Organization : Archcare Community Life(Catholic MLTC ......Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757 Period Ending : 6/30/2018 Created : Tuesday, October

Managed Long Term Care Medicaid Managed Care Operations Report

Organization : Archcare Community Life(Catholic MLTC) (03466800)

Coverage : Statewide

Period Ending : 6/30/2018

Dcn : 10162018062757

Date : Tuesday, October 16, 2018

Page 1

Configuration InformationConfiguration Information

Submission Type 0.1005 MLTCCRSubmission Year 0.1010 2018Submission Period 0.1011 Q02DCN 0.1004 10162018062757Submitter ID 0.1000 03466800Region ID 0.1003 1Region Name 0.1002 STATEWIDEName of Organization 0.10 ARCHCARE COMMUNITY LIFE(CATHOLIC MLTC) (03466800)Begin Date 0.34 01/01/2018End Date 0.35 06/30/2018

ContactsContact Person:

Name: 0.70 Timothy JohnsonTitle: 0.71 Senior Director of FinanceTelephone Number: 0.72 646-633-4737Fax Number: 0.73 646-633-4701Email Address: 0.82 [email protected]

CertifiersChief Executive Officer

Role 999930000.1 CEOName 999930000.2 Scott LaRueTitle 999930000.3 President, Chief Executive OfficerPhone Number 999930000.4 646-475-4868Fax Number 999930000.5 646-395-5902Email Address 999930000.6 [email protected]

Chief Financial Officer

Role 999930001.1 CFOName 999930001.2 Annmarie CovoneTitle 999930001.3 Executive VP/Chief Financial OfficerPhone Number 999930001.4 646-633-4702Fax Number 999930001.5 646-633-4701Email Address 999930001.6 [email protected]

AddressesMailing Address:

Item 0.66 ArchCare Community LifeLine 1 0.67 205 Lexington Avenue, 2nd FloorLine 2 0.68 New York, NY 10016Line 3 0.69

Additional InformationAdditional Information

Date Operations Started (MM/DD/YYYY):0.65 11/01/2012

Counties of OperationCounties of Operation:

Item 0.4 NY (MANHATTAN)County 0.5 QUEENSCounty 0.6 RICHMOND (STATEN ISLAND)County 0.7 BRONXCounty 0.8 KINGS (BROOKLYN)County 0.9 WESTCHESTERCounty 0.11 PUTNAM

Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018

Page 2

Schedule ABalance Sheet

Assets Nonadmitted Assets Net AdmittedAssets

Net Admitted AssetsAs of 12/31

00010 02225 00011 00013 00014 00012

CURRENT ASSETS

Cash 0001 $32,230,454 $32,230,454 $5,158,551

Short-Term Investments 0002 $3,795,202 $3,795,202 $3,721,950

Premiums Receivable-net 0003 $3,409,984 $3,409,984 $18,219,713

Interest Receivable 0004

NYS Medicaid Reinsurance Recovery Receivable 0140

Other Receivables - Net 0006

Prepaid Expenses 0007 $183,178 $183,178 $190,588

Risk Share Receivable 0200

Aggregate Write-Ins for Current Assets (list below) 0008 $4,290,822 $4,290,822 $4,750,340

Due from Third Party Payors 0009 $4,290,822 $4,290,822 $4,750,340

0010

0011

0012

0013

TOTAL CURRENT ASSETS 0015 $43,909,640 $43,909,640 $32,041,142

OTHER ASSETS

NYS Escrow Account Balance 0016 $14,058,586 $14,058,586 $9,062,671

Amounts Due from Affiliates 0018 $8,371,883 $8,371,883 $1,931,995

Loan Escrow 0019

Long-Term Investments 0020

Intangible Investments and Goodwill 0111

Lease Acquisition Costs, Net 0112 $93,897 $93,897 $93,897

Security Deposit 0113 $102,500 $102,500 $102,500

0114

0115

0116

Other Restricted Assets 0017

Aggregate Write-Ins for Other Assets (list below) 0124

0024

0025

0026

0027

0028

TOTAL OTHER ASSETS 0030 $22,626,866 $22,626,866 $11,191,063

PROPERTY AND EQUIPMENT

Land 0031

Building and Improvements 0032

Construction In Progress 0035

Furniture and Equipment 0033 $3,071,376 $3,071,376 $2,723,505

Leasehold Improvements 0034 $3,132,099 $3,132,099 $2,997,754

Aggregate Write-Ins for Other Equipment (list below) 0137

0037

0038

0039

0040

0041

TOTAL PROPERTY AND EQUIPMENT 0045 $6,203,475 $6,203,475 $5,721,259

TOTAL ASSETS 0050 $72,739,981 $72,739,981 $48,953,464


Page 3

Schedule ABalance Sheet (continued)

Current Year Previous Calendar Yearas of 12/31

00010 02226 00011 00012

CURRENT LIABILITIES

Accounts Payable 0051 $12,637,916 $13,511,662

Claims Payable 0052

Accrued Inpatient Claims (Not Reported) 0054

Accrued Physician Claims (Not Reported) 0055

Accrued Referral Claims (Not Reported) 0056

Accrued Other Medical 0057

Accrued Medical Incentive Pool 0058

Unearned Premiums 0059 $2,378,756 $5,000

Loans and Notes Payable 0060

Risk Share Payable 0201

Aggregate Write-Ins for Current Liabilities (list below) 0162 $40,008,223 $24,934,308

Incurred But not Reported (IBNR) 0062 $40,008,222 $21,163,142

Due to Third Party Payors 0063 $1 $3,771,166

0064

0065

0066

TOTAL CURRENT LIABILITES 0070 $55,024,895 $38,450,970

OTHER LIABILITIES

Loans and Notes 0071

Amounts Due to Affiliates 0072 $5,276,145 $243,630

Aggregate Write-Ins for Other Liabilities (list below) 0173 $191,783 $195,251

Deferred Rent Payable 0073 $191,783 $195,251

0074

0075

0076

0077

TOTAL OTHER LIABILITIES 0079 $5,467,928 $438,881

TOTAL LIABILITIES 0080 $60,492,823 $38,889,851

NET WORTH

Donated Capital 0121

Capital 0122

Paid In Surplus 0123

NYS Contingent Reserve Requirement 0081 $14,037,806 $9,047,062

Aggregate Write-Ins For Other Net Worth Items (List Below) 0183

0083

0084

0085

0086

0087

Unassigned Surplus 0089 ($1,790,647) $1,016,551

TOTAL NET WORTH EXCLUDING NON ADMITTED ASSETS 0105 $12,247,159 $10,063,613

TOTAL LIABILITIES AND NET WORTH EXCLUDING NON ADMITTED ASSETS 0110 $72,739,982 $48,953,464

TOTAL NET WORTH INCLUDING NON ADMITTED ASSETS 0090 $12,247,158 $10,063,613

TOTAL LIABILITIES AND NET WORTH INCLUDING NON ADMITTED ASSETS 0100 $72,739,981 $48,953,464


Page 4

Schedule A1 - Net Worth Reconciliation

00030 30127 00031

Net Worth Last Year 0001 $10,063,613

Total Net Income 0002 $2,188,802

Change in nonadmitted assets 0020

Dividends to stockholders 0003

Withdrawals of equity 0004

Change in Net unrealized capital gains & losses less capital gains tax 0019 ($5,259)

