Tennessee Nursing Facility Case Mix Rate Setting Training May 21, - - PDF document
Tennessee Nursing Facility Case Mix Rate Setting Training May 21, 2018 Presented by: Daniel Brendel Kevin Londeen, CPA CONTACT INFORMATION Myers and Stauffer 700 W. 47 th Street, Suite 1100 Kansas City, MO 64112 PH: (800) 374-6858 Email:
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Tennessee Nursing Facility Case Mix Rate Setting Training May 21, 2018
Presented by: Daniel Brendel Kevin Londeen, CPA 2
CONTACT INFORMATION
Myers and Stauffer 700 W. 47th Street, Suite 1100 Kansas City, MO 64112 PH: (800) 374-6858 Email: TNCaseMix@mslc.com Website: www.mslc.com/Tennessee
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DOWNLOAD INFORMATION
Visit the Myers and Stauffer Tennessee Website www.mslc.com/Tennessee to download the following information:
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AGENDA
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Case Mix System Overview Cost Report Use in Rate Setting Rate Setting Cost Component Calculation Overview Direct Care Cost Component Administrative & Operating Cost Component Capital (FRV) Component Cost-Based Component Quality Component
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AGENDA
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Adjustments to the Rate Budget Adjustment Factor (BAF) Phase-In Adjustment Questions & Answers
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Case Mix System Overview
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CASE MIX SYSTEM OVERVIEW What is Case Mix?
population
utilizes patient case mix index (CMI) or acuity during the rate setting process
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CASE MIX SYSTEM OVERVIEW Why Case Mix?
needs and requirements of residents
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CASE MIX SYSTEM OVERVIEW
Tennessee Case Mix System
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CASE MIX SYSTEM OVERVIEW
Tennessee Case Mix System
factors:
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CASE MIX OVERVIEW Tennessee Case Mix System
resident acuity in a nursing facility based on the applicable resource utilization group weights (RUG)
Resident Classification System is used to classify residents
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CASE MIX OVERVIEW Tennessee Case Mix System
weighted by the number of days in the period that the MDS assessment was considered active
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Rehabilitation Plus Extensive Rehabilitation Extensive Services Special Care High Special Care Low Clinically Complex Behavioral Symptoms & Cognitive Performance Reduced Physical Function Extensive Services Rehabilitation Special Care High Special Care Low Clinically Complex Behavioral Symptoms & Cognitive Performance Reduced Physical Function
RUG-IV 66-Group RUG-IV 48-Group
MEDICAID GROUPER MEDICARE GROUPER
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CASE MIX OVERVIEW Tennessee Case Mix System
RUG-IV 48 Grouper
RUG with the greatest CMI is utilized
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CASE MIX OVERVIEW Tennessee Case Mix System
utilized to more accurately capture RUG classification
Portal
provided to facilities
and amend MDS records prior to rate setting use
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CASE MIX OVERVIEW Tennessee Case Mix System
calculation, the following are available on the Myers and Stauffer website (www.mslc.com/Tennessee)
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CASE MIX OVERVIEW Tennessee Case Mix System
Other System Changes:
Cost Report Use in Rate Setting
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COST REPORT USE IN RATE SETTING Two separate cost reporting forms will be used for Medicaid rate setting purposes:
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COST REPORT USE IN RATE SETTING
allowable cost
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COST REPORT USE IN RATE SETTING MediCARE Cost Reporting Form
revenue producing and non-reimbursable cost centers
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COST REPORT USE IN RATE SETTING MediCAID Supplemental Cost Reporting Form
calculation for FRV rate
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COST REPORT USE IN RATE SETTING MediCAID Supplemental Cost Reporting Form
Medicare CR cost center (Wkrsht A, Col 7 amounts), in order to be treated separately for Medicaid rate setting classification purposes
subscripted cost center line for each cost item listed for cost component tracking purposes
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COST REPORT USE IN RATE SETTING MediCAID Supplemental Cost Reporting Form
comply with Medicaid allowable cost guidance
covered services, provider assessment expense, bad debt, etc.
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COST REPORT USE IN RATE SETTING
Rate Setting Mechanics
setting
SNF/NF cost center expense will be designated as Administrative and Operating cost component expense
Medicaid rate setting
reimbursable cost centers (lines 60.00 – 99.99) are excluded from Medicaid rate
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COST REPORT USE IN RATE SETTING
Description Medicare
Exp. Medicare
Exp. Medicaid CR Salary Reclasses (Sch. C) Medicaid CR Other Reclasses (Sch. C) Medicaid CR Salary Adjust. (Sch. D) Medicaid CR Other Adjust. (Sch. D) Total
9.00 Nursing Administration 747,130 141,615 (732,776) (1,000) (2,000) (25,000) 127,969 9.00 Reconcile DON
1,000
9.00 Reconcile RN
9.00 Reconcile MDS Coord.
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COST REPORT USE IN RATE SETTING Rate Setting Mechanics
included in a cost component other than Administrative and Operating or Excluded
setting purposes
into the MediCARE CR
MediCARE cost-finding apportionment process
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COST REPORT USE IN RATE SETTING Rate Setting Mechanics
Medicaid rate setting purposes:
included in the same cost component as the original expense.
reimbursable cost centers (lines 60.00-99.99) will be excluded
based on percentage of salary expense
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COST REPORT USE IN RATE SETTING Rate Setting Mechanics
the M&S Tennessee website (www.mslc.com/Tennesee)
document that details how expenses are allocated to cost components.
finding apportionment process has been completed.
