

2120 SSI AGED WITH QMB 6,882.55 6,894.57 6,931.41 6,959.00 6,912.01 6,877.74 6,793.05 0.00 0.00 0.00 0.00 0.00 48,250.33


15.37 11.69 15.04 8.49 7.84 15.98 15.49 0.00 0.00 0.00 0.00 0.00 89.90


4,533.09 4,580.31 4,564.34 4,601.67 4,644.94 4,670.07 4,703.97 0.00 0.00 0.00 0.00 0.00 32,298.39


76.80 114.50 83.91 84.20 89.43 101.34 121.78 0.00 0.00 0.00 0.00 0.00 671.96


23,507.92 23,531.40 23,602.80 23,688.69 23,739.70 23,856.61 23,959.65 0.00 0.00 0.00 0.00 0.00 165,886.77


66.29 100.82 77.20 157.14 108.65 61.41 108.54 0.00 0.00 0.00 0.00 0.00 680.05


6,463.99 6,478.93 6,505.75 6,509.62 6,512.41 6,471.21 6,465.21 0.00 0.00 0.00 0.00 0.00 45,407.12


1.09 2.18 0.49 4.60 0.00 0.88 6.08 0.00 0.00 0.00 0.00 0.00 15.32



125.00 126.00 125.93 128.00 129.40 135.83 135.11 0.00 0.00 0.00 0.00 0.00 905.27

2320 SSI BLIND WITH QMB 46.93 45.00 47.00 44.43 44.00 45.00 43.98 0.00 0.00 0.00 0.00 0.00 316.34

54,848.73SUBTOTAL: 55,000.97 55,059.64 55,413.06 55,383.24 55,540.15 55,699.93 0.00 0.00 0.00 0.00 0.00 386,945.72


22.00 19.93 19.00 20.00 19.00 20.00 20.00 0.00 0.00 0.00 0.00 0.00 139.93


23.00 24.00 24.00 23.00 23.00 22.00 22.00 0.00 0.00 0.00 0.00 0.00 161.00


4.00 4.00 4.00 4.00 5.00 5.00 5.00 0.00 0.00 0.00 0.00 0.00 31.00

49.00SUBTOTAL: 47.93 47.00 47.00 47.00 47.00 47.00 0.00 0.00 0.00 0.00 0.00 331.93

54,897.73 TOTAL: 55,048.90 55,106.64 55,460.06 55,430.24 55,587.15 55,746.93 0.00 0.00 0.00 0.00 0.00 387,277.65

36

MENTAL HEALTH CAPITATION AMOUNTS - CHILDRENFor The Period Ending January 31, 2014





39.14 117.42 117.42 73.10 73.10 36.80 36.98 0.00 0.00 0.00 0.00 0.00 493.96


596,415.32 594,849.72 597,902.64 431,290.00 430,303.15 431,594.65 433,220.70 0.00 0.00 0.00 0.00 0.00 3,515,576.18


665.38 665.38 626.24 365.50 365.50 367.00 369.80 0.00 0.00 0.00 0.00 0.00 3,424.80


2,974.64 2,857.22 2,974.64 1,315.80 1,535.10 1,394.70 1,405.24 0.00 0.00 0.00 0.00 0.00 14,457.34

4300 SOBRA CHILD WITH MED

39.14 39.14 78.28 36.55 36.55 36.70 36.98 0.00 0.00 0.00 0.00 0.00 303.34

4310 SOBRA CHILD NON-MEDI

10,948,553.92 10,938,260.10 11,053,840.52 10,024,641.60 10,004,319.80 9,942,485.80 9,800,550.54 0.00 0.00 0.00 0.00 0.00 72,712,652.28

5010 SOBRA PREGNANT WOMAN

17,534.72 17,886.98 18,787.20 17,032.30 15,899.25 14,904.65 14,274.28 0.00 0.00 0.00 0.00 0.00 116,319.38

22,591,490.58SUBTOTAL: 22,565,423.34 22,740,340.00 20,500,273.65 20,465,697.35 20,280,578.80 20,027,813.30 0.00 0.00 0.00 0.00 0.00 149,171,617.02

1110 TANF EXPANDED FOR FI

257,697.76 257,267.22 259,889.60 239,329.40 237,684.65 239,174.75 225,836.86 0.00 0.00 0.00 0.00 0.00 1,716,880.24


195.70 195.70 195.70 109.65 109.65 110.10 110.94 0.00 0.00 0.00 0.00 0.00 1,027.44

257,893.46SUBTOTAL: 257,462.92 260,085.30 239,439.05 237,794.30 239,284.85 225,947.80 0.00 0.00 0.00 0.00 0.00 1,717,907.68

3610 AHC CARE EXPANDED FO

0.00 0.00 39.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 39.14

0.00SUBTOTAL: 0.00 39.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 39.14

22,849,384.04 TOTAL: 22,822,886.26 23,000,464.44 20,739,712.70 20,703,491.65 20,519,863.65 20,253,761.10 0.00 0.00 0.00 0.00 0.00 150,889,563.84

37

MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDRENFor The Period Ending January 31, 2014



1010 TANF NON-MEDICARE 281,686.00 281,315.00 282,727.00 274,294.00 273,956.00 269,461.00 264,409.00 0.00 0.00 0.00 0.00 0.00 1,927,848.00


1.00 3.00 3.00 2.00 2.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 13.00


15,238.00 15,198.00 15,276.00 11,800.00 11,773.00 11,760.00 11,715.00 0.00 0.00 0.00 0.00 0.00 92,760.00


17.00 17.00 16.00 10.00 10.00 10.00 10.00 0.00 0.00 0.00 0.00 0.00 90.00


76.00 73.00 76.00 36.00 42.00 38.00 38.00 0.00 0.00 0.00 0.00 0.00 379.00


1.00 1.00 2.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 8.00


279,728.00 279,465.00 282,418.00 274,272.00 273,716.00 270,904.00 265,023.00 0.00 0.00 0.00 0.00 0.00 1,925,526.00


448.00 457.00 480.00 466.00 435.00 406.00 386.00 0.00 0.00 0.00 0.00 0.00 3,078.00

577,197.00SUBTOTAL: 576,531.00 581,000.00 560,883.00 559,937.00 552,583.00 541,585.00 0.00 0.00 0.00 0.00 0.00 3,949,716.00


6,584.00 6,573.00 6,640.00 6,548.00 6,503.00 6,517.00 6,107.00 0.00 0.00 0.00 0.00 0.00 45,472.00


5.00 5.00 5.00 3.00 3.00 3.00 3.00 0.00 0.00 0.00 0.00 0.00 27.00

6,589.00SUBTOTAL: 6,578.00 6,645.00 6,551.00 6,506.00 6,520.00 6,110.00 0.00 0.00 0.00 0.00 0.00 45,499.00


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

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

583,786.00 TOTAL: 583,109.00 587,646.00 567,434.00 566,443.00 559,103.00 547,695.00 0.00 0.00 0.00 0.00 0.00 3,995,216.00

38

MENTAL HEALTH CAPITATION AMOUNTS - ADULTFor The Period Ending January 31, 2014




1020 TANF WITH QMB 1,862.88 1,630.02 1,552.40 1,800.48 1,964.16 1,810.68 2,152.71 0.00 0.00 0.00 0.00 0.00 12,773.33


321,812.52 319,949.64 321,113.94 339,063.12 346,756.08 355,781.76 353,762.01 0.00 0.00 0.00 0.00 0.00 2,358,239.07


399,743.00 403,546.38 404,322.58 423,440.16 428,268.72 430,614.72 417,466.28 0.00 0.00 0.00 0.00 0.00 2,907,401.84

2120 SSI AGED WITH QMB 1,572,736.44 1,577,936.98 1,579,877.48 1,673,464.32 1,669,536.00 1,676,755.44 1,623,541.99 0.00 0.00 0.00 0.00 0.00 11,373,848.65


327,634.02 329,108.80 331,437.40 349,293.12 365,415.60 377,808.03 371,382.34 0.00 0.00 0.00 0.00 0.00 2,452,079.31


3,760,766.62 3,774,427.74 3,788,476.96 3,965,311.68 3,971,858.88 3,999,671.55 3,871,529.34 0.00 0.00 0.00 0.00 0.00 27,132,042.77


2,265,417.32 2,270,074.52 2,275,818.40 2,402,167.68 2,393,165.28 2,404,208.94 2,324,448.42 0.00 0.00 0.00 0.00 0.00 16,335,300.56



31,901.82 32,057.06 32,289.92 33,963.60 34,618.32 34,479.51 33,087.95 0.00 0.00 0.00 0.00 0.00 232,398.18



0.00 77.62 77.62 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 155.24


1,398,013.82 1,385,672.24 1,384,197.46 1,395,535.68 1,366,809.84 1,330,595.28 1,237,887.98 0.00 0.00 0.00 0.00 0.00 9,498,712.30


4,424.34 3,648.14 4,036.24 4,337.52 4,173.84 4,361.07 3,508.12 0.00 0.00 0.00 0.00 0.00 28,489.27


1,125,334.76 1,135,580.60 1,153,200.34 1,188,234.96 1,184,797.68 1,148,109.90 1,078,587.44 0.00 0.00 0.00 0.00 0.00 8,013,845.68


465.72 388.10 310.48 327.36 163.68 164.88 159.46 0.00 0.00 0.00 0.00 0.00 1,979.68

22,206,616.28SUBTOTAL: 22,226,642.24 22,368,065.88 23,330,783.52 23,348,952.00 23,207,146.65 22,112,477.66 0.00 0.00 0.00 0.00 0.00 158,800,684.23

1100 TANF EXPANDED FPR FI

423,261.86 424,348.54 429,316.22 448,974.24 449,956.32 449,722.95 434,448.77 0.00 0.00 0.00 0.00 0.00 3,060,028.90


7,779,309.26 7,760,447.60 7,847,304.38 8,193,411.60 8,151,264.00 8,114,335.23 7,688,682.82 0.00 0.00 0.00 0.00 0.00 55,534,754.89


19,405.00 19,948.34 20,491.68 20,951.04 21,605.76 21,395.40 20,570.34 0.00 0.00 0.00 0.00 0.00 144,367.56


26,701.28 23,518.86 24,062.20 26,352.48 32,490.48 39,791.01 47,997.46 0.00 0.00 0.00 0.00 0.00 220,913.77


88,176.32 87,244.88 86,002.96 89,287.44 90,596.88 91,338.60 89,855.71 0.00 0.00 0.00 0.00 0.00 622,502.79


1,668,907.62 1,678,842.98 1,688,312.62 1,784,357.52 1,780,674.72 1,787,438.94 1,725,596.39 0.00 0.00 0.00 0.00 0.00 12,114,130.79


931.44 931.44 1,086.68 1,063.92 1,063.92 1,069.77 1,036.49 0.00 0.00 0.00 0.00 0.00 7,183.66


24,295.06 25,692.22 24,295.06 27,989.28 42,147.60 48,666.63 52,302.88 0.00 0.00 0.00 0.00 0.00 245,388.73


189,548.04 180,621.74 172,471.64 174,401.04 172,273.20 169,042.86 157,387.02 0.00 0.00 0.00 0.00 0.00 1,215,745.54


714,569.72 719,459.78 731,258.02 776,988.96 771,342.00 774,363.75 747,787.67 0.00 0.00 0.00 0.00 0.00 5,235,769.90

10,935,105.60SUBTOTAL: 10,921,056.38 11,024,601.46 11,543,777.52 11,513,414.88 11,497,165.14 10,965,665.55 0.00 0.00 0.00 0.00 0.00 78,400,786.53


2,871.94 2,949.56 3,260.04 3,273.60 3,437.28 3,291.90 0.00 0.00 0.00 0.00 0.00 0.00 19,084.32


1,301,765.02 1,284,067.66 1,279,488.08 1,328,836.08 1,305,020.64 1,281,247.77 797.30 0.00 0.00 0.00 0.00 0.00 7,781,222.55


2,406.22 2,483.84 2,483.84 2,537.04 2,537.04 2,469.00 0.00 0.00 0.00 0.00 0.00 0.00 14,916.98

1,307,043.18SUBTOTAL: 1,289,501.06 1,285,231.96 1,334,646.72 1,310,994.96 1,287,008.67 797.30 0.00 0.00 0.00 0.00 0.00 7,815,223.85


2,018.12 1,862.88 2,095.74 2,291.52 2,209.68 1,976.01 0.00 0.00 0.00 0.00 0.00 0.00 12,453.95


4,454,999.90 4,361,545.42 4,283,770.18 4,407,411.36 4,329,008.64 4,238,907.45 159.46 0.00 0.00 0.00 0.00 0.00 26,075,802.41

39

MENTAL HEALTH CAPITATION AMOUNTS - ADULTFor The Period Ending January 31, 2014



155.24 155.24 155.24 163.68 163.68 164.58 0.00 0.00 0.00 0.00 0.00 0.00 957.66

4,457,173.26SUBTOTAL: 4,363,563.54 4,286,021.16 4,409,866.56 4,331,382.00 4,241,048.04 159.46 0.00 0.00 0.00 0.00 0.00 26,089,214.02

3500 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 9,647.33 0.00 0.00 0.00 0.00 0.00 9,647.33

3510 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 1,592,287.83 0.00 0.00 0.00 0.00 0.00 1,592,287.83

3520 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 2,710.82 0.00 0.00 0.00 0.00 0.00 2,710.82

3700 ADULT <40% EXP FOR F

0.00 0.00 0.00 0.00 0.00 0.00 8,610.84 0.00 0.00 0.00 0.00 0.00 8,610.84


0.00 0.00 0.00 0.00 0.00 0.00 6,055,254.31 0.00 0.00 0.00 0.00 0.00 6,055,254.31


0.00 0.00 0.00 0.00 0.00 0.00 478.38 0.00 0.00 0.00 0.00 0.00 478.38

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 7,668,989.51 0.00 0.00 0.00 0.00 0.00 7,668,989.51

4510 BC PATIENT FOR FINAN

22,276.94 23,674.10 24,838.40 26,679.84 26,516.16 28,630.02 27,825.77 0.00 0.00 0.00 0.00 0.00 180,441.23

4610 CC PATIENT FOR FINAN

3,648.14 3,648.14 4,113.86 4,501.20 4,337.52 5,099.58 5,262.18 0.00 0.00 0.00 0.00 0.00 30,610.62

25,925.08SUBTOTAL: 27,322.24 28,952.26 31,181.04 30,853.68 33,729.60 33,087.95 0.00 0.00 0.00 0.00 0.00 211,051.85


0.00 0.00 0.00 0.00 0.00 81.99 79.73 0.00 0.00 0.00 0.00 0.00 161.72


94,774.02 94,463.54 95,938.32 100,990.56 101,563.44 103,268.70 97,111.14 0.00 0.00 0.00 0.00 0.00 688,109.72


14,592.56 14,359.70 14,282.08 15,304.08 14,976.72 14,239.77 13,314.91 0.00 0.00 0.00 0.00 0.00 101,069.82


12,884.92 12,419.20 12,574.44 12,848.88 12,685.20 12,263.31 12,437.88 0.00 0.00 0.00 0.00 0.00 88,113.83

122,251.50SUBTOTAL: 121,242.44 122,794.84 129,143.52 129,225.36 129,853.77 122,943.66 0.00 0.00 0.00 0.00 0.00 877,455.09

39,054,114.90 TOTAL: 38,949,327.90 39,115,667.56 40,779,398.88 40,664,822.88 40,395,951.87 40,904,121.09 0.00 0.00 0.00 0.00 0.00 279,863,405.08

40

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULTFor The Period Ending January 31, 2014


1000 TANF WITH MEDICARE 563.00 579.00 576.00 570.00 586.00 583.00 576.00 0.00 0.00 0.00 0.00 0.00 4,033.00

1010 TANF NON-MEDICARE 140,829.00 140,762.00 142,037.00 140,325.00 140,644.00 138,176.00 134,534.00 0.00 0.00 0.00 0.00 0.00 977,307.00

1020 TANF WITH QMB 24.00 21.00 20.00 22.00 24.00 22.00 27.00 0.00 0.00 0.00 0.00 0.00 160.00


4,146.00 4,122.00 4,137.00 4,143.00 4,237.00 4,324.00 4,437.00 0.00 0.00 0.00 0.00 0.00 29,546.00


5,150.00 5,199.00 5,209.00 5,174.00 5,233.00 5,233.00 5,236.00 0.00 0.00 0.00 0.00 0.00 36,434.00

2120 SSI AGED WITH QMB 20,262.00 20,329.00 20,354.00 20,448.00 20,400.00 20,376.00 20,363.00 0.00 0.00 0.00 0.00 0.00 142,532.00


4,221.00 4,240.00 4,270.00 4,268.00 4,465.00 4,592.00 4,658.00 0.00 0.00 0.00 0.00 0.00 30,714.00


48,451.00 48,627.00 48,808.00 48,452.00 48,532.00 48,605.00 48,558.00 0.00 0.00 0.00 0.00 0.00 340,033.00


29,186.00 29,246.00 29,320.00 29,352.00 29,242.00 29,216.00 29,154.00 0.00 0.00 0.00 0.00 0.00 204,716.00



411.00 413.00 416.00 415.00 423.00 419.00 415.00 0.00 0.00 0.00 0.00 0.00 2,912.00



0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00


18,011.00 17,852.00 17,833.00 17,052.00 16,701.00 16,167.00 15,526.00 0.00 0.00 0.00 0.00 0.00 119,142.00


57.00 47.00 52.00 53.00 51.00 53.00 44.00 0.00 0.00 0.00 0.00 0.00 357.00


14,498.00 14,630.00 14,857.00 14,519.00 14,477.00 13,950.00 13,528.00 0.00 0.00 0.00 0.00 0.00 100,459.00


6.00 5.00 4.00 4.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 25.00

286,094.00SUBTOTAL: 286,352.00 288,174.00 285,078.00 285,300.00 282,005.00 277,342.00 0.00 0.00 0.00 0.00 0.00 1,990,345.00


5,453.00 5,467.00 5,531.00 5,486.00 5,498.00 5,465.00 5,449.00 0.00 0.00 0.00 0.00 0.00 38,349.00


100,223.00 99,980.00 101,099.00 100,115.00 99,600.00 98,602.00 96,434.00 0.00 0.00 0.00 0.00 0.00 696,053.00


250.00 257.00 264.00 256.00 264.00 260.00 258.00 0.00 0.00 0.00 0.00 0.00 1,809.00


344.00 303.00 310.00 322.00 397.00 484.00 602.00 0.00 0.00 0.00 0.00 0.00 2,762.00


1,136.00 1,124.00 1,108.00 1,091.00 1,107.00 1,110.00 1,127.00 0.00 0.00 0.00 0.00 0.00 7,803.00


21,501.00 21,629.00 21,751.00 21,803.00 21,758.00 21,721.00 21,643.00 0.00 0.00 0.00 0.00 0.00 151,806.00


12.00 12.00 14.00 13.00 13.00 13.00 13.00 0.00 0.00 0.00 0.00 0.00 90.00


313.00 331.00 313.00 342.00 515.00 592.00 656.00 0.00 0.00 0.00 0.00 0.00 3,062.00


2,442.00 2,327.00 2,222.00 2,131.00 2,105.00 2,054.00 1,974.00 0.00 0.00 0.00 0.00 0.00 15,255.00


9,206.00 9,269.00 9,421.00 9,494.00 9,425.00 9,410.00 9,379.00 0.00 0.00 0.00 0.00 0.00 65,604.00

140,880.00SUBTOTAL: 140,699.00 142,033.00 141,053.00 140,682.00 139,711.00 137,535.00 0.00 0.00 0.00 0.00 0.00 982,593.00


37.00 38.00 42.00 40.00 42.00 40.00 0.00 0.00 0.00 0.00 0.00 0.00 239.00


16,771.00 16,543.00 16,484.00 16,237.00 15,946.00 15,568.00 10.00 0.00 0.00 0.00 0.00 0.00 97,559.00


31.00 32.00 32.00 31.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 187.00

16,839.00SUBTOTAL: 16,613.00 16,558.00 16,308.00 16,019.00 15,638.00 10.00 0.00 0.00 0.00 0.00 0.00 97,985.00


26.00 24.00 27.00 28.00 27.00 24.00 0.00 0.00 0.00 0.00 0.00 0.00 156.00


57,395.00 56,191.00 55,189.00 53,854.00 52,896.00 51,505.00 2.00 0.00 0.00 0.00 0.00 0.00 327,032.00

41

MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULTFor The Period Ending January 31, 2014



2.00 2.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00

57,423.00SUBTOTAL: 56,217.00 55,218.00 53,884.00 52,925.00 51,531.00 2.00 0.00 0.00 0.00 0.00 0.00 327,200.00

3500 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 121.00 0.00 0.00 0.00 0.00 0.00 121.00

3510 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 19,971.00 0.00 0.00 0.00 0.00 0.00 19,971.00

3520 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 34.00 0.00 0.00 0.00 0.00 0.00 34.00


0.00 0.00 0.00 0.00 0.00 0.00 108.00 0.00 0.00 0.00 0.00 0.00 108.00


0.00 0.00 0.00 0.00 0.00 0.00 75,947.00 0.00 0.00 0.00 0.00 0.00 75,947.00


0.00 0.00 0.00 0.00 0.00 0.00 6.00 0.00 0.00 0.00 0.00 0.00 6.00

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 96,187.00 0.00 0.00 0.00 0.00 0.00 96,187.00


287.00 305.00 320.00 326.00 324.00 348.00 349.00 0.00 0.00 0.00 0.00 0.00 2,259.00


47.00 47.00 53.00 55.00 53.00 62.00 66.00 0.00 0.00 0.00 0.00 0.00 383.00

334.00SUBTOTAL: 352.00 373.00 381.00 377.00 410.00 415.00 0.00 0.00 0.00 0.00 0.00 2,642.00


0.00 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 2.00


1,221.00 1,217.00 1,236.00 1,234.00 1,241.00 1,255.00 1,218.00 0.00 0.00 0.00 0.00 0.00 8,622.00


188.00 185.00 184.00 187.00 183.00 173.00 167.00 0.00 0.00 0.00 0.00 0.00 1,267.00


166.00 160.00 162.00 157.00 155.00 149.00 156.00 0.00 0.00 0.00 0.00 0.00 1,105.00

1,575.00SUBTOTAL: 1,562.00 1,582.00 1,578.00 1,579.00 1,578.00 1,542.00 0.00 0.00 0.00 0.00 0.00 10,996.00

503,145.00 TOTAL: 501,795.00 503,938.00 498,282.00 496,882.00 490,873.00 513,033.00 0.00 0.00 0.00 0.00 0.00 3,507,948.00

42

MENTAL HEALTH CAPITATION AMOUNTS - GENERALFor The Period Ending January 31, 2014




1020 TANF WITH QMB 1,056.96 924.84 880.80 977.46 1,066.32 980.86 1,214.73 0.00 0.00 0.00 0.00 0.00 7,101.97


182,589.84 181,532.88 182,193.48 184,073.49 188,249.91 192,750.52 199,620.63 0.00 0.00 0.00 0.00 0.00 1,311,010.75


226,806.00 228,963.96 229,404.36 229,880.82 232,502.19 233,284.19 235,567.64 0.00 0.00 0.00 0.00 0.00 1,616,409.16

2120 SSI AGED WITH QMB 892,338.48 895,289.16 896,390.16 908,504.64 906,372.00 908,366.88 916,131.37 0.00 0.00 0.00 0.00 0.00 6,323,392.69


185,892.84 186,729.60 188,050.80 189,627.24 198,379.95 204,688.81 209,563.42 0.00 0.00 0.00 0.00 0.00 1,362,932.66


2,133,782.04 2,141,533.08 2,149,504.32 2,152,722.36 2,156,276.76 2,166,799.60 2,184,624.42 0.00 0.00 0.00 0.00 0.00 15,085,242.58


1,285,351.44 1,287,993.84 1,291,252.80 1,304,109.36 1,299,222.06 1,302,457.38 1,311,638.46 0.00 0.00 0.00 0.00 0.00 9,082,025.34



18,100.44 18,188.52 18,320.64 18,438.45 18,793.89 18,679.02 18,670.85 0.00 0.00 0.00 0.00 0.00 129,191.81



0.00 44.04 44.04 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 88.08


793,204.44 786,202.08 785,365.32 757,620.36 742,025.43 720,795.81 698,514.74 0.00 0.00 0.00 0.00 0.00 5,283,728.18


2,510.28 2,069.88 2,290.08 2,354.79 2,265.93 2,362.64 1,979.56 0.00 0.00 0.00 0.00 0.00 15,833.16


638,491.92 644,305.20 654,302.28 645,079.17 643,213.11 621,945.80 608,624.72 0.00 0.00 0.00 0.00 0.00 4,455,962.20


264.24 220.20 176.16 177.72 88.86 89.26 89.98 0.00 0.00 0.00 0.00 0.00 1,106.42

12,599,579.76SUBTOTAL: 12,610,942.08 12,691,182.96 12,666,015.54 12,675,879.00 12,572,101.30 12,477,616.58 0.00 0.00 0.00 0.00 0.00 88,293,317.22


240,150.12 240,766.68 243,585.24 243,742.98 244,276.14 243,632.40 245,150.51 0.00 0.00 0.00 0.00 0.00 1,701,304.07


4,413,820.92 4,403,119.20 4,452,399.96 4,448,109.45 4,425,228.00 4,395,802.71 4,338,565.66 0.00 0.00 0.00 0.00 0.00 30,877,045.90


11,010.00 11,318.28 11,626.56 11,374.08 11,729.52 11,590.80 11,607.42 0.00 0.00 0.00 0.00 0.00 80,256.66


15,149.76 13,344.12 13,652.40 14,306.46 17,638.71 21,564.27 27,083.98 0.00 0.00 0.00 0.00 0.00 122,739.70


50,029.44 49,500.96 48,796.32 48,473.13 49,184.01 49,482.70 50,703.73 0.00 0.00 0.00 0.00 0.00 346,170.29


946,904.04 952,541.16 957,914.04 968,707.29 966,707.94 968,328.13 973,718.57 0.00 0.00 0.00 0.00 0.00 6,734,821.17


528.48 528.48 616.56 577.59 577.59 579.54 584.87 0.00 0.00 0.00 0.00 0.00 3,993.11


13,784.52 14,577.24 13,784.52 15,195.06 22,881.45 26,375.01 29,513.44 0.00 0.00 0.00 0.00 0.00 136,111.24


