| Revenue |
| 1a. Capitation revenue for Services |
0 |
0 |
0 |
0 |
0 |
| 1b. Fee-for-Service revenue for Services |
0 |
0 |
0 |
6,153 |
6,153 |
| 1. Total revenue for Services (Lines
1a + 1b) |
0 |
0 |
0 |
6,153 |
6,153 |
| 3a. Collections from Medicaid or Medicare
reconciliation/wrap around (for current
Year) |
0 |
0 |
|
|
0 |
| 3b. Collections from Medicaid or Medicare
reconciliation/wrap around (for prior
years) |
0 |
0 |
|
|
0 |
| 3c. Collections from patient co-payments
and from managed care plans for other
retroactive payments/ risk pool/ incentive/
withhold |
0 |
0 |
0 |
2,014 |
2,014 |
| 3d. Penalties or paybacks to managed
care plans |
0 |
0 |
0 |
0 |
0 |
4. Total Managed Care Revenue
(Line 1 + 3a + 3b + 3c) - (Line 3d) |
0 |
0 |
0 |
8,167 |
8,167 |
| Expenses |
| 5a. Capitation expenses for Services |
0 |
0 |
0 |
0 |
0 |
| 5b. Fee-for-Service expenses for Services |
0 |
0 |
0 |
10,370 |
10,370 |
5. Total expenses for Services
(Lines 5a + 5b) |
0 |
0 |
0 |
10,370 |
10,370 |
7. Total Managed Care Expenses
(Line 5) |
0 |
0 |
0 |
10,370 |
10,370 |
Surplus / Deficit
(Line 4 - Line 7) |
0 |
0 |
0 |
-2,203 |
-2,203 |
Surplus / Deficit as Percent of Expenses
(L4 - L7)/L7 |
--- |
--- |
--- |
- 21.2% |
- 21.2% |
| Utilization Data |
| 8a. Member months for managed care (capitated) |
0 |
0 |
0 |
0 |
0 |
| 8b. Member months for managed care (fee-for-service) |
0 |
0 |
0 |
867 |
867 |
8. Total Member months for managed care
(Lines 8a + 8b) |
0 |
0 |
0 |
867 |
867 |
| 9a. Managed Care Encounters (capitated) |
0 |
0 |
0 |
0 |
0 |
| 9b. Managed Care Encounters (fee-for-service) |
0 |
0 |
0 |
93 |
93 |
9. Total Managed Care Encounters
(Lines 9a + 9b) |
0 |
0 |
0 |
93 |
93 |
| 10a. Enrollees in Managed Care Plans
(capitated) (as of 12/31) |
0 |
0 |
0 |
0 |
0 |
| 10b. Enrollees in Managed Care Plans
(fee-for-service) (as of 12/31) |
0 |
0 |
0 |
74 |
74 |
10. Total Managed Care Enrollees
(Lines 10a + 10b) (as of 12/31) |
0 |
0 |
0 |
74 |
74 |
| 11. Enrollees in Primary Care Case Management
Programs (PCCM) |
49,324 |
0 |
0 |
0 |
49,324 |
| 12. Number of Managed Care Contracts |
0 |
0 |
0 |
1 |
1 |