Rate Setting Cost Component Calculations
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MEDICAID REIMBURSEMENT RATE
Each NF provider’s Medicaid reimbursement rate is determined as the sum of the following:
Case Mix Adjusted Component, and the Direct Care Spending Floor Adjustment
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MEDICAID REIMBURSEMENT RATE
July 1, 2018
making process
most recently audited or desk reviewed CRs that are:
reimbursement rates
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MEDICAID REIMBURSEMENT RATE
Ongoing Case Mix Rate Setting
Base-year annualized Medicaid resident-day weighted median cost and prices shall be rebased at an interval no longer than 3 years after a new base year period is established
cost reports containing substantial issues during the desk review process will be excluded from component median and price calculations
rate setting will be considered in the component median and price calculations
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MEDICAID REIMBURSEMENT RATE
Ongoing Case Mix Rate Setting
components, from midpoint of previous rate year to midpoint of prospective rate year:
medians
day-weighted median; and
Capital inflationary index published by IHS Global Insights.
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MEDICAID REIMBURSEMENT RATE
Quality Informed Components:
A goal of the case mix system is to help drive quality of care and life for NF residents. As such, a majority of cost components in the case mix system are quality informed.
in to the calculation:
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MEDICAID REIMBURSEMENT RATE
Quality Informed Components:
As part of the quality incentive factor process, QuILTSS scoring is used to establish quality tiers. These quality tiers in turn drive some of the incentive payments:
classify a provider in a quality tier:
Quality Tier Cut Point Range Quality Tier 1 75 ‐ 110 Quality Tier 2 50 ‐ 74.99 Quality Tier 3 0 ‐ 49.99
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DIRECT CARE
The NF provider’s direct care portion of the reimbursement rate is calculated as the sum of the following:
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DIRECT CARE CASE MIX ADJUSTED
Price Calculation (Prior to Spending Floor Reduction) Statewide Price Per Provider Times Direct Care Non CMI Median Cost Quality Incentive Factor Times the Facility Medicaid Average Case Mix Index Facility Specific Total Direct Care Rate (Prior to Floor Adj.) Spending Floor Requirement Calculation: Spending Floor Percentage of Total Direct Care Rate Floor Spending Requirement Spending Floor Adjustment Calculation: Base Year Per Diem Cost - C/R Period Ending 12/31/2015 Divided by the Facility Cost Report Period Case Mix Index Facility Neutralized Direct Care CMI and Direct Care Non CMI Cost Times the Facility Medicaid Average Case Mix Index Medicaid CMI Adjusted Inflated/Neutralized Direct Care Cost Spending Floor Adjustment Facility Specific Rate (After Spending Floor Adjustment): Facility Specific Total Direct Care Per Diem Rate [$86.80 + ($0.00)] DIRECT CARE CASE MIX ADJ DIRECT CARE NON CASE MIX ADJ TOTAL $67.56 $18.79 $86.35 N/A 105.00% 0.9928 N/A $67.07 $19.73 $86.80 82.50% $71.61 $92.18 $40.17 1.0784 N/A $85.48 $40.17 0.9928 N/A $84.86 $40.17 $125.03 $0.00 $86.80
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DIRECT CARE CASE MIX ADJUSTED
DC CMI Cost Component Expenses:
(MediCAID CR)
payroll taxes (MediCARE CR)
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DIRECT CARE CASE MIX ADJUSTED
DC CMI Cost Component Expenses:
MediCAID CR schedule C to be included
cost apportionment methods
(SNF/NF) cost centers, as designated by TennCare, will be excluded from cost component totals
ADON, MDS coordinator, QA coordinator, Inservice/Training coordinator, etc.) are specifically excluded from this rate component
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DIRECT CARE CASE MIX ADJUSTED
Determination of DC CMI Facility Specific Medicaid Rate:
STEP # 1
The provider’s DC CMI base year cost is inflated by the SNF Market Basket without Capital Index factor
base year cost reporting period to the midpoint of the rate year
DC CMI Base Year Cost (1/1/2015 to 12/31/2015 Cost Report) 1,196,672 $ Inflation Factor to 12/31/2017 1.071908 Inflated Cost 1,282,722 $ 42
DIRECT CARE CASE MIX ADJUSTED
Determination of DC CMI Facility Specific Medicaid Rate:
STEP # 2
Inflated cost is divided by total base year resident days to calculate the direct care per diem
DC CMI Inflated Cost 1,282,722 $ Total Base Year Cost Report Resident Days 13,916 Inflated Per Diem Cost 92.18 $