107,545.68 102,481.08 97,856.88 94,680.33 93,525.15 91,573.72 88,810.26 0.00 0.00 0.00 0.00 0.00 676,473.10


405,432.24 408,206.76 414,900.84 421,818.42 418,752.75 419,502.75 421,961.21 0.00 0.00 0.00 0.00 0.00 2,910,574.97

6,204,355.20SUBTOTAL: 6,196,383.96 6,255,133.32 6,266,984.79 6,250,501.26 6,228,432.03 6,187,699.65 0.00 0.00 0.00 0.00 0.00 43,589,490.21


1,629.48 1,673.52 1,849.68 1,777.20 1,866.06 1,783.30 0.00 0.00 0.00 0.00 0.00 0.00 10,579.24


738,594.84 728,553.72 725,955.36 721,409.91 708,480.78 694,073.79 449.90 0.00 0.00 0.00 0.00 0.00 4,317,518.30


1,365.24 1,409.28 1,409.28 1,377.33 1,377.33 1,337.50 0.00 0.00 0.00 0.00 0.00 0.00 8,275.96

741,589.56SUBTOTAL: 731,636.52 729,214.32 724,564.44 711,724.17 697,194.59 449.90 0.00 0.00 0.00 0.00 0.00 4,336,373.50


1,145.04 1,056.96 1,189.08 1,244.04 1,199.61 1,070.27 0.00 0.00 0.00 0.00 0.00 0.00 6,905.00


2,527,675.80 2,474,651.64 2,430,523.56 2,392,733.22 2,350,169.28 2,296,279.90 89.98 0.00 0.00 0.00 0.00 0.00 14,472,123.38

43

MENTAL HEALTH CAPITATION AMOUNTS - GENERALFor The Period Ending January 31, 2014



88.08 88.08 88.08 88.86 88.86 89.16 0.00 0.00 0.00 0.00 0.00 0.00 531.12

2,528,908.92SUBTOTAL: 2,475,796.68 2,431,800.72 2,394,066.12 2,351,457.75 2,297,439.33 89.98 0.00 0.00 0.00 0.00 0.00 14,479,559.50

3500 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 5,443.79 0.00 0.00 0.00 0.00 0.00 5,443.79

3510 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 898,495.29 0.00 0.00 0.00 0.00 0.00 898,495.29

3520 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 1,529.66 0.00 0.00 0.00 0.00 0.00 1,529.66


0.00 0.00 0.00 0.00 0.00 0.00 4,858.92 0.00 0.00 0.00 0.00 0.00 4,858.92


0.00 0.00 0.00 0.00 0.00 0.00 3,416,855.53 0.00 0.00 0.00 0.00 0.00 3,416,855.53


0.00 0.00 0.00 0.00 0.00 0.00 269.94 0.00 0.00 0.00 0.00 0.00 269.94

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 4,327,453.13 0.00 0.00 0.00 0.00 0.00 4,327,453.13


12,639.48 13,432.20 14,092.80 14,484.18 14,395.32 15,511.54 15,701.51 0.00 0.00 0.00 0.00 0.00 100,257.03


2,069.88 2,069.88 2,334.12 2,443.65 2,354.79 2,763.16 2,969.34 0.00 0.00 0.00 0.00 0.00 17,004.82

14,709.36SUBTOTAL: 15,502.08 16,426.92 16,927.83 16,750.11 18,274.70 18,670.85 0.00 0.00 0.00 0.00 0.00 117,261.85


0.00 0.00 0.00 0.00 0.00 44.48 44.99 0.00 0.00 0.00 0.00 0.00 89.47


53,772.84 53,596.68 54,433.44 54,826.62 55,137.63 55,946.15 54,797.82 0.00 0.00 0.00 0.00 0.00 382,511.18


8,279.52 8,147.40 8,103.36 8,308.41 8,130.69 7,713.54 7,513.33 0.00 0.00 0.00 0.00 0.00 56,196.25


7,310.64 7,046.40 7,134.48 6,975.51 6,886.65 6,643.12 7,018.44 0.00 0.00 0.00 0.00 0.00 49,015.24

69,363.00SUBTOTAL: 68,790.48 69,671.28 70,110.54 70,154.97 70,347.29 69,374.58 0.00 0.00 0.00 0.00 0.00 487,812.14

22,158,505.80 TOTAL: 22,099,051.80 22,193,429.52 22,138,669.26 22,076,467.26 21,883,789.24 23,081,354.67 0.00 0.00 0.00 0.00 0.00 155,631,267.55

44

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERALFor The Period Ending January 31, 2014


1000 TANF WITH MEDICARE 563.00 579.00 576.00 570.00 586.00 583.00 576.00 0.00 0.00 0.00 0.00 0.00 4,033.00


1020 TANF WITH QMB 24.00 21.00 20.00 22.00 24.00 22.00 27.00 0.00 0.00 0.00 0.00 0.00 160.00


4,146.00 4,122.00 4,137.00 4,143.00 4,237.00 4,324.00 4,437.00 0.00 0.00 0.00 0.00 0.00 29,546.00


5,150.00 5,199.00 5,209.00 5,174.00 5,233.00 5,233.00 5,236.00 0.00 0.00 0.00 0.00 0.00 36,434.00

2120 SSI AGED WITH QMB 20,262.00 20,329.00 20,354.00 20,448.00 20,400.00 20,376.00 20,363.00 0.00 0.00 0.00 0.00 0.00 142,532.00


4,221.00 4,240.00 4,270.00 4,268.00 4,465.00 4,592.00 4,658.00 0.00 0.00 0.00 0.00 0.00 30,714.00


48,451.00 48,627.00 48,808.00 48,452.00 48,532.00 48,605.00 48,558.00 0.00 0.00 0.00 0.00 0.00 340,033.00


29,186.00 29,246.00 29,320.00 29,352.00 29,242.00 29,216.00 29,154.00 0.00 0.00 0.00 0.00 0.00 204,716.00



411.00 413.00 416.00 415.00 423.00 419.00 415.00 0.00 0.00 0.00 0.00 0.00 2,912.00



0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00


18,011.00 17,852.00 17,833.00 17,052.00 16,701.00 16,167.00 15,526.00 0.00 0.00 0.00 0.00 0.00 119,142.00


57.00 47.00 52.00 53.00 51.00 53.00 44.00 0.00 0.00 0.00 0.00 0.00 357.00


14,498.00 14,630.00 14,857.00 14,519.00 14,477.00 13,950.00 13,528.00 0.00 0.00 0.00 0.00 0.00 100,459.00


6.00 5.00 4.00 4.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 25.00

286,094.00SUBTOTAL: 286,352.00 288,174.00 285,078.00 285,300.00 282,005.00 277,342.00 0.00 0.00 0.00 0.00 0.00 1,990,345.00


5,453.00 5,467.00 5,531.00 5,486.00 5,498.00 5,465.00 5,449.00 0.00 0.00 0.00 0.00 0.00 38,349.00


100,223.00 99,980.00 101,099.00 100,115.00 99,600.00 98,602.00 96,434.00 0.00 0.00 0.00 0.00 0.00 696,053.00


250.00 257.00 264.00 256.00 264.00 260.00 258.00 0.00 0.00 0.00 0.00 0.00 1,809.00


344.00 303.00 310.00 322.00 397.00 484.00 602.00 0.00 0.00 0.00 0.00 0.00 2,762.00


1,136.00 1,124.00 1,108.00 1,091.00 1,107.00 1,110.00 1,127.00 0.00 0.00 0.00 0.00 0.00 7,803.00


21,501.00 21,629.00 21,751.00 21,803.00 21,758.00 21,721.00 21,643.00 0.00 0.00 0.00 0.00 0.00 151,806.00


12.00 12.00 14.00 13.00 13.00 13.00 13.00 0.00 0.00 0.00 0.00 0.00 90.00


313.00 331.00 313.00 342.00 515.00 592.00 656.00 0.00 0.00 0.00 0.00 0.00 3,062.00


2,442.00 2,327.00 2,222.00 2,131.00 2,105.00 2,054.00 1,974.00 0.00 0.00 0.00 0.00 0.00 15,255.00


9,206.00 9,269.00 9,421.00 9,494.00 9,425.00 9,410.00 9,379.00 0.00 0.00 0.00 0.00 0.00 65,604.00

140,880.00SUBTOTAL: 140,699.00 142,033.00 141,053.00 140,682.00 139,711.00 137,535.00 0.00 0.00 0.00 0.00 0.00 982,593.00


37.00 38.00 42.00 40.00 42.00 40.00 0.00 0.00 0.00 0.00 0.00 0.00 239.00


16,771.00 16,543.00 16,484.00 16,237.00 15,946.00 15,568.00 10.00 0.00 0.00 0.00 0.00 0.00 97,559.00


31.00 32.00 32.00 31.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 187.00

16,839.00SUBTOTAL: 16,613.00 16,558.00 16,308.00 16,019.00 15,638.00 10.00 0.00 0.00 0.00 0.00 0.00 97,985.00


26.00 24.00 27.00 28.00 27.00 24.00 0.00 0.00 0.00 0.00 0.00 0.00 156.00


57,395.00 56,191.00 55,189.00 53,854.00 52,896.00 51,505.00 2.00 0.00 0.00 0.00 0.00 0.00 327,032.00

45

MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERALFor The Period Ending January 31, 2014



2.00 2.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00

57,423.00SUBTOTAL: 56,217.00 55,218.00 53,884.00 52,925.00 51,531.00 2.00 0.00 0.00 0.00 0.00 0.00 327,200.00

3500 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 121.00 0.00 0.00 0.00 0.00 0.00 121.00

3510 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 19,971.00 0.00 0.00 0.00 0.00 0.00 19,971.00

3520 ADULT 40-100% FOR FI 0.00 0.00 0.00 0.00 0.00 0.00 34.00 0.00 0.00 0.00 0.00 0.00 34.00


0.00 0.00 0.00 0.00 0.00 0.00 108.00 0.00 0.00 0.00 0.00 0.00 108.00


0.00 0.00 0.00 0.00 0.00 0.00 75,947.00 0.00 0.00 0.00 0.00 0.00 75,947.00


0.00 0.00 0.00 0.00 0.00 0.00 6.00 0.00 0.00 0.00 0.00 0.00 6.00

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 96,187.00 0.00 0.00 0.00 0.00 0.00 96,187.00


287.00 305.00 320.00 326.00 324.00 348.00 349.00 0.00 0.00 0.00 0.00 0.00 2,259.00


47.00 47.00 53.00 55.00 53.00 62.00 66.00 0.00 0.00 0.00 0.00 0.00 383.00

334.00SUBTOTAL: 352.00 373.00 381.00 377.00 410.00 415.00 0.00 0.00 0.00 0.00 0.00 2,642.00


0.00 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 2.00


1,221.00 1,217.00 1,236.00 1,234.00 1,241.00 1,255.00 1,218.00 0.00 0.00 0.00 0.00 0.00 8,622.00


188.00 185.00 184.00 187.00 183.00 173.00 167.00 0.00 0.00 0.00 0.00 0.00 1,267.00


166.00 160.00 162.00 157.00 155.00 149.00 156.00 0.00 0.00 0.00 0.00 0.00 1,105.00

1,575.00SUBTOTAL: 1,562.00 1,582.00 1,578.00 1,579.00 1,578.00 1,542.00 0.00 0.00 0.00 0.00 0.00 10,996.00

503,145.00 TOTAL: 501,795.00 503,938.00 498,282.00 496,882.00 490,873.00 513,033.00 0.00 0.00 0.00 0.00 0.00 3,507,948.00

46

MENTAL HEALTH CAPITATION AMOUNTS - CMDPFor The Period Ending January 31, 2014




379,620.79 368,660.61 366,667.84 333,652.49 330,327.04 353,881.31 358,214.28 0.00 0.00 0.00 0.00 0.00 2,491,024.36


996.38 2,989.14 2,989.14 2,216.96 2,216.96 2,226.02 2,252.92 0.00 0.00 0.00 0.00 0.00 15,887.52


9,524,396.45 9,712,712.28 9,924,941.22 11,027,159.30 11,415,127.34 11,657,716.79 11,967,511.04 0.00 0.00 0.00 0.00 0.00 75,229,564.42


26,902.26 29,891.41 28,895.04 35,471.38 35,471.40 32,286.36 25,908.58 0.00 0.00 0.00 0.00 0.00 214,826.43

13,387,361.75SUBTOTAL: 13,436,184.37 13,559,735.50 14,783,798.14 14,979,999.22 15,068,699.74 15,175,669.12 0.00 0.00 0.00 0.00 0.00 100,391,447.84


996.38 996.38 996.38 1,108.48 1,108.48 1,113.01 1,126.46 0.00 0.00 0.00 0.00 0.00 7,445.57

996.38SUBTOTAL: 996.38 996.38 1,108.48 1,108.48 1,113.01 1,126.46 0.00 0.00 0.00 0.00 0.00 7,445.57

13,388,358.13 TOTAL: 13,437,180.75 13,560,731.88 14,784,906.62 14,981,107.70 15,069,812.75 15,176,795.58 0.00 0.00 0.00 0.00 0.00 100,398,893.41

47

MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDPFor The Period Ending January 31, 2014




382.00 371.00 368.00 302.00 298.00 318.00 318.00 0.00 0.00 0.00 0.00 0.00 2,357.00


1.00 3.00 3.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 15.00


9,562.00 9,752.00 9,965.00 9,974.00 10,328.00 10,483.00 10,624.00 0.00 0.00 0.00 0.00 0.00 70,688.00


27.00 31.00 31.00 34.00 36.00 30.00 23.00 0.00 0.00 0.00 0.00 0.00 212.00

13,443.00SUBTOTAL: 13,492.00 13,617.00 13,375.00 13,564.00 13,551.00 13,472.00 0.00 0.00 0.00 0.00 0.00 94,514.00


1.00 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 7.00

1.00SUBTOTAL: 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 7.00

13,444.00 TOTAL: 13,493.00 13,618.00 13,376.00 13,565.00 13,552.00 13,473.00 0.00 0.00 0.00 0.00 0.00 94,521.00

48

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTSFor The Period Ending January 31, 2014


1005 TANF 14-20 FEMALE WI 197.13 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 197.13

1010 TANF NON-MEDICARE 89,839.87 92,092.51 95,776.69 215,307.35 239,375.00 0.00 122,081.25 0.00 0.00 0.00 0.00 0.00 854,472.67

1011 TANF <1 M & F NON-ME 85,544.84 86,262.23 87,752.55 90,890.53 29,763.59 0.00 17,254.63 0.00 0.00 0.00 0.00 0.00 397,468.37

1012 TANF 01-05 M & F NON 741,166.05 742,840.18 732,185.50 774,811.12 130,400.88 0.00 59,777.50 0.00 0.00 0.00 0.00 0.00 3,181,181.23

1013 TANF 06-13 M & F NON 985,673.39 1,002,998.33 998,531.24 1,047,719.52 116,845.77 0.00 53,583.74 0.00 0.00 0.00 0.00 0.00 4,205,351.99

1014 TANF 14-20 MALE NON- 202,286.36 209,950.40 205,956.22 223,620.68 29,243.01 0.00 13,818.59 0.00 0.00 0.00 0.00 0.00 884,875.26


245,815.29 251,430.21 257,761.24 259,398.64 26,415.85 0.00 11,370.04 0.00 0.00 0.00 0.00 0.00 1,052,191.27

1020 TANF WITH QMB 369.61 369.61 369.61 848.36 957.50 0.00 478.75 0.00 0.00 0.00 0.00 0.00 3,393.44


369.61 369.61 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,478.44


3,660.33 4,435.32 5,830.30 9,743.76 10,532.50 0.00 6,223.75 0.00 0.00 0.00 0.00 0.00 40,425.96


3,824,877.78 3,827,676.31 3,803,777.85 6,572,375.02 5,595,745.47 0.00 2,814,530.63 0.00 0.00 0.00 0.00 0.00 26,438,983.06


16,484.60 15,189.78 14,355.18 24,971.64 21,852.92 0.00 10,926.46 0.00 0.00 0.00 0.00 0.00 103,780.58


34,607.82 36,460.24 34,886.42 58,420.83 52,233.37 0.00 26,834.81 0.00 0.00 0.00 0.00 0.00 243,443.49

4305 SOBRA CHILD 14-20 FE 369.61 369.61 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,478.44

4311 SOBRA CHILD <1 M & F 189,267.30 184,314.23 177,798.72 180,021.42 31,646.73 0.00 14,442.11 0.00 0.00 0.00 0.00 0.00 777,490.51

4312 SOBRA CHILD 01-05 M 798,097.23 789,653.86 791,518.51 847,741.09 154,698.51 0.00 77,427.18 0.00 0.00 0.00 0.00 0.00 3,459,136.38

4313 SOBRA CHILD 06-13 M 1,043,444.00 1,045,352.47 1,048,357.05 1,085,533.79 126,667.35 0.00 58,755.93 0.00 0.00 0.00 0.00 0.00 4,408,110.59

4314 SOBRA CHILD 14-20 MA 255,249.48 258,667.38 261,576.57 273,310.39 44,953.98 0.00 22,775.25 0.00 0.00 0.00 0.00 0.00 1,116,533.05

4315 SOBRA CHILD 14-20 FE 320,340.19 316,779.61 319,927.28 338,250.75 38,156.71 0.00 18,411.70 0.00 0.00 0.00 0.00 0.00 1,351,866.24


13,416.84 11,088.30 13,675.57 14,414.21 2,757.72 0.00 1,660.63 0.00 0.00 0.00 0.00 0.00 57,013.27

8,851,077.33SUBTOTAL: 8,876,300.19 8,850,775.72 12,018,118.32 6,652,246.86 0.00 3,330,352.95 0.00 0.00 0.00 0.00 0.00 48,578,871.37


369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 739.22

1112 TANF EXPANDED 01-05 8,747.44 8,584.49 9,848.32 8,894.99 787.92 0.00 393.96 0.00 0.00 0.00 0.00 0.00 37,257.12

1113 TANF EXPANDED 06-13 31,786.46 32,024.92 31,786.46 32,229.12 1,575.84 0.00 787.92 0.00 0.00 0.00 0.00 0.00 130,190.72

1114 TANF EXPANDED 14-20 11,457.91 11,302.92 10,551.77 12,664.14 3,151.68 0.00 1,969.80 0.00 0.00 0.00 0.00 0.00 51,098.22

1115 TANF EXPANDED 14-20 18,862.43 18,146.66 18,850.11 19,292.77 1,575.84 0.00 393.96 0.00 0.00 0.00 0.00 0.00 77,121.77


369.61 369.61 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,478.44


2,633.77 2,658.81 2,587.27 369.61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8,249.46


788.50 739.22 739.22 739.22 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,006.16

75,015.73SUBTOTAL: 74,196.24 74,732.76 74,559.46 7,091.28 0.00 3,545.64 0.00 0.00 0.00 0.00 0.00 309,141.11

3314 AHC CARE MALE 14-20 11,457.91 12,197.13 12,566.74 11,888.83 787.92 0.00 0.00 0.00 0.00 0.00 0.00 0.00 48,898.53


12,406.58 12,566.74 15,154.01 14,032.57 787.92 0.00 0.00 0.00 0.00 0.00 0.00 0.00 54,947.82

23,864.49SUBTOTAL: 24,763.87 27,720.75 25,921.40 1,575.84 0.00 0.00 0.00 0.00 0.00 0.00 0.00 103,846.35

3614 AHC CARE/MI MALE 14- 54,431.23 62,440.24 60,544.51 66,944.03 14,182.56 0.00 0.00 0.00 0.00 0.00 0.00 0.00 258,542.57


63,462.03 62,392.56 62,809.86 61,907.06 6,697.32 0.00 0.00 0.00 0.00 0.00 0.00 0.00 257,268.83

49

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTSFor The Period Ending January 31, 2014


3616 AHC CARE/MI MALE 21- 0.00 0.00 0.00 0.00 393.96 0.00 0.00 0.00 0.00 0.00 0.00 0.00 393.96

117,893.26SUBTOTAL: 124,832.80 123,354.37 128,851.09 21,273.84 0.00 0.00 0.00 0.00 0.00 0.00 0.00 516,205.36

3516 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 393.96 0.00 0.00 0.00 0.00 0.00 393.96


0.00 0.00 0.00 0.00 0.00 0.00 393.96 0.00 0.00 0.00 0.00 0.00 393.96

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 7,485.24 0.00 0.00 0.00 0.00 0.00 7,485.24


0.00 0.00 0.00 0.00 0.00 0.00 3,939.60 0.00 0.00 0.00 0.00 0.00 3,939.60

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 393.96 0.00 0.00 0.00 0.00 0.00 393.96


0.00 0.00 0.00 0.00 0.00 0.00 393.96 0.00 0.00 0.00 0.00 0.00 393.96

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 13,000.68 0.00 0.00 0.00 0.00 0.00 13,000.68

9,067,850.81 TOTAL: 9,100,093.10 9,076,583.60 12,247,450.27 6,682,187.82 0.00 3,346,899.27 0.00 0.00 0.00 0.00 0.00 49,521,064.87

50

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHSFor The Period Ending January 31, 2014


1005 TANF 14-20 FEMALE WI 0.53 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.53


1011 TANF <1 M & F NON-ME 231.40 233.33 237.34 242.00 70.58 0.00 41.00 0.00 0.00 0.00 0.00 0.00 1,055.65

1012 TANF 01-05 M & F NON 2,005.23 2,009.74 1,980.93 2,078.57 319.17 0.00 147.00 0.00 0.00 0.00 0.00 0.00 8,540.64

1013 TANF 06-13 M & F NON 2,666.74 2,713.59 2,701.52 2,819.73 288.16 0.00 133.00 0.00 0.00 0.00 0.00 0.00 11,322.74

1014 TANF 14-20 MALE NON- 547.28 568.01 557.18 601.53 71.00 0.00 34.00 0.00 0.00 0.00 0.00 0.00 2,379.00


665.05 680.21 697.35 698.26 64.90 0.00 28.00 0.00 0.00 0.00 0.00 0.00 2,833.77

1020 TANF WITH QMB 1.00 1.00 1.00 2.00 2.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 8.00


1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00


9.91 12.00 15.77 24.00 22.00 0.00 13.00 0.00 0.00 0.00 0.00 0.00 96.68


10,348.31 10,355.84 10,291.20 16,155.94 11,862.11 0.00 5,968.00 0.00 0.00 0.00 0.00 0.00 64,981.40


44.60 41.09 38.83 61.00 46.00 0.00 23.00 0.00 0.00 0.00 0.00 0.00 254.52


93.63 98.63 94.37 145.00 113.00 0.00 58.00 0.00 0.00 0.00 0.00 0.00 602.63

4305 SOBRA CHILD 14-20 FE 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00

4311 SOBRA CHILD <1 M & F 512.03 498.58 480.94 480.89 72.83 0.00 33.00 0.00 0.00 0.00 0.00 0.00 2,078.27

4312 SOBRA CHILD 01-05 M 2,159.24 2,136.36 2,141.43 2,255.63 342.96 0.00 172.00 0.00 0.00 0.00 0.00 0.00 9,207.62

4313 SOBRA CHILD 06-13 M 2,823.05 2,828.21 2,836.32 2,909.00 287.72 0.00 133.00 0.00 0.00 0.00 0.00 0.00 11,817.30

4314 SOBRA CHILD 14-20 MA 690.58 699.80 707.67 730.00 102.40 0.00 52.00 0.00 0.00 0.00 0.00 0.00 2,982.45

4315 SOBRA CHILD 14-20 FE 866.67 857.03 865.54 907.86 87.58 0.00 42.00 0.00 0.00 0.00 0.00 0.00 3,626.68


36.29 30.00 37.00 38.86 7.00 0.00 4.00 0.00 0.00 0.00 0.00 0.00 153.15

23,946.60SUBTOTAL: 24,014.57 23,945.50 30,661.27 14,259.41 0.00 7,137.00 0.00 0.00 0.00 0.00 0.00 123,964.35


1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00

1112 TANF EXPANDED 01-05 23.66 23.22 26.64 24.00 2.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 100.52

1113 TANF EXPANDED 06-13 86.00 86.64 86.00 87.00 4.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 351.64

1114 TANF EXPANDED 14-20 31.00 30.57 28.54 34.00 8.00 0.00 5.00 0.00 0.00 0.00 0.00 0.00 137.11

1115 TANF EXPANDED 14-20 51.03 49.09 51.00 52.00 4.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 208.12


1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00


7.13 7.19 7.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22.32


2.13 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.13

202.95SUBTOTAL: 200.71 202.18 201.00 18.00 0.00 9.00 0.00 0.00 0.00 0.00 0.00 833.84

3314 AHC CARE MALE 14-20 31.00 33.00 34.00 32.10 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 132.10


33.56 34.00 41.00 37.90 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 148.46

64.56SUBTOTAL: 67.00 75.00 70.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 280.56

3614 AHC CARE/MI MALE 14- 147.26 168.93 163.80 180.06 36.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 696.05


171.70 168.80 169.93 166.90 17.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 694.33

51

CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHSFor The Period Ending January 31, 2014


3616 AHC CARE/MI MALE 21- 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00

318.96SUBTOTAL: 337.73 333.73 346.96 54.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,391.38

3516 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 1.00


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

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 19.00 0.00 0.00 0.00 0.00 0.00 19.00


0.00 0.00 0.00 0.00 0.00 0.00 10.00 0.00 0.00 0.00 0.00 0.00 10.00

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 1.00


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

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 33.00 0.00 0.00 0.00 0.00 0.00 33.00

24,533.07 TOTAL: 24,620.01 24,556.41 31,279.23 14,335.41 0.00 7,179.00 0.00 0.00 0.00 0.00 0.00 126,503.13

52

ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICESFor The Period Ending January 31, 2014


1006 TANF 21-44 MALE WITH 1,772.09 1,388.98 7,721.79 8,257.27 2,962.82 3,918.66 5,358.63 0.00 0.00 0.00 0.00 0.00 31,380.24

1007 TANF 21-44 FEMALE WI 76,566.84 11,769.17 12,943.77 12,859.14 7,370.03 6,540.06 10,037.67 0.00 0.00 0.00 0.00 0.00 138,086.68

1008 TANF 45-64 M & F WIT 12,777.82 5,225.51 6,120.50 10,384.33 4,217.75 4,667.07 7,257.19 0.00 0.00 0.00 0.00 0.00 50,650.17