Adjusted Net Worth 0005 $12,247,156

Current Net Worth 0006 $12,247,159

Difference 0007 $3

Explanations:

Rounding 0008 $3

0009

0010

0011

0012

0013

0014

0015

0016

0017

Total Explanations 0018 $3


Page 5

Schedule B - Revenue and Expense Statement - Total Line of Business Total PlanAmount

MedicaidEnrolleesAmount

OtherEnrolleesAmount

Total PlanPMPM

MedicaidPMPM

OtherPMPM

Total Plan Previous YearPMPM

(as of 12/31)

00110 02228 00111 00112 00113 00114 00115 00116 00117

Total Member Months 0001 21,705 21,705 $32,106.00

Revenue

Medicare Part C Premium Revenue 0401 $0.00

Medicare Part D Premium Revenue 0402 $0.00

Medicaid Premium Revenue 0003 $101,988,313 $101,988,313 $4,698.84 $4,698.84 $4,619.26

Other Payor Premium Revenue 0004 $0.00

Spenddown and NAMI 0013 $3,742,550 $3,742,550 $172.43 $172.43 $164.69

Coordination of Benefits(COB) 0014 $0.00 $0.00

Reinsurance Recoveries 0077 $0.00 $0.00

Net Investment Income (Schedule G) 0016 $94,633 $94,633 $4.36 $4.36 $2.33

HR&R Revenue 0018 $0.00 $0.00

Quality Incentive Pool Award 0416 $0.00 $0.00

Quality Incentive VAPP 0417 $0.00 $0.00

Minimum Wage 0419 $10,079,088 $10,079,088 $464.37 $464.37

Other Revenue (Double click Below)

0019 $0.00 $0.00

0020 $0.00 $0.00

TOTAL PREMIUM REVENUE 0010 $105,730,863 $105,730,863 $4,871.27 $4,871.27 $4,783.95

TOTAL REVENUE 0030 $115,904,584 $115,904,584 $5,339.99 $5,339.99 $4,786.28

Expenses

Medical and Hospital Expenses

Inpatient:Acute Medical/Surgical 0031

Inpatient:Mental Health/Substance/Abuse 0032

Inpatient Maternity Delivery 0403

Total Hospital Inpatient Care 0404

Other Medical and Hospital:

Primary Care Physician 0034

Specialty Care 0035

Prenatal/Postpartum Maternity Services 0405

Ambulatory Surgery 0036

Outpatient/Physical Rehab/Therapy 0406 $13,479 $13,479 $0.62 $0.62 $0.62

Other Professional Services 0037 $36,094 $36,094 $1.66 $1.66 $0.50

Emergency Room 0038

Outpatient Mental Health 0039

Outpatient Drug and Alcohol Treatment 0040

Dental 0041 $243,169 $243,169 $11.20 $11.20 $11.07

Pharmacy-Part D 0407

Pharmacy-Non-Part D 0408

Home Health Care 0409 $744,377 $744,377 $34.30 $34.30 $56.77

Nursing Facility 0033 $25,969,986 $25,969,986 $1,196.50 $1,196.50 $1,278.44

Transportation - Emergent 0410

Transportation - Non Emergent 0411 $2,154,188 $2,154,188 $99.25 $99.25 $102.68

Diagnostic Test/Lab/X-Ray 0048

Family Planning 0412

Vision Care Inc. Eyeglasses 0049 $12,531 $12,531 $0.58 $0.58 $0.50

Foot Care 0050 $17,392 $17,392 $0.80 $0.80 $0.68

Durable Medical Equipment & Supplies 0060 $892,422 $892,422 $41.12 $41.12 $39.81

Personal Care 0057 $50,354,620 $50,354,620 $2,319.95 $2,319.95 $2,584.48

CDPAP 0125 $8,396,199 $8,396,199 $386.83 $386.83

Personal Emergency Response Services 0062 $156,536 $156,536 $7.21 $7.21 $8.68

Home Delivered and Congregate Meals 0064 $44,681 $44,681 $2.06 $2.06 $2.48

Adult Day Health Care 0044 $766,088 $766,088 $35.30 $35.30 $11.98

Social Day Care 0045 $176,621 $176,621 $8.14 $8.14 $10.84

Other Medical Services 0413 $0.00 $0.00

GROSS MEDICAL & HOSPITAL EXPENSES 0075 $89,978,383 $89,978,383 $4,145.51 $4,145.51 $4,109.53

PLUS: Reinsurance Premium Cost(1) 0015 $0.00 $0.00

Global Capitation Surplus/(Loss) 0415 $0.00 $0.00 $0.00

Quality Incentive VAPP 0418 $0.00 $0.00 $0.00

Minimum Wage 0420 $10,079,088 $10,079,088 $464.37 $464.37 $0.00

Incentive Pool Adjustment 0076 $0.00 $0.00 $4,273.07

TOTAL MEDICAL & HOSPITAL EXPENSES 0080 $100,057,471 $100,057,471 $4,609.88 $4,609.88 $8,382.60

Care Management (Schedule D-2) 0047 $4,206,957 $4,206,957 $0 $193.82 $193.82 $219.63

Administration

Allowable Administration Expenses (Schedule D-3) 0081 $7,264,412 $7,264,412 $0 $334.69 $334.69 $334.69 $384.86

TOTAL EXPENSES 0085 $111,528,840 $111,528,840 $0 $5,138.39 $5,138.39 $8,987.09

Premium Income(Loss) 0086 ($5,797,977) ($5,797,977) $0 ($267.13) ($267.13) ($4,203.14)

Nonallowable Administrative Expenses 0098 $938,438 $938,438 $0 $43.24 $43.24 $55.00

Operating Incomes(Loss) 0090 $3,437,306 $3,437,306 $0 $158.36 $158.36 ($4,255.81)

Aggregate Write-ins for Other Expenses 0095 $0.00 $0.00

Prior Period Adjustments and Extraordinary Items 0096 $0.00 $0.00

Provision for Taxes 0093 $0.00 $0.00

Adj. For Prior Period IBNR Adjustment 0094 ($35,053) ($35,053) ($1.61) ($1.61) $5.80