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DIRECT CARE CASE MIX ADJUSTED
Determination of DC CMI Facility Specific Medicaid Rate:
STEP # 3
The nursing facility cost report period CMI is calculated as the average of the semi-annual facility-wide CMIs that most closely coincide with the facility’s cost reporting period used in the rebase
(A) (B) (A)*(B) Portion of Cost Report Year Applicable CMI Period Days CMI Average CMI 1/1/15 ‐ 3/31/15 10/1/14 ‐ 3/31/15 90/365 1.0890 0.2685 4/1/15 ‐ 9/30/15 4/1/15 ‐ 9/30/15 183/365 1.0827 0.5428 10/1/15 ‐ 12/31/15 10/1/15 ‐ 3/31/16 92/365 1.0784 0.2718 1.0832 44
DIRECT CARE CASE MIX ADJUSTED
Determination of DC CMI Facility Specific Medicaid Rate:
STEP # 3 (cont’d)
For the initial July 1, 2018 rate period, the quarterly CMI period for assessments ending 12/31/2015 will be utilized as the nursing facility cost report period CMI
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DIRECT CARE CASE MIX ADJUSTED
Determination of DC CMI Facility Specific Medicaid Rate:
STEP # 4
The provider’s inflated direct care case mix adjusted cost per diem is divided by the provider’s cost report period case mix index resulting in a neutralized direct care cost per diem.
DC CMI Inflated Per Diem Cost 92.18 $ Cost Report Period Case Mix Index 1.0784 Neutralized Direct Care Cost Per Diem 85.48 $ 46
DIRECT CARE CASE MIX ADJUSTED
Determination of DC CMI Facility Specific Medicaid Rate:
STEP # 5
The per diem neutralized inflated direct care case mix adjusted cost, for each participating NF, is arrayed from low to high and the annualized Medicaid resident-day-weighted median cost is determined.
STEP # 6
The statewide direct care CMI adjusted price is established at 106% of the direct care CMI adjusted annualized resident-day-weighted median cost.
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DIRECT CARE CASE MIX ADJUSTED
Name Inflated Per Diem Cost Annualized Medicaid Resident Days Cumulative Days (Running Total) Facility B 50.00 $ 15,000 15,000 Facility D 51.64 $ 16,246 31,246 Facility A 55.05 $ 25,000 56,246 Facility E 61.38 $ 19,000 75,246 Facility G 63.74 $ 22,613 97,859 Example Facility 85.48 $ 3,267 101,126 Facility F 101.93 $ 18,638 119,764 Facility H 109.00 $ 31,265 151,029 Days Used for Median (0.5 x 151,029) 75,515 Median Selected 63.74 $ Multiply by Price % (per rule) 106% Direct Care CMI Adjusted Statewide Price 67.56 $ 48
DIRECT CARE CASE MIX ADJUSTED
Determination of DC CMI Facility Specific Medicaid Rate:
STEP # 7
The statewide direct care CMI adjusted price is then multiplied by each NF’s own Medicaid facility-wide semi-annual average CMI for the rate period to establish the provider specific direct care CMI adjusted cost component.
(A) (B) (A)*(B) Facility Direct Care CMI Adjusted Statewide Medicaid Facility‐Wide Semi‐Annual Average Facility Specific Direct Care CMI Adjusted Facility A 67.56 $ 1.1065 74.76 $ Facility B 67.56 $ 0.9242 62.44 $ Example Facility 67.56 $ 0.9928 67.07 $ Facility C 67.56 $ 0.9626 65.03 $
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DIRECT CARE NON-CASE MIX ADJUSTED
Price Calculation (Prior to Spending Floor Reduction) Statewide Price Per Provider Times Direct Care Non CMI Median Cost Quality Incentive Factor Times the Facility Medicaid Average Case Mix Index Facility Specific Total Direct Care Rate (Prior to Floor Adj.) Spending Floor Requirement Calculation: Spending Floor Percentage of Total Direct Care Rate Floor Spending Requirement Spending Floor Adjustment Calculation: Base Year Per Diem Cost - C/R Period Ending 12/31/2015 Divided by the Facility Cost Report Period Case Mix Index Facility Neutralized Direct Care CMI and Direct Care Non CMI Cost Times the Facility Medicaid Average Case Mix Index Medicaid CMI Adjusted Inflated/Neutralized Direct Care Cost Spending Floor Adjustment Facility Specific Rate (After Spending Floor Adjustment): Facility Specific Total Direct Care Per Diem Rate [$86.80 + ($0.00)] DIRECT CARE CASE MIX ADJ DIRECT CARE NON CASE MIX ADJ TOTAL $67.56 $18.79 $86.35 N/A 105.00% 0.9928 N/A $67.07 $19.73 $86.80 82.50% $71.61 $92.18 $40.17 1.0784 N/A $85.48 $40.17 0.9928 N/A $84.86 $40.17 $125.03 $0.00 $86.80
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DIRECT CARE NON-CASE MIX ADJUSTED
DC NCMI Cost Component Expenses:
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DIRECT CARE NON-CASE MIX ADJUSTED
DC NCMI Cost Component Expenses:
(MediCAID CR)
payroll taxes (MediCARE CR)
feeding, such as elemental high nitrogen diet, even when prescribed by a physician as defined by CMS Publication # 15-1, section 2203.1
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DIRECT CARE NON-CASE MIX ADJUSTED
DC NCMI Cost Component Expenses:
MediCAID CR schedule C to be included
cost apportionment methods
(SNF/NF) cost centers, as designated by TennCare, will be excluded from cost component totals
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DIRECT CARE NON-CASE MIX ADJUSTED
Determination of DC NCMI Facility Specific Medicaid Rate:
STEP # 1
The provider’s DC NCMI base year cost is inflated by the SNF Market Basket without Capital Index factor
base year cost reporting period to the midpoint of the rate year
DC NCMI Base Year Cost (1/1/2015 to 12/31/2015 Cost Report) 521,478 $ Inflation Factor to 12/31/2017 1.071908 Inflated Cost 558,976 $ 54
DIRECT CARE NON-CASE MIX ADJUSTED
Determination of DC NCMI Facility Specific Medicaid Rate: STEP # 2
Inflated cost is divided by total base year resident days to calculate the direct care non-case mix per diem
DC NCMI Inflated Cost 558,976 $ Total Base Year Cost Report Resident Days 13,916 Inflated Per Diem Cost 40.17 $
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DIRECT CARE NON-CASE MIX ADJUSTED
Determination of DC NCMI Facility Specific Medicaid Rate:
STEP # 3
The per diem inflated direct care non-case mix adjusted cost, for each NF, is arrayed from low to high and the annualized Medicaid resident- day-weighted median cost is determined
STEP # 4
The statewide direct care non-case mix adjusted price is established at 106% of the direct care case mix adjusted annualized Medicaid resident- day-weighted median cost
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DIRECT CARE NON-CASE MIX ADJUSTED
Name Inflated Per Diem Cost Annualized Medicaid Resident Days Cumulative Days (Running Total) Facility B 8.70 $ 12,000 12,000 Facility D 10.28 $ 23,800 35,800 Facility A 13.96 $ 25,000 60,800 Facility E 17.73 $ 15,159 75,959 Facility G 25.28 $ 13,581 89,540 Facility F 25.28 $ 19,000 108,540 Facility H 29.38 $ 10,358 118,898 Example Facility 40.17 $ 3,267 122,165 Days Used for Median (0.5 x 122,165) 61,083 Median Selected 17.73 $ Multiply by Price % (per rule) 106% Direct Care Non‐Case Mix Adjusted Statewide Price 18.79 $
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DIRECT CARE NON-CASE MIX ADJUSTED
Determination of DC NCMI Facility Specific Medicaid Rate:
STEP # 5
The statewide direct care non-case mix adjusted price is then multiplied by each NF provider’s direct care non-case mix adjusted quality incentive multiplier to establish the provider’s direct care non-case mix adjusted cost component.
(A) (B) (A)*(B) Facility Direct Care Non‐CMI Adjusted Statewide Quality Tier Quality Incentive Multiplier Provider Specific Direct Care Non‐CMI Adjusted Facility A 18.79 $ 1 105.00% 19.73 $ Facility B 18.79 $ 2 102.50% 19.26 $ Example Facility 18.79 $ 1 105.00% 19.73 $ Facility C 18.79 $ 3 100.00% 18.79 $ 58
DIRECT CARE NON-CASE MIX ADJUSTED
Determination of DC NCMI Facility Specific Medicaid Rate:
STEP # 5 (cont.)
The quality incentive multiplier will be determined based on the quality tier that the provider qualifies for based on their QuILTSS score. The following is a table containing the applicable incentive multipliers: Quality Tier Price Multiplier Quality Tier 1 105.00% Quality Tier 2 102.50% Quality Tier 3 100.00%
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DIRECT CARE SPENDING FLOOR ADJUSTMENT
Price Calculation (Prior to Spending Floor Reduction) Statewide Price Per Provider Times Direct Care Non CMI Median Cost Quality Incentive Factor Times the Facility Medicaid Average Case Mix Index Facility Specific Total Direct Care Rate (Prior to Floor Adj.) Spending Floor Requirement Calculation: Spending Floor Percentage of Total Direct Care Rate Floor Spending Requirement Spending Floor Adjustment Calculation: Base Year Per Diem Cost - C/R Period Ending 12/31/2015 Divided by the Facility Cost Report Period Case Mix Index Facility Neutralized Direct Care CMI and Direct Care Non CMI Cost Times the Facility Medicaid Average Case Mix Index Medicaid CMI Adjusted Inflated/Neutralized Direct Care Cost Spending Floor Adjustment Facility Specific Rate (After Spending Floor Adjustment): Facility Specific Total Direct Care Per Diem Rate [$86.80 + ($0.00)] DIRECT CARE CASE MIX ADJ DIRECT CARE NON CASE MIX ADJ TOTAL $67.56 $18.79 $86.35 N/A 105.00% 0.9928 N/A $67.07 $19.73 $86.80 82.50% $71.61 $92.18 $40.17 1.0784 N/A $85.48 $40.17 0.9928 N/A $84.86 $40.17 $125.03 $0.00 $86.80
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DIRECT CARE SPENDING FLOOR ADJUSTMENT
DC Spending Floor Adjustment Calculation:
STEP # 1
The sum of the provider’s DC CMI and DC NCMI adjusted cost components are multiplied by the provider specific spending floor percentage to determine the DC spending floor threshold.