1009 TANF 65+ M & F WITH 916.31 586.66 2,619.74 1,539.35 169.80 660.00 572.00 0.00 0.00 0.00 0.00 0.00 7,063.86

1011 TANF <1 M & F NON-ME 2,224,224.74 1,733,745.89 1,528,818.51 1,666,823.51 1,260,256.34 1,504,286.37 1,841,532.88 0.00 0.00 0.00 0.00 0.00 11,759,688.24

1012 TANF 01-05 M & F NON 2,936,147.98 2,497,175.80 2,685,714.36 3,422,118.33 2,239,634.37 2,852,224.03 2,278,460.87 0.00 0.00 0.00 0.00 0.00 18,911,475.74

1013 TANF 06-13 M & F NON 3,340,460.82 3,274,105.25 3,451,659.33 3,961,298.12 3,125,393.31 3,820,238.28 2,682,625.03 0.00 0.00 0.00 0.00 0.00 23,655,780.14

1014 TANF 14-20 MALE NON- 711,659.56 734,609.53 750,485.23 926,532.23 610,785.86 997,967.21 542,190.41 0.00 0.00 0.00 0.00 0.00 5,274,230.03


1,440,031.74 1,263,864.92 1,267,242.14 1,347,847.41 1,107,144.60 1,256,914.25 987,820.96 0.00 0.00 0.00 0.00 0.00 8,670,866.02

1016 TANF 21-44 MALE NON- 1,620,009.32 1,293,561.45 1,509,095.61 1,691,638.58 1,332,421.86 1,461,361.63 1,198,565.38 0.00 0.00 0.00 0.00 0.00 10,106,653.83


7,405,431.53 6,691,392.54 6,814,009.20 7,623,126.67 6,086,294.51 7,077,273.51 5,488,343.34 0.00 0.00 0.00 0.00 0.00 47,185,871.30

1018 TANF 45-64 M & F NON 1,953,573.00 1,711,442.00 1,707,488.40 2,093,866.34 1,530,377.83 1,869,973.49 1,553,331.42 0.00 0.00 0.00 0.00 0.00 12,420,052.48

1019 TANF 65+ M & F NON-M 78.06 330.00 696.38 3,097.33 660.00 814.59 990.00 0.00 0.00 0.00 0.00 0.00 6,666.36

1028 TANF 45-64 M & F WIT 0.00 0.00 0.00 0.00 222.87 0.00 101.90 0.00 0.00 0.00 0.00 0.00 324.77


93,041.09 53,542.63 61,591.47 139,558.56 49,650.39 61,355.31 85,932.73 0.00 0.00 0.00 0.00 0.00 544,672.18


112,986.93 92,991.55 101,925.88 127,518.18 84,995.19 92,132.82 128,767.49 0.00 0.00 0.00 0.00 0.00 741,318.04

2120 SSI AGED WITH QMB 453,899.33 272,304.02 342,218.16 458,314.66 300,771.26 364,865.72 335,988.42 0.00 0.00 0.00 0.00 0.00 2,528,361.57


292,823.54 208,464.00 288,819.29 347,480.40 305,550.81 271,568.73 321,799.99 0.00 0.00 0.00 0.00 0.00 2,036,506.76


9,959,047.85 7,880,152.85 7,651,940.11 9,253,953.12 7,043,925.67 7,924,270.46 6,519,394.26 0.00 0.00 0.00 0.00 0.00 56,232,684.32


1,350,697.55 864,636.71 1,027,771.59 1,486,687.26 853,127.54 1,084,509.17 1,006,755.61 0.00 0.00 0.00 0.00 0.00 7,674,185.43

2300 SSI BLIND WITH MEDIC 1,664.23 640.25 1,243.93 973.56 1,842.62 1,864.82 10,235.53 0.00 0.00 0.00 0.00 0.00 18,464.94


60,247.89 50,845.31 53,971.04 58,889.63 79,175.67 107,580.83 163,783.52 0.00 0.00 0.00 0.00 0.00 574,493.89


4304 SOBRA CHILD 14-20 MA 0.00 138.83 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 138.83

4311 SOBRA CHILD <1 M & F 2,131,827.20 1,931,274.95 1,683,477.82 1,832,712.85 1,515,618.69 1,874,454.45 1,583,941.12 0.00 0.00 0.00 0.00 0.00 12,553,307.08

4312 SOBRA CHILD 01-05 M 1,281,311.87 1,314,884.69 1,261,499.41 1,452,561.18 1,310,589.81 1,458,203.91 1,076,363.31 0.00 0.00 0.00 0.00 0.00 9,155,414.18

4313 SOBRA CHILD 06-13 M 1,968,465.65 1,741,624.28 1,534,469.11 2,277,782.38 1,543,562.07 1,531,426.92 1,314,104.15 0.00 0.00 0.00 0.00 0.00 11,911,434.56

4314 SOBRA CHILD 14-20 MA 872,771.99 629,731.84 574,986.98 941,772.37 517,330.06 927,458.23 517,777.66 0.00 0.00 0.00 0.00 0.00 4,981,829.13

4315 SOBRA CHILD 14-20 FE 822,092.79 809,462.10 849,985.21 1,035,922.28 697,739.23 770,460.52 683,542.91 0.00 0.00 0.00 0.00 0.00 5,669,205.04


277.72 1,158.08 1,431.76 992.46 66.85 386.60 623.15 0.00 0.00 0.00 0.00 0.00 4,936.62


0.00 0.00 0.00 0.00 0.00 0.00 90.27 0.00 0.00 0.00 0.00 0.00 90.27


567,357.22 479,789.95 527,363.06 611,047.04 403,942.90 459,734.48 377,790.68 0.00 0.00 0.00 0.00 0.00 3,427,025.33


1,772,084.95 1,672,046.49 1,469,191.81 1,861,183.85 1,422,663.81 1,570,362.07 1,241,808.22 0.00 0.00 0.00 0.00 0.00 11,009,341.20


356.67 2,283.22 5,423.15 775.78 2,310.00 2,014.08 1,329.61 0.00 0.00 0.00 0.00 0.00 14,492.51


10,836.75 14,772.94 15,724.78 13,530.00 12,500.42 9,240.00 1,344.00 0.00 0.00 0.00 0.00 0.00 77,948.89

53



43,490,727.00SUBTOTAL: 37,249,577.28 37,206,970.39 44,686,827.40 33,462,187.59 39,379,934.40 31,983,955.01 0.00 0.00 0.00 0.00 0.00 267,460,179.07

1106 TANF EXPANDED 21-44 19,587.30 9,420.20 12,719.28 17,788.25 15,479.27 19,440.65 21,217.46 0.00 0.00 0.00 0.00 0.00 115,652.41

1107 TANF EXPANDED 21-44 35,453.84 22,963.80 30,089.78 37,178.61 18,125.42 24,706.67 22,266.20 0.00 0.00 0.00 0.00 0.00 190,784.32

1108 TANF EXPANDED 45-64 77,405.92 62,144.21 41,318.90 94,470.24 61,612.46 56,009.18 64,091.87 0.00 0.00 0.00 0.00 0.00 457,052.78


23,099.59 19,462.63 20,030.56 33,227.18 15,844.84 18,430.65 13,707.68 0.00 0.00 0.00 0.00 0.00 143,803.13


303.00 330.00 1,292.00 433.69 0.00 250.26 541.27 0.00 0.00 0.00 0.00 0.00 3,150.22

1112 TANF EXPANDED 01-05 11,242.03 10,809.39 16,272.04 17,750.14 17,157.71 19,002.98 15,606.06 0.00 0.00 0.00 0.00 0.00 107,840.35

1113 TANF EXPANDED 06-13 39,953.70 52,990.81 81,980.04 92,811.85 60,175.38 64,895.55 42,026.69 0.00 0.00 0.00 0.00 0.00 434,834.02

1114 TANF EXPANDED 14-20 182,485.42 56,598.75 36,206.62 37,355.76 17,421.28 17,711.10 24,955.78 0.00 0.00 0.00 0.00 0.00 372,734.71

1115 TANF EXPANDED 14-20 67,182.28 51,377.93 71,258.86 66,170.32 50,351.84 51,646.34 42,459.15 0.00 0.00 0.00 0.00 0.00 400,446.72

1116 TANF EXPANDED 21-44 826,194.87 730,897.46 640,232.44 851,871.91 649,335.32 673,495.43 509,541.63 0.00 0.00 0.00 0.00 0.00 4,881,569.06

1117 TANF EXPANDED 21-44 1,861,720.13 1,602,395.87 1,776,968.29 2,024,144.96 1,616,310.54 1,740,286.87 1,350,891.22 0.00 0.00 0.00 0.00 0.00 11,972,717.88

1118 TANF EXPANDED 45-64 1,030,281.85 886,777.16 916,775.37 977,303.75 901,968.25 985,163.61 693,403.29 0.00 0.00 0.00 0.00 0.00 6,391,673.28


2,933.85 1,504.09 2,288.39 5,674.31 3,806.52 3,343.26 2,381.68 0.00 0.00 0.00 0.00 0.00 21,932.10

1126 TANF EXPANDED 21-44 0.00 0.00 331.22 66.75 27.94 56.60 386.60 0.00 0.00 0.00 0.00 0.00 869.11

1128 TANF EXPANDED 45-64 13,132.56 11,277.40 5,937.79 11,301.89 5,042.06 7,935.51 10,504.80 0.00 0.00 0.00 0.00 0.00 65,132.01


376.78 169.14 893.20 819.35 769.23 1,680.21 386.79 0.00 0.00 0.00 0.00 0.00 5,094.70


11,822.86 5,415.06 15,289.37 8,618.96 10,687.27 8,633.07 5,325.24 0.00 0.00 0.00 0.00 0.00 65,791.83


69,911.47 70,056.49 73,017.52 87,238.90 64,663.54 77,525.93 71,221.61 0.00 0.00 0.00 0.00 0.00 513,635.46


366,991.32 278,108.08 304,402.06 460,853.28 292,373.11 336,655.79 318,319.30 0.00 0.00 0.00 0.00 0.00 2,357,702.94


2,508.52 660.88 0.00 1,318.12 609.83 926.33 1,494.23 0.00 0.00 0.00 0.00 0.00 7,517.91


23,232.86 12,772.53 13,000.20 20,027.28 17,555.45 49,233.14 14,556.34 0.00 0.00 0.00 0.00 0.00 150,377.80


186,282.39 134,719.60 269,700.85 116,402.84 71,809.48 123,340.57 85,456.65 0.00 0.00 0.00 0.00 0.00 987,712.38


220,215.15 161,793.96 155,391.81 227,137.07 155,612.39 197,870.19 158,291.27 0.00 0.00 0.00 0.00 0.00 1,276,311.84

5,072,317.69SUBTOTAL: 4,182,645.44 4,485,396.59 5,189,965.41 4,046,739.13 4,478,239.89 3,469,032.81 0.00 0.00 0.00 0.00 0.00 30,924,336.96

3306 AHC CARE MALE 21-44 0.00 71.60 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 71.60


497.26 42.00 1,179.28 0.00 113.20 174.20 838.00 0.00 0.00 0.00 0.00 0.00 2,843.94

3309 AHC CARE M&F 65+ W/ 2,729.25 966.76 3,211.98 2,108.71 1,477.96 707.49 1,847.92 0.00 0.00 0.00 0.00 0.00 13,050.07

3314 AHC CARE MALE 14-20 3,832.70 3,054.45 2,146.16 5,380.96 4,265.76 3,930.12 3,233.73 0.00 0.00 0.00 0.00 0.00 25,843.88


14,130.97 10,501.39 6,619.07 4,122.47 5,292.88 7,069.20 2,288.21 0.00 0.00 0.00 0.00 0.00 50,024.19

3316 AHC CARE MALE 21-44 59,817.61 38,323.75 60,393.42 44,375.32 38,939.80 40,670.53 26,670.24 0.00 0.00 0.00 0.00 0.00 309,190.67


67,585.35 83,014.65 53,208.62 65,650.86 44,738.61 34,296.36 32,774.25 0.00 0.00 0.00 0.00 0.00 381,268.70

3318 AHC CARE M&F 45-64 N 462,122.50 403,754.70 419,045.97 407,405.97 280,654.89 428,086.43 174,487.10 0.00 0.00 0.00 0.00 0.00 2,575,557.56

3319 AHC CARE M&F 65+ NO 0.00 0.00 330.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 330.00


0.00 18.79 0.00 0.00 0.00 107.05 0.00 0.00 0.00 0.00 0.00 0.00 125.84

54



3329 AHC CARE M&F 65+ W/ 130.93 26.40 34.07 97.95 94.58 4.14 265.15 0.00 0.00 0.00 0.00 0.00 653.22

610,846.57SUBTOTAL: 539,774.49 546,168.57 529,142.24 375,577.68 515,045.52 242,404.60 0.00 0.00 0.00 0.00 0.00 3,358,959.67

3400 MED ELIGIBILITY W/ M -106.89 0.00 -83.27 192.52 0.00 21.85 0.00 0.00 0.00 0.00 0.00 0.00 24.21

3410 MED ELIGIBILITY NON- -88.86 -38.84 -81.61 -25.60 0.00 0.00 -7,036.00 0.00 0.00 0.00 0.00 0.00 -7,270.91

3604 AHC CARE/MI MALE 14- 540.52 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 540.52

3606 AHC CARE/MI MALE 21- 143.84 0.00 0.00 0.00 75.82 0.00 0.00 0.00 0.00 0.00 0.00 0.00 219.66


0.00 0.00 0.00 393.42 432.00 990.00 1,980.00 0.00 0.00 0.00 0.00 0.00 3,795.42

3608 AHC CARE/MI M&F 45-6 2,334.72 2,338.86 995.91 3,733.84 1,668.74 3,932.52 132.19 0.00 0.00 0.00 0.00 0.00 15,136.78

3614 AHC CARE/MI MALE 14- 182,055.83 167,311.80 263,691.27 171,442.23 158,984.65 167,780.48 78,409.39 0.00 0.00 0.00 0.00 0.00 1,189,675.65


225,942.86 194,885.88 218,887.84 242,872.97 190,368.37 211,933.40 125,093.71 0.00 0.00 0.00 0.00 0.00 1,409,985.03

3616 AHC CARE/MI MALE 21- 1,603,875.68 1,423,784.04 1,512,268.68 1,515,372.06 1,040,385.39 1,295,113.37 617,121.03 0.00 0.00 0.00 0.00 0.00 9,007,920.25


1,030,947.24 914,027.39 928,785.06 983,238.73 655,767.41 813,107.88 514,412.27 0.00 0.00 0.00 0.00 0.00 5,840,285.98

3618 AHC CARE/MI M&F 45-6 3,424,623.88 3,046,865.95 2,863,404.91 3,124,360.87 2,424,269.46 2,890,937.31 1,599,295.76 0.00 0.00 0.00 0.00 0.00 19,373,758.14

3619 AHC CARE/MI M&F 65+ 3,925.21 116.58 660.00 2,005.25 1,013.45 1,543.80 330.00 0.00 0.00 0.00 0.00 0.00 9,594.29

6,474,194.03SUBTOTAL: 5,749,291.66 5,788,528.79 6,043,586.29 4,472,965.29 5,385,360.61 2,929,738.35 0.00 0.00 0.00 0.00 0.00 36,843,665.02

3514 ADULT 40-100% MALE 1 0.00 0.00 0.00 0.00 0.00 0.00 2,302.00 0.00 0.00 0.00 0.00 0.00 2,302.00


0.00 0.00 0.00 0.00 0.00 0.00 7,733.07 0.00 0.00 0.00 0.00 0.00 7,733.07

3516 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 13,729.85 0.00 0.00 0.00 0.00 0.00 13,729.85


0.00 0.00 0.00 0.00 0.00 0.00 37,277.81 0.00 0.00 0.00 0.00 0.00 37,277.81

3518 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 137,569.92 0.00 0.00 0.00 0.00 0.00 137,569.92

3706 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 990.00 0.00 0.00 0.00 0.00 0.00 990.00


0.00 0.00 0.00 0.00 0.00 0.00 1,133.28 0.00 0.00 0.00 0.00 0.00 1,133.28

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 45,460.39 0.00 0.00 0.00 0.00 0.00 45,460.39


0.00 0.00 0.00 0.00 0.00 0.00 75,669.32 0.00 0.00 0.00 0.00 0.00 75,669.32

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 658,986.61 0.00 0.00 0.00 0.00 0.00 658,986.61


0.00 0.00 0.00 0.00 0.00 0.00 365,516.42 0.00 0.00 0.00 0.00 0.00 365,516.42


0.00 0.00 0.00 0.00 0.00 0.00 1,060,593.51 0.00 0.00 0.00 0.00 0.00 1,060,593.51

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 2,406,962.18 0.00 0.00 0.00 0.00 0.00 2,406,962.18


0.00 1,320.00 3,073.01 8,884.22 5,080.11 76.03 0.00 0.00 0.00 0.00 0.00 0.00 18,433.37


1,185.39 4,283.40 2,401.24 4,134.66 2,500.21 14,825.53 7,126.00 0.00 0.00 0.00 0.00 0.00 36,456.43


0.00 0.00 0.00 3,178.38 660.00 220.64 990.00 0.00 0.00 0.00 0.00 0.00 5,049.02

1,185.39SUBTOTAL: 5,603.40 5,474.25 16,197.26 8,240.32 15,122.20 8,116.00 0.00 0.00 0.00 0.00 0.00 59,938.82


2,647.85 376.91 1,528.97 1,745.83 812.59 336.60 2,587.31 0.00 0.00 0.00 0.00 0.00 10,036.06


2,319.43 6,510.96 2,906.29 458.90 827.04 1,320.00 1,686.00 0.00 0.00 0.00 0.00 0.00 16,028.62

55




0.00 15.22 0.00 41.29 127.89 15.22 56.60 0.00 0.00 0.00 0.00 0.00 256.22

4,967.28SUBTOTAL: 6,903.09 4,435.26 2,246.02 1,767.52 1,671.82 4,329.91 0.00 0.00 0.00 0.00 0.00 26,320.90

55,654,237.96 TOTAL: 47,733,795.36 48,036,973.85 56,467,964.62 42,367,477.53 49,775,374.44 41,044,538.86 0.00 0.00 0.00 0.00 0.00 341,080,362.62

56

FEE FOR SERVICE - NEWLY ELIGIBLE ADULTSFor The Period Ending January 31, 2014



0.00 0.00 0.00 0.00 0.00 0.00 644.15 0.00 0.00 0.00 0.00 0.00 644.15


0.00 0.00 0.00 0.00 0.00 0.00 1,650.00 0.00 0.00 0.00 0.00 0.00 1,650.00



0.00 0.00 0.00 0.00 0.00 0.00 2,271.54 0.00 0.00 0.00 0.00 0.00 2,271.54


0.00 0.00 0.00 0.00 0.00 0.00 16,896.89 0.00 0.00 0.00 0.00 0.00 16,896.89

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 31,566.22 0.00 0.00 0.00 0.00 0.00 31,566.22

0.00 TOTAL: 0.00 0.00 0.00 0.00 0.00 31,566.22 0.00 0.00 0.00 0.00 0.00 31,566.22

57

FEE FOR SERVICE - CHILD EXPANSIONFor The Period Ending January 31, 2014


4413 SOBRA 100-133% M&F 6

0.00 0.00 0.00 0.00 0.00 0.00 12,786.39 0.00 0.00 0.00 0.00 0.00 12,786.39

4414 SOBRA 100-133% MALE 0.00 0.00 0.00 0.00 0.00 0.00 2,895.91 0.00 0.00 0.00 0.00 0.00 2,895.91


0.00 0.00 0.00 0.00 0.00 0.00 2,146.63 0.00 0.00 0.00 0.00 0.00 2,146.63

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 17,828.93 0.00 0.00 0.00 0.00 0.00 17,828.93

0.00 TOTAL: 0.00 0.00 0.00 0.00 0.00 17,828.93 0.00 0.00 0.00 0.00 0.00 17,828.93

58

FAMILY PLANNING SERVICESFor The Period Ending January 31, 2014



5,891.54 6,486.62 6,416.40 7,060.07 6,741.70 5,463.02 2,310.00 0.00 0.00 0.00 0.00 0.00 40,369.35

5,891.54SUBTOTAL: 6,486.62 6,416.40 7,060.07 6,741.70 5,463.02 2,310.00 0.00 0.00 0.00 0.00 0.00 40,369.35

5,891.54 TOTAL: 6,486.62 6,416.40 7,060.07 6,741.70 5,463.02 2,310.00 0.00 0.00 0.00 0.00 0.00 40,369.35

59

FEDERAL EMERGENCY SERVICESFor The Period Ending January 31, 2014


1005 TANF 14-20 FEMALE WI 1,812.60 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,812.60

1006 TANF 21-44 MALE WITH 0.00 0.00 0.00 1,346.78 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,346.78

1007 TANF 21-44 FEMALE WI 29.18 1,437.59 0.00 0.00 0.00 954.76 387.80 0.00 0.00 0.00 0.00 0.00 2,809.33

1008 TANF 45-64 M & F WIT 74.22 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 74.22

1011 TANF <1 M & F NON-ME 55,226.78 5,253.83 7,451.72 401.76 6,401.75 3,733.52 0.00 0.00 0.00 0.00 0.00 0.00 78,469.36

1012 TANF 01-05 M & F NON 6,930.75 5,738.45 5,347.23 9,646.24 3,633.03 5,524.39 3,818.46 0.00 0.00 0.00 0.00 0.00 40,638.55

1013 TANF 06-13 M & F NON 48,884.46 101,682.11 138,013.40 62,830.38 56,073.87 69,484.22 39,478.61 0.00 0.00 0.00 0.00 0.00 516,447.05

1014 TANF 14-20 MALE NON- 158,166.84 153,495.94 118,161.54 120,888.15 88,947.07 131,645.90 56,316.17 0.00 0.00 0.00 0.00 0.00 827,621.61


578,462.04 492,604.28 551,640.33 654,546.79 512,510.52 647,075.21 436,936.28 0.00 0.00 0.00 0.00 0.00 3,873,775.45

1016 TANF 21-44 MALE NON- 309,751.09 193,748.71 138,665.00 147,641.46 164,764.66 76,269.89 75,617.99 0.00 0.00 0.00 0.00 0.00 1,106,458.80


4,043,355.63 3,636,306.98 3,260,868.51 4,299,622.10 3,528,932.36 4,002,640.03 2,725,674.65 0.00 0.00 0.00 0.00 0.00 25,497,400.26

1018 TANF 45-64 M & F NON 179,692.50 150,352.97 140,257.99 225,465.50 191,031.65 293,252.68 126,089.48 0.00 0.00 0.00 0.00 0.00 1,306,142.77

1019 TANF 65+ M & F NON-M 3,184.59 1,223.00 1,440.40 486.45 0.00 43.90 140.86 0.00 0.00 0.00 0.00 0.00 6,519.20


10,654.15 6,227.78 6,743.16 3,166.43 25,775.43 4,967.15 6,471.50 0.00 0.00 0.00 0.00 0.00 64,005.60


792,784.78 619,392.64 432,208.76 608,610.35 436,615.21 511,790.34 328,620.01 0.00 0.00 0.00 0.00 0.00 3,730,022.09


37,696.08 40,601.84 13,294.04 29,303.64 18,742.12 20,767.19 20,332.21 0.00 0.00 0.00 0.00 0.00 180,737.12


1,171,957.77 1,101,553.70 988,270.65 1,282,376.93 913,758.53 1,204,646.25 772,309.56 0.00 0.00 0.00 0.00 0.00 7,434,873.39


1,143.35 7,354.77 4,089.72 9,440.37 7,883.67 6,222.13 27,877.66 0.00 0.00 0.00 0.00 0.00 64,011.67

7,399,806.81SUBTOTAL: 6,516,974.59 5,806,452.45 7,455,773.33 5,955,069.87 6,979,017.56 4,620,071.24 0.00 0.00 0.00 0.00 0.00 44,733,165.85

1106 TANF EXPANDED 21-44 1,517.07 9,782.38 327.70 5,109.44 23.64 820.63 1,012.09 0.00 0.00 0.00 0.00 0.00 18,592.95

1107 TANF EXPANDED 21-44 1,273.01 42.43 -8.16 -523.94 686.96 -686.96 107.71 0.00 0.00 0.00 0.00 0.00 891.05

1108 TANF EXPANDED 45-64 2,359.16 3,296.19 1,812.20 1,969.27 1,711.52 2,382.58 2,157.16 0.00 0.00 0.00 0.00 0.00 15,688.08


0.00 0.00 0.00 0.00 0.00 0.00 64.35 0.00 0.00 0.00 0.00 0.00 64.35

1113 TANF EXPANDED 06-13 186.36 1,666.01 101.27 260.77 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,214.41

1114 TANF EXPANDED 14-20 114.19 477.98 639.26 0.00 449.14 145.69 2,170.61 0.00 0.00 0.00 0.00 0.00 3,996.87

1115 TANF EXPANDED 14-20 30,694.26 9,091.97 3,029.13 11,152.49 6,325.93 20,735.82 3,623.09 0.00 0.00 0.00 0.00 0.00 84,652.69

1116 TANF EXPANDED 21-44 362,057.84 429,917.34 362,835.41 343,714.85 271,967.20 362,415.90 328,733.65 0.00 0.00 0.00 0.00 0.00 2,461,642.19

1117 TANF EXPANDED 21-44 623,386.79 560,329.06 497,869.16 526,220.70 427,294.54 555,327.77 359,141.27 0.00 0.00 0.00 0.00 0.00 3,549,569.29

1118 TANF EXPANDED 45-64 209,714.36 266,493.09 208,893.54 204,965.52 228,094.34 188,254.96 150,455.31 0.00 0.00 0.00 0.00 0.00 1,456,871.12


0.00 0.00 0.00 1,510.45 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,510.45


0.00 0.00 239.41 0.00 2,798.30 -610.60 0.00 0.00 0.00 0.00 0.00 0.00 2,427.11


1,979.97 240.00 6,346.70 240.00 384.27 890.31 2,624.95 0.00 0.00 0.00 0.00 0.00 12,706.20


4,173.02 3,499.09 2,952.61 2,302.77 3,589.41 3,026.79 3,979.15 0.00 0.00 0.00 0.00 0.00 23,522.84

1,237,456.03SUBTOTAL: 1,284,835.54 1,085,038.23 1,096,922.32 943,325.25 1,132,702.89 854,069.34 0.00 0.00 0.00 0.00 0.00 7,634,349.60