NET INCOME (LOSS) 0100 $3,472,359 $3,472,359 $0 $159.98 $159.98 $17.73


Page 6

Schedule B Consolidated Revenue and Expense Summary

All Lines of Business

PACE Partial MedicareAdvantage

MedicaidAdvantage

Plus

FIDA DISCO HARP Other Total

00120 02229 00121 00122 00123 00126 00127 00128 00129 00124 00125

Members 1001 712 3,796 4,508

Member Months 0001 4,119 21,705 25,824

Revenue

Medicare Part C Premium Revenue 0401 $12,319,711 $12,319,711

Medicare Part D Premium Revenue 0402 $3,158,849 $3,158,849

Medicaid Premium Revenue 0003 $21,704,590 $101,988,313 $123,692,903

Other Payor Premium Revenue 0004 $108,186 $108,186

Spenddown and NAMI 0013 $429,761 $3,742,550 $4,172,311

Coordination of Benefits(COB) 0014

Reinsurance Recoveries 0077 $54,053 $54,053

Net Investment Income (Schedule G) 0016 $7,214 $94,633 $101,847

HR&R Revenue 0018

Quality Incentive Pool Award 0416

Quality Incentive VAPP 0417

Minimum Wage 0419 $1,909,400 $10,079,088 $11,988,488

Other Revenue

Grants/Contributions/Other Revenue 0019 $1,582,662 $1,582,662

Social Day Care Revenue 0020 $132,279 $132,279

TOTAL PREMIUM REVENUE 0010 $37,721,097 $105,730,863 $143,451,960

TOTAL REVENUE 0030 $41,406,705 $115,904,584 $157,311,289

Expenses


Inpatient:Acute Medical/Surgical 0031 $4,608,888 $4,608,888

Inpatient:Mental Health/Substance/Abuse 0032


Total Hospital Inpatient Care 0404 $4,608,888 $4,608,888


Primary Care Physician 0034 $1,297,080 $1,297,080

Specialty Care 0035 $227,386 $227,386



Outpatient/Physical Rehab/Therapy 0406 $957,386 $13,479 $970,865

Other Professional Services 0037 $907,412 $36,094 $943,506

Emergency Room 0038 $78,672 $78,672

Outpatient Mental Health 0039 $151,376 $151,376

Outpatient Drug and Alcohol Treatment 0040

Dental 0041 $50,766 $243,169 $293,935

Pharmacy-Part D 0407 $2,500,845 $2,500,845

Pharmacy-Non-Part D 0408 $77,346 $77,346

Home Health Care 0409 $13,394,021 $744,377 $14,138,398

Nursing Facility 0033 $2,511,953 $25,969,986 $28,481,939

Transportation - Emergent 0410 $138,337 $138,337

Transportation - Non Emergent 0411 $2,058,765 $2,154,188 $4,212,953

Diagnostic Test/Lab/X-Ray 0048 $452,531 $452,531


Vision Care Inc. Eyeglasses 0049 $83,772 $12,531 $96,303

Foot Care 0050 $103,167 $17,392 $120,559

Durable Medical Equipment & Supplies 0060 $381,966 $892,422 $1,274,388

Personal Care 0057 $50,354,620 $50,354,620

CDPAP 0125 $8,396,199 $8,396,199

Personal Emergency Response Services 0062 $10,922 $156,536 $167,458

Home Delivered and Congregate Meals 0064 $227,613 $44,681 $272,294

Adult Day Health Care 0044 $3,600 $766,088 $769,688

Social Day Care 0045 $3,309,170 $176,621 $3,485,791

Supplemental Benefits 0099

Other Medical Services 0413 $32,450 $32,450

GROSS MEDICAL & HOSPITAL EXPENSES 0075 $33,565,424 $89,978,383 $123,543,807

PLUS: Reinsurance Premium Cost(1) 0015 $15,026 $15,026

Global Capitation Surplus/(Loss) 0415

Quality Incentive VAPP 0418

Minimum Wage 0420 $1,909,400 $10,079,088 $11,988,488

Incentive Pool Adjustment 0076

TOTAL MEDICAL & HOSPITAL EXPENSES 0080 $35,489,850 $100,057,471 $135,547,321

Care Management 0047 $1,557,117 $4,206,957 $5,764,074

Administration

Allowable Administration Expenses 0081 $4,959,557 $7,264,412 $12,223,969

TOTAL EXPENSES 0085 $42,006,524 $111,528,840 $153,535,364

Premium Income(Loss) 0086 ($4,285,427) ($5,797,977) ($10,083,404)

Nonallowable Administrative Expenses 0098 $237,381 $938,438 $1,175,819

Operating Incomes(Loss) 0090 ($837,200) $3,437,306 $2,600,106

Aggregate Write-ins for Other Expenses 0095

Prior Period Adjustments and Extraordinary Items 0096

Provision for Taxes 0093

Adj. For Prior Period IBNR Adjustment 0094 $446,357 ($35,053) $411,304

NET INCOME (LOSS) 0100 ($1,283,557) $3,472,359 $2,188,802

(1) Plans purchasing reinsurance should enter its reinsurance costs on this line.


Page 7

Schedule B-1 - Medicaid Revenue and Expense Analysis Community MedicaidCurrent

YTD

MedicaidCurrent YTD

PMPM

MedicaidPrevious Calendar

Year PMPMas of 12/31

00210 22210 00211 00212 00213

Medicaid Member Months 0101 18,795 27,717

Revenue

Medicare Part C Premium Revenue 0501

Medicare Part D Premium Revenue 0502

Medicaid Premium Revenue 0103 $86,966,046 $4,627.08 $4,619.26

Other Payor Premium Revenue 0104

Spenddown and NAMI 0113 $867,973 $46.18 $164.69

Coordination of Benefits(COB) 0114 $0.00

Reinsurance Recoveries 0177 $0.00

Net Investment Income 0116 $81,948 $4.36 $2.33

HR&R Revenue 0118 $0.00

Quality Incentive Pool Award 0416 $0.00

Quality Incentive VAPP 0417 $0.00

Minimum Wage 0419 $10,079,088 $536.26

Other Revenue (Double Click Below)

0119 $0.00

0120 $0.00

TOTAL PREMIUM REVENUE 0110 $87,834,019 $4,673.27 $4,783.95

TOTAL REVENUE 0130 $97,995,055 $5,213.89 $4,786.28

Expenses


Inpatient Acute Medical Surgical 0131

Inpatient Mental Health & Substance Abuse 0132





Specialty Care 0135



Outpatient/Physical Rehab/Therapy 0506 $13,479 $0.72 $0.62

Other Professional Services 0137 $36,025 $1.92 $0.50

Emergency Room (In/Out of Area) 0138

Outpatient: Mental Health 0139

Outpatient Drug & Alcohol Treatment 0140

Dental 0141 $243,169 $12.94 $11.07



Home Health Care 0509 $744,377 $39.61 $56.77

Nursing Facility 0133 $927,048 $49.32 $1,278.44


Transportation - Non Emergent 0511 $2,055,341 $109.36 $102.68

Diagnostic Testing, Lab & X-Ray 0148


Vision Care Inc. Eyeglasses 0149 $2,748 $0.15 $0.50

Foot Care 0150 $14,741 $0.78 $0.68

Durable Medical Equipment & Other 0160 $886,146 $47.15 $39.81

Personal Care 0157 $50,279,262 $2,675.14 $2,584.48

CDPAP 0125 $8,393,821 $446.60 $163.53

Personal Emergency Response Services 0162 $156,281 $8.32 $8.68

Home Delivered and Congregate Meals 0164 $44,510 $2.37 $2.48

Adult Day Care 0144 $765,494 $40.73 $11.98

Social Day Care 0145 $174,567 $9.29 $10.84

Other Medical Services: (Enter labels on Exhibit B)

0513 $0.00

0514 $0.00

0515 $0.00

0516 $0.00

0517 $0.00

Total: Other Medical Services 0530 $0.00

GROSS MEDICAL & HOSPITAL EXPENSES 0175 $64,737,009 $3,444.37 $4,273.06

PLUS: Reinsurance Premium Cost 0115 $0.00

Global Capitation Surplus/(Loss) 0415 $0.00


Minimum Wage 0420 $10,079,088 $536

Incentive Pool Adjustment 0176 $0.00

TOTAL MEDICAL & HOSPITAL EXPENSES 0180 $74,816,097 $3,980.64 $4,273.06

Care Management (Schedule D-2) 0147 $3,026,792 $161.04 $219.63

Administration

Allowable Administration Expenses (Schedule D-3) 0181 $6,290,469 $334.69 $384.86

TOTAL EXPENSES 0185 $84,133,357 $4,476.37 $4,877.55

Premium Income(Loss) 0186 $3,700,662 $196.90 ($93.60)

Nonallowable Expense 0198 $812,621 $43.24 $55.00

Operating Incomes(Loss) 0190 $13,049,077 $694.28 ($146.27)




Adj. For Prior Period IBNR Adjustment 0194

NET INCOME (LOSS) 0199

(1) Plans purchasing reinsurance should enter its reinsurance costs on this line.