(A) (B) (C) = (A) + (B) (D) (E) = (C) * (D) Provider DC CMI Adjusted Rate DC NCMI Adjusted Rate Direct Care Rate Spending Floor Percentage Floor Spending Requirement Facility A 74.76 $ 19.73 $ 94.49 $ 87.50% 82.68 $ Facility B 62.44 $ 19.26 $ 81.70 $ 85.00% 69.45 $ Example Facility 67.07 $ 19.73 $ 86.80 $ 82.50% 71.61 $
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DIRECT CARE SPENDING FLOOR ADJUSTMENT
DC Spending Floor Adjustment Calculation:
STEP # 1 (cont.)
The value of the DC spending floor percentage will be phased-in over time to its final amount. The value of the DC spending floor will also be adjusted depending on the quality tier of the associated provider. The table below provides the applicable floor percentage values:
Effective Date of Quality Tier Floor Percentage Quality Tier 1 Quality Tier 2 Quality Tier 3 July 1, 2018 82.50% 85.00% 87.50% July 1, 2019 85.00% 87.50% 90.00% July 1, 2020 87.50% 90.00% 92.50% July 1, 2021 90.00% 92.00% 94.00% 62
DIRECT CARE SPENDING FLOOR ADJUSTMENT
DC Spending Floor Adjustment Calculation:
STEP # 2
The provider’s Medicaid nursing facility-wide semi-annual CMI is multiplied by the provider’s neutralized inflated DC CMI cost. This calculated cost is then added to the NF provider’s inflated DC NCMI per diem cost to create the Medicaid DC cost per diem.
(A) (B) (C) (A*B) + (C) Provider Medicaid Facility‐ Wide Semi‐Annual CMI Neutralized Inflated DC CMI Per Diem Cost Inflated DC NCMI Per Diem Cost Medicaid DC Cost Per Diem Example Facility 0.9928 85.48 $ 40.17 $ 125.03 $
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DIRECT CARE SPENDING FLOOR ADJUSTMENT
DC Spending Floor Adjustment Calculation:
STEP # 3
The provider’s calculated DC spending floor threshold is subtracted from the provider’s DC Medicaid cost per diem to determine the amount of the rate adjustment. Should the difference be negative, that same amount will be applied as the DC spending floor adjustment. If the difference is positive, no adjustment is applied.
Provider Medicaid DC Cost Per Diem Floor Spending Requirement Spending Floor Adjustment Example Facility 125.03 $ 71.61 $ ‐ $ Facility J 75.25 $ 77.95 $ (2.70) $ 64
DIRECT CARE SPENDING FLOOR ADJUSTMENT
DC Spending Floor Adjustment Calculation:
STEP # 4 [step to be eliminated with first system rebase]
On an annual basis, the most currently reviewed or audited provider cost reports will be used to revise each provider’s Medicaid DC cost per diem
in the spending floor calculation if it results in a reduced or eliminated DC spending floor liability for the provider.
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ADMINISTRATIVE AND OPERATING
Administrative and Operating Rate Facility Specific Direct Care Case Mix and Direct Care Non Case Mix Adjusted Rate Capital Rate (Fair Rental Value Per Diem) Cost-Based Component Rate: Property Tax (Inflated from base year to 12/31/2017) Nursing Facility Provider Assessment Quality Incentive Payment Per Diem Medicaid Reimbursement Rate Prior to BAF and Phase-In Budget Adjustment Factor (BAF) Medicaid Reimbursement Rate After BAF and Prior to Phase-In Corridor Phase-In Calculation Medicaid Reimbursement Rate Effective January 1, 2018 Phase-In Adjustment (+$7.98/-$6.00 Corridor Applied From Prior System Rate) $83.22 $86.80 $13.99 $0.81 $13.04 $10.55 $208.41 99.7744% $207.94 $6.30 $214.24
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ADMINISTRATIVE AND OPERATING
A&O Cost Component Expenses:
cost)
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ADMINISTRATIVE AND OPERATING
A&O Cost Component Expenses:
contained in another rate component
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ADMINISTRATIVE AND OPERATING
A&O Cost Component Expenses:
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ADMINISTRATIVE AND OPERATING
A&O Cost Component Expenses:
(MediCAID CR)
payroll taxes (MediCARE CR)
cost apportionment methods
(SNF/NF) cost centers, as designated by TennCare, will be excluded from cost component totals
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ADMINISTRATIVE AND OPERATING
A&O Cost Component Expenses:
Medicaid rate setting are as follows:
and non-routine SNF/NF cost centers
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ADMINISTRATIVE AND OPERATING
A&O Cost Component Expenses:
Medicaid rate setting are as follows (cont.):
cost centers, outpatient cost center, special purpose cost centers, and non-reimbursable cost centers, as determined by TennCare.