0.00 0.00 0.00 0.00 0.00 0.00 286.29 0.00 0.00 0.00 0.00 0.00 286.29

60

FEDERAL EMERGENCY SERVICESFor The Period Ending January 31, 2014


0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 286.29 0.00 0.00 0.00 0.00 0.00 286.29

8,637,262.84 TOTAL: 7,801,810.13 6,891,490.68 8,552,695.65 6,898,395.12 8,111,720.45 5,474,426.87 0.00 0.00 0.00 0.00 0.00 52,367,801.74

61

QMB - FEE FOR SERVICEFor The Period Ending January 31, 2014


8020 QMB ONLY 226,696.25 369,590.30 185,144.74 269,660.55 235,564.71 192,484.42 264,176.59 0.00 0.00 0.00 0.00 0.00 1,743,317.56

226,696.25SUBTOTAL: 369,590.30 185,144.74 269,660.55 235,564.71 192,484.42 264,176.59 0.00 0.00 0.00 0.00 0.00 1,743,317.56

226,696.25 TOTAL: 369,590.30 185,144.74 269,660.55 235,564.71 192,484.42 264,176.59 0.00 0.00 0.00 0.00 0.00 1,743,317.56

62

INPATIENT INMATES FEE FOR SERVICEFor The Period Ending January 31, 2014


3618 AHC CARE/MI M&F 45-6 0.00 0.00 -322.92 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -322.92

0.00SUBTOTAL: 0.00 -322.92 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -322.92

0.00 TOTAL: 0.00 -322.92 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -322.92

63

COCHISE COUNTY INMATES FEE FOR SERVICEFor The Period Ending January 31, 2014



0.00 0.00 0.00 0.00 1.76 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.76

0.00SUBTOTAL: 0.00 0.00 0.00 1.76 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.76

0.00 TOTAL: 0.00 0.00 0.00 1.76 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.76

64

COCONINO COUNTY INMATES FEE FOR SERVICEFor The Period Ending January 31, 2014



1,030.27 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,030.27

1,030.27SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,030.27

1,030.27 TOTAL: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,030.27

65

PIMA COUNTY INMATES FEE FOR SERVICEFor The Period Ending January 31, 2014


1016 TANF 21-44 MALE NON- 0.00 0.00 0.00 0.00 917.28 0.00 0.00 0.00 0.00 0.00 0.00 0.00 917.28


0.00 1,308.95 5,261.20 1,112.75 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7,682.90


1,048.25 136.77 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,185.02


0.00 4,377.34 0.00 1,756.44 0.00 3,746.07 2,872.89 0.00 0.00 0.00 0.00 0.00 12,752.74

1,048.25SUBTOTAL: 5,823.06 5,261.20 2,869.19 917.28 3,746.07 2,872.89 0.00 0.00 0.00 0.00 0.00 22,537.94

1106 TANF EXPANDED 21-44 0.00 0.00 0.00 0.00 0.00 0.00 1,013.18 0.00 0.00 0.00 0.00 0.00 1,013.18

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 1,013.18 0.00 0.00 0.00 0.00 0.00 1,013.18

1,048.25 TOTAL: 5,823.06 5,261.20 2,869.19 917.28 3,746.07 3,886.07 0.00 0.00 0.00 0.00 0.00 23,551.12

66

PINAL COUNTY INMATES FEE FOR SERVICEFor The Period Ending January 31, 2014



0.00 0.00 0.00 0.00 0.00 65.56 160.87 0.00 0.00 0.00 0.00 0.00 226.43


0.00 0.00 0.00 0.00 0.00 709.91 4,248.00 0.00 0.00 0.00 0.00 0.00 4,957.91


0.00 0.00 0.00 8,570.40 0.00 70.70 0.00 0.00 0.00 0.00 0.00 0.00 8,641.10

0.00SUBTOTAL: 0.00 0.00 8,570.40 0.00 846.17 4,408.87 0.00 0.00 0.00 0.00 0.00 13,825.44


0.00 4,239.99 9,286.08 955.09 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14,481.16

0.00SUBTOTAL: 4,239.99 9,286.08 955.09 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14,481.16

3616 AHC CARE/MI MALE 21- 42.59 0.00 0.00 238.90 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 281.49

42.59SUBTOTAL: 0.00 0.00 238.90 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 281.49

42.59 TOTAL: 4,239.99 9,286.08 9,764.39 0.00 846.17 4,408.87 0.00 0.00 0.00 0.00 0.00 28,588.09

67

LONG TERM CARE FEE FOR SERVICE - EPD AND DES DDFor The Period Ending January 31, 2014


1010 TANF NON-MEDICARE 0.00 0.00 0.00 660.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 660.00


2,646,620.33 2,261,292.78 2,305,096.60 2,682,056.39 2,178,508.00 2,469,734.66 2,333,436.05 0.00 0.00 0.00 0.00 0.00 16,876,744.81


206,362.27 186,868.67 239,488.76 222,874.19 230,112.09 228,021.05 237,857.11 0.00 0.00 0.00 0.00 0.00 1,551,584.14

2120 SSI AGED WITH QMB 3,355,436.82 2,788,861.53 2,922,599.28 3,367,486.28 2,531,100.17 3,296,335.06 2,912,982.65 0.00 0.00 0.00 0.00 0.00 21,174,801.79


581,645.08 470,052.42 509,618.82 622,227.07 490,578.46 600,428.71 567,840.11 0.00 0.00 0.00 0.00 0.00 3,842,390.67


2,856,726.77 2,531,769.39 2,648,494.74 2,953,963.89 2,358,089.76 2,757,266.10 2,280,597.49 0.00 0.00 0.00 0.00 0.00 18,386,908.14


810,763.08 687,602.58 669,316.79 789,848.32 640,335.04 719,645.98 698,386.83 0.00 0.00 0.00 0.00 0.00 5,015,898.62

2300 SSI BLIND WITH MEDIC 1,241.60 0.00 3,092.20 1,471.19 255.62 1,622.12 1,682.24 0.00 0.00 0.00 0.00 0.00 9,364.97


17,701.82 18,248.18 13,423.55 15,094.38 14,793.44 16,190.17 20,051.39 0.00 0.00 0.00 0.00 0.00 115,502.93


10,483,090.95SUBTOTAL: 8,958,877.62 9,323,332.63 10,672,111.85 8,451,036.90 10,103,466.95 9,063,579.60 0.00 0.00 0.00 0.00 0.00 67,055,496.50


2,234.88 339.16 5,031.76 3,130.04 114.29 11,962.91 4,664.96 0.00 0.00 0.00 0.00 0.00 27,478.00


0.00 0.00 0.00 0.00 1,607.52 330.96 1,512.96 0.00 0.00 0.00 0.00 0.00 3,451.44

2,234.88SUBTOTAL: 339.16 5,031.76 3,130.04 1,721.81 12,293.87 6,177.92 0.00 0.00 0.00 0.00 0.00 30,929.44

10,485,325.83 TOTAL: 8,959,216.78 9,328,364.39 10,675,241.89 8,452,758.71 10,115,760.82 9,069,757.52 0.00 0.00 0.00 0.00 0.00 67,086,425.94

68

ACUTE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLSFor The Period Ending January 31, 2014


1012 TANF 01-05 M & F NON 118,177.25 26,140.74 12,053.40 43,928.41 35,732.21 54,192.40 52,870.38 0.00 0.00 0.00 0.00 0.00 343,094.79

1013 TANF 06-13 M & F NON 204,629.13 31,429.95 16,243.46 88,414.34 83,955.03 121,179.02 110,797.86 0.00 0.00 0.00 0.00 0.00 656,648.79

1014 TANF 14-20 MALE NON- 16,753.36 3,674.96 881.05 9,146.24 8,176.66 12,677.98 11,757.49 0.00 0.00 0.00 0.00 0.00 63,067.74


7,527.80 982.69 434.89 4,764.80 2,719.28 4,709.35 5,089.53 0.00 0.00 0.00 0.00 0.00 26,228.34


326,195.18 101,564.01 41,962.53 168,135.94 132,507.94 206,735.28 258,904.85 0.00 0.00 0.00 0.00 0.00 1,236,005.73


-321.32 0.00 0.00 200.80 0.00 71.96 0.00 0.00 0.00 0.00 0.00 0.00 -48.56

2300 SSI BLIND WITH MEDIC -180.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -180.14


2,156.71 928.13 80.97 540.67 442.36 1,213.93 1,563.06 0.00 0.00 0.00 0.00 0.00 6,925.83

2320 SSI BLIND WITH QMB -55.37 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -55.37

4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 0.00 0.00 156.03 83.36 0.00 0.00 0.00 0.00 0.00 239.39

4312 SOBRA CHILD 01-05 M 108,173.59 27,024.81 13,275.36 50,968.67 40,844.21 53,096.93 54,262.41 0.00 0.00 0.00 0.00 0.00 347,645.98

4313 SOBRA CHILD 06-13 M 169,807.97 23,311.32 18,668.17 91,402.90 78,009.33 108,012.11 98,323.34 0.00 0.00 0.00 0.00 0.00 587,535.14

4314 SOBRA CHILD 14-20 MA 12,386.67 2,700.20 707.07 7,299.69 4,503.25 5,929.46 9,409.23 0.00 0.00 0.00 0.00 0.00 42,935.57

4315 SOBRA CHILD 14-20 FE 5,303.71 454.50 262.57 3,579.36 2,329.55 3,627.97 4,734.75 0.00 0.00 0.00 0.00 0.00 20,292.41


0.00 0.00 0.00 7.57 0.00 0.00 56.43 0.00 0.00 0.00 0.00 0.00 64.00

970,554.54SUBTOTAL: 218,211.31 104,569.47 468,389.39 389,219.82 571,602.42 607,852.69 0.00 0.00 0.00 0.00 0.00 3,330,399.64

1112 TANF EXPANDED 01-05 1,535.04 320.79 194.54 173.91 46.18 197.02 151.86 0.00 0.00 0.00 0.00 0.00 2,619.34

1113 TANF EXPANDED 06-13 4,923.68 612.91 567.70 3,240.88 2,251.25 3,195.56 2,956.27 0.00 0.00 0.00 0.00 0.00 17,748.25

1114 TANF EXPANDED 14-20 983.34 244.84 107.19 736.99 273.35 452.78 564.38 0.00 0.00 0.00 0.00 0.00 3,362.87

1115 TANF EXPANDED 14-20 -269.78 70.44 0.00 118.73 114.39 352.40 387.56 0.00 0.00 0.00 0.00 0.00 773.74


975.82 0.00 236.86 221.76 341.87 390.55 221.21 0.00 0.00 0.00 0.00 0.00 2,388.07

8,148.10SUBTOTAL: 1,248.98 1,106.29 4,492.27 3,027.04 4,588.31 4,281.28 0.00 0.00 0.00 0.00 0.00 26,892.27

3314 AHC CARE MALE 14-20 77.36 0.00 0.00 38.83 0.00 0.00 70.77 0.00 0.00 0.00 0.00 0.00 186.96

77.36SUBTOTAL: 0.00 0.00 38.83 0.00 0.00 70.77 0.00 0.00 0.00 0.00 0.00 186.96

3614 AHC CARE/MI MALE 14- 158.97 63.56 0.00 288.83 92.62 169.53 142.18 0.00 0.00 0.00 0.00 0.00 915.69


101.91 98.29 26.82 274.03 62.78 102.43 249.19 0.00 0.00 0.00 0.00 0.00 915.45

3616 AHC CARE/MI MALE 21- 0.00 0.00 0.00 97.83 0.00 127.17 0.00 0.00 0.00 0.00 0.00 0.00 225.00

260.88SUBTOTAL: 161.85 26.82 660.69 155.40 399.13 391.37 0.00 0.00 0.00 0.00 0.00 2,056.14

979,040.88 TOTAL: 219,622.14 105,702.58 473,581.18 392,402.26 576,589.86 612,596.11 0.00 0.00 0.00 0.00 0.00 3,359,535.01

69

LONG TERM CARE FEE FOR SERVICE MEDICAID IN PUBLIC SCHOOLSFor The Period Ending January 31, 2014




4,663.48 2,373.71 333.79 1,283.74 1,091.71 933.80 1,712.27 0.00 0.00 0.00 0.00 0.00 12,392.50


1,630,651.33 534,543.46 196,242.29 784,761.99 538,789.08 931,480.02 1,151,898.88 0.00 0.00 0.00 0.00 0.00 5,768,367.05


5,261.38 1,427.69 630.96 4,449.14 4,957.24 4,416.40 5,184.92 0.00 0.00 0.00 0.00 0.00 26,327.73


3,810.00 6,195.83 1,235.33 6,245.37 3,382.25 6,805.98 10,973.41 0.00 0.00 0.00 0.00 0.00 38,648.17

1,709,095.04SUBTOTAL: 560,146.09 204,506.24 826,876.60 569,724.86 976,790.86 1,209,130.86 0.00 0.00 0.00 0.00 0.00 6,056,270.55

1,709,095.04 TOTAL: 560,146.09 204,506.24 826,876.60 569,724.86 976,790.86 1,209,130.86 0.00 0.00 0.00 0.00 0.00 6,056,270.55

70

ACUTE REINSURANCEFor The Period Ending January 31, 2014


1007 TANF 21-44 FEMALE WI 0.00 12,961.42 2,586.39 0.00 0.00 -13,695.03 0.00 0.00 0.00 0.00 0.00 0.00 1,852.78

1008 TANF 45-64 M & F WIT 0.00 0.00 0.00 0.00 -2,782.83 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -2,782.83

1011 TANF <1 M & F NON-ME 1,193,052.57 -46,587.25 1,451,828.43 1,442,118.87 809,205.11 825,302.49 294,784.19 0.00 0.00 0.00 0.00 0.00 5,969,704.41

1012 TANF 01-05 M & F NON 222,521.09 150,098.59 352,633.65 359,174.66 190,603.06 199,114.01 226,196.02 0.00 0.00 0.00 0.00 0.00 1,700,341.08

1013 TANF 06-13 M & F NON 116,598.03 157,789.11 78,766.19 228,271.31 96,157.56 262,142.34 95,685.98 0.00 0.00 0.00 0.00 0.00 1,035,410.52

1014 TANF 14-20 MALE NON- 45,131.74 18,673.92 105,432.94 139,132.14 55,932.37 329,667.87 147,129.48 0.00 0.00 0.00 0.00 0.00 841,100.46


37,419.25 44,418.63 27,704.40 44,982.58 -10,243.33 -4,556.78 799.85 0.00 0.00 0.00 0.00 0.00 140,524.60

1016 TANF 21-44 MALE NON- 196,027.99 176,633.21 345,084.59 266,380.04 61,937.89 171,077.74 99,058.73 0.00 0.00 0.00 0.00 0.00 1,316,200.19


189,633.96 164,576.92 140,089.71 269,063.95 409,936.67 225,184.44 31,659.65 0.00 0.00 0.00 0.00 0.00 1,430,145.30

1018 TANF 45-64 M & F NON 50,937.23 -2,830.54 158,776.85 134,027.12 42,631.60 174,473.09 43,686.18 0.00 0.00 0.00 0.00 0.00 601,701.53

1019 TANF 65+ M & F NON-M 0.00 0.00 0.00 0.00 0.00 395.68 3,461.30 0.00 0.00 0.00 0.00 0.00 3,856.98


9,077.38 28,200.63 57,515.09 2,672.79 16,780.03 62,764.89 20,984.50 0.00 0.00 0.00 0.00 0.00 197,995.31


196,634.48 114,623.47 163,960.41 143,964.38 112,341.22 141,113.31 20,794.92 0.00 0.00 0.00 0.00 0.00 893,432.19


52,599.93 1,733.28 28,014.89 31,076.38 42,831.55 19,601.67 29,595.58 0.00 0.00 0.00 0.00 0.00 205,453.28


3,379,757.74 3,300,159.25 5,715,870.19 4,509,063.45 5,703,458.68 5,153,897.79 2,986,679.75 0.00 0.00 0.00 0.00 0.00 30,748,886.85



0.00 7,514.19 13,655.16 8,571.52 27,732.95 5,234.76 5,704.64 0.00 0.00 0.00 0.00 0.00 68,413.22

4311 SOBRA CHILD <1 M & F 2,000,800.66 1,300,008.89 2,370,154.70 1,633,094.68 2,039,110.13 2,786,602.89 1,940,936.98 0.00 0.00 0.00 0.00 0.00 14,070,708.93

4312 SOBRA CHILD 01-05 M 184,435.06 220,494.10 120,456.86 262,540.07 68,213.55 201,825.23 109,890.72 0.00 0.00 0.00 0.00 0.00 1,167,855.59

4313 SOBRA CHILD 06-13 M 1,126,838.15 270,847.41 315,216.92 178,589.86 118,709.47 484,293.99 98,982.97 0.00 0.00 0.00 0.00 0.00 2,593,478.77

4314 SOBRA CHILD 14-20 MA 308,230.97 495,332.33 312,345.49 851,756.82 729,555.18 939,676.58 1,878,634.89 0.00 0.00 0.00 0.00 0.00 5,515,532.26

4315 SOBRA CHILD 14-20 FE 30,976.88 40,377.99 26,432.26 9,262.94 27,009.83 50,205.70 31,974.02 0.00 0.00 0.00 0.00 0.00 216,239.62


72,279.90 22,085.04 44,909.68 11,015.90 19,405.35 -26,179.53 851.89 0.00 0.00 0.00 0.00 0.00 144,368.23


39,833.44 13,521.66 -7,377.76 53,371.16 99,080.14 62,927.91 46,958.63 0.00 0.00 0.00 0.00 0.00 308,315.18

9,453,420.60SUBTOTAL: 6,490,632.25 11,824,057.04 10,578,130.62 10,657,606.18 12,051,071.04 8,114,450.87 0.00 0.00 0.00 0.00 0.00 69,169,368.60


1,895.15 2,262.20 2,026.25 1,394.91 1,430.83 19,882.07 2,018.34 0.00 0.00 0.00 0.00 0.00 30,909.75

1,895.15SUBTOTAL: 2,262.20 2,026.25 1,394.91 1,430.83 19,882.07 2,018.34 0.00 0.00 0.00 0.00 0.00 30,909.75

1106 TANF EXPANDED 21-44 3.96 0.00 0.00 0.00 0.00 158.83 0.00 0.00 0.00 0.00 0.00 0.00 162.79

1108 TANF EXPANDED 45-64 3,317.27 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,317.27

1113 TANF EXPANDED 06-13 0.00 0.00 0.00 0.00 2,392.90 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,392.90

1114 TANF EXPANDED 14-20 387.30 0.00 0.00 0.00 1,928.60 0.00 -387.30 0.00 0.00 0.00 0.00 0.00 1,928.60

1115 TANF EXPANDED 14-20 3,159.30 475.29 -3,940.85 16,301.02 29,119.33 2,521.03 3,634.59 0.00 0.00 0.00 0.00 0.00 51,269.71

1116 TANF EXPANDED 21-44 246,207.26 92,992.35 40,921.00 182,422.50 52,046.70 88,974.20 54,476.11 0.00 0.00 0.00 0.00 0.00 758,040.12

1117 TANF EXPANDED 21-44 50,578.21 191,966.83 220,778.40 119,849.06 87,558.00 13,036.13 37,215.78 0.00 0.00 0.00 0.00 0.00 720,982.41

1118 TANF EXPANDED 45-64 173,624.41 146,268.93 212,470.51 111,229.81 195,919.49 41,892.40 75,426.56 0.00 0.00 0.00 0.00 0.00 956,832.11

71

ACUTE REINSURANCEFor The Period Ending January 31, 2014



0.00 0.00 9,948.46 1,997.43 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 11,945.89


262.32 0.00 0.00 0.00 0.00 7,318.72 0.00 0.00 0.00 0.00 0.00 0.00 7,581.04


42,214.35 154,368.27 27,653.96 16,833.46 20,010.55 21,212.98 22,373.16 0.00 0.00 0.00 0.00 0.00 304,666.73


3.64 89.34 335.58 3,113.38 11.85 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,553.79


33,404.77 65,478.96 57,209.58 45,886.44 33,113.56 21,302.17 10,284.58 0.00 0.00 0.00 0.00 0.00 266,680.06

553,162.79SUBTOTAL: 651,639.97 565,376.64 497,633.10 422,100.98 196,416.46 203,023.48 0.00 0.00 0.00 0.00 0.00 3,089,353.42


0.00 -1,980.67 0.00 0.00 0.00 -395.47 0.00 0.00 0.00 0.00 0.00 0.00 -2,376.14

3314 AHC CARE MALE 14-20 53,440.40 948.81 12,423.96 37,996.50 39,796.81 0.00 42,646.79 0.00 0.00 0.00 0.00 0.00 187,253.27

3316 AHC CARE MALE 21-44 10,379.43 27,455.51 12,471.46 5,665.77 -69,303.32 39,855.38 838.68 0.00 0.00 0.00 0.00 0.00 27,362.91


25,921.43 40,207.20 40,708.68 4,396.26 14,063.29 20,384.98 990.77 0.00 0.00 0.00 0.00 0.00 146,672.61

3318 AHC CARE M&F 45-64 N 118,578.86 34,104.73 316,805.40 173,356.56 75,916.18 71,959.49 98,677.64 0.00 0.00 0.00 0.00 0.00 889,398.86

208,320.12SUBTOTAL: 100,735.58 382,409.50 221,415.09 60,472.96 131,804.38 143,153.88 0.00 0.00 0.00 0.00 0.00 1,248,311.51

3410 MED ELIGIBILITY NON- 0.00 0.00 0.00 0.00 0.00 0.00 -27,007.48 0.00 0.00 0.00 0.00 0.00 -27,007.48


-3,504.19 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -3,504.19

3608 AHC CARE/MI M&F 45-6 1,143.51 0.00 -7,207.86 0.00 284.93 45,593.41 -45,930.16 0.00 0.00 0.00 0.00 0.00 -6,116.17

3614 AHC CARE/MI MALE 14- 22,384.15 19,736.79 36.31 54,233.55 23,077.92 11,000.65 12,696.03 0.00 0.00 0.00 0.00 0.00 143,165.40


9,234.29 -3,061.47 4,794.85 14,160.60 -982.26 13,398.86 1,559.05 0.00 0.00 0.00 0.00 0.00 39,103.92

3616 AHC CARE/MI MALE 21- 429,401.49 217,219.19 387,199.27 392,242.72 332,987.03 326,627.98 378,591.43 0.00 0.00 0.00 0.00 0.00 2,464,269.11


20,955.05 29,247.34 53,116.23 46,003.60 -25,173.27 40,832.29 83,817.28 0.00 0.00 0.00 0.00 0.00 248,798.52

3618 AHC CARE/MI M&F 45-6 528,412.12 312,256.78 520,333.84 783,296.03 328,118.03 331,175.21 230,226.87 0.00 0.00 0.00 0.00 0.00 3,033,818.88

1,008,026.42SUBTOTAL: 575,398.63 958,272.64 1,289,936.50 658,312.38 768,628.40 633,953.02 0.00 0.00 0.00 0.00 0.00 5,892,527.99


0.00 0.00 7,850.87 47,640.48 3,636.72 20,199.00 0.00 0.00 0.00 0.00 0.00 0.00 79,327.07

0.00SUBTOTAL: 0.00 7,850.87 47,640.48 3,636.72 20,199.00 0.00 0.00 0.00 0.00 0.00 0.00 79,327.07


0.00 15,347.39 3,363.95 1,745.16 -442.89 3,027.46 0.00 0.00 0.00 0.00 0.00 0.00 23,041.07

0.00SUBTOTAL: 15,347.39 3,363.95 1,745.16 -442.89 3,027.46 0.00 0.00 0.00 0.00 0.00 0.00 23,041.07

11,224,825.08 TOTAL: 7,836,016.02 13,743,356.89 12,637,895.86 11,803,117.16 13,191,028.81 9,096,599.59 0.00 0.00 0.00 0.00 0.00 79,532,839.41

72

LONG TERM CARE REINSURANCEFor The Period Ending January 31, 2014


1010 TANF NON-MEDICARE -355.41 0.00 -201.50 0.00 0.00 0.00 10,279.60 0.00 0.00 0.00 0.00 0.00 9,722.69


753,659.50 239,227.46 605,863.47 225,805.81 523,020.01 318,857.08 114,917.42 0.00 0.00 0.00 0.00 0.00 2,781,350.75


94,724.22 242,226.44 302,542.71 132,360.24 204,649.76 206,244.36 17,426.62 0.00 0.00 0.00 0.00 0.00 1,200,174.35


1,210,067.03 403,491.08 1,045,987.02 840,532.61 822,958.42 1,091,864.62 245,203.64 0.00 0.00 0.00 0.00 0.00 5,660,104.42


1,987,404.81 3,433,851.10 3,636,913.94 2,812,980.82 2,394,797.61 2,846,732.58 1,295,718.28 0.00 0.00 0.00 0.00 0.00 18,408,399.14


12,237.47 20,650.63 18,356.69 15,044.95 23,692.00 18,638.55 485.66 0.00 0.00 0.00 0.00 0.00 109,105.95

4312 SOBRA CHILD 01-05 M 0.00 0.00 0.00 0.00 1,106.66 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,106.66

4,057,737.62SUBTOTAL: 4,339,446.71 5,609,462.33 4,026,724.43 3,970,224.46 4,482,337.19 1,684,031.22 0.00 0.00 0.00 0.00 0.00 28,169,963.96

4,057,737.62 TOTAL: 4,339,446.71 5,609,462.33 4,026,724.43 3,970,224.46 4,482,337.19 1,684,031.22 0.00 0.00 0.00 0.00 0.00 28,169,963.96

73

ACUTE SMIBFor The Period Ending January 31, 2014




1020 TANF WITH QMB 2,202.90 2,202.90 2,202.90 2,307.80 2,202.90 2,202.90 2,307.80 0.00 0.00 0.00 0.00 0.00 15,630.10


30,316.10 26,120.10 27,274.00 26,120.10 30,835.60 59,688.10 55,597.00 0.00 0.00 0.00 0.00 0.00 255,951.00


389,668.60 394,713.70 388,369.80 394,698.20 389,286.90 381,340.00 387,099.00 0.00 0.00 0.00 0.00 0.00 2,725,176.20

2120 SSI AGED WITH QMB 2,098,270.40 2,116,835.50 2,131,176.90 2,112,311.20 2,132,325.80 2,111,023.20 2,117,539.60 0.00 0.00 0.00 0.00 0.00 14,819,482.60


