| Revenue |
| 1a. Capitation revenue for Services |
0 |
0 |
0 |
0 |
0 |
| 1b. Fee-for-Service revenue for Services |
0 |
0 |
0 |
0 |
0 |
| 1. Total revenue for Services (Lines 1a + 1b) |
0 |
0 |
0 |
0 |
0 |
| 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 |
0 |
0 |
| 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 |
0 |
0 |
| Expenses |
| 5a. Capitation expenses for Services |
0 |
0 |
0 |
0 |
0 |
| 5b. Fee-for-Service expenses for Services |
0 |
0 |
0 |
0 |
0 |
5. Total expenses for Services
(Lines 5a + 5b) |
0 |
0 |
0 |
0 |
0 |
7. Total Managed Care Expenses
(Line 5) |
0 |
0 |
0 |
0 |
0 |
Surplus / Deficit
(Line 4 - Line 7) |
0 |
0 |
0 |
0 |
0 |
Surplus / Deficit as Percent of Expenses
(L4 - L7)/L7 |
--- |
--- |
--- |
--- |
--- |
| 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 |
0 |
0 |
8. Total Member months for managed care
(Lines 8a + 8b) |
0 |
0 |
0 |
0 |
0 |
| 9a. Managed Care Encounters (capitated) |
0 |
0 |
0 |
0 |
0 |
| 9b. Managed Care Encounters (fee-for-service) |
0 |
0 |
0 |
0 |
0 |
9. Total Managed Care Encounters
(Lines 9a + 9b) |
0 |
0 |
0 |
0 |
0 |
| 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 |
0 |
0 |
10. Total Managed Care Enrollees
(Lines 10a + 10b) (as of 12/31) |
0 |
0 |
0 |
0 |
0 |
| 11. Enrollees in Primary Care Case Management Programs (PCCM) |
0 |
0 |
0 |
0 |
0 |
| 12. Number of Managed Care Contracts |
0 |
0 |
0 |
0 |
0 |