cost centers other than routine SNF/NF
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ADMINISTRATIVE AND OPERATING
Determination of A&O Medicaid Rate:
STEP # 1
The provider’s base year A&O cost is inflated by the SNF Market Basket without Capital Index factor.
base year cost reporting period to the midpoint of the rate year
Administrative & Operating Base Year Cost (1/1/2015 to 12/31/2015 Cost Report) 1,822,025 $ Inflation Factor to 12/31/2017 1.071908 Inflated Cost 1,953,043 $
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ADMINISTRATIVE AND OPERATING
Determination of A&O Medicaid Rate:
STEP # 2
The inflated cost is divided by total base year resident days to calculate the A&O per diem
Administrative & Operating Inflated Cost 1,953,043 $ Total Base Year Cost Report Resident Days 13,916 Inflated Per Diem Cost 140.35 $ 74
ADMINISTRATIVE AND OPERATING
Determination of A&O Medicaid Rate:
STEP # 3
The per diem cost for each NF is arrayed from low to high and the annualized Medicaid resident-day weighted median cost is determined.
STEP # 4
The statewide administrative and operating cost component is established at 101% of the administrative and operating annualized Medicaid resident-day-weighted median cost.
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ADMINISTRATIVE AND OPERATING
Name Inflated Per Diem Cost Annualized Medicaid Resident Days Cumulative Days (Running Total) Facility B 61.69 $ 12,000 12,000 Facility D 65.23 $ 27,000 39,000 Facility A 69.30 $ 16,000 55,000 Facility E 72.58 $ 19,000 74,000 Facility G 82.40 $ 39,000 113,000 Facility F 97.80 $ 19,000 132,000 Example Facility 140.35 $ 3,267 135,267 Facility H 207.82 $ 57,904 193,171 Days Used for Median (0.5 x 193,171) 96,586 Median Selected 82.40 $ Multiply by Price % (per rule) 101% Administrative and Operating Statewide Price 83.22 $ 76
ADMINISTRATIVE AND OPERATING
Determination of A&O Medicaid Rate:
administrative and operating expenditures.
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CAPITAL (FRV)
Appraisal Undepreciated Facility Replacement Cost Calculated Depreciation Applied for Rate Setting (70.00% of Appraisal Depreciation) Depreciated Net Facility Value for Rate Setting Allowable Land Value Facility Fixed Asset Additions (After Appraisal) Total Facility Base Value Maximum Allowable Base Value (42 Licensed Beds * ($75,000 Base Value + $3,000 Private Room Additional Value) Lesser of Facility Base Value or Maximum Allowable Base Value Allowable Base Value Add-on for Movable Equipment (42 Licensed Beds * $7,500) Total Facility Value Rental Rate Annual Fair Rental Value Divided by Greater of Total Annual Patient Days or 85.00% of Total Annual Bed Days Available Fair Rental Value Per Diem $2,300,000 $665,000 $1,635,000 $145,000 $0 $1,780,000 $3,276,000 $1,780,000 $315,000 $2,095,000 8.70% $182,265 13,031 $13.99
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CAPITAL (FRV)
rental value (FRV) appraisal based system
specific costs such as depreciation, amortization, interest, rent/lease expenses, etc.
centers (unless included on MediCAID CR schedule C) would be excluded from Medicaid rate setting:
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CAPITAL (FRV)
and net depreciated facility value for the provider
weighted construction year of the provider as follows for Medicaid rate setting purposes:
appraisal values in years where an initial appraisal or re- appraisal (voluntary or mandatory) is not completed.