118,614.50 115,142.90 120,687.40 121,007.60 126,899.00 166,124.60 163,909.70 0.00 0.00 0.00 0.00 0.00 932,385.70


305,049.20 308,480.90 306,255.10 314,595.10 310,599.90 311,343.20 313,364.30 0.00 0.00 0.00 0.00 0.00 2,169,687.70


3,048,229.90 3,055,980.90 3,066,494.00 3,071,386.20 3,079,369.40 3,056,126.00 3,060,868.10 0.00 0.00 0.00 0.00 0.00 21,438,454.50

2300 SSI BLIND WITH MEDIC 104.90 104.90 104.90 104.90 314.70 -929.10 314.70 0.00 0.00 0.00 0.00 0.00 119.90


2,622.50 2,622.50 2,622.50 2,622.50 2,622.50 3,566.60 3,042.10 0.00 0.00 0.00 0.00 0.00 19,721.20



209.80 104.90 104.90 104.90 104.90 104.90 104.90 0.00 0.00 0.00 0.00 0.00 839.20


0.00 0.00 0.00 314.70 104.90 104.90 104.90 0.00 0.00 0.00 0.00 0.00 629.40


2,727.40 3,566.60 2,937.20 2,202.90 3,042.10 3,042.10 3,566.60 0.00 0.00 0.00 0.00 0.00 21,084.90


524.50 419.60 314.70 524.50 419.60 209.80 209.80 0.00 0.00 0.00 0.00 0.00 2,622.50

8000 SMIB ONLY NOT ELIGIB 0.00 -209.80 -419.60 0.00 0.00 -209.80 0.00 0.00 0.00 0.00 0.00 0.00 -839.20

8020 QMB ONLY 472,340.60 469,218.60 465,637.00 475,088.00 464,844.80 467,114.70 469,427.50 0.00 0.00 0.00 0.00 0.00 3,283,671.20

8040 SLMB 2,806,712.60 2,823,469.70 2,863,726.80 2,865,759.20 2,924,686.90 2,933,368.20 2,937,913.40 0.00 0.00 0.00 0.00 0.00 20,155,636.80

8888 SMIB ONLY NOT ELIGIB -16,993.80 -8,491.80 -10,070.40 -10,280.20 -8,916.50 -9,650.80 -9,441.00 0.00 0.00 0.00 0.00 0.00 -73,844.50

9999 SMIB ONLY NOT ELIGIB 143,426.80 106,610.90 131,557.20 129,934.20 65,182.50 154,868.70 74,595.60 0.00 0.00 0.00 0.00 0.00 806,175.90

9,487,002.80SUBTOTAL: 9,499,344.40 9,581,911.20 9,591,567.90 9,607,636.10 9,724,407.20 9,664,825.50 0.00 0.00 0.00 0.00 0.00 67,156,695.10


550,258.10 559,374.40 558,481.40 568,107.00 570,718.60 563,685.30 562,529.40 0.00 0.00 0.00 0.00 0.00 3,933,154.20


104.90 104.90 104.90 104.90 104.90 314.70 0.00 0.00 0.00 0.00 0.00 0.00 839.20


25,910.30 26,329.90 26,702.50 26,423.90 24,861.30 25,280.90 24,127.00 0.00 0.00 0.00 0.00 0.00 179,635.80


35,036.60 24,861.30 23,078.00 24,127.00 24,966.20 24,231.90 24,336.80 0.00 0.00 0.00 0.00 0.00 180,637.80


314.70 314.70 209.80 314.70 629.40 524.50 419.60 0.00 0.00 0.00 0.00 0.00 2,727.40


2,229,978.40 2,255,757.10 2,264,669.60 2,288,275.00 2,276,697.70 2,261,241.80 2,263,864.20 0.00 0.00 0.00 0.00 0.00 15,840,483.80


1,258.80 1,258.80 1,258.80 1,363.70 1,573.50 1,363.70 1,363.70 0.00 0.00 0.00 0.00 0.00 9,441.00


-209.80 104.90 0.00 -419.60 104.90 209.80 104.90 0.00 0.00 0.00 0.00 0.00 -104.90


942,665.00 961,317.80 968,765.40 986,814.20 990,115.00 965,555.90 972,478.90 0.00 0.00 0.00 0.00 0.00 6,787,712.20

3,785,317.00SUBTOTAL: 3,829,423.80 3,843,270.40 3,895,110.80 3,889,771.50 3,842,408.50 3,849,224.50 0.00 0.00 0.00 0.00 0.00 26,934,526.50


3,356.80 3,251.90 3,251.90 2,832.30 2,937.20 2,937.20 2,937.20 0.00 0.00 0.00 0.00 0.00 21,504.50

3,356.80SUBTOTAL: 3,251.90 3,251.90 2,832.30 2,937.20 2,937.20 2,937.20 0.00 0.00 0.00 0.00 0.00 21,504.50


104.90 104.90 104.90 104.90 209.80 209.80 209.80 0.00 0.00 0.00 0.00 0.00 1,049.00

74

ACUTE SMIBFor The Period Ending January 31, 2014


104.90SUBTOTAL: 104.90 104.90 104.90 209.80 209.80 209.80 0.00 0.00 0.00 0.00 0.00 1,049.00


17,098.70 16,472.00 16,154.60 16,259.50 15,735.00 15,315.40 15,420.30 0.00 0.00 0.00 0.00 0.00 112,455.50

17,098.70SUBTOTAL: 16,472.00 16,154.60 16,259.50 15,735.00 15,315.40 15,420.30 0.00 0.00 0.00 0.00 0.00 112,455.50

13,292,880.20 TOTAL: 13,348,597.00 13,444,693.00 13,505,875.40 13,516,289.60 13,585,278.10 13,532,617.30 0.00 0.00 0.00 0.00 0.00 94,226,230.60

75

ACUTE HIBFor The Period Ending January 31, 2014



0.00 0.00 0.00 -288.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -288.00


0.00 1,323.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,323.00

2120 SSI AGED WITH QMB 184,216.40 184,227.30 187,027.20 187,333.20 189,232.20 182,912.80 181,668.00 0.00 0.00 0.00 0.00 0.00 1,296,617.10


76,285.80 77,058.00 77,058.90 80,718.30 77,499.90 80,938.80 76,730.40 0.00 0.00 0.00 0.00 0.00 546,290.10


8020 QMB ONLY 2,734.20 3,087.00 3,131.10 4,454.10 4,013.10 4,895.10 3,450.60 0.00 0.00 0.00 0.00 0.00 25,765.20

9999 SMIB ONLY NOT ELIGIB -2,491.20 -3,662.10 -7,674.30 -396.90 -1,168.20 -2,448.00 -5,544.00 0.00 0.00 0.00 0.00 0.00 -23,384.70

261,627.20SUBTOTAL: 262,915.20 260,424.90 272,702.70 270,459.00 267,180.70 257,157.00 0.00 0.00 0.00 0.00 0.00 1,852,466.70


1,610.10 2,492.10 2,051.10 2,051.10 2,051.10 2,051.10 1,980.60 0.00 0.00 0.00 0.00 0.00 14,287.20

1,610.10SUBTOTAL: 2,492.10 2,051.10 2,051.10 2,051.10 2,051.10 1,980.60 0.00 0.00 0.00 0.00 0.00 14,287.20

263,237.30 TOTAL: 265,407.30 262,476.00 274,753.80 272,510.10 269,231.80 259,137.60 0.00 0.00 0.00 0.00 0.00 1,866,753.90

76

Q1For The Period Ending January 31, 2014


8050 QI1 1,646,857.40 1,662,395.00 1,657,426.10 1,674,785.60 1,696,356.90 1,690,795.30 1,575,274.90 0.00 0.00 0.00 0.00 0.00 11,603,891.20

9999 SMIB ONLY NOT ELIGIB -3,356.80 -4,510.70 -2,937.20 -2,307.80 -4,300.90 -3,881.30 102,759.90 0.00 0.00 0.00 0.00 0.00 81,465.20

1,643,500.60SUBTOTAL: 1,657,884.30 1,654,488.90 1,672,477.80 1,692,056.00 1,686,914.00 1,678,034.80 0.00 0.00 0.00 0.00 0.00 11,685,356.40

1,643,500.60 TOTAL: 1,657,884.30 1,654,488.90 1,672,477.80 1,692,056.00 1,686,914.00 1,678,034.80 0.00 0.00 0.00 0.00 0.00 11,685,356.40

77

LTC SMIBFor The Period Ending January 31, 2014



1020 TANF WITH QMB 314.70 314.70 314.70 314.70 314.70 314.70 314.70 0.00 0.00 0.00 0.00 0.00 2,202.90


831,495.00 840,391.50 851,845.60 852,131.80 847,334.90 866,951.20 871,564.80 0.00 0.00 0.00 0.00 0.00 5,961,714.80


148,113.80 148,223.70 148,013.90 154,336.20 150,426.60 151,056.00 150,741.30 0.00 0.00 0.00 0.00 0.00 1,050,911.50

2120 SSI AGED WITH QMB 724,079.40 722,655.80 724,124.40 723,410.10 731,177.60 722,714.00 717,516.00 0.00 0.00 0.00 0.00 0.00 5,065,677.30


315,351.20 315,702.00 317,380.40 312,555.00 317,742.10 323,931.20 326,029.20 0.00 0.00 0.00 0.00 0.00 2,228,691.10


13,427.20 14,266.40 15,210.50 16,469.30 15,105.60 15,735.00 15,839.90 0.00 0.00 0.00 0.00 0.00 106,053.90


676,290.00 671,464.60 675,625.60 678,406.00 677,863.50 676,919.40 675,555.70 0.00 0.00 0.00 0.00 0.00 4,732,124.80

2300 SSI BLIND WITH MEDIC 734.30 734.30 629.40 629.40 629.40 734.30 944.10 0.00 0.00 0.00 0.00 0.00 5,035.20


314.70 314.70 314.70 314.70 314.70 314.70 314.70 0.00 0.00 0.00 0.00 0.00 2,202.90


2,715,050.60SUBTOTAL: 2,718,788.20 2,738,179.70 2,743,602.40 2,745,629.60 2,763,391.00 2,763,645.80 0.00 0.00 0.00 0.00 0.00 19,188,287.30


314.70 314.70 314.70 314.70 419.60 419.60 419.60 0.00 0.00 0.00 0.00 0.00 2,517.60

314.70SUBTOTAL: 314.70 314.70 314.70 419.60 419.60 419.60 0.00 0.00 0.00 0.00 0.00 2,517.60

2,715,365.30 TOTAL: 2,719,102.90 2,738,494.40 2,743,917.10 2,746,049.20 2,763,810.60 2,764,065.40 0.00 0.00 0.00 0.00 0.00 19,190,804.90

78

LTC HIBFor The Period Ending January 31, 2014



0.00 0.00 0.00 0.00 0.00 0.00 660.00 0.00 0.00 0.00 0.00 0.00 660.00

2120 SSI AGED WITH QMB 248,547.60 255,648.60 254,471.40 262,130.40 262,790.10 263,232.90 258,543.60 0.00 0.00 0.00 0.00 0.00 1,805,364.60


441.00 0.00 0.00 0.00 441.00 441.00 -441.00 0.00 0.00 0.00 0.00 0.00 882.00


20,508.30 17,421.30 17,664.30 18,987.30 14,930.10 16,253.10 15,477.60 0.00 0.00 0.00 0.00 0.00 121,242.00

269,496.90SUBTOTAL: 273,069.90 272,135.70 281,117.70 278,161.20 279,927.00 274,240.20 0.00 0.00 0.00 0.00 0.00 1,928,148.60

269,496.90 TOTAL: 273,069.90 272,135.70 281,117.70 278,161.20 279,927.00 274,240.20 0.00 0.00 0.00 0.00 0.00 1,928,148.60

79

ACUTE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICESFor The Period Ending January 31, 2014


1006 TANF 21-44 MALE WITH 66.48 14.88 1,291.27 1,576.00 27.61 134.08 136.98 0.00 0.00 0.00 0.00 0.00 3,247.30

1007 TANF 21-44 FEMALE WI 5,766.86 6,487.64 3,138.35 4,733.64 1,933.95 1,719.65 3,003.91 0.00 0.00 0.00 0.00 0.00 26,784.00

1008 TANF 45-64 M & F WIT 3,119.98 1,978.14 1,505.87 2,794.44 1,937.98 1,488.08 220.34 0.00 0.00 0.00 0.00 0.00 13,044.83

1009 TANF 65+ M & F WITH 916.31 586.66 2,619.74 1,535.73 169.80 660.00 413.33 0.00 0.00 0.00 0.00 0.00 6,901.57

1011 TANF <1 M & F NON-ME 1,313,912.79 1,054,051.98 959,008.96 1,091,075.29 740,413.93 939,046.13 912,633.56 0.00 0.00 0.00 0.00 0.00 7,010,142.64

1012 TANF 01-05 M & F NON 2,114,862.49 1,998,530.98 2,060,299.16 2,355,687.47 1,783,929.98 2,104,218.33 1,710,747.33 0.00 0.00 0.00 0.00 0.00 14,128,275.74

1013 TANF 06-13 M & F NON 2,658,829.08 2,783,217.70 2,832,040.64 3,135,276.05 2,398,842.69 2,825,098.98 2,087,180.55 0.00 0.00 0.00 0.00 0.00 18,720,485.69

1014 TANF 14-20 MALE NON- 576,554.86 629,741.55 616,390.93 743,075.05 490,350.10 862,741.59 438,547.38 0.00 0.00 0.00 0.00 0.00 4,357,401.46


1,119,425.39 1,017,413.12 1,016,316.78 1,049,719.33 789,521.26 969,973.69 730,865.64 0.00 0.00 0.00 0.00 0.00 6,693,235.21

1016 TANF 21-44 MALE NON- 1,190,627.47 1,006,373.93 993,433.31 1,156,913.25 891,420.41 1,031,727.86 863,194.73 0.00 0.00 0.00 0.00 0.00 7,133,690.96


5,516,877.42 5,164,867.81 5,108,508.00 5,579,642.18 4,427,732.96 5,120,013.61 3,965,175.40 0.00 0.00 0.00 0.00 0.00 34,882,817.38

1018 TANF 45-64 M & F NON 1,360,627.61 1,326,163.83 1,229,381.83 1,388,103.82 1,010,993.80 1,214,365.33 1,034,898.61 0.00 0.00 0.00 0.00 0.00 8,564,534.83

1019 TANF 65+ M & F NON-M 78.06 330.00 696.38 3,097.33 660.00 696.38 990.00 0.00 0.00 0.00 0.00 0.00 6,548.15

1028 TANF 45-64 M & F WIT 0.00 0.00 0.00 0.00 56.60 0.00 26.64 0.00 0.00 0.00 0.00 0.00 83.24


29,609.75 20,948.18 30,645.50 94,122.75 2,287.82 27,580.06 20,452.05 0.00 0.00 0.00 0.00 0.00 225,646.11


68,377.15 63,540.58 70,639.01 62,254.46 53,966.99 62,358.44 76,851.45 0.00 0.00 0.00 0.00 0.00 457,988.08

2120 SSI AGED WITH QMB 194,419.14 108,279.70 163,368.61 272,555.69 148,881.19 158,083.54 139,900.66 0.00 0.00 0.00 0.00 0.00 1,185,488.53


109,761.86 69,616.81 118,877.90 171,035.56 93,436.28 126,872.93 82,283.03 0.00 0.00 0.00 0.00 0.00 771,884.37


4,988,851.95 4,435,479.76 4,595,847.35 5,044,240.30 3,652,813.33 3,929,102.35 3,483,673.94 0.00 0.00 0.00 0.00 0.00 30,130,008.98


408,570.13 302,206.40 379,481.44 594,407.57 319,264.00 334,249.72 299,570.68 0.00 0.00 0.00 0.00 0.00 2,637,749.94

2300 SSI BLIND WITH MEDIC 1,498.63 500.70 612.15 719.95 927.64 1,211.86 9,845.82 0.00 0.00 0.00 0.00 0.00 15,316.75


38,590.70 33,205.11 37,843.59 39,188.40 55,129.04 61,873.73 43,677.06 0.00 0.00 0.00 0.00 0.00 309,507.63


4304 SOBRA CHILD 14-20 MA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4311 SOBRA CHILD <1 M & F 1,260,705.40 1,039,595.81 1,076,449.42 1,108,983.01 830,460.93 1,112,844.91 937,597.78 0.00 0.00 0.00 0.00 0.00 7,366,637.26

4312 SOBRA CHILD 01-05 M 1,000,111.70 1,034,408.90 1,008,478.84 1,153,946.93 934,664.04 1,043,034.89 850,970.01 0.00 0.00 0.00 0.00 0.00 7,025,615.31

4313 SOBRA CHILD 06-13 M 1,745,169.41 1,466,736.13 1,284,571.19 1,927,488.74 1,199,300.11 1,215,434.57 1,054,530.82 0.00 0.00 0.00 0.00 0.00 9,893,230.97

4314 SOBRA CHILD 14-20 MA 731,412.78 543,918.20 481,707.60 818,242.33 383,427.93 807,999.01 424,916.12 0.00 0.00 0.00 0.00 0.00 4,191,623.97

4315 SOBRA CHILD 14-20 FE 689,346.25 675,379.14 715,597.74 853,666.22 578,626.27 638,495.81 543,717.30 0.00 0.00 0.00 0.00 0.00 4,694,828.73


5.01 255.76 0.00 992.46 66.85 386.60 623.15 0.00 0.00 0.00 0.00 0.00 2,329.83


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


376,334.40 337,129.17 366,963.27 419,146.12 281,006.48 332,916.45 240,596.40 0.00 0.00 0.00 0.00 0.00 2,354,092.29


1,231,090.80 1,162,264.79 1,118,552.61 1,356,178.00 1,011,364.65 1,095,450.87 866,717.21 0.00 0.00 0.00 0.00 0.00 7,841,618.93


330.00 1,320.00 330.00 775.78 2,310.00 660.00 1,320.00 0.00 0.00 0.00 0.00 0.00 7,045.78


10,836.75 14,772.94 15,724.78 13,530.00 12,500.42 9,240.00 1,344.00 0.00 0.00 0.00 0.00 0.00 77,948.89

80



28,750,255.93SUBTOTAL: 26,301,926.06 26,294,087.03 30,450,726.88 22,102,068.38 26,033,762.75 20,832,664.63 0.00 0.00 0.00 0.00 0.00 180,765,491.66

1106 TANF EXPANDED 21-44 1,650.53 1,180.79 3,073.72 4,449.54 5,531.49 4,183.38 3,822.41 0.00 0.00 0.00 0.00 0.00 23,891.86

1107 TANF EXPANDED 21-44 7,072.24 5,278.69 8,125.86 8,576.20 5,887.20 6,867.24 4,762.60 0.00 0.00 0.00 0.00 0.00 46,570.03

1108 TANF EXPANDED 45-64 22,440.34 18,143.13 17,928.17 41,041.12 16,261.74 18,581.78 15,162.51 0.00 0.00 0.00 0.00 0.00 149,558.79


7,382.07 7,951.15 9,456.02 22,366.65 9,275.41 10,498.70 7,948.75 0.00 0.00 0.00 0.00 0.00 74,878.75


303.00 330.00 1,292.00 433.69 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,358.69

1112 TANF EXPANDED 01-05 10,678.57 10,541.98 9,612.00 15,308.18 11,880.00 15,630.08 12,210.00 0.00 0.00 0.00 0.00 0.00 85,860.81

1113 TANF EXPANDED 06-13 35,421.59 39,824.92 44,786.30 73,444.05 51,343.48 54,786.13 37,131.88 0.00 0.00 0.00 0.00 0.00 336,738.35

1114 TANF EXPANDED 14-20 165,394.23 44,312.69 30,230.16 27,259.64 14,472.25 13,403.23 23,032.45 0.00 0.00 0.00 0.00 0.00 318,104.65

1115 TANF EXPANDED 14-20 48,634.07 40,386.28 62,430.52 49,488.56 44,687.44 44,704.06 32,578.94 0.00 0.00 0.00 0.00 0.00 322,909.87

1116 TANF EXPANDED 21-44 621,339.24 531,887.24 495,509.32 654,890.90 461,197.88 492,083.85 387,625.86 0.00 0.00 0.00 0.00 0.00 3,644,534.29

1117 TANF EXPANDED 21-44 1,474,471.46 1,312,006.34 1,454,208.60 1,632,929.42 1,282,706.89 1,352,216.06 1,067,648.21 0.00 0.00 0.00 0.00 0.00 9,576,186.98

1118 TANF EXPANDED 45-64 766,368.16 657,247.42 705,310.32 719,259.97 545,574.31 651,996.25 524,040.91 0.00 0.00 0.00 0.00 0.00 4,569,797.34


1,320.00 660.00 660.00 2,970.00 1,361.10 660.00 990.00 0.00 0.00 0.00 0.00 0.00 8,621.10

1126 TANF EXPANDED 21-44 0.00 0.00 169.80 66.75 27.94 56.60 386.60 0.00 0.00 0.00 0.00 0.00 707.69

1128 TANF EXPANDED 45-64 3,396.44 1,674.19 1,099.34 2,045.97 591.30 1,109.30 2,475.39 0.00 0.00 0.00 0.00 0.00 12,391.93


363.76 148.18 753.20 812.00 413.49 1,680.21 272.07 0.00 0.00 0.00 0.00 0.00 4,442.91


5,529.92 8,343.02 7,321.59 4,166.15 6,421.88 3,759.96 3,569.18 0.00 0.00 0.00 0.00 0.00 39,111.70


42,226.82 43,144.90 39,218.46 46,953.42 42,796.75 48,190.90 52,055.01 0.00 0.00 0.00 0.00 0.00 314,586.26


141,059.29 105,988.87 132,135.85 218,584.13 126,204.76 127,105.31 116,122.15 0.00 0.00 0.00 0.00 0.00 967,200.36


330.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 330.00


2,591.49 4,157.27 5,117.00 5,338.37 5,307.27 2,206.06 7,649.68 0.00 0.00 0.00 0.00 0.00 32,367.14


108,780.49 88,333.27 65,293.23 75,391.69 55,540.30 79,958.16 49,764.94 0.00 0.00 0.00 0.00 0.00 523,062.08


56,139.48 39,291.09 42,857.89 65,816.27 44,397.48 51,706.94 46,225.21 0.00 0.00 0.00 0.00 0.00 346,434.36

3,522,893.19SUBTOTAL: 2,960,831.42 3,136,589.35 3,671,592.67 2,731,880.36 2,981,384.20 2,395,474.75 0.00 0.00 0.00 0.00 0.00 21,400,645.94

3306 AHC CARE MALE 21-44 0.00 71.60 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 71.60


497.26 42.00 1,157.43 0.00 113.20 174.20 838.00 0.00 0.00 0.00 0.00 0.00 2,822.09

3309 AHC CARE M&F 65+ W/ 27.94 22.87 0.00 211.49 0.00 11.94 12.24 0.00 0.00 0.00 0.00 0.00 286.48

3314 AHC CARE MALE 14-20 2,274.00 1,980.00 2,061.60 4,759.20 3,099.60 2,722.80 708.00 0.00 0.00 0.00 0.00 0.00 17,605.20


11,735.88 8,810.00 5,623.16 3,630.00 4,950.00 6,600.00 1,650.00 0.00 0.00 0.00 0.00 0.00 42,999.04

3316 AHC CARE MALE 21-44 40,431.51 34,334.57 42,453.38 33,487.39 24,877.97 29,064.00 4,973.92 0.00 0.00 0.00 0.00 0.00 209,622.74


55,081.27 62,291.00 45,684.40 47,279.48 36,073.22 28,278.17 20,814.56 0.00 0.00 0.00 0.00 0.00 295,502.10

3318 AHC CARE M&F 45-64 N 329,618.61 326,810.94 271,695.30 315,555.34 212,546.65 278,745.73 117,526.46 0.00 0.00 0.00 0.00 0.00 1,852,499.03

3319 AHC CARE M&F 65+ NO 0.00 0.00 330.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 330.00


0.00 0.00 0.00 0.00 0.00 107.05 0.00 0.00 0.00 0.00 0.00 0.00 107.05

81



3329 AHC CARE M&F 65+ W/ 47.67 0.00 0.00 37.79 94.58 4.14 41.99 0.00 0.00 0.00 0.00 0.00 226.17

439,714.14SUBTOTAL: 434,362.98 369,005.27 404,960.69 281,755.22 345,708.03 146,565.17 0.00 0.00 0.00 0.00 0.00 2,422,071.50

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 0.00

3410 MED ELIGIBILITY NON- 0.00 0.00 0.00 0.00 0.00 0.00 -7,036.00 0.00 0.00 0.00 0.00 0.00 -7,036.00

3604 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 0.00

3606 AHC CARE/MI MALE 21- 0.00 0.00 0.00 0.00 75.82 0.00 0.00 0.00 0.00 0.00 0.00 0.00 75.82


0.00 0.00 0.00 393.42 432.00 990.00 1,980.00 0.00 0.00 0.00 0.00 0.00 3,795.42

3608 AHC CARE/MI M&F 45-6 66.48 448.84 725.20 660.00 850.96 1,103.20 5.27 0.00 0.00 0.00 0.00 0.00 3,859.95

3614 AHC CARE/MI MALE 14- 151,964.68 140,527.10 121,939.52 113,337.02 118,394.89 117,695.24 55,502.76 0.00 0.00 0.00 0.00 0.00 819,361.21


180,152.09 163,050.29 176,377.77 211,622.63 166,608.88 159,928.26 98,686.60 0.00 0.00 0.00 0.00 0.00 1,156,426.52

3616 AHC CARE/MI MALE 21- 1,107,472.70 910,882.11 945,253.20 921,688.88 683,859.57 792,899.13 370,999.57 0.00 0.00 0.00 0.00 0.00 5,733,055.16


820,503.23 719,778.15 737,986.17 740,736.24 510,612.68 634,632.75 398,998.23 0.00 0.00 0.00 0.00 0.00 4,563,247.45

3618 AHC CARE/MI M&F 45-6 2,264,704.40 1,955,979.70 2,019,479.10 2,027,444.09 1,595,539.67 1,832,867.64 1,007,932.68 0.00 0.00 0.00 0.00 0.00 12,703,947.28

