City of Orange
Agreement: IGT-23-0012
Health Plan County Category of Aid SIS/UIS Contribution PMPM
Estimated
Member Months*
Estimated
Contribution (Non-
Federal Share)
CalOptima Orange Child SIS 0.04$ 3,471,771 138,871$ CalOptima Orange Child UIS 0.01$ 148,266 1,483$ CalOptima Orange Adult SIS 0.07$ 1,421,709 99,520$ CalOptima Orange Adult UIS 0.04$ 267,086 10,683$ CalOptima Orange ACA Optional Expansion SIS 0.01$ 3,771,614 37,716$ CalOptima Orange ACA Optional Expansion UIS 0.02$ 419,208 8,384$ CalOptima Orange SPD SIS 0.23$ 444,422 102,217$ CalOptima Orange SPD UIS 0.20$ 86,155 17,231$ CalOptima Orange SPD/Full-Dual SIS 0.08$ 1,302,239 104,179$ CalOptima Orange SPD/Full-Dual UIS 0.04$ 6,500 260$ CalOptima Orange LTC SIS 0.24$ 2,577 618$ CalOptima Orange LTC UIS 0.20$ 1,550 310$ CalOptima Orange LTC/Full-Dual SIS 0.08$ 31,835 2,547$ CalOptima Orange LTC/Full-Dual UIS 0.04$ 127 5$ CalOptima Orange Whole Child Model SIS 0.41$ 134,022 54,949$ CalOptima Orange Whole Child Model UIS 0.14$ 4,182 585$ CalOptima Orange Est. FE Total 11,513,263 579,558$ Total CY 2023 (January 2023 - December 2023) Section 1 Amount 579,558$ CY 2023 Section 3 Amount under the Agreement:
Total CY 2023 Section 1 Amount (above) 579,558$
Less amount not subject to fee (Section 3.2) -$
Basis for 20% Assessment Fee 579,558$
20% Assessment Fee (Basis * 20%) 115,912$
Total CY 2023 Amount (as of 08/2024 estimated Member Months) 695,470$ Balance remaining from CY 2022 (see 2022 invoice for details) 41,898$ DHCS Correction (Credit) from FY 18-19 (not applicable if blank) (54)$ Total Payment Transfer Amount 737,314$