Weighted Contruction Year Age Amount of Appraisal Depreciation Utilized 30 years or younger 50% Greater than 30 years 70% 80
CAPITAL (FRV)
Fair Rental Value Modification
April 1 prior to each July 1 rate setting
certain criteria
FRV rates on a semi-annual basis
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CAPITAL (FRV)
website (www.mslc.com/Tennessee)
TNCaseMix@MSLC.com or mailed to: Attn: Tennessee NF Myers and Stauffer, LC 700 W. 47th Street, Suite 1100 Kansas City, Missouri 64112
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CAPITAL (FRV)
The FRV reimbursement system contains two points of quality incentive integration:
Quality Tier Rental Factor 1 8.70% 2 8.35% 3 8.00%
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CAPITAL (FRV)
The FRV reimbursement system contains two points of quality incentive integration:
room resident days to total base year bed days available
value threshold
Total Addition to Per Bed Value Medicaid Private Room Resident Day Percentage Threshold $3,000 10% $1,500 5% $0 Less than 5%
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CAPITAL (FRV)
Example:
Provider Assumptions: (A) Quality Tier One (1) (B) Medicaid Private Room Resident Day Percentage 10.49% (C) Facility Fixed Asset Additions (After Appraisal) 50,000 $ (D) Weighted Construction Year 34.00 Maximum Building Value Maximum Facility Value Per Bed 75,000 $ Add: Additional Per Bed Value (>10% Medicaid Private Resident Days) + 3,000 $ Total Per Bed Value 78,000 $ Multiply: Licensed Beds x 42 Maximum Allowable Base Value 3,276,000 $ Maximum Land Value Maximum Land Value Per Bed 7,500 $ Multiply: Licensed Beds x 42 Maximum Allowable Base Value 315,000 $
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CAPITAL (FRV)
Example (cont’d):
Step 1: Appraisal Undepreciated Facility Value 2,300,000 $ Less: Appraisal Net Depreciated Facility Value ‐ 1,350,000 $ Depreciated Net Facility Value for Rate Setting 950,000 $ Multiply: Medicaid Depreciation Percentage for FRV 70.00% Calculated Depreciation Applied for Rate Setting 665,000 $ Step 2: Appraisal Undepreciated Facility Value 2,300,000 $ Less: Calculated Depreciation Applied for Rate Setting ‐ 665,000 $ Depreciated Net Facility Value for Rate Setting 1,635,000 $ Add: Land Value (Maximum Allowable $315,000) 145,000 $ Add: Facility Fixed Asset Additions (After Appraisal from CIUR) + 50,000 $ Total Facility Base Value (Maximum Allowable $3,276,000) 1,830,000 $ 86
CAPITAL (FRV)
Example (cont’d):
Step 3: Lesser of Facility Base Value or Maximum Allowable Base Value 1,830,000 $ + 315,000 $ Total Facility Value 2,145,000 $ Multiply: Rental Rate (Quality Tier 1) x 8.70% Annual Fair Rental Value 186,615 $ ÷ 13,031 Fair Rental Value Per Diem 14.32 $ Divide: Greater of Total Annual Patient Days or 85% of Total Annual Bed Days Available Add: Allowable Base Value Add‐On for Movable Equipment (Licensed Beds x $7,500)
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87
COST-BASED
Administrative and Operating Rate Facility Specific Direct Care Case Mix and Direct Care Non Case Mix Adjusted Rate Capital Rate (Fair Rental Value Per Diem) Cost-Based Component Rate: Property Tax (Inflated from base year to 12/31/2017) Nursing Facility Provider Assessment Quality Incentive Payment Per Diem Medicaid Reimbursement Rate Prior to BAF and Phase-In Budget Adjustment Factor (BAF) Medicaid Reimbursement Rate After BAF and Prior to Phase-In Corridor Phase-In Calculation Medicaid Reimbursement Rate Effective January 1, 2018 Phase-In Adjustment (+$7.98/-$6.00 Corridor Applied From Prior System Rate) $83.22 $86.80 $13.99 $0.81 $13.04 $10.55 $208.41 99.7744% $207.94 $6.30 $214.24
88
COST-BASED
The cost-based reimbursement component is the sum
determined by TennCare.
45
89
COST-BASED
NF Related Real Estate Tax Per Diem Calculation:
STEP # 1
The provider’s base year NF related real estate tax cost, from MediCAID CR schedule C is inflated by the SNF Market Basket without Capital Index factor.
base year cost reporting period to the midpoint of the rate year
NF Related Real Estate Tax Base Year Cost (1/1/2015 to 12/31/2015 Cost Report) 10,715 $ Inflation Factor to 12/31/2017 1.071908 Inflated Cost 11,485 $
90
COST-BASED
NF Related Real Estate Tax Per Diem Calculation:
STEP # 2
The inflated NF related real estate tax cost is divided by the greater of actual base year cost report resident days or 85% of base year cost report licensed beds capacity of the provider.
NF Related Real Estate Tax Inflated Cost 11,485 $ Calculated Divisor 14,187 Real Estate Tax Per Diem 0.81 $
46
91
COST-BASED
Provider Assessment Reimbursement Rate Calculation:
fee collected divided by the total class resident days (all payer types).
92
QUALITY INCENTIVE PAYMENT PER DIEM
Quality Tier Rating Increase in Direct Care Non CMI Adjusted Price Due to Quality Tier Rating Increase in FRV Maximum Square Footage Per Bed Due to Medicaid Private Room Occupancy Percentage Stand-alone Quality Incentive Payment Per Diem Tier 1 5.00% $3,000 $10.55
47
93
QUALITY INCENTIVE PAYMENT PER DIEM
during each fiscal year for purposes of calculating a quality-based component of each NF provider’s per diem payment.