3619 AHC CARE/MI M&F 65+ 2,652.77 116.58 660.00 1,980.00 1,003.12 660.00 330.00 0.00 0.00 0.00 0.00 0.00 7,402.47

4,527,516.35SUBTOTAL: 3,890,782.77 4,002,420.96 4,017,862.28 3,077,377.59 3,540,776.22 1,927,399.11 0.00 0.00 0.00 0.00 0.00 24,984,135.28

3514 ADULT 40-100% MALE 1 0.00 0.00 0.00 0.00 0.00 0.00 1,320.00 0.00 0.00 0.00 0.00 0.00 1,320.00


0.00 0.00 0.00 0.00 0.00 0.00 2,970.00 0.00 0.00 0.00 0.00 0.00 2,970.00

3516 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 11,235.42 0.00 0.00 0.00 0.00 0.00 11,235.42


0.00 0.00 0.00 0.00 0.00 0.00 32,352.62 0.00 0.00 0.00 0.00 0.00 32,352.62

3518 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 98,721.61 0.00 0.00 0.00 0.00 0.00 98,721.61

3706 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 990.00 0.00 0.00 0.00 0.00 0.00 990.00


0.00 0.00 0.00 0.00 0.00 0.00 330.00 0.00 0.00 0.00 0.00 0.00 330.00

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 29,233.76 0.00 0.00 0.00 0.00 0.00 29,233.76


0.00 0.00 0.00 0.00 0.00 0.00 66,747.64 0.00 0.00 0.00 0.00 0.00 66,747.64

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 347,085.81 0.00 0.00 0.00 0.00 0.00 347,085.81


0.00 0.00 0.00 0.00 0.00 0.00 245,084.80 0.00 0.00 0.00 0.00 0.00 245,084.80


0.00 0.00 0.00 0.00 0.00 0.00 642,338.05 0.00 0.00 0.00 0.00 0.00 642,338.05

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 1,478,409.71 0.00 0.00 0.00 0.00 0.00 1,478,409.71


0.00 1,320.00 660.00 0.00 660.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,640.00


1,130.00 1,664.00 2,310.00 660.00 2,310.00 9,746.20 3,549.48 0.00 0.00 0.00 0.00 0.00 21,369.68


0.00 0.00 0.00 2,970.00 660.00 0.00 990.00 0.00 0.00 0.00 0.00 0.00 4,620.00

1,130.00SUBTOTAL: 2,984.00 2,970.00 3,630.00 3,630.00 9,746.20 4,539.48 0.00 0.00 0.00 0.00 0.00 28,629.68


608.21 217.74 514.99 -141.33 562.40 182.74 512.29 0.00 0.00 0.00 0.00 0.00 2,457.04


1,980.00 1,446.00 1,320.00 1,650.00 660.00 1,320.00 1,686.00 0.00 0.00 0.00 0.00 0.00 10,062.00

82




0.00 0.00 0.00 0.00 127.89 15.22 56.60 0.00 0.00 0.00 0.00 0.00 199.71

2,588.21SUBTOTAL: 1,663.74 1,834.99 1,508.67 1,350.29 1,517.96 2,254.89 0.00 0.00 0.00 0.00 0.00 12,718.75

37,244,097.82 TOTAL: 33,592,550.97 33,806,907.60 38,550,281.19 28,198,061.84 32,912,895.36 26,787,307.74 0.00 0.00 0.00 0.00 0.00 231,092,102.52

83

ACUTE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERVFor The Period Ending January 31, 2014


1006 TANF 21-44 MALE WITH 1,601.85 1,374.10 6,167.67 5,767.86 2,135.33 2,223.86 4,337.20 0.00 0.00 0.00 0.00 0.00 23,607.87

1007 TANF 21-44 FEMALE WI 70,445.15 4,680.37 8,389.22 6,766.10 5,426.68 4,820.41 7,033.76 0.00 0.00 0.00 0.00 0.00 107,561.69

1008 TANF 45-64 M & F WIT 8,094.08 3,127.75 4,412.06 7,164.06 1,738.63 2,521.12 5,110.89 0.00 0.00 0.00 0.00 0.00 32,168.59

1009 TANF 65+ M & F WITH 0.00 0.00 0.00 3.62 0.00 0.00 158.67 0.00 0.00 0.00 0.00 0.00 162.29

1011 TANF <1 M & F NON-ME 754,680.59 601,769.18 527,679.89 499,288.01 452,677.22 484,015.12 857,929.71 0.00 0.00 0.00 0.00 0.00 4,178,039.72

1012 TANF 01-05 M & F NON 756,669.75 458,976.39 527,510.02 853,406.34 609,120.58 696,275.78 514,520.73 0.00 0.00 0.00 0.00 0.00 4,416,479.59

1013 TANF 06-13 M & F NON 630,305.51 445,977.54 585,074.94 784,333.87 691,082.37 935,972.06 557,363.70 0.00 0.00 0.00 0.00 0.00 4,630,109.99

1014 TANF 14-20 MALE NON- 122,141.99 92,142.16 126,440.60 161,879.40 107,675.64 121,628.19 97,645.55 0.00 0.00 0.00 0.00 0.00 829,553.53


299,795.74 205,506.53 218,828.90 258,492.68 282,455.42 257,895.78 244,389.36 0.00 0.00 0.00 0.00 0.00 1,767,364.41

1016 TANF 21-44 MALE NON- 404,620.98 246,557.07 462,363.15 456,975.03 374,792.57 386,264.12 289,022.29 0.00 0.00 0.00 0.00 0.00 2,620,595.21


1,649,261.79 1,336,788.41 1,474,298.63 1,709,582.54 1,444,036.05 1,717,231.15 1,342,947.48 0.00 0.00 0.00 0.00 0.00 10,674,146.05

1018 TANF 45-64 M & F NON 502,551.22 367,199.95 446,478.30 660,781.95 440,024.14 588,967.97 431,899.59 0.00 0.00 0.00 0.00 0.00 3,437,903.12

1019 TANF 65+ M & F NON-M 0.00 0.00 0.00 0.00 0.00 118.21 0.00 0.00 0.00 0.00 0.00 0.00 118.21

1028 TANF 45-64 M & F WIT 0.00 0.00 0.00 0.00 166.27 0.00 75.26 0.00 0.00 0.00 0.00 0.00 241.53


59,926.95 28,825.97 29,481.46 42,027.19 47,249.38 31,799.19 62,004.55 0.00 0.00 0.00 0.00 0.00 301,314.69


43,122.17 27,902.21 25,470.52 57,410.19 28,525.12 24,412.78 46,785.70 0.00 0.00 0.00 0.00 0.00 253,628.69

2120 SSI AGED WITH QMB 241,901.04 153,640.46 165,884.44 175,971.32 135,854.19 202,584.40 187,923.89 0.00 0.00 0.00 0.00 0.00 1,263,759.74


177,129.20 129,003.61 158,092.67 170,031.09 207,571.74 139,613.49 210,481.68 0.00 0.00 0.00 0.00 0.00 1,191,923.48


3,434,426.87 2,722,137.01 2,576,692.20 3,370,052.00 2,724,331.82 3,179,042.60 2,443,663.74 0.00 0.00 0.00 0.00 0.00 20,450,346.24


893,641.00 532,352.06 618,286.27 842,017.18 498,136.17 720,148.72 668,563.91 0.00 0.00 0.00 0.00 0.00 4,773,145.31

2300 SSI BLIND WITH MEDIC 132.94 139.55 631.78 253.61 914.98 652.96 389.71 0.00 0.00 0.00 0.00 0.00 3,115.53


21,657.19 17,707.48 16,077.31 17,302.55 23,532.08 41,604.77 119,257.34 0.00 0.00 0.00 0.00 0.00 257,138.72


4304 SOBRA CHILD 14-20 MA 0.00 138.83 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 138.83

4311 SOBRA CHILD <1 M & F 653,325.20 711,624.89 469,922.50 575,912.86 318,466.37 658,697.82 389,947.24 0.00 0.00 0.00 0.00 0.00 3,777,896.88

4312 SOBRA CHILD 01-05 M 240,187.42 253,956.82 211,492.31 249,020.66 318,124.36 372,809.43 198,735.58 0.00 0.00 0.00 0.00 0.00 1,844,326.58

4313 SOBRA CHILD 06-13 M 201,220.91 251,443.25 229,741.79 309,213.05 283,243.42 288,205.34 245,204.81 0.00 0.00 0.00 0.00 0.00 1,808,272.57

4314 SOBRA CHILD 14-20 MA 127,918.74 76,724.53 81,953.64 107,700.66 114,236.33 106,955.73 77,559.01 0.00 0.00 0.00 0.00 0.00 693,048.64

4315 SOBRA CHILD 14-20 FE 114,896.43 107,104.64 114,958.09 166,856.77 111,598.63 121,716.00 126,033.46 0.00 0.00 0.00 0.00 0.00 863,164.02


161.46 320.39 1,431.76 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,913.61


0.00 0.00 0.00 0.00 0.00 0.00 90.27 0.00 0.00 0.00 0.00 0.00 90.27


157,039.74 95,264.13 143,489.51 166,617.83 114,052.49 109,360.52 102,653.52 0.00 0.00 0.00 0.00 0.00 888,477.74


443,989.24 414,479.40 289,444.78 423,362.38 355,413.93 361,934.58 311,094.86 0.00 0.00 0.00 0.00 0.00 2,599,719.17


26.67 126.37 2,400.83 0.00 0.00 1,354.08 9.61 0.00 0.00 0.00 0.00 0.00 3,917.56


0.00 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



12,020,841.48SUBTOTAL: 9,293,951.40 9,528,548.46 12,087,739.88 9,697,634.98 11,565,735.80 9,550,825.15 0.00 0.00 0.00 0.00 0.00 73,745,277.15

1106 TANF EXPANDED 21-44 16,541.91 7,373.47 8,183.49 12,876.27 9,886.11 13,916.03 17,011.38 0.00 0.00 0.00 0.00 0.00 85,788.66

1107 TANF EXPANDED 21-44 27,426.58 15,996.08 19,526.65 27,261.15 20,171.86 17,813.56 17,111.83 0.00 0.00 0.00 0.00 0.00 145,307.71

1108 TANF EXPANDED 45-64 48,247.68 39,683.47 20,979.82 48,997.27 43,314.42 33,491.50 42,734.52 0.00 0.00 0.00 0.00 0.00 277,448.68


15,695.64 9,474.70 9,298.92 9,686.08 6,457.38 7,931.95 5,751.21 0.00 0.00 0.00 0.00 0.00 64,295.88


0.00 0.00 0.00 0.00 0.00 250.26 541.27 0.00 0.00 0.00 0.00 0.00 791.53

1112 TANF EXPANDED 01-05 159.32 267.41 6,143.97 1,838.23 2,442.96 2,075.24 3,241.33 0.00 0.00 0.00 0.00 0.00 16,168.46

1113 TANF EXPANDED 06-13 3,466.44 13,076.28 36,864.50 18,796.84 8,050.05 9,324.31 4,642.72 0.00 0.00 0.00 0.00 0.00 94,221.14

1114 TANF EXPANDED 14-20 16,173.02 9,004.68 5,922.53 9,708.08 2,740.02 4,307.87 1,605.59 0.00 0.00 0.00 0.00 0.00 49,461.79

1115 TANF EXPANDED 14-20 16,817.47 7,885.46 5,478.17 9,604.02 5,722.72 4,903.47 8,861.06 0.00 0.00 0.00 0.00 0.00 59,272.37

1116 TANF EXPANDED 21-44 134,391.89 163,079.82 108,809.91 161,680.39 163,528.14 159,716.05 108,337.19 0.00 0.00 0.00 0.00 0.00 999,543.39

1117 TANF EXPANDED 21-44 339,873.24 205,561.81 280,359.63 327,678.08 251,915.26 289,344.93 213,892.88 0.00 0.00 0.00 0.00 0.00 1,908,625.83

1118 TANF EXPANDED 45-64 231,825.96 193,262.19 159,754.90 193,050.43 308,556.11 279,009.65 157,787.30 0.00 0.00 0.00 0.00 0.00 1,523,246.54


1,613.85 844.09 499.55 2,673.59 2,259.74 2,283.78 1,391.68 0.00 0.00 0.00 0.00 0.00 11,566.28

1126 TANF EXPANDED 21-44 0.00 0.00 161.42 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 161.42

1128 TANF EXPANDED 45-64 9,042.34 9,035.06 4,710.62 7,953.01 3,780.02 6,202.99 7,749.69 0.00 0.00 0.00 0.00 0.00 48,473.73


13.02 20.96 140.00 7.35 355.74 0.00 114.72 0.00 0.00 0.00 0.00 0.00 651.79


5,870.40 -3,025.69 7,839.98 4,378.77 4,194.21 2,632.49 416.00 0.00 0.00 0.00 0.00 0.00 22,306.16


26,179.48 24,620.49 33,260.97 32,388.96 16,208.51 23,165.67 17,024.61 0.00 0.00 0.00 0.00 0.00 172,848.69


206,328.08 161,469.69 158,084.17 221,036.27 155,186.71 189,903.87 188,580.42 0.00 0.00 0.00 0.00 0.00 1,280,589.21


2,178.52 660.88 0.00 1,318.12 609.83 926.33 1,494.23 0.00 0.00 0.00 0.00 0.00 7,187.91


20,619.96 8,453.83 7,860.33 14,345.80 10,514.09 46,647.41 6,850.70 0.00 0.00 0.00 0.00 0.00 115,292.12


62,760.76 45,058.57 22,984.46 29,182.59 15,404.27 42,334.64 32,791.66 0.00 0.00 0.00 0.00 0.00 250,516.95


152,369.82 112,292.23 108,686.97 149,436.57 105,488.81 138,624.93 107,819.41 0.00 0.00 0.00 0.00 0.00 874,718.74

1,337,595.38SUBTOTAL: 1,024,095.48 1,005,550.96 1,283,897.87 1,136,786.96 1,274,806.93 945,751.40 0.00 0.00 0.00 0.00 0.00 8,008,484.98

3306 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 0.00


0.00 0.00 21.85 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 21.85

3309 AHC CARE M&F 65+ W/ 2,701.31 897.20 1,879.67 1,850.52 1,477.96 611.40 1,673.10 0.00 0.00 0.00 0.00 0.00 11,091.16

3314 AHC CARE MALE 14-20 1,465.12 395.03 84.56 537.20 1,166.16 1,207.32 2,525.73 0.00 0.00 0.00 0.00 0.00 7,381.12


1,385.43 1,691.39 187.38 301.60 342.88 469.20 -34.85 0.00 0.00 0.00 0.00 0.00 4,343.03

3316 AHC CARE MALE 21-44 19,300.83 3,989.18 14,577.00 8,888.89 4,752.39 10,701.91 1,925.57 0.00 0.00 0.00 0.00 0.00 64,135.77


10,977.36 11,459.27 5,707.68 14,743.23 6,952.79 4,496.87 9,773.23 0.00 0.00 0.00 0.00 0.00 64,110.43

3318 AHC CARE M&F 45-64 N 122,334.51 59,849.47 141,639.82 70,918.68 46,559.60 90,945.16 51,671.72 0.00 0.00 0.00 0.00 0.00 583,918.96

3319 AHC CARE M&F 65+ 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 0.00


0.00 18.79 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.79

85



3329 AHC CARE M&F 65+ W/ 83.26 26.40 34.07 60.16 0.00 0.00 223.16 0.00 0.00 0.00 0.00 0.00 427.05

158,247.82SUBTOTAL: 78,326.73 164,132.03 97,300.28 61,251.78 108,431.86 67,757.66 0.00 0.00 0.00 0.00 0.00 735,448.16

3400 MED ELIGIBILITY W/ M -190.19 0.00 -83.27 170.67 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -102.79

3410 MED ELIGIBILITY NON- 0.00 0.00 5.84 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.84

3604 AHC CARE/MI MALE 14- 540.52 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 540.52

3606 AHC CARE/MI MALE 21- 143.84 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 143.84


0.00 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 2,007.09 1,890.02 21.89 2,593.84 576.86 571.80 126.92 0.00 0.00 0.00 0.00 0.00 7,788.42

3614 AHC CARE/MI MALE 14- 21,176.85 22,794.65 140,960.64 55,576.18 38,532.52 42,429.68 22,719.45 0.00 0.00 0.00 0.00 0.00 344,189.97


40,400.62 27,129.98 38,207.81 27,758.99 20,693.43 46,538.53 21,063.94 0.00 0.00 0.00 0.00 0.00 221,793.30

3616 AHC CARE/MI MALE 21- 425,137.00 427,729.67 377,941.84 511,576.04 340,932.94 463,937.57 223,000.21 0.00 0.00 0.00 0.00 0.00 2,770,255.27


193,385.68 135,309.12 181,179.49 218,734.86 141,783.49 167,613.73 108,161.80 0.00 0.00 0.00 0.00 0.00 1,146,168.17

3618 AHC CARE/MI M&F 45-6 1,122,571.02 964,357.32 794,840.03 966,860.93 779,472.03 878,489.28 552,903.60 0.00 0.00 0.00 0.00 0.00 6,059,494.21

3619 AHC CARE/MI M&F 65+ 748.29 0.00 0.00 25.25 10.33 883.80 0.00 0.00 0.00 0.00 0.00 0.00 1,667.67

1,805,920.72SUBTOTAL: 1,579,210.76 1,533,074.27 1,783,296.76 1,322,001.60 1,600,464.39 927,975.92 0.00 0.00 0.00 0.00 0.00 10,551,944.42

3514 ADULT 40-100% MALE 1 0.00 0.00 0.00 0.00 0.00 0.00 982.00 0.00 0.00 0.00 0.00 0.00 982.00


0.00 0.00 0.00 0.00 0.00 0.00 4,763.07 0.00 0.00 0.00 0.00 0.00 4,763.07

3516 ADULT 40-100% MALE 2 0.00 0.00 0.00 0.00 0.00 0.00 2,483.10 0.00 0.00 0.00 0.00 0.00 2,483.10


0.00 0.00 0.00 0.00 0.00 0.00 3,624.72 0.00 0.00 0.00 0.00 0.00 3,624.72

3518 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 36,406.05 0.00 0.00 0.00 0.00 0.00 36,406.05

3706 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


0.00 0.00 0.00 0.00 0.00 0.00 803.28 0.00 0.00 0.00 0.00 0.00 803.28

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 16,028.43 0.00 0.00 0.00 0.00 0.00 16,028.43


0.00 0.00 0.00 0.00 0.00 0.00 8,339.77 0.00 0.00 0.00 0.00 0.00 8,339.77

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 292,703.75 0.00 0.00 0.00 0.00 0.00 292,703.75


0.00 0.00 0.00 0.00 0.00 0.00 115,214.27 0.00 0.00 0.00 0.00 0.00 115,214.27


0.00 0.00 0.00 0.00 0.00 0.00 384,580.63 0.00 0.00 0.00 0.00 0.00 384,580.63

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 865,929.07 0.00 0.00 0.00 0.00 0.00 865,929.07


0.00 0.00 2,413.01 8,884.22 4,420.11 76.03 0.00 0.00 0.00 0.00 0.00 0.00 15,793.37


0.00 0.00 0.00 970.84 0.00 81.95 990.61 0.00 0.00 0.00 0.00 0.00 2,043.40


0.00 0.00 0.00 208.38 0.00 220.64 0.00 0.00 0.00 0.00 0.00 0.00 429.02

0.00SUBTOTAL: 0.00 2,413.01 10,063.44 4,420.11 378.62 990.61 0.00 0.00 0.00 0.00 0.00 18,265.79


2,018.49 159.17 1,013.98 1,872.76 250.19 153.86 2,075.02 0.00 0.00 0.00 0.00 0.00 7,543.47


339.43 3,797.14 1,586.29 0.00 167.04 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,889.90

86




0.00 15.22 0.00 16.28 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 31.50

2,357.92SUBTOTAL: 3,971.53 2,600.27 1,889.04 417.23 153.86 2,075.02 0.00 0.00 0.00 0.00 0.00 13,464.87

15,324,963.32 TOTAL: 11,979,555.90 12,236,319.00 15,264,187.27 12,222,512.66 14,549,971.46 12,361,304.83 0.00 0.00 0.00 0.00 0.00 93,938,814.44

87

ACUTE FEE FOR SERVICE - IHS NON-CATEGORICAL REFERRALS - EXCLUDING EMERGENCY SERVICESFor The Period Ending January 31, 2014


1006 TANF 21-44 MALE WITH 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1007 TANF 21-44 FEMALE WI 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1008 TANF 45-64 M & F WIT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1009 TANF 65+ M & F WITH 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1011 TANF <1 M & F NON-ME 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1012 TANF 01-05 M & F NON 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1013 TANF 06-13 M & F NON 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1014 TANF 14-20 MALE NON- 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


0.00 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 0.00


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

1018 TANF 45-64 M & F NON 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1019 TANF 65+ M & F NON-M 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1028 TANF 45-64 M & F WIT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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


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

2120 SSI AGED WITH QMB 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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


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


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



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


4304 SOBRA CHILD 14-20 MA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4311 SOBRA CHILD <1 M & F 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4312 SOBRA CHILD 01-05 M 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4313 SOBRA CHILD 06-13 M 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4314 SOBRA CHILD 14-20 MA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4315 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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


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


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


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


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


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

88



0.00SUBTOTAL: 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 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 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 0.00


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


0.00 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 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 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 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 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 0.00

1117 TANF EXPANDED 21-44 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1118 TANF EXPANDED 45-64 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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

1126 TANF EXPANDED 21-44 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1128 TANF EXPANDED 45-64 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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


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


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


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


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


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


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


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

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

3306 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 0.00


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

3309 AHC CARE M&F 65+ 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 0.00

3314 AHC CARE MALE 14-20 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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

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 0.00


0.00 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 0.00

3319 AHC CARE M&F 65+ 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 0.00


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

89



3329 AHC CARE M&F 65+ 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 0.00

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



3604 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 0.00

3606 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 0.00


0.00 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 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 0.00


0.00 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 0.00


0.00 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 0.00

3619 AHC CARE/MI M&F 65+ 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.00SUBTOTAL: 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 0.00


0.00 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 0.00


0.00 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 0.00

3706 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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


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

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


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


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


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

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


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


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

90




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

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

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

91

ACUTE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICESFor The Period Ending January 31, 2014


1006 TANF 21-44 MALE WITH 0.00 0.00 103.09 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 103.09

1007 TANF 21-44 FEMALE WI 47.15 267.06 0.00 0.00 9.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 323.61

1008 TANF 45-64 M & F WIT 0.00 55.96 0.00 0.00 0.00 378.57 0.00 0.00 0.00 0.00 0.00 0.00 434.53

1009 TANF 65+ M & F WITH 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1011 TANF <1 M & F NON-ME 47,575.32 2,993.47 3,234.85 -435.93 1,858.43 3,194.85 1,522.72 0.00 0.00 0.00 0.00 0.00 59,943.71

1012 TANF 01-05 M & F NON 9,667.79 8,580.96 12,994.11 17,468.91 9,621.94 8,007.98 14,876.77 0.00 0.00 0.00 0.00 0.00 81,218.46

1013 TANF 06-13 M & F NON 7,572.22 4,716.03 6,149.76 6,028.19 5,480.69 3,133.81 3,319.76 0.00 0.00 0.00 0.00 0.00 36,400.46

1014 TANF 14-20 MALE NON- 601.59 1,474.80 971.81 1,130.87 509.45 2,094.75 1,702.79 0.00 0.00 0.00 0.00 0.00 8,486.06


2,526.39 14,238.81 1,644.79 6,757.51 8,887.60 1,343.05 1,905.02 0.00 0.00 0.00 0.00 0.00 37,303.17

1016 TANF 21-44 MALE NON- 3,645.44 12,070.07 13,669.38 40,093.57 14,526.13 4,844.79 4,332.83 0.00 0.00 0.00 0.00 0.00 93,182.21


34,596.69 24,213.79 33,506.96 38,669.25 49,348.92 36,243.37 29,247.48 0.00 0.00 0.00 0.00 0.00 245,826.46

1018 TANF 45-64 M & F NON 7,909.73 794.18 11,755.59 18,178.20 33,730.36 11,466.22 51,455.71 0.00 0.00 0.00 0.00 0.00 135,289.99

1019 TANF 65+ M & F NON-M 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1028 TANF 45-64 M & F WIT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


2,564.81 1,117.73 791.92 868.14 -188.06 130.05 47.15 0.00 0.00 0.00 0.00 0.00 5,331.74


297.20 0.00 4,770.21 804.37 2,076.39 4,638.26 2,158.29 0.00 0.00 0.00 0.00 0.00 14,744.72

2120 SSI AGED WITH QMB 554.66 361.94 70.93 174.51 1,750.83 830.56 853.76 0.00 0.00 0.00 0.00 0.00 4,597.19


2,522.11 1,841.32 938.93 900.91 2,189.17 683.54 1,545.35 0.00 0.00 0.00 0.00 0.00 10,621.33


477,871.27 414,448.18 154,890.55 517,926.78 373,522.20 444,444.01 289,193.34 0.00 0.00 0.00 0.00 0.00 2,672,296.33


181.50 1,276.54 1,288.45 1,490.39 1,524.83 3,102.85 3,671.98 0.00 0.00 0.00 0.00 0.00 12,536.54



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


4304 SOBRA CHILD 14-20 MA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4311 SOBRA CHILD <1 M & F 73,362.70 20,399.38 16,867.24 105,195.18 37,161.50 19,683.79 5,292.01 0.00 0.00 0.00 0.00 0.00 277,961.80

4312 SOBRA CHILD 01-05 M 19,706.69 9,898.20 28,708.11 24,571.90 17,241.23 31,741.08 12,347.77 0.00 0.00 0.00 0.00 0.00 144,214.98

4313 SOBRA CHILD 06-13 M 6,203.27 9,974.31 12,197.44 15,041.15 8,365.85 16,722.85 3,276.45 0.00 0.00 0.00 0.00 0.00 71,781.32

4314 SOBRA CHILD 14-20 MA 6,783.18 3,212.86 1,247.81 2,965.19 14,966.84 3,862.04 7,082.76 0.00 0.00 0.00 0.00 0.00 40,120.68

4315 SOBRA CHILD 14-20 FE 5,018.94 15,191.80 10,846.04 5,446.60 3,799.46 1,235.79 6,018.81 0.00 0.00 0.00 0.00 0.00 47,557.44


111.25 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 111.25


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


1,445.76 3,520.25 1,319.30 8,658.41 2,656.41 5,861.75 2,761.56 0.00 0.00 0.00 0.00 0.00 26,223.44