Page 8

Schedule B-1 - Medicaid Revenue and Expense Analysis Nursing Home Permanent Placement MedicaidCurrent

YTD

MedicaidCurrent YTD

PMPM

MedicaidPrevious Calendar

Year PMPMas of 12/31

00224 22411 00225 00226 00227

Medicaid Member Months 0101 2,910 4,389

Revenue

Medicare Part C Premium Revenue 0501

Medicare Part D Premium Revenue 0502

Medicaid Premium Revenue 0103 $15,022,267 $5,162.29 $4,619.26

Other Payor Premium Revenue 0104

Spenddown and NAMI 0113 $2,874,577 $987.83 $164.69

Coordination of Benefits(COB) 0114 $0.00

Reinsurance Recoveries 0177 $0.00

Net Investment Income 0116 $12,685 $4.36 $2.33

HR&R Revenue 0118 $0.00

Quality Incentive Pool Award 0416 $0.00


Minimum Wage 0419 $0.00

Other Revenue (Double Click Below)

0119 $0.00

0120 $0.00

TOTAL PREMIUM REVENUE 0110 $17,896,844 $6,150.12 $4,783.95

TOTAL REVENUE 0130 $17,909,529 $6,154.48 $4,786.28

Expenses


Inpatient Acute Medical Surgical 0131

Inpatient Mental Health & Substance Abuse 0132





Specialty Care 0135



Outpatient/Physical Rehab/Therapy 0506 $0.00 $0.62

Other Professional Services 0137 $69 $0.02 $0.50

Emergency Room (In/Out of Area) 0138

Outpatient: Mental Health 0139

Outpatient Drug & Alcohol Treatment 0140

Dental 0141 $0.00 $11.07



Home Health Care 0509 $0.00 $56.77

Nursing Facility 0133 $25,042,938 $8,605.82 $1,278.44


Transportation - Non Emergent 0511 $98,847 $33.97 $102.68



Vision Care Inc. Eyeglasses 0149 $9,783 $3.36 $0.50

Foot Care 0150 $2,651 $0.91 $0.68

Durable Medical Equipment & Other 0160 $6,276 $2.16 $39.81

Personal Care 0157 $75,358 $25.90 $2,584.48

CDPAP 0125 $2,378 $0.82 $163.53

Personal Emergency Response Services 0162 $255 $0.09 $8.68

Home Delivered and Congregate Meals 0164 $171 $0.06 $2.48

Adult Day Care 0144 $594 $0.20 $11.98

Social Day Care 0145 $2,054 $0.71 $10.84

Other Medical Services: (Enter labels on Exhibit B)

0513 $0.00

0514 $0.00

0515 $0.00

0516 $0.00

0517 $0.00

Total: Other Medical Services 0530 $0.00

GROSS MEDICAL & HOSPITAL EXPENSES 0175 $25,241,374 $8,674.01 $4,273.06

PLUS: Reinsurance Premium Cost 0115 $0.00

Global Capitation Surplus/(Loss) 0415 $0.00


Minimum Wage 0420 $0

Incentive Pool Adjustment 0176 $0.00

TOTAL MEDICAL & HOSPITAL EXPENSES 0180 $25,241,374 $8,674.01 $4,273.06

Care Management (Schedule D-2) 0147 $1,180,165 $405.56 $219.63

Administration

Allowable Administration Expenses (Schedule D-3) 0181 $973,943 $334.69 $384.86

TOTAL EXPENSES 0185 $27,395,483 $9,414.26 $4,877.55

Premium Income(Loss) 0186 ($9,498,639) ($3,264.14) ($93.60)

Nonallowable Expense 0198 $125,817 $43.24 $55.00

Operating Incomes(Loss) 0190 ($9,611,771) ($3,303.01) ($146.27)




Adj. For Prior Period IBNR Adjustment 0194

NET INCOME (LOSS) 0199

* Total actual hours paid during the report period.|

(Includes vacation, sick and holiday time)/(weeks in report period x standard hrs. per workweek)|

** Care Management Supervisor ratio is to CM EMPLOYEES, not to enrollees.


Page 9

Schedule D-2 - Care Management *F.T.E.s Salary and Fringes *F.T.E.s Salary and Fringes Total **Staffing Ratios

00610 61016 00611 00612 00614 00615 00617 00618

Care Management Supervisor 0001 7.36 $653,774 $653,774 7:39

Care Manager 0002 28.71 $1,545,239 3.74 $805,158 $2,350,397 32:3796

Other - (Double click Below)

Social Services 0004 10.42 $517,406 $517,406 10:3796

Reassessment Nurse 0005 10.15 $685,380 $685,380 10:3796

0006

0007

0008

0009

0010

0011

0012

0013

TOTAL CARE MANAGEMENT 0025 56.64 $3,401,799 3.74 $805,158 $4,206,957 29.96

PACE Center Staff 0026

Non-PACE Center Staff 0027 56.64 $3,401,799 3.74 $805,158 $4,206,957


Page 10

Schedule D-2A - Care Management Expense - Contracted Services Panel Size (Members) Member Months Contracted Fee PMPM Contracted Care Management Expense Reported on Table D-2

00619 00620 00621 00622 00623 00624

CASSENA CARE IPA LLC 0001 $382,859

EDISON HOME HEALTH CARE 0002 $42,951

FAMILY HOME HEALTH CARE INC 0004 $1,971

GREATER NEW YORK HOME HEALTH CARE LLC 0005 $72,103

SPLIT ROCK REHABILITATION & HEALTH CARE CENTER LLC 0006 $305,274

0007

0008

0009

0010

0011

0012

0013

0014

0015

0016

0017

0018

0019

0020

0021

0022

0023

0024

TOTAL CONTRACTED CARE MANAGEMENT 0025 $805,158


Page 11

Schedule D-3 - Administration Expense - Total Total Direct Expense Total Contracted Expense Total Administration Expense

00710 71017 00713 00716 00719

Rent ($0 for Occupancy of Own Building) 0001 $44,718 $293,862 $338,580

Salaries and Fringe Benefits (Schedule D-3B) 0002 $2,072,248 $265,969 $2,338,217

Legal Fees amd Expenses 0003 $13,230 $13,230

Utilization Management/Quality Improvement 0004 $29,785 $29,785

Traveling Expense 0005 $6,765 $6,765

Advertising 0006

Marketing 0026 $57,792 $57,792

Finance, Auditing & Actuarial 0007 $11,564 $37,190 $48,754

Claims Processing 0008 $15,295 $707,688 $722,983

Provider Relations, Recruitment & Contracting 0009

Member Services 0010 $184,580 $184,580

Management Information System(MIS) 0011 $177,949 $155,902 $333,851

Telephone, Postage, Express & Telegraph 0012 $169,324 $169,324

Printing & Stationary 0013 $17,653 $17,653

Occupancy, Depreciation & Amortization 0014 $88,019 $16,325 $104,344

Rental of Equipment 0015 $6,761 $6,761

Boards, Bureaus and Association Fees 0016 $17,190 $17,190

Insurance, Except for Real Estate 0017 $9,837 $9,837

Collection and Bank Service Charge 0018

Payroll Taxes 0019 $179,951 $179,951

Other Taxes (Excluding Fed. Inc. Tax & RE Tax) 0020

Intake and Enrollment 0022

Employee Recruitment and Retention 0024 $130,030 $130,030

Franchise Tax 0045

Aggregate Write-in for Other Expenses 0099 $2,554,785 $2,554,785

(Double click on lines 51 - 59 Below)

