City of Orange
Agreement: IGT-22-0011
Health Plan County Category of Aid SIS/UIS Contribution PMPM
Estimated
Member Months*
Estimated
Contribution (Non-
Federal Share)
CalOptima Orange Child SIS 0.03$ 3,500,200 105,006$ CalOptima Orange Child UIS 0.05$ 125,256 6,263$ CalOptima Orange Adult SIS 0.05$ 1,307,501 65,375$ CalOptima Orange Adult UIS 0.23$ 199,584 45,904$ CalOptima Orange ACA Optional Expansion SIS 0.02$ 3,542,724 70,854$ CalOptima Orange ACA Optional Expansion UIS 0.19$ 306,611 58,256$ CalOptima Orange SPD SIS 0.17$ 434,205 73,815$ CalOptima Orange SPD UIS 0.52$ 60,748 31,589$ CalOptima Orange SPD/Full-Dual SIS 0.05$ 74,620 3,731$ CalOptima Orange SPD/Full-Dual UIS 0.15$ 1,357 204$ CalOptima Orange LTC (non-dual) SIS 1.67$ 11,358 18,968$ CalOptima Orange LTC (non-dual) UIS 3.53$ 2,983 10,530$ CalOptima Orange LTC/Full-Dual SIS 0.93$ 33,418 31,079$ CalOptima Orange LTC/Full-Dual UIS 2.11$ 97 205$ CalOptima Orange Whole Child Model SIS 0.43$ 137,565 59,153$ CalOptima Orange Whole Child Model UIS 0.84$ 3,931 3,302$ CalOptima Orange Est. FE Total 9,742,158 584,234$ Total CY 2022 (January 2022 - December 2022) Section 1 Amount 584,234$ CY 2022 January 2022 - December 2022) Section 3 Amount under the Agreement:
Total CY 2022 (January 2022-December 2022) Section 1 Amount (above) 584,234$ Less amount not subject to fee (Section 3.2) -$
Basis for 20% Assessment Fee 584,234$
20% Assessment Fee (Basis * 20%) 116,847$
Total CY 2022 Amount (January 2022 - December 2022) as of 8/2024 Estimated Member Months 701,081$ Previous CY 2022 amount collected in February 2024 659,183$ Balance remaining from CY 2022 Invoicing February 2024: (+/-) 41,898$