24,068.95 37,115.80 19,850.77 16,929.38 9,930.57 24,396.73 5,191.29 0.00 0.00 0.00 0.00 0.00 137,483.49


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


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

92



734,834.61SUBTOTAL: 587,763.44 337,818.04 828,863.48 598,970.14 628,040.69 447,803.60 0.00 0.00 0.00 0.00 0.00 4,164,094.00

1106 TANF EXPANDED 21-44 392.45 0.00 0.00 0.00 0.00 111.92 0.00 0.00 0.00 0.00 0.00 0.00 504.37

1107 TANF EXPANDED 21-44 155.83 37.19 1,204.61 -522.45 0.00 0.00 111.01 0.00 0.00 0.00 0.00 0.00 986.19

1108 TANF EXPANDED 45-64 40.41 28.97 37.36 0.00 28.43 62.15 0.00 0.00 0.00 0.00 0.00 0.00 197.32


0.00 0.00 82.04 0.00 64.21 0.00 7.72 0.00 0.00 0.00 0.00 0.00 153.97


0.00 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 01-05 288.30 0.00 0.00 120.83 2,508.61 1,297.66 154.73 0.00 0.00 0.00 0.00 0.00 4,370.13

1113 TANF EXPANDED 06-13 891.37 89.61 213.40 486.40 423.46 439.18 0.00 0.00 0.00 0.00 0.00 0.00 2,543.42

1114 TANF EXPANDED 14-20 918.17 316.10 53.93 51.97 29.73 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,369.90

1115 TANF EXPANDED 14-20 575.79 813.55 2,750.09 6,993.18 -58.32 466.49 778.20 0.00 0.00 0.00 0.00 0.00 12,318.98

1116 TANF EXPANDED 21-44 42,808.47 7,844.81 5,382.63 26,828.28 5,025.04 6,598.65 5,864.05 0.00 0.00 0.00 0.00 0.00 100,351.93

1117 TANF EXPANDED 21-44 10,226.71 2,211.61 13,595.20 29,329.95 32,435.49 16,956.94 24,591.58 0.00 0.00 0.00 0.00 0.00 129,347.48

1118 TANF EXPANDED 45-64 15,421.38 4,245.16 9,981.20 40,291.33 4,186.97 22,640.81 4,228.31 0.00 0.00 0.00 0.00 0.00 100,995.16


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

1126 TANF EXPANDED 21-44 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1128 TANF EXPANDED 45-64 0.00 0.00 21.15 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 21.15


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


199.61 97.73 127.80 52.89 9.14 0.00 1,340.06 0.00 0.00 0.00 0.00 0.00 1,827.23


55.07 0.00 503.02 7,233.74 276.75 1,488.33 2,112.38 0.00 0.00 0.00 0.00 0.00 11,669.29


1,462.65 1,804.67 442.25 2,904.06 1,751.72 720.35 1,405.80 0.00 0.00 0.00 0.00 0.00 10,491.50


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


21.41 0.00 0.00 0.00 1,734.09 182.76 0.00 0.00 0.00 0.00 0.00 0.00 1,938.26


13,771.58 1,059.63 181,321.91 11,828.56 18.86 779.98 966.84 0.00 0.00 0.00 0.00 0.00 209,747.36


4,493.11 2,374.51 48.01 4,756.05 2,402.56 1,868.31 645.80 0.00 0.00 0.00 0.00 0.00 16,588.35

91,722.31SUBTOTAL: 20,923.54 215,764.60 130,354.79 50,836.74 53,613.53 42,206.48 0.00 0.00 0.00 0.00 0.00 605,421.99

3306 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 0.00


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

3309 AHC CARE M&F 65+ 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 0.00

3314 AHC CARE MALE 14-20 0.00 220.36 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 220.36


1,009.66 0.00 808.53 108.53 0.00 0.00 673.06 0.00 0.00 0.00 0.00 0.00 2,599.78

3316 AHC CARE MALE 21-44 34.63 0.00 0.00 0.00 0.00 475.39 0.00 0.00 0.00 0.00 0.00 0.00 510.02


0.00 0.00 674.66 1,092.79 50.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,817.78

3318 AHC CARE M&F 45-64 N 151.71 4,369.91 32.50 244.89 0.00 0.00 1,170.53 0.00 0.00 0.00 0.00 0.00 5,969.54

3319 AHC CARE M&F 65+ 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 0.00


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

93



3329 AHC CARE M&F 65+ 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 0.00

1,196.00SUBTOTAL: 4,590.27 1,515.69 1,446.21 50.33 475.39 1,843.59 0.00 0.00 0.00 0.00 0.00 11,117.48


3410 MED ELIGIBILITY NON- -88.86 -38.84 -87.45 -25.60 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -240.75

3604 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 0.00

3606 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 0.00


0.00 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 21.15 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 21.15

3614 AHC CARE/MI MALE 14- 930.33 67.80 512.85 0.00 210.38 291.26 179.89 0.00 0.00 0.00 0.00 0.00 2,192.51


341.14 847.99 0.00 701.64 49.13 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,939.90

3616 AHC CARE/MI MALE 21- -842.99 1,883.93 2,032.23 230.27 44.09 849.12 185.42 0.00 0.00 0.00 0.00 0.00 4,382.07


-369.06 172.96 0.00 0.00 455.37 1,469.77 247.09 0.00 0.00 0.00 0.00 0.00 1,976.13

3618 AHC CARE/MI M&F 45-6 6,488.53 3,124.82 989.67 1,512.96 7,601.00 2,232.10 242.94 0.00 0.00 0.00 0.00 0.00 22,192.02

3619 AHC CARE/MI M&F 65+ 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

6,563.54SUBTOTAL: 6,058.66 3,447.30 2,441.12 8,359.97 4,864.10 855.34 0.00 0.00 0.00 0.00 0.00 32,590.03

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 0.00


0.00 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 0.00


0.00 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 35.55 0.00 0.00 0.00 0.00 0.00 35.55

3706 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 198.20 0.00 0.00 0.00 0.00 0.00 198.20


0.00 0.00 0.00 0.00 0.00 0.00 581.91 0.00 0.00 0.00 0.00 0.00 581.91

3716 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 670.60 0.00 0.00 0.00 0.00 0.00 670.60


0.00 0.00 0.00 0.00 0.00 0.00 79.96 0.00 0.00 0.00 0.00 0.00 79.96


0.00 0.00 0.00 0.00 0.00 0.00 4,689.12 0.00 0.00 0.00 0.00 0.00 4,689.12

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 6,255.34 0.00 0.00 0.00 0.00 0.00 6,255.34


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


0.00 0.00 0.00 50.60 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 50.60


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

0.00SUBTOTAL: 0.00 0.00 50.60 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 50.60


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


0.00 1,267.82 0.00 -1,191.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 76.72

94




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

0.00SUBTOTAL: 1,267.82 0.00 -1,191.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 76.72

834,316.46 TOTAL: 620,603.73 558,545.63 961,965.10 658,217.18 686,993.71 498,964.35 0.00 0.00 0.00 0.00 0.00 4,819,606.16

95

QMB - FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERVICESFor The Period Ending January 31, 2014



0.00 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 11,291.00 14,967.07 9,859.09 15,593.97 13,589.14 8,341.42 11,360.33 0.00 0.00 0.00 0.00 0.00 85,002.02

11,291.00SUBTOTAL: 14,967.07 9,859.09 15,593.97 13,589.14 8,341.42 11,360.33 0.00 0.00 0.00 0.00 0.00 85,002.02

11,291.00 TOTAL: 14,967.07 9,859.09 15,593.97 13,589.14 8,341.42 11,360.33 0.00 0.00 0.00 0.00 0.00 85,002.02

96

QMB - FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERFor The Period Ending January 31, 2014



0.00 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 0.00 730.49 0.00 0.00 -388.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 342.49

0.00SUBTOTAL: 730.49 0.00 0.00 -388.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 342.49

0.00 TOTAL: 730.49 0.00 0.00 -388.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 342.49

97

QMB - FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICESFor The Period Ending January 31, 2014



0.00 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 214,811.21 352,703.05 175,175.56 253,369.42 221,841.45 183,533.44 249,739.33 0.00 0.00 0.00 0.00 0.00 1,651,173.46

214,811.21SUBTOTAL: 352,703.05 175,175.56 253,369.42 221,841.45 183,533.44 249,739.33 0.00 0.00 0.00 0.00 0.00 1,651,173.46

214,811.21 TOTAL: 352,703.05 175,175.56 253,369.42 221,841.45 183,533.44 249,739.33 0.00 0.00 0.00 0.00 0.00 1,651,173.46

98

ACUTE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SERVFor The Period Ending January 31, 2014


1006 TANF 21-44 MALE WITH 103.76 0.00 159.76 913.41 799.88 1,560.72 884.45 0.00 0.00 0.00 0.00 0.00 4,421.98

1007 TANF 21-44 FEMALE WI 307.68 334.10 1,416.20 1,359.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,417.38

1008 TANF 45-64 M & F WIT 1,563.76 63.66 202.57 425.83 541.14 279.30 1,925.96 0.00 0.00 0.00 0.00 0.00 5,002.22

1009 TANF 65+ M & F WITH 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1011 TANF <1 M & F NON-ME 108,056.04 74,931.26 38,894.81 76,896.14 61,719.76 78,030.27 69,446.89 0.00 0.00 0.00 0.00 0.00 507,975.17

1012 TANF 01-05 M & F NON 54,947.95 31,087.47 84,911.07 195,555.61 -163,038.13 43,721.94 38,316.04 0.00 0.00 0.00 0.00 0.00 285,501.95

1013 TANF 06-13 M & F NON 43,754.01 40,193.98 28,393.99 35,660.01 29,987.56 56,033.43 34,761.02 0.00 0.00 0.00 0.00 0.00 268,784.00

1014 TANF 14-20 MALE NON- 12,361.12 11,251.02 6,681.89 20,446.91 12,250.67 11,502.68 4,294.69 0.00 0.00 0.00 0.00 0.00 78,788.98


18,284.22 26,706.46 30,451.67 32,877.89 26,280.32 27,701.73 10,660.94 0.00 0.00 0.00 0.00 0.00 172,963.23

1016 TANF 21-44 MALE NON- 21,115.43 28,560.38 39,629.77 37,656.73 51,682.75 38,524.86 42,015.53 0.00 0.00 0.00 0.00 0.00 259,185.45


204,695.63 165,522.53 197,695.61 295,232.70 165,176.58 203,785.38 150,972.98 0.00 0.00 0.00 0.00 0.00 1,383,081.41

1018 TANF 45-64 M & F NON 82,484.44 17,284.04 19,872.68 26,802.37 45,629.53 55,173.97 35,077.51 0.00 0.00 0.00 0.00 0.00 282,324.54

1019 TANF 65+ M & F NON-M 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1028 TANF 45-64 M & F WIT 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


939.58 2,650.75 672.59 2,540.48 301.25 1,846.01 3,428.98 0.00 0.00 0.00 0.00 0.00 12,379.64


1,190.41 1,548.76 1,046.14 7,049.16 426.69 723.34 2,972.05 0.00 0.00 0.00 0.00 0.00 14,956.55

2120 SSI AGED WITH QMB 17,024.49 10,021.92 12,894.18 9,613.14 14,285.05 3,367.22 7,310.11 0.00 0.00 0.00 0.00 0.00 74,516.11


3,410.37 8,002.26 10,909.79 5,512.84 2,353.62 4,398.77 19,389.93 0.00 0.00 0.00 0.00 0.00 53,977.58


270,129.43 298,687.90 324,510.01 311,795.04 283,319.32 243,850.50 302,863.24 0.00 0.00 0.00 0.00 0.00 2,035,155.44


48,304.92 28,801.71 28,715.43 48,772.12 34,202.54 27,007.88 34,949.04 0.00 0.00 0.00 0.00 0.00 250,753.64



0.00 -67.28 50.14 2,398.68 514.55 4,102.33 849.12 0.00 0.00 0.00 0.00 0.00 7,847.54

2320 SSI BLIND WITH QMB 1,746.99 64.78 102.84 211.12 216.24 213.21 1,359.87 0.00 0.00 0.00 0.00 0.00 3,915.05

4304 SOBRA CHILD 14-20 MA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4311 SOBRA CHILD <1 M & F 144,433.90 159,654.87 120,238.66 42,621.80 329,529.89 83,227.93 68,504.09 0.00 0.00 0.00 0.00 0.00 948,211.14

4312 SOBRA CHILD 01-05 M 21,306.06 16,620.77 12,820.15 25,021.69 40,560.18 10,618.51 14,309.95 0.00 0.00 0.00 0.00 0.00 141,257.31

4313 SOBRA CHILD 06-13 M 15,872.06 13,470.59 7,958.69 26,039.44 52,652.69 11,064.16 11,092.07 0.00 0.00 0.00 0.00 0.00 138,149.70

4314 SOBRA CHILD 14-20 MA 6,657.29 5,876.25 10,077.93 12,864.19 4,698.96 8,641.45 8,219.77 0.00 0.00 0.00 0.00 0.00 57,035.84

4315 SOBRA CHILD 14-20 FE 12,831.17 11,786.52 8,583.34 9,952.69 3,714.87 9,012.92 7,773.34 0.00 0.00 0.00 0.00 0.00 63,654.85


0.00 581.93 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 581.93


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


32,537.32 43,876.40 15,590.98 16,624.68 6,227.52 11,595.76 31,779.20 0.00 0.00 0.00 0.00 0.00 158,231.86


72,935.96 58,186.50 41,343.65 64,714.09 45,954.66 88,579.89 58,804.86 0.00 0.00 0.00 0.00 0.00 430,519.61


0.00 836.85 2,692.32 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,529.17


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

99



1,197,026.65SUBTOTAL: 1,056,536.38 1,046,516.86 1,309,558.16 1,049,988.09 1,024,564.16 961,961.63 0.00 0.00 0.00 0.00 0.00 7,646,151.93

1106 TANF EXPANDED 21-44 1,002.41 865.94 1,462.07 462.44 61.67 1,229.32 383.67 0.00 0.00 0.00 0.00 0.00 5,467.52

1107 TANF EXPANDED 21-44 799.19 1,651.84 1,232.66 1,863.71 166.36 25.87 280.76 0.00 0.00 0.00 0.00 0.00 6,020.39

1108 TANF EXPANDED 45-64 6,677.49 4,288.64 2,373.55 4,431.85 2,007.87 3,873.75 6,194.84 0.00 0.00 0.00 0.00 0.00 29,847.99


21.88 2,036.78 1,193.58 1,174.45 47.84 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4,474.53


0.00 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 01-05 115.84 0.00 516.07 482.90 326.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,440.95

1113 TANF EXPANDED 06-13 174.30 0.00 115.84 84.56 358.39 345.93 252.09 0.00 0.00 0.00 0.00 0.00 1,331.11

1114 TANF EXPANDED 14-20 0.00 2,965.28 0.00 336.07 179.28 0.00 317.74 0.00 0.00 0.00 0.00 0.00 3,798.37

1115 TANF EXPANDED 14-20 1,154.95 2,292.64 600.08 84.56 0.00 1,572.32 240.95 0.00 0.00 0.00 0.00 0.00 5,945.50

1116 TANF EXPANDED 21-44 27,655.27 28,085.59 30,530.58 8,472.34 19,584.26 15,096.88 7,714.53 0.00 0.00 0.00 0.00 0.00 137,139.45

1117 TANF EXPANDED 21-44 37,148.72 82,616.11 28,804.86 34,207.51 49,252.90 81,768.94 44,758.55 0.00 0.00 0.00 0.00 0.00 358,557.59

1118 TANF EXPANDED 45-64 16,666.35 32,022.39 41,728.95 24,702.02 43,650.86 31,516.90 7,346.77 0.00 0.00 0.00 0.00 0.00 197,634.24


0.00 0.00 1,128.84 30.72 185.68 399.48 0.00 0.00 0.00 0.00 0.00 0.00 1,744.72

1126 TANF EXPANDED 21-44 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

1128 TANF EXPANDED 45-64 693.78 568.15 106.68 1,302.91 670.74 623.22 279.72 0.00 0.00 0.00 0.00 0.00 4,245.20


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


222.93 0.00 0.00 21.15 62.04 2,240.62 0.00 0.00 0.00 0.00 0.00 0.00 2,546.74


1,450.10 2,291.10 35.07 662.78 5,381.53 4,681.03 29.61 0.00 0.00 0.00 0.00 0.00 14,531.22


18,141.30 8,844.85 13,739.79 18,328.82 9,229.92 18,926.26 12,210.93 0.00 0.00 0.00 0.00 0.00 99,421.87


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


0.00 161.43 22.87 343.11 0.00 196.91 55.96 0.00 0.00 0.00 0.00 0.00 780.28


969.56 268.13 101.25 0.00 846.05 267.79 1,933.21 0.00 0.00 0.00 0.00 0.00 4,385.99


7,212.74 7,836.13 3,798.94 7,128.18 3,323.54 5,670.01 3,600.85 0.00 0.00 0.00 0.00 0.00 38,570.39

120,106.81SUBTOTAL: 176,795.00 127,491.68 104,120.08 135,335.07 168,435.23 85,600.18 0.00 0.00 0.00 0.00 0.00 917,884.05

3306 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 0.00


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

3309 AHC CARE M&F 65+ W/ 0.00 46.69 1,332.31 46.70 0.00 84.15 162.58 0.00 0.00 0.00 0.00 0.00 1,672.43

3314 AHC CARE MALE 14-20 93.58 459.06 0.00 84.56 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 637.20


0.00 0.00 0.00 82.34 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 82.34

3316 AHC CARE MALE 21-44 50.64 0.00 3,363.04 1,999.04 9,309.44 429.23 19,770.75 0.00 0.00 0.00 0.00 0.00 34,922.14


1,526.72 9,264.38 1,141.88 2,535.36 1,662.27 1,521.32 2,186.46 0.00 0.00 0.00 0.00 0.00 19,838.39

3318 AHC CARE M&F 45-64 N 10,017.67 12,724.38 5,678.35 20,687.06 21,548.64 58,395.54 4,118.39 0.00 0.00 0.00 0.00 0.00 133,170.03

3319 AHC CARE M&F 65+ 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 0.00


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

100



3329 AHC CARE M&F 65+ 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 0.00

11,688.61SUBTOTAL: 22,494.51 11,515.58 25,435.06 32,520.35 60,430.24 26,238.18 0.00 0.00 0.00 0.00 0.00 190,322.53



3604 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 0.00

3606 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 0.00


0.00 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 45-6 240.00 0.00 248.82 480.00 240.92 2,257.52 0.00 0.00 0.00 0.00 0.00 0.00 3,467.26

3614 AHC CARE/MI MALE 14- 7,983.97 3,922.25 278.26 2,529.03 1,846.86 7,364.30 7.29 0.00 0.00 0.00 0.00 0.00 23,931.96


5,049.01 3,857.62 4,302.26 2,789.71 3,016.93 5,466.61 5,343.17 0.00 0.00 0.00 0.00 0.00 29,825.31

3616 AHC CARE/MI MALE 21- 72,108.97 83,288.33 67,386.41 81,876.87 15,548.79 28,264.55 22,935.83 0.00 0.00 0.00 0.00 0.00 371,409.75


17,427.39 58,767.16 9,619.40 23,767.63 2,915.87 9,391.63 7,005.15 0.00 0.00 0.00 0.00 0.00 128,894.23

3618 AHC CARE/MI M&F 45-6 30,859.93 123,404.11 48,096.11 128,542.89 41,656.76 177,348.29 38,216.54 0.00 0.00 0.00 0.00 0.00 588,124.63

3619 AHC CARE/MI M&F 65+ 524.15 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 524.15

134,193.42SUBTOTAL: 273,239.47 129,931.26 239,986.13 65,226.13 230,092.90 73,507.98 0.00 0.00 0.00 0.00 0.00 1,146,177.29

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 0.00


0.00 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 11.33 0.00 0.00 0.00 0.00 0.00 11.33


0.00 0.00 0.00 0.00 0.00 0.00 1,300.47 0.00 0.00 0.00 0.00 0.00 1,300.47

3518 ADULT 40-100% M&F 45 0.00 0.00 0.00 0.00 0.00 0.00 2,406.71 0.00 0.00 0.00 0.00 0.00 2,406.71

3706 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


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

3714 ADULT <40% EXP MALE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


0.00 0.00 0.00 0.00 0.00 0.00 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 18,526.45 0.00 0.00 0.00 0.00 0.00 18,526.45


0.00 0.00 0.00 0.00 0.00 0.00 5,137.39 0.00 0.00 0.00 0.00 0.00 5,137.39


0.00 0.00 0.00 0.00 0.00 0.00 28,985.71 0.00 0.00 0.00 0.00 0.00 28,985.71

0.00SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 56,368.06 0.00 0.00 0.00 0.00 0.00 56,368.06


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


55.39 2,619.40 91.24 2,453.22 190.21 4,997.38 2,585.91 0.00 0.00 0.00 0.00 0.00 12,992.75


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

55.39SUBTOTAL: 2,619.40 91.24 2,453.22 190.21 4,997.38 2,585.91 0.00 0.00 0.00 0.00 0.00 12,992.75


21.15 0.00 0.00 14.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 35.55


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

101




0.00 0.00 0.00 25.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 25.01

21.15SUBTOTAL: 0.00 0.00 39.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 60.56

1,463,092.03 TOTAL: 1,531,684.76 1,315,546.62 1,681,592.06 1,283,259.85 1,488,519.91 1,206,261.94 0.00 0.00 0.00 0.00 0.00 9,969,957.17

102

LONG TERM CARE FEE FOR SERVICE - IHS FACILITY SERVICES ONLY - EXCLUDING EMERGENCY SERFor The Period Ending January 31, 2014




170,421.34 129,162.18 157,747.82 209,361.42 113,819.13 133,151.08 102,978.53 0.00 0.00 0.00 0.00 0.00 1,016,641.50


42,967.00 35,033.56 33,371.90 24,119.40 19,362.82 45,325.49 49,757.26 0.00 0.00 0.00 0.00 0.00 249,937.43

2120 SSI AGED WITH QMB 153,374.63 106,597.55 129,592.42 215,053.51 128,985.09 129,358.51 114,074.62 0.00 0.00 0.00 0.00 0.00 977,036.33


29,264.65 20,697.05 17,518.32 36,434.88 20,740.01 24,281.65 21,294.49 0.00 0.00 0.00 0.00 0.00 170,231.05


881,426.21 780,665.08 745,766.99 773,703.13 618,283.41 650,392.15 524,608.78 0.00 0.00 0.00 0.00 0.00 4,974,845.75


51,711.09 40,274.98 41,591.37 83,653.41 42,830.84 42,250.37 37,644.46 0.00 0.00 0.00 0.00 0.00 339,956.52



10,890.00 9,367.04 6,768.64 9,240.00 6,930.00 8,972.09 13,160.00 0.00 0.00 0.00 0.00 0.00 65,327.77

2320 SSI BLIND WITH QMB 89.88 135.81 1,165.19 66.48 459.91 193.50 71.82 0.00 0.00 0.00 0.00 0.00 2,182.59

1,340,144.80SUBTOTAL: 1,121,933.25 1,133,522.65 1,352,349.02 951,411.21 1,034,016.80 863,589.96 0.00 0.00 0.00 0.00 0.00 7,796,967.69


0.00 0.00 0.00 375.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 375.80


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

0.00SUBTOTAL: 0.00 0.00 375.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 375.80

1,340,144.80 TOTAL: 1,121,933.25 1,133,522.65 1,352,724.82 951,411.21 1,034,016.80 863,589.96 0.00 0.00 0.00 0.00 0.00 7,797,343.49

103

LONG TERM CARE FEE FOR SERVICE - IHS NON-CONTRACTED CATEGORICAL REFERRALS - EXCL EMERFor The Period Ending January 31, 2014




2,422,613.51 2,041,575.92 2,132,229.65 2,432,414.35 2,018,774.64 2,306,760.29 2,193,749.74 0.00 0.00 0.00 0.00 0.00 15,548,118.10


161,907.04 148,828.27 201,131.33 193,593.94 191,687.40 173,552.21 186,079.54 0.00 0.00 0.00 0.00 0.00 1,256,779.73

2120 SSI AGED WITH QMB 3,178,042.43 2,656,921.20 2,775,675.86 3,132,045.54 2,390,779.88 3,153,300.07 2,788,246.77 0.00 0.00 0.00 0.00 0.00 20,075,011.75


539,844.78 429,096.30 474,574.01 577,200.95 457,518.04 561,780.22 539,229.88 0.00 0.00 0.00 0.00 0.00 3,579,244.18


1,876,973.29 1,622,797.03 1,752,736.58 2,019,157.12 1,696,835.23 1,992,612.05 1,626,539.49 0.00 0.00 0.00 0.00 0.00 12,587,650.79


742,702.51 638,026.42 623,362.41 694,877.21 581,080.80 668,289.57 655,366.20 0.00 0.00 0.00 0.00 0.00 4,603,705.12

2300 SSI BLIND WITH MEDIC 1,241.60 0.00 3,092.20 1,414.40 255.62 1,530.16 1,682.24 0.00 0.00 0.00 0.00 0.00 9,216.22


6,811.82 8,881.14 6,654.91 5,854.38 7,635.72 7,218.08 6,891.39 0.00 0.00 0.00 0.00 0.00 49,947.44


8,936,593.13SUBTOTAL: 7,560,117.81 7,980,446.50 9,071,681.38 7,351,324.59 8,879,072.25 8,008,403.20 0.00 0.00 0.00 0.00 0.00 57,787,638.86


2,234.88 339.16 5,031.76 2,754.24 114.29 11,962.91 4,664.96 0.00 0.00 0.00 0.00 0.00 27,102.20


0.00 0.00 0.00 0.00 1,607.52 330.96 1,512.96 0.00 0.00 0.00 0.00 0.00 3,451.44

2,234.88SUBTOTAL: 339.16 5,031.76 2,754.24 1,721.81 12,293.87 6,177.92 0.00 0.00 0.00 0.00 0.00 30,553.64

8,938,828.01 TOTAL: 7,560,456.97 7,985,478.26 9,074,435.62 7,353,046.40 8,891,366.12 8,014,581.12 0.00 0.00 0.00 0.00 0.00 57,818,192.50