Total Allowable Administration Expense 0030 $5,602,896 $1,661,516 $7,264,412

Nonallowable Administration

Contributions and Donations 0032

Lobbying Expenses 0033

Entertainment costs 0034

Interest, Fines and Penalties 0035

Uncollectible Spenddown and NAMI 0060 $918,353 $918,353

State Income Taxes 0061

Other Nonallowable expenses 0036 $20,085 $20,085

Total Nonallowable expenses 0037 $938,438 $938,438

Total Administration Expense 0100 $6,541,334 $1,661,516 $8,202,850

CHCS Administrative Fees 0051 $2,437,776 $2,437,776

Other Administrative Expenses 0052 $117,009 $117,009

0053

0054

0055

0056

0057

0058

0059

Summary of Items on the Note Pad 0097

Total of Items 0051-0097 (Line 0099 Above) 0098 $2,554,785 $2,554,785

Statewide Member Months 0096 $21,705

Note: Report all contracts, such as management contracts, legal services, claims processing, financial services,|

actuarial, etc., for services that are reported as administrative expenses by the plan.|

(1) Under Type of Affiliation, enter the number code of all that apply.|

1. None|

2. Common Ownership|

3. Common Board of Directors|

4. Part of same Holding Company System|

5. Share Key Personnel


Page 12

Schedule D-3A - Administrative Expense - Contracted Services Service Performed (1)Type of

Affiliation

MLTC Expense

00721 72118 00722 00723 00724

Name of Contractor (Double click Below)

BLUE CHIP BLDG MAINTENANCE INC 0001 Building Maintenance 1 $16,325

CHCS 0002 Rent 3 $293,862

MEDITURE, LLC 0003 Care Management Software 1 $155,902

SPS COMMUNITY SOLUTIONS 0004 Consulting 1 $189,770

TRISTATE BENEFIT SOLUTIONS 0005 Claims Processing 1 $707,688

GREENKEY 0006 Agency 1 $265,969

PKF O'CONNOR DAVIES 0007 Financial Statement Audit 1 $32,000

0008

0009

0010

0011

0012

0013

0014

0015

0016

0017

0018

0019

0020

Total (Should equal Schedule D-3, Column 00716, line 100) 0050 $1,661,516


Page 13

Schedule D-3B - Administrative Expense - Personnel Expense MLTCFTEs

MLTCSalaries and

Fringe Benefits

MLTCFTEs

MLTCSalaries and

Fringe Benefits

MLTCFTEs

MLTCSalaries and

Fringe Benefits

00750 75019 00751 00752 00753 00754 00755 00756

Administrative Category

Executive Management 0001 1.00 $181,085 1.00 $181,085

Administrative Support 0075 4.67 $234,411 0.18 $18,059 4.85 $252,470

Employee Recruitment and Retention 0002

Medical Director 0003 0.13 0.11 $81,022 0.24 $81,022

Legal Services 0004

Utilization Management/Quality Improvement 0005 11.80 $519,957 $47,449 11.80 $567,406

Advertising 0006

Marketing 0016 4.00 $168,968 4.00 $168,968

Finance, Auditing and Actuarial 0007 0.95 $34,402 $1 0.95 $34,403

Claims Processing 0008 1.00 $38,017 0.16 $16,400 1.16 $54,417

Provider Relations, Cre. & Contr. 0009 3.74 $138,470 3.74 $138,470

Member Services 0010 10.92 $408,039 10.92 $408,039

Management Information Sys. 0011 $1 $1

Intake and Enrollment 0012 5.20 $249,529 1.03 $103,039 6.23 $352,568

Aggregate Write-in for Other Admin. 0049 1.56 $99,370 ($2) 1.56 $99,368

Totals 0050 44.97 $2,072,248 1.48 $265,969 46.45 $2,338,217

Detail; Aggregate Write-in (Double click Below)

Corporate Compliance 0025 1.56 $99,370 1.56 $99,370

Finance/Management Info Systems (Net Zero) 0026 ($2) ($2)

0027

0028

0029

Summary of Write-ins From Notepad 0030

Totals (Lines 0025-0030) To Line 49 0048 1.56 $99,370 ($2) 1.56 $99,368


Page 14

Schedule D-6Claims Analysis

A.Total

Expenses(B+C+D)

B.Claims

Paid

C.Claims

Reported ButNot Paid

D.Claims

IncurredBut Not

Reported(IBNR)

E.IBNR as a Percent of

Total(D/A)

02022 02021 01014 01011 01012 01013 01016

A. Claims Incurred During Current Period

Category of Service

Inpatient 0001

Nursing Home 0002 $25,969,986 $15,985,443 $9,984,543 38.45%

Physician(s) 0003

Emergency Room 0005

Home Health Care 0013 $744,377 $587,870 $0 $156,507 21.03%

Personal Care 0014 $50,354,620 $35,794,133 $0 $14,560,487 28.92%

CDPAP 0120 $8,396,199 $6,014,551 $0 $2,381,647 28.37%

Other Medical Services 0007 $4,513,201 $3,818,104 $0 $695,097 15.40%

TOTAL 0025 $89,978,383 $62,200,101 $0 $27,778,282 30.87%

Total Expenses - Capitated 0051 $3,472,119

Total Expenses - Paid FFS 0052 $86,506,264 32.11%

Number of Claims Processed 0053 137,982


Page 15

Schedule D-6Claims Analysis (continued)1

A.On ClaimsIncurredDuring

Prior Years

B.On ClaimsIncurredDuring

Current Year

C.On ClaimsIncurredDuring

Prior Years

D.On ClaimsIncurredDuring

Current Year

E.Total

UnpaidClaims

(A+B+C+D)

22121 22123 01011 01012 01013 01014 01015

B. Claims Unpaid

Category of Service

Inpatient 0026

Nursing Home 0027 $99,898 $9,984,543 $10,084,441

Physician(s) 0028

Emergency Room 0030

Home Health Care 0038 $0 $2,937 $156,507 $159,444

Personal Care 0039 $0 $316,995 $14,560,487 $14,877,482

CDPAP 0125 $0 $51,746 $2,381,647 $2,433,393

Other Medical Services 0032 $0 $26,951 $695,097 $722,048

TOTAL 0050 $0 $498,527 $27,778,282 $28,276,809


Page 16

Schedule D-6Claims Analysis (continued)2

A.IBNR On Claims Incurred

4 Years Prior to theReporting Period

B.IBNR On Claims Incurred


C.IBNR on Claims Incurred


D.IBNR on Claims Incurred

1 Year Prior to theReporting Period

E.Total Prior Period IBNR

(A+B+C+D)

