T4

Reporting Period: January 1, 2014 through December 31, 2014

TABLE 4 – SELECTED PATIENT CHARACTERISTICS

Characteristic							Number Of Patients ( a )
Income As Percent of Poverty Level
1.		100% and below
2.		101 – 150%
3.		151 – 200%
4.		Over 200%
5.		Unknown
6.		Total (Sum Lines 1 – 5)
Principal Third Party Medical Insurance Source					0-17 years old ( a )			18 and older ( b )
7.		None/ Uninsured
8a.		Regular Medicaid (Title XIX)
8b.		CHIP Medicaid
8.		Total Medicaid (Line 8a + 8b)
9.		Medicare (Title XVIII)
10a.		Other Public Insurance Non-CHIP (specify:)
10b.		Other Public Insurance CHIP
10.		Total Public Insurance (Line 10a + 10b)
11.		Private Insurance
12.		Total (Sum Lines 7 + 8 + 9 +10 +11)
Managed Care Utilization
Payor Category			Medicaid ( a )	Medicare ( b )		Other Public Including Non-Medicaid CHIP ( c )			Private ( d )	Total ( e )
13a.	Capitated Member months
13b.	Fee-for-service Member months
13c.	Total Member months ( 13a + 13b)
Characteristics – Special Populations							Number of Patients -- (a)
14.		Migratory (330g grantees only)
15.		Seasonal (330g grantees only)
16.		Total Agricultural Workers or Dependents (All Grantees Report This Line)
17.		Homeless Shelter (330h grantees only)
18.		Transitional (330h grantees only)
19.		Doubling Up (330h grantees only)
20.		Street (330h grantees only)
21.		Other (330h grantees only)
22.		Unknown (330h grantees only)
23.		Total Homeless (All Grantees Report This Line)
26.		Public Housing Patients (All Grantees Report This Line)
24.		Total School Based Health Center Patients (All Grantees Report This Line)
25.		Total Veterans (All grantees report this line)