104

LONG TERM CARE FEE FOR SERVICE - NON IHS ONLY - EXCLUDING EMERGENCY SERVICESFor The Period Ending January 31, 2014




35,333.97 60,575.44 7,427.02 25,845.88 22,608.53 23,847.48 26,301.97 0.00 0.00 0.00 0.00 0.00 201,940.29


144.45 2,784.67 0.00 4,572.89 7,094.81 689.24 928.38 0.00 0.00 0.00 0.00 0.00 16,214.44

2120 SSI AGED WITH QMB 66.55 8,087.69 -11.74 84.61 2,158.31 0.00 104.82 0.00 0.00 0.00 0.00 0.00 10,490.24


9,862.03 16,064.87 12,799.85 1,918.56 9,841.92 12,520.04 4,411.44 0.00 0.00 0.00 0.00 0.00 67,418.71


62,664.07 101,886.38 114,836.84 124,042.80 21,658.20 24,509.30 19,005.56 0.00 0.00 0.00 0.00 0.00 468,603.15


6,565.47 2,706.49 2,252.60 3,728.95 10,622.11 1,793.27 707.01 0.00 0.00 0.00 0.00 0.00 28,375.90



0.00 0.00 0.00 0.00 227.72 0.00 0.00 0.00 0.00 0.00 0.00 0.00 227.72


114,636.54SUBTOTAL: 192,105.54 137,304.57 160,193.69 74,211.60 63,359.33 51,459.18 0.00 0.00 0.00 0.00 0.00 793,270.45


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 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

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

114,636.54 TOTAL: 192,105.54 137,304.57 160,193.69 74,211.60 63,359.33 51,459.18 0.00 0.00 0.00 0.00 0.00 793,270.45

105

LONG TERM CARE FEE FOR SERVICE - IHS CONTRACTED CATEGORICAL REFERRALS - EXCL EMERG SRVFor The Period Ending January 31, 2014




18,251.51 29,979.24 7,692.11 14,434.74 23,305.70 5,975.81 10,405.81 0.00 0.00 0.00 0.00 0.00 110,044.92


1,343.78 222.17 4,985.53 587.96 11,967.06 8,454.11 1,091.93 0.00 0.00 0.00 0.00 0.00 28,652.54

2120 SSI AGED WITH QMB 23,953.21 17,255.09 17,342.74 20,302.62 9,176.89 13,676.48 10,556.44 0.00 0.00 0.00 0.00 0.00 112,263.47


2,673.62 4,194.20 4,726.64 6,672.68 2,478.49 1,846.80 2,904.30 0.00 0.00 0.00 0.00 0.00 25,496.73


35,663.20 26,420.90 35,154.33 37,060.84 21,312.92 89,752.60 110,443.66 0.00 0.00 0.00 0.00 0.00 355,808.45


9,784.01 6,594.69 2,110.41 7,588.75 5,801.29 7,312.77 4,669.16 0.00 0.00 0.00 0.00 0.00 43,861.08



0.00 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 47.15 54.73 47.15 1,240.17 47.15 0.00 55.96 0.00 0.00 0.00 0.00 0.00 1,492.31

91,716.48SUBTOTAL: 84,721.02 72,058.91 87,887.76 74,089.50 127,018.57 140,127.26 0.00 0.00 0.00 0.00 0.00 677,619.50


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


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

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

91,716.48 TOTAL: 84,721.02 72,058.91 87,887.76 74,089.50 127,018.57 140,127.26 0.00 0.00 0.00 0.00 0.00 677,619.50

106

KidsCare - CAPITATION AMOUNTSFor The Period Ending January 31, 2014


6011 KIDS <1M&F NON MEDIC

168,800.00 174,607.51 174,254.49 158,371.94 151,221.93 129,777.84 100,599.74 0.00 0.00 0.00 0.00 0.00 1,057,633.45

6012 KIDS 1-5 M & F NON-M 859,588.60 852,338.81 880,477.66 962,387.70 1,004,387.46 935,775.13 806,990.19 0.00 0.00 0.00 0.00 0.00 6,301,945.55

6013 KIDS 6-13 M & F NON- 2,280,458.14 2,284,331.50 2,334,007.14 2,577,126.98 2,674,113.04 2,544,439.85 1,823,814.84 0.00 0.00 0.00 0.00 0.00 16,518,291.49

6014 KIDS 14-19 MALE NON- 882,781.75 889,269.03 909,042.77 1,046,635.20 1,080,991.21 1,037,143.42 771,936.76 0.00 0.00 0.00 0.00 0.00 6,617,800.14

6015 KIDS 14-19 FEMALE NO 1,358,636.13 1,355,615.95 1,384,312.63 1,559,862.09 1,611,100.34 1,555,318.74 1,155,264.92 0.00 0.00 0.00 0.00 0.00 9,980,110.80

9960 KIDSCARE KICK PAYMEN

23,804.93 24,298.35 17,737.64 17,483.46 6,169.00 17,946.82 17,800.00 0.00 0.00 0.00 0.00 0.00 125,240.20

5,574,069.55SUBTOTAL: 5,580,461.15 5,699,832.33 6,321,867.37 6,527,982.98 6,220,401.80 4,676,406.45 0.00 0.00 0.00 0.00 0.00 40,601,021.63

5,574,069.55 TOTAL: 5,580,461.15 5,699,832.33 6,321,867.37 6,527,982.98 6,220,401.80 4,676,406.45 0.00 0.00 0.00 0.00 0.00 40,601,021.63

107

KidsCare - CAPITATION MEMBER MONTHSFor The Period Ending January 31, 2014



347.57 359.11 357.83 339.43 323.62 277.04 216.35 0.00 0.00 0.00 0.00 0.00 2,220.95

6012 KIDS 1-5 M & F NON-M 8,318.75 8,249.89 8,512.95 8,665.66 9,077.37 8,429.38 7,408.72 0.00 0.00 0.00 0.00 0.00 58,662.72

6013 KIDS 6-13 M & F NON- 22,039.82 22,071.36 22,550.28 22,964.33 23,855.11 22,732.53 16,313.47 0.00 0.00 0.00 0.00 0.00 152,526.90

6014 KIDS 14-19 MALE NON- 6,183.17 6,222.19 6,361.11 6,498.26 6,716.89 6,440.50 4,783.37 0.00 0.00 0.00 0.00 0.00 43,205.49

6015 KIDS 14-19 FEMALE NO 6,010.60 5,997.43 6,121.90 6,279.65 6,507.64 6,283.84 4,672.63 0.00 0.00 0.00 0.00 0.00 41,873.69

9960 KIDSCARE KICK PAYMEN

4.00 4.00 3.00 3.00 1.00 3.00 3.00 0.00 0.00 0.00 0.00 0.00 21.00

42,903.91SUBTOTAL: 42,903.98 43,907.07 44,750.33 46,481.63 44,166.29 33,397.54 0.00 0.00 0.00 0.00 0.00 298,510.75

42,903.91 TOTAL: 42,903.98 43,907.07 44,750.33 46,481.63 44,166.29 33,397.54 0.00 0.00 0.00 0.00 0.00 298,510.75

108

KidsCare - MENTAL HEALTH CAPITATION AMOUNTSFor The Period Ending January 31, 2014



9,696.80 9,775.85 10,118.40 11,549.80 12,463.55 10,537.05 7,950.70 0.00 0.00 0.00 0.00 0.00 72,092.15

6012 KIDS 1-5 M & F NON-M 229,561.20 225,819.50 233,803.55 308,518.55 340,792.20 320,735.65 284,635.06 0.00 0.00 0.00 0.00 0.00 1,943,865.71

6013 KIDS 6-13 M & F NON- 608,368.80 604,469.00 623,151.15 836,081.25 896,981.43 866,102.08 799,951.36 0.00 0.00 0.00 0.00 0.00 5,235,105.07

6014 KIDS 14-19 MALE NON- 170,985.15 171,275.00 176,044.35 243,059.64 259,223.12 252,765.28 235,828.71 0.00 0.00 0.00 0.00 0.00 1,509,181.25

6015 KIDS 14-19 FEMALE NO 168,244.75 167,059.00 170,958.80 236,040.20 252,872.31 246,880.69 232,123.37 0.00 0.00 0.00 0.00 0.00 1,474,179.12

1,186,856.70SUBTOTAL: 1,178,398.35 1,214,076.25 1,635,249.44 1,762,332.61 1,697,020.75 1,560,489.20 0.00 0.00 0.00 0.00 0.00 10,234,423.30

1,186,856.70 TOTAL: 1,178,398.35 1,214,076.25 1,635,249.44 1,762,332.61 1,697,020.75 1,560,489.20 0.00 0.00 0.00 0.00 0.00 10,234,423.30

109

KidsCare - MENTAL HEALTH CAPITATION MEMBER MONTHSFor The Period Ending January 31, 2014



368.00 371.00 384.00 316.00 341.00 287.00 215.00 0.00 0.00 0.00 0.00 0.00 2,282.00

6012 KIDS 1-5 M & F NON-M 8,712.00 8,570.00 8,873.00 8,441.00 9,324.00 8,739.00 7,697.00 0.00 0.00 0.00 0.00 0.00 60,356.00

6013 KIDS 6-13 M & F NON- 23,088.00 22,940.00 23,649.00 22,875.00 24,541.00 23,599.00 21,632.00 0.00 0.00 0.00 0.00 0.00 162,324.00

6014 KIDS 14-19 MALE NON- 6,489.00 6,500.00 6,681.00 6,464.00 6,892.00 6,695.00 6,192.00 0.00 0.00 0.00 0.00 0.00 45,913.00

6015 KIDS 14-19 FEMALE NO 6,385.00 6,340.00 6,488.00 6,292.00 6,737.00 6,545.00 6,097.00 0.00 0.00 0.00 0.00 0.00 44,884.00

45,042.00SUBTOTAL: 44,721.00 46,075.00 44,388.00 47,835.00 45,865.00 41,833.00 0.00 0.00 0.00 0.00 0.00 315,759.00

45,042.00 TOTAL: 44,721.00 46,075.00 44,388.00 47,835.00 45,865.00 41,833.00 0.00 0.00 0.00 0.00 0.00 315,759.00

110

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTSFor The Period Ending January 31, 2014



2,217.66 2,217.66 2,408.43 2,587.27 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9,431.02

6012 KIDS 1-5 M & F NON-M 47,876.81 52,544.24 58,219.53 60,810.84 7,879.20 0.00 3,151.68 0.00 0.00 0.00 0.00 0.00 230,482.30

6013 KIDS 6-13 M & F NON- 159,390.79 158,753.46 170,211.38 175,905.65 9,849.00 0.00 5,121.48 0.00 0.00 0.00 0.00 0.00 679,231.76

6014 KIDS 14-19 MALE NON- 54,985.64 59,077.99 53,593.45 59,949.87 2,363.76 0.00 1,181.88 0.00 0.00 0.00 0.00 0.00 231,152.59

6015 KIDS 14-19 FEMALE NO 62,291.61 62,559.47 62,786.01 67,045.51 4,727.52 0.00 2,363.76 0.00 0.00 0.00 0.00 0.00 261,773.88

326,762.51SUBTOTAL: 335,152.82 347,218.80 366,299.14 24,819.48 0.00 11,818.80 0.00 0.00 0.00 0.00 0.00 1,412,071.55

326,762.51 TOTAL: 335,152.82 347,218.80 366,299.14 24,819.48 0.00 11,818.80 0.00 0.00 0.00 0.00 0.00 1,412,071.55

111

KidsCare - CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHSFor The Period Ending January 31, 2014



6.00 6.00 6.49 7.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 25.49

6012 KIDS 1-5 M & F NON-M 129.53 142.14 157.50 164.00 20.00 0.00 8.00 0.00 0.00 0.00 0.00 0.00 621.17

6013 KIDS 6-13 M & F NON- 431.24 429.49 460.48 475.00 25.00 0.00 13.00 0.00 0.00 0.00 0.00 0.00 1,834.21

6014 KIDS 14-19 MALE NON- 148.76 159.83 145.00 162.00 6.00 0.00 3.00 0.00 0.00 0.00 0.00 0.00 624.59

6015 KIDS 14-19 FEMALE NO 168.53 169.24 169.87 181.00 12.00 0.00 6.00 0.00 0.00 0.00 0.00 0.00 706.64

884.06SUBTOTAL: 906.70 939.34 989.00 63.00 0.00 30.00 0.00 0.00 0.00 0.00 0.00 3,812.10

884.06 TOTAL: 906.70 939.34 989.00 63.00 0.00 30.00 0.00 0.00 0.00 0.00 0.00 3,812.10

112

KidsCare - FEE FOR SERVICEFor The Period Ending January 31, 2014



1,660.89 35,107.37 1,750.31 212.28 179.00 938.61 750.91 0.00 0.00 0.00 0.00 0.00 40,599.37

6012 KIDS 1-5 M & F NON-M 19,919.68 19,183.25 31,457.10 54,480.16 24,491.07 35,275.77 28,187.23 0.00 0.00 0.00 0.00 0.00 212,994.26

6013 KIDS 6-13 M & F NON- 70,875.14 45,310.00 76,737.00 108,176.09 80,186.16 99,516.63 65,189.48 0.00 0.00 0.00 0.00 0.00 545,990.50

6014 KIDS 14-19 MALE NON- 19,410.96 29,794.34 31,498.58 46,800.69 12,018.01 16,008.52 9,397.19 0.00 0.00 0.00 0.00 0.00 164,928.29

6015 KIDS 14-19 FEMALE NO 24,681.18 35,884.48 22,587.58 51,743.43 38,974.23 25,525.15 20,776.26 0.00 0.00 0.00 0.00 0.00 220,172.31

136,547.85SUBTOTAL: 165,279.44 164,030.57 261,412.65 155,848.47 177,264.68 124,301.07 0.00 0.00 0.00 0.00 0.00 1,184,684.73

136,547.85 TOTAL: 165,279.44 164,030.57 261,412.65 155,848.47 177,264.68 124,301.07 0.00 0.00 0.00 0.00 0.00 1,184,684.73

113

KidsCare - REINSURANCEFor The Period Ending January 31, 2014



-8,441.73 13,801.50 0.00 0.00 16,603.24 0.00 0.00 0.00 0.00 0.00 0.00 0.00 21,963.01

6012 KIDS 1-5 M & F NON-M -40.73 29,903.23 0.00 2,238.90 0.00 14,154.69 145.06 0.00 0.00 0.00 0.00 0.00 46,401.15

6013 KIDS 6-13 M & F NON- 81,558.68 50,020.35 112,227.99 89,392.47 35,116.88 213,407.76 67,947.72 0.00 0.00 0.00 0.00 0.00 649,671.85

6014 KIDS 14-19 MALE NON- 60,868.41 26,984.90 22,591.13 53,885.11 33,542.25 75,962.38 34,212.71 0.00 0.00 0.00 0.00 0.00 308,046.89

6015 KIDS 14-19 FEMALE NO 0.00 0.00 0.00 11,560.55 37,923.68 3,168.53 27,847.91 0.00 0.00 0.00 0.00 0.00 80,500.67

133,944.63SUBTOTAL: 120,709.98 134,819.12 157,077.03 123,186.05 306,693.36 130,153.40 0.00 0.00 0.00 0.00 0.00 1,106,583.57

133,944.63 TOTAL: 120,709.98 134,819.12 157,077.03 123,186.05 306,693.36 130,153.40 0.00 0.00 0.00 0.00 0.00 1,106,583.57

114

110007For The Period Ending January 31, 2014


DES-DD - CAP MEMBER MONTHS



101Z TANF ALTCS NON-MEDIC 0.00 0.00 0.00 0.00 0.00 0.00 0.16 0.00 0.00 0.00 0.00 0.00 0.16

1020 TANF WITH QMB 3.00 3.00 3.00 3.00 3.00 3.00 3.00 0.00 0.00 0.00 0.00 0.00 21.00

2100 SSI AGED WITH MEDICA 142.00 139.79 139.10 137.56 136.69 142.93 138.80 0.00 0.00 0.00 0.00 0.00 976.87

2110 SSI AGED NON-MEDICAR 7.00 6.12 5.00 5.00 5.00 5.00 5.00 0.00 0.00 0.00 0.00 0.00 38.12

2120 SSI AGED WITH QMB 207.15 207.54 210.00 209.51 209.56 212.64 218.68 0.00 0.00 0.00 0.00 0.00 1,475.08

2200 SSI DISABLED WITH ME 1,638.96 1,651.39 1,649.70 1,669.83 1,690.77 1,699.52 1,705.29 0.00 0.00 0.00 0.00 0.00 11,705.46

2210 SSI DISABLED NON-MED 19,505.23 19,543.79 19,608.71 19,680.33 19,729.73 19,842.98 19,955.84 0.00 0.00 0.00 0.00 0.00 137,866.61

221Z SSI DISABLED NON-MED 0.00 0.00 0.00 0.77 0.03 -0.77 3.61 0.00 0.00 0.00 0.00 0.00 3.64

2220 SSI DISABLED WITH QM 3,721.81 3,727.50 3,741.03 3,748.58 3,756.82 3,740.83 3,728.49 0.00 0.00 0.00 0.00 0.00 26,165.06


2310 SSI BLIND NON-MEDICA 104.00 105.00 104.93 107.00 107.00 110.83 112.11 0.00 0.00 0.00 0.00 0.00 750.87


8700 SSI DISABLED FREEDOM 5.00 5.00 5.00 5.00 5.00 6.00 6.00 0.00 0.00 0.00 0.00 0.00 37.00



25,959.80SUBTOTAL: 26,016.53 26,103.58 26,203.13 26,281.62 26,408.19 26,523.83 0.00 0.00 0.00 0.00 0.00 183,496.68

25,959.80 TOTAL: 26,016.53 26,103.58 26,203.13 26,281.62 26,408.19 26,523.83 0.00 0.00 0.00 0.00 0.00 183,496.68

115

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM EPD/DD EXPENDITURES For the Period Ending January 31, 2014

EPD/DD CAPITATION-LTC

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN TOTALTRIBAL 374,390.15 374,309.91 373,456.57 374,592.03 374,012.45 372,718.29 366,304.78 0.00 0.00 0.00 0.00 0.00 2,609,784.18EPD 77,489,011.90 87,060,078.55 78,288,354.96 81,059,726.05 90,791,353.42 81,194,273.29 81,031,270.50 0.00 0.00 0.00 0.00 0.00 576,914,068.67 TOTAL AHCCCS LTC 77,863,402.05 87,434,388.46 78,661,811.53 81,434,318.08 91,165,365.87 81,566,991.58 81,397,575.28 0.00 0.00 0.00 0.00 0.00 579,523,852.85DES/DD 80,791,850.36 80,967,826.64 81,238,368.03 83,363,987.97 89,237,760.61 84,027,375.80 84,395,292.73 0.00 0.00 0.00 0.00 0.00 584,022,462.14 TOTAL DES LTC 80,791,850.36 80,967,826.64 81,238,368.03 83,363,987.97 89,237,760.61 84,027,375.80 84,395,292.73 0.00 0.00 0.00 0.00 0.00 584,022,462.14TOTAL LTC - CAP 158,655,252.41 168,402,215.10 159,900,179.56 164,798,306.05 180,403,126.48 165,594,367.38 165,792,868.01 0.00 0.00 0.00 0.00 0.00 1,163,546,314.99

EPD/DD FEE-FOR-SERVICE - LTC

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN TOTAL TOTAL AHCCCS LTC 10,485,325.83 8,959,216.78 9,328,364.39 10,675,241.89 8,452,758.71 10,115,760.82 9,069,757.52 0.00 0.00 0.00 0.00 0.00 67,086,425.94DES/DD 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 TOTAL DES LTC 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00TOTAL LTC - FFS 10,485,325.83 8,959,216.78 9,328,364.39 10,675,241.89 8,452,758.71 10,115,760.82 9,069,757.52 0.00 0.00 0.00 0.00 0.00 67,086,425.94

EPD/DD REINSURANCE - LTC

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN TOTAL TOTAL AHCCCS LTC 3,711,314.90 3,809,831.95 5,475,206.21 3,845,604.72 3,672,323.24 4,359,634.23 1,349,820.40 0.00 0.00 0.00 0.00 0.00 26,223,735.65DES/DD 346,422.72 529,614.76 134,256.12 181,119.71 297,901.22 122,702.96 334,210.82 0.00 0.00 0.00 0.00 0.00 1,946,228.31 TOTAL DES LTC 346,422.72 529,614.76 134,256.12 181,119.71 297,901.22 122,702.96 334,210.82 0.00 0.00 0.00 0.00 0.00 1,946,228.31TOTAL LTC - REIN 4,057,737.62 4,339,446.71 5,609,462.33 4,026,724.43 3,970,224.46 4,482,337.19 1,684,031.22 0.00 0.00 0.00 0.00 0.00 28,169,963.96

EPD/DD SMIB/HIB-LTC

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN TOTALTOTAL SMIB/HIB LTC 2,984,862.20 2,992,172.80 3,010,630.10 3,025,034.80 3,024,210.40 3,043,737.60 3,038,305.60 0.00 0.00 0.00 0.00 0.00 21,118,953.50

Note to the ASR:1- EPD reflects the Federal and County share for both acute and LTC services.2- 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.

116


CRS INTEGRATED HEALTH PLANS - CAPITATION AMOUNTSFor the Period Ending January 31, 2014

TOTAL

CRS FULLY INTEGRATED PLAN - CAP 0.00 0.00 -2,964.88 11,894,500.73 11,881,494.40 11,714,043.20 11,362,181.08 0.00 0.00 0.00 0.00 0.00 46,849,254.53010115

CRS ACUTE SEMI INTEGRATED - CAP 0.00 0.00 0.00 96,812.83 94,940.95 94,720.03 94,801.19 0.00 0.00 0.00 0.00 0.00 381,275.00010145

CRS SEMI INTEGRATED PLAN - CAP 0.00 0.00 0.00 2,895,943.20 5,841,320.70 0.00 2,928,513.75 0.00 0.00 0.00 0.00 0.00 11,665,777.65999125

CRS ONLY PLAN - CAP 0.00 0.00 0.00 422,719.08 840,867.12 0.00 418,385.52 0.00 0.00 0.00 0.00 0.00 1,681,971.72999135

Subtotal 0.00 0.00 -2,964.88 15,309,975.84 18,658,623.17 11,808,763.23 14,803,881.54 0.00 0.00 0.00 0.00 0.00 60,578,278.90

CRS REINSURANCE ONLY 0.00 0.00 0.00 0.00 0.00 705,704.75 518,407.30 0.00 0.00 0.00 0.00 0.00 1,224,112.05999155

Subtotal 0.00 0.00 0.00 0.00 0.00 705,704.75 518,407.30 0.00 0.00 0.00 0.00 0.00 1,224,112.05

CRS FULLY INTEGRATED PLAN - KC CAP 0.00 0.00 0.00 701,026.76 710,847.52 674,886.41 483,659.93 0.00 0.00 0.00 0.00 0.00 2,570,420.62010115

CRS ACUTE SEMI INTEGRATED - KC CAP 0.00 0.00 0.00 7,898.34 7,241.91 7,877.16 6,034.93 0.00 0.00 0.00 0.00 0.00 29,052.34010145

CRS ONLY PLAN - KC CAP 0.00 0.00 0.00 12,212.76 24,819.48 0.00 11,818.80 0.00 0.00 0.00 0.00 0.00 48,851.04999135

Subtotal 0.00 0.00 0.00 721,137.86 742,908.91 682,763.57 501,513.66 0.00 0.00 0.00 0.00 0.00 2,648,324.00

GRAND TOTAL 0.00 0.00 -2,964.88 16,031,113.70 19,401,532.08 13,197,231.55 15,823,802.50 0.00 0.00 0.00 0.00 0.00 64,450,714.95

Friday, February 14, 2014 Page 117

1) Expenditures are from the PMMIS Financial subsystem and may not reconcile to data from other PMMIS subsystems or AFIS due to timing and other factors.2) Expenditures are based on date-of-payment.3) Expenditures do not include manual adjustments or reconciliations.


CRS INTEGRATED HEALTH PLANS - MEMBER MONTHSFor the Period Ending January 31, 2014

TOTAL

CRS FULLY INTEGRATED PLAN - MM 0.00 0.00 -4.00 16,044.79 16,027.41 15,800.24 15,325.12 0.00 0.00 0.00 0.00 0.00 63,193.56010115

CRS ACUTE SEMI INTEGRATED - MM 0.00 0.00 0.00 147.44 144.57 144.21 144.30 0.00 0.00 0.00 0.00 0.00 580.52010145

CRS SEMI INTEGRATED PLAN - MM 0.00 0.00 0.00 6,048.96 12,201.13 0.00 6,117.00 0.00 0.00 0.00 0.00 0.00 24,367.09999125

CRS ONLY PLAN - MM 0.00 0.00 0.00 1,073.00 2,134.28 0.00 1,062.00 0.00 0.00 0.00 0.00 0.00 4,269.28999135

Subtotal 0.00 0.00 -4.00 23,314.19 30,507.39 15,944.45 22,648.42 0.00 0.00 0.00 0.00 0.00 92,410.45

CRS FULLY INTEGRATED PLAN - KC MM 0.00 0.00 0.00 945.49 958.81 910.24 652.12 0.00 0.00 0.00 0.00 0.00 3,466.66010115

CRS ACUTE SEMI INTEGRATED - KC MM 0.00 0.00 0.00 12.03 11.03 12.00 9.17 0.00 0.00 0.00 0.00 0.00 44.23010145

CRS ONLY PLAN - KC MM 0.00 0.00 0.00 31.00 63.00 0.00 30.00 0.00 0.00 0.00 0.00 0.00 124.00999135

Subtotal 0.00 0.00 0.00 988.52 1,032.84 922.24 691.29 0.00 0.00 0.00 0.00 0.00 3,634.89

GRAND TOTAL 0.00 0.00 -4.00 24,302.71 31,540.23 16,866.69 23,339.71 0.00 0.00 0.00 0.00 0.00 96,045.34

Friday, February 14, 2014 Page 118

1) Expenditures are from the PMMIS Financial subsystem and may not reconcile to data from other PMMIS subsystems or AFIS due to timing and other factors.2) Expenditures are based on date-of-payment.3) Expenditures do not include manual adjustments or reconciliations.

Janice K. Brewer, Governor Thomas J. Betlach, Director · 2016. 9. 9. · Janice K. Brewer, Governor Thomas J. Betlach, Director 801 East Jefferson, Phoenix, AZ 85034 PO Box 25520,

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