00241 24125 01025 01021 01022 01023 01024

C. Summary of Prior Period IBNR

Category of Service

Inpatient 0026

Nursing Home 0027 99,898 99,898

Physician(s) 0028

Emergency Room 0030

Home Health Care 0038 2,937 2,937

Personal Care 0039 316,995 316,995

CDPAP 0130 51,746 51,746

Other Medical Services 0032 26,951 26,951

TOTAL 0050 498,527 498,527


Page 17

Schedule D-6 - Claims Analysis(continued)3

Current Period Year 1 Prior to theReporting Period

Year 2 Prior to theReporting Period

07481 07491 01017 01018 01019

D. Global Capitation Reconciliation(Total Plan)

Member Months 0009

Premium Revenue 0010

Total Global Capitation Paid 0001

Additional Plan Payments 0006

Total Global Capitation Payments 0007

Actual Claims Paid 0002

Claims Reported but Not Paid 0003

Claims Incurred but Not Reported 0004

Total Global Capitation Expenses 0008

IPA/Providers' Surplus or (Loss) 0005


Page 18

Schedule D-7Premium Receivables

Total Dollars inthe Category

Up to 30 Days 30 Days to 59Days

60 Days to 89Days

90 Days to 119 120 Days to 365Days

Over One Year

01050 105026 01051 01052 01053 01054 01055 01056 01057

Premium Receivables Categories

Medicaid 0001 1,965,956 1,254,834 225,871 102,449 95,547 287,255

Medicare 0002

Private Pay 0003 226,046 12,210 21,235 17,660 4,675 25,812 144,454

Spenddown/NAMI 0004 7,036,802 707,056 636,873 343,440 214,378 1,457,976 3,677,079

Allowance for Doubtful Accounts (Entered as Negative) 0005 -5,818,820 -226,244 -1,771,043 -3,821,533

Other - (Double click Below)

0006

0007

0008

0009

Total By Aging Category 0010 3,409,984 1,974,100 883,979 463,549 88,356 0 0


Page 19

Schedule FIBNR

Reserve Calculation

AClaims Reported

(Paid and Unpaid)

BPercent

Complete

CEstimatedExpense

(A/B)

DAdjustment

EProjected Expense

(C + D)

FIBNR Reserve

(E-A)

00271 27128 01101 01102 01103 01104 01105 01106

Description

December 0001

November 0002

October 0003

September 0004

August 0005

July 0006

June 0007 $3,239,181 20.41665% 15,865,395 0 $15,865,395 $12,626,213

May 0008 $8,058,084 48.18701% 16,722,524 0 $16,722,524 $8,664,440

April 0009 $10,833,672 72.54845% 14,933,017 0 $14,933,017 $4,099,345

March 0010 $13,994,111 93.75332% 14,926,523 0 $14,926,523 $932,412

February 0011 $12,541,142 94.94318% 13,209,103 0 $13,209,103 $667,961

January 0012 $13,533,910 94.49852% 14,321,822 0 $14,321,822 $787,911

CURRENT YEAR TOTAL 0020 $62,200,101 89,978,383 0 $89,978,383 $27,778,282

PERCENT COMPLETED Yes=1,No=2

Historical Experience 0021 1

Authorized Claims 0022 2

Other (Explain on Notepad) 0023 2


Page 20

Schedule GSchedule of

Net Investment Income

Amount Accrued During the Year

00291 29130 01201

INVESTMENT INCOME

Interest Income 0001 $16,123

Dividend and Real Estate Income 0002

Net Realized Capital Gains or Losses 0003 $44,902

Other Investment Income 0004 $41,400

TOTAL INVESTMENT INCOME 0010 $102,425

DEDUCTIONS

Investment Expenses 0011 $7,792

Interest Expense 0012

Interest on Claims Paid after 45 Days 0014

Other Deductions 0013

TOTAL DEDUCTIONS 0020 $7,792

NET INVESTMENT INCOME 0025 $94,633


Page 21

Schedule G-1Schedule of Adjustments for Prior Period IBNR

Amount of Write-off

03111 311132 01202

Details of Adj for Prior Period IBNR on line 94 cc 112

1 Year Prior to the Reporting Period 0001 ($35,053)

2 Years Prior to the Reporting Period 0002



TOTAL ADJUSTMENTS FOR PRIOR PERIOD IBNR 0010 ($35,053)


Page 22

Schedule G-2Total Plan Schedule of Aggregate Write-ins for Other Expenses

Amount of Write-off

01213 121333 01214

Details of Write-ins aggregated on line 0095 from Schedule B:

0001

0002

0003

0004

0005

Non-State Plan Services 0006

Increase in Reserves for A&H Contracts 0007

TOTAL PLAN SCHEDULE OF AGGREGATE WRITE-INS 0099


Page 23

Schedule G-3Total Plan Schedule of Prior Period Revenue Adjustments and Extraordinary Items

Amount of Write-off

01223 12234 01224

Details of Extraordinary Items on line 0096 from Schedule B:

Adjustment for Prior Period Revenue 0001

Adjustment for Prior Period HR & R Revenue 0002

0003

0004

0005

0006

0007

0008

0009

All Other 0010

TOTAL EXTRAORDINARY ITEMS 0099


Page 24

Schedule G-4Schedule of Recovered Provider Payments

For Services Provided in Prior Periods

Amount of Recovered Payments

00351 35136 01225

Details of Prior Period Provider Recoveries included in the Prior Period IBNR Schedule:

1 Year Prior to Reporting Period 0001

2 Years Prior to Reporting Period 0002



TOTAL RECOVERIES INCLUDED IN PRIOR PERIOD IBNR ADJUSTMENT 0099

Individually list all health care creditors of $5,000 or more or 10% of total claims payable (reported, excluding amounts withheld), whichever is larger.|

See additional directions in the report instructions.


Page 25

Schedule HClaims Payable

Aging Analysis of Unpaid Claims

1-30 Days 31-45 Days 46-90 Days 91 + Days Total

01600 160037 01604 01605 01606 01607 01603

Claims Payable (Reported) Detail Below 0001

0002

0003

0004

0005

0006

0007

0008

0009

0010

0011

0012

0013

0014

0015

0016

0017

0018

0019

0020

0021

0022

0023

0024

0025

Sum of Individually Listed Claims Payable 0026

Aggregate Accounts Not Individually Listed 0028

Totals 0029

(1) TYPE OF AFFILIATION (Enter number code for type of affiliation)|

1. Common Ownership|

2. Common Board of Directors|

3. Part of the Same Holding Company System|

4. Share Key Personnel


Page 26

Schedule I - Schedule of Plan's Transactions with AnyAffiliate

(1)Type ofAffiliatio

n

CapitalContributions

Purchases, Sales, orExchanges of Loans,

Securities, Real Estate,Mortgage Loans orOther Investments

Income/(Disbursements) Incurred in

Connection withGuarantees or

Undertakings for theBenefit of any

Affiliate(s)

ManagementAgreements andAdministrative

Service Contracts

MedicalServices

Any Other MaterialActivity Not in the

Ordinary Course ofthe Insurer's

Business

TOTALS

01401 140138 01402 01403 01404 01405 01406 01407 01408 01409

Names of Insurers and Parent, Subsidiaries or Affiliates

(Double click Below)

Catholic Health Care System 0001 1 ($2,437,776) ($697,695) ($3,135,471)

ArchCare Community Life (MLTC) 0002 1 $2,437,776 $697,695 $3,135,471

0003

0004

0005

0006

0007

0008

0009

0010

0011

0012

0013

0014

0015

0016

0017

0018

0019

0020

0021

0022

0023

0024

0025

0026

0027

0028

0029

0030

0031

0032

0033

TOTAL 0999 $0 $0 $0


Page 27

Schedule J - Schedule of Claims and Interest Penalties PaidDuring the Year

TotalClaim Count

TotalDollar Value

Number of CleanClaims Paid in Excess

of 45 Days

Dollar Value of CleanClaims Paid in Excess

of 45 Days

Number of CleanClaims in Excess of 45

Days For WhichInterest Was Paid

Interest Paid DuringYear

00391 39140 01501 01502 01503 01504 01505 01506

Account Description

Inpatient 0001

Nursing Facility 0002 3,276 $15,985,443 $12,850

Physicians 0003

Home Health Care 0006 904 $593,695 $1,070

Personal Care 0007 91,066 $41,942,503 $6,640

CDPAP 0004 14,865 $7,033,392 $1,084

Other Medical Services 0005 27,871 $3,818,104 $422

TOTAL 0025 137,982 $69,373,137 $22,066

a) Disenrollments should be entered as positive numbers. The program will automatically reduce the totals.


Page 28

Exhibit A1 - Analysis of Enrolled Population TotalEnrollees

(End of Prior Period)

Net Shifts AmongGroups

YTD

New EnrolleesYTD

DisenrollmentsYTD

Total Enrollment

03100 310041 03101 03105 03102 03103 03104

PREMIUM GROUP

Community 0003 2,829 -26 905 423 3,285

Nursing Home Permanent Placement 0004 449 26 114 78 511

Other Medicaid Enrollees: (Double click Below)

0010

0011

0012

0013

0014

Total Medicaid Members 0020 3,278 0 1,019 501 3,796

Non-Medicaid Enrollees 0021

TOTALS 0030 3,278 0 1,019 501 3,796


Page 29

Exhibit A2 - Analysis of Enrolled Population By County Community Nursing HomePermanent Placement

TOTAL MEDICAIDMEMBER MONTHS TO

DATE

NON-MEDICAIDENROLLEE MONTHS

TOTAL MEMBERMONTHS TO DATE

03200 03421 03201 03202 03206 03207 03208

MEMBER MONTHS BREAKDOWN BY COUNTY

Region/County

One/New York City 0001 2,546 337 2,883 2,883

One/Nassau 0002

One/Rockland 0003

One/Suffolk 0004

One/Westchester 0005 4,717 1,238 5,955 5,955

Two/Monroe 0006

Two/Onondaga 0007

Two/Orange 0008

Three/Erie 0009

Three/Herkimer 0010

Three/Oneida 0011

Three/Schenectady 0012

Other Enrollees: (Double click Below)

Four/Putnam County 0020 343 60 403 403

One/Bronx County 0021 3,938 684 4,622 4,622

One/Kings County 0022 3,871 130 4,001 4,001

One/Richmond County 0023 1,501 234 1,735 1,735

One/Queens County 0024 1,879 227 2,106 2,106

Total Member Months to Date 0030 18,795 2,910 21,705 21,705

PACE plans should only complete rows 2 and 13.


Page 30

Exhibit A3 - Hospital and Nursing Facility Utilization FirstQuarter

SecondQuarter

ThirdQuarter

FourthQuarter

TOTALY-T-D

04311 431144 03301 03302 03303 03304 03305

HOSPITAL AND NURSING FACILIITY DAYS

Hospital Days For Period 0001

Total Number of Enrollees Receiving Nursing Facility

Care During Quarter, Excl. Respite 0002

Total Number of Admissions to Nursing Facility during Quarter, excluding respite 0013

Breakdown of Nursing Facility Days, Excl. Respite:

Total Number of Days Covered 100% by Medicare 0003

Total Number of Days Covered by Medicare & MLTC Plan (Medicaid Co-Pay days) 0004 1,632 1,826 3,458

Total Number of Days Covered 100% by MLTC Plan 0005 31,002 34,699 65,701

Total Number of Days Covered by Other Payors 0006

Total Number of Nursing Facility Days of Care, Excl. Respite 0010 32,634 36,525 69,159

Total Number of Enrollees Receiving Nursing Facility

Care During Quarter For Respite 0011

Total Number of Nursing Facility Days for Respite 0012


Page 31

Exhibit A4 - Nursing Facility Discharges 0 - 30 31 - 60 61 - 90 91 - 180 181 - 365 366+ TOTAL

00451 45146 03401 03402 03403 03404 03405 03406 03407

FIRST QUARTER:

Death 0001

Other 0002

Total 0003

SECOND QUARTER:

Death 0004

Other: 0005

Total 0006

THIRD QUARTER:

Death 0007

Other 0008

Total 0009

FOURTH QUARTER:

Death 0010

Other 0011

Total 0012

TOTAL Y-T-D:

Death 0020

Other 0021

Total 0030


Page 32

Exhibit A5 - Personal Care Hours Year-to-Date Member Months Total Number of Hours

00471 47148 03501 03502

MEMBER BREAKDOWN BY USE

Category Based on Hours per Month

700+ hours per month 0001 140 102,030

480-699 hours per month 0002 123 73,253

320-479 hours per month 0003 1,488 558,237

240-319 hours per month 0004 1,016 273,313

160-239 hours per month 0005 2,623 495,394

80-159 hours per month 0006 7,047 810,469

1-79 hours per month 0007 5,131 168,554

TOTALS 0010 17,568 2,481,250


Page 33

Exhibit A6 - Home Health Care and PCA Hours Year-to-Date Member Months Total Number of Hours

00491 49150 03503 03504



700+ hours per month 0001 140 102,030

480-699 hours per month 0002 123 73,253

320-479 hours per month 0003 1,488 558,237

240-319 hours per month 0004 1,016 273,313

160-239 hours per month 0005 2,623 495,394

80-159 hours per month 0006 7,047 810,469

1-79 hours per month 0007 5,131 170,653

TOTALS 0010 17,568 2,483,349


Page 34

Exhibit A7 - CDPAP Hours Year-to-Date Member Months Total Number of Hours

00492 49155 03505 03506



700+ hours per month 0001 16 11,695

480-699 hours per month 0002 13 7,382

320-479 hours per month 0003 160 59,630

240-319 hours per month 0004 199 52,890

160-239 hours per month 0005 581 112,254

80-159 hours per month 0006 1,243 147,304

1-79 hours per month 0007 462 18,601

TOTALS 0010 2,674 409,756


Page 35

Exhibit B - Utilization of Services: Total Medicaid ServiceUnits

Total Number OfService Units

(Actual)

Total Number ofService Units

(Accrued)

Unit Cost Avg. Number Of ServiceUnits

Used Per Enrollee PerYear

04010 401051 04011 04012 04016 04017 04015

Inpatient Medical/Surgical 0001 Days

Inpatient Medical/Surgical 0051 Discharges

Inpatient Mental Health/Substance Abuse 0002 Days

Inpatient Mental Health/Substance Abuse 0052 Discharges

Inpatient: Maternity Delivery 0047 Days

Inpatient: Maternity Delivery 0048 Discharges

Primary Care Physician 0004 Visits

Specialty Care 0033 Visits

Prenatal/Postpartum Maternity Services 0049 Visits

Ambulatory Surgery 0005 Procedures

Outpatient/Physical Rehab/Therapy 0050 Visits 121 308 $43.76 0.17

Other Professional Services 0053 Visits 45 146 $247.22 0.08

Emergency Room 0006 Visits

Outpatient Mental Health 0007 Visits

Outpatient Drug & Alcohol Treatment 0008 Visits

Dental 0009 Visits 4,053 4,053 $60.00 2.24

Pharmacy - Part D 0054

Pharmacy - Non Part D 0055

Home Health Care 0056 Hours 1,487 2,099 $354.63 1.16

Home Health Care 0083 Visits 523 1,134 $656.42 0.63

Nursing Facility 0003 Days 40,368 69,159 $375.51 38.24

Transportation - Emergent 0057 One Way Trips

Transportation - Non Emergent 0058 One Way Trips 69,001 70,637 $30.50 39.05


Family Planning 0059 Visits

Vision Care Inc. Eyeglasses 0017 Visits 49 113 $110.89 0.06

Foot Care 0018 Visits 257 563 $30.89 0.31

Durable Medical Equipment & Other 0028

Personal Care 0025 Hours 1,726,197 2,481,250 $20.29 1,371.80

CDPAP 0045 Hours 285,062 409,756 $20.49 226.54

Personal Emergency Response Services 0030 No. Of Units 4,836 6,326 $24.74 3.50

Home Delivered and Congregate Meals 0032 No. Of Meals 5,035 6,378 $7.01 3.53

Adult Day Care 0012 Days 9,229 12,321 $62.18 6.81

Social Day Care 0013 Days 509 1,357 $130.16 0.75

Other Medical Services:

(Double click below)

0035 0.00

0036 0.00

0037 0.00

0038 0.00

0039 0.00


Page 36

Exhibit B-1 - Medicaid Utilization of Services Community ServiceUnits


(Actual)


(Accrued)

Unit Cost Avg. Number OfService Units

Used Per EnrolleePer Year

04010 401052 04011 04012 04016 04017 04015











Outpatient/Physical Rehab/Therapy 0150 Visits 121 308 $43.76 0.20





Dental 0109 Visits 4,053 4,053 $60.00 2.59



Home Health Care 0156 Hours 1,487 2,099 $354.63 1.34

Home Health Care 0183 Visits 523 1,134 $656.42 0.72







Foot Care 0118 Visits 194 454 $32.47 0.29

Durable Medical Equipment & Other 0128

Personal Care 0125 Hours 1,723,994 2,478,083 $20.29 1,582.18

CDPAP 0145 Hours 284,994 409,657 $20.49 261.55

Personal Emergency Response Services 0130 No. Of Units 4,828 6,316 $24.74 4.03

Home Delivered and Congregate Meals 0132 No. Of Meals 5,017 6,355 $7.00 4.06

Adult Day Care 0112 Days 9,223 12,313 $62.17 7.86

Social Day Care 0113 Days 501 1,339 $130.37 0.85


(Enter labels on Exhibit B)

0135 0.00

0136 0.00

0137 0.00

0138 0.00

0139 0.00


Page 37

Exhibit B-1 - Medicaid Utilization of Services Nursing Home Permanent Placement ServiceUnits


(Actual)


(Accrued)

Unit Cost Avg. Number OfService Units

Used Per EnrolleePer Year

04019 401953 04020 04021 04022 04023 04024











Outpatient/Physical Rehab/Therapy 0150 Visits 0.00





Dental 0109 Visits 0.00



Home Health Care 0156 Hours 0.00

Home Health Care 0183 Visits 0.00







Foot Care 0118 Visits 63 109 $24.32 0.45

Durable Medical Equipment & Other 0128 0.16

Personal Care 0125 Hours 2,203 3,167 $23.79 13.06

CDPAP 0145 Hours 69 99 $24.02 0.41

Personal Emergency Response Services 0130 No. Of Units 8 10 $25.50 0.04

Home Delivered and Congregate Meals 0132 No. Of Meals 18 23 $7.43 0.09

Adult Day Care 0112 Days 6 8 $74.25 0.03

Social Day Care 0113 Days 8 18 $114.11 0.07


(Enter labels on Exhibit B)

0135 0.00

0136 0.00

0137 0.00

0138 0.00

0139 0.00


Page 38

Exhibit B-2 - Medicaid Utilization of HHC Services Community ServiceUnits

Medicaid TotalNumber of

Service Units(Actual)


Service Units(Accrued)

Medicaid TotalCost

Medicaid UnitCost

Medicaid Avg.Number of

Service UnitsUsed Per Enrollee

Per Year

04010 401056 04011 04012 04016 04018 04017 04015

Home Health Care Aide 0500 Hours 1,487 2,099 $78,343 $37.32 1.34

Home Health Care-Other 0501 Visits 523 1,133 $666,034 $587.85 0.72

Total Home Health Care 0502 $744,377


Page 39

Exhibit B-2 - Medicaid Utilization of HHC Services Nursing Home Permanent Placement ServiceUnits





Medicaid TotalCost

Medicaid UnitCost

Medicaid Avg.Number of

Service UnitsUsed Per

Enrollee PerYear

04031 403157 04032 04033 04034 04035 04036 04037

Home Health Care Aide 0500 Hours 0.00

Home Health Care-Other 0501 Visits 0.00

Total Home Health Care 0502


Page 40

Exhibit B-2 - Utilization of HHC Services - Total Medicaid ServiceUnits





Medicaid Total Cost Medicaid Unit Cost Medicaid Avg.Number of Service

UnitsUsed Per Enrollee

Per Year

04010 401060 04011 04012 04016 04018 04017 04015

Home Health Care Aide 0400 Hours 1,487 2,099 $78,343 $37.32 1.2

Home Health Care-Other 0401 Visits 523 1,133 $666,034 $587.85 0.6

Total Home Health Care 0402 $744,377


Page 41

Exhibit C - Number of Enrollees Utilizing Services Number of Enrollees

06101 610162 05000

Identify the number of enrollees during the quarter that used the following services:

NURSING FACILITY (NF) ONLY

Enrollees that were in a nursing facility for the entire quarter 0001 483

PACE CENTER SOCIAL DAY CARE PROGRAM

Count only enrollees who used the PACE Social Day Care Program

but did not use personal care, home health care or NF. 0002

Count only enrollees who used the PACE Social Day Care Program

and personal care and/or home health care. 0003

Total PACE Center Care Program 0012

PERSONAL CARE (PC) ONLY

Count only enrollees who used personal care but did not use NF,

PACE Social Day, or Home Health Care. 0004 2,894

CDPAP ONLY

Count only enrollees who used only CDPAP

CDPAP 0015 90

HOME HEALTH CARE (HHC) ONLY

Count only enrollees who used home health care service but did not use NF,

PACE Social Day Care, or PC.

Nursing and Therapies only 0007

HHA and Nursing and/or Therapies 0008 17

Total Home Health Care 0009 17

PERSONAL CARE AND HOME HEALTH CARE ONLY

Count only enrollees that used PC and HHC but did not use NF or PACE Social Day. 0010 247

NURSING FACILITY AND PERSONAL CARE OR HOME HEALTH CARE

Count enrollees who were in a NF AND used personal care or Home Health

Personal care 0013 65

Number of enrollees who did not use PACE Social Day, Personal Care,

Home Health Care, or any Nursing Facility 0011

Total Number of Enrollees 0014 3,796

Documents

Organization : Archcare Community Life(Catholic MLTC ......Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757 Period Ending : 6/30/2018 Created : Tuesday, October