4% of the total projected fiscal year expenditures for NFs
index factor inflation until the quality-based component is 10% of the total projected NF expenditures and will remain at 10% thereafter.
Medicaid resident days and the percentage of total quality points earned for the measurement period.
94
QUALITY INCENTIVE PAYMENT PER DIEM Quality-Based Component Per Diem Calculation:
STEP # 1
Provider’s QuILTSS score from the measurement period is divided by total possible QuILTSS score
STEP # 2
QuILTSS score percentage is multiplied by annualized Medicaid days to determine total quality adjusted annualized Medicaid days
(A) (B) (C) = (A) * (B) Quality Incentive Score Annualized Medicaid Resident Days Quality Adjusted Annualized Medicaid Days 82/110 3,267 2,435
48
95
QUALITY INCENTIVE PAYMENT PER DIEM Quality-Based Component Per Diem Calculation:
STEP # 3 Provider’s quality adjusted annualized Medicaid days are divided by quality adjusted Medicaid days in State STEP # 4 Percentage is multiplied by total fiscal year quality incentive dollars
(C) (D) (E) (F) = (C) / (D) * (E) (G) (H) = (F) / (G) Quality Adjusted Annualized Medicaid Days Total Quality Adjusted Days In State Total Fiscal Year Quality Incentive Dollars Total Annual Quality Payment Annualized Medicaid Resident Days Per Diem 2,435 3,515,000 49,761,367 $ 34,471.96 $ 3,267 10.55 $
Adjustments to the Rate
49
97
BUDGET ADJUSTMENT FACTOR (BAF)
Administrative and Operating Rate Facility Specific Direct Care Case Mix and Direct Care Non Case Mix Adjusted Rate Capital Rate (Fair Rental Value Per Diem) Cost-Based Component Rate: Property Tax (Inflated from base year to 12/31/2017) Nursing Facility Provider Assessment Quality Incentive Payment Per Diem Medicaid Reimbursement Rate Prior to BAF and Phase-In Budget Adjustment Factor (BAF) Medicaid Reimbursement Rate After BAF and Prior to Phase-In Corridor Phase-In Calculation Medicaid Reimbursement Rate Effective January 1, 2018 Phase-In Adjustment (+$7.98/-$6.00 Corridor Applied From Prior System Rate) $83.22 $86.80 $13.99 $0.81 $13.04 $10.55 $208.41 99.7744% $207.94 $6.30 $214.24
98
BUDGET ADJUSTMENT FACTOR (BAF)
will establish a NF program budget target and compare that to the annual expected Medicaid expenditures of the reimbursement system for the upcoming rate year using established rate setting mechanics
Medicaid expenditures to meet the program’s NF budget target
the board percentage adjustment to all NF providers.
50
99
PHASE-IN ADJUSTMENT
Administrative and Operating Rate Facility Specific Direct Care Case Mix and Direct Care Non Case Mix Adjusted Rate Capital Rate (Fair Rental Value Per Diem) Cost-Based Component Rate: Property Tax (Inflated from base year to 12/31/2017) Nursing Facility Provider Assessment Quality Incentive Payment Per Diem Medicaid Reimbursement Rate Prior to BAF and Phase-In Budget Adjustment Factor (BAF) Medicaid Reimbursement Rate After BAF and Prior to Phase-In Corridor Phase-In Calculation Medicaid Reimbursement Rate Effective January 1, 2018 Phase-In Adjustment (+$7.98/-$6.00 Corridor Applied From Prior System Rate) $83.22 $86.80 $13.99 $0.81 $13.04 $10.55 $208.41 99.7744% $207.94 $6.30 $214.24
100
PHASE-IN ADJUSTMENT
a phase-in of provider reimbursement rates will occur
the transition for providers to the case mix reimbursement system
cap a facility’s loss/gain from the previous reimbursement system based on specified parameters
Rate Period Begin Date Max Loss Max Gain July 1, 2018 $6 Budget Neutral Amount July 1, 2019 $12 Budget Neutral Amount
51
101
PHASE-IN ADJUSTMENT
Prior System Reimbursement Rate Calculation:
Based on reimbursement rates in effect on July 1, 2017 as determined
NF1/NF2 cost report days)
102
PHASE-IN ADJUSTMENT
Example 1: Current System Rate (After BAF) < Prior System Rate
Current Rate After BAF (Prior to Phase‐In) 207.94 $ Phase‐In Adjustment 6.30 $ Rate After BAF and Phase‐In Adjustment 214.24 $ + $6.30 Corridor $214.24 $228.22 $207.94 Maximum Allowable Corridor Rate $6.30 Phase‐In Adjustment to Current System Rate $220.24 Current System Rate (After BAF) ($6.00) Minimum Allowable Corridor Rate Prior System Rate $0.00 $7.98
52
103
PHASE-IN ADJUSTMENT
Example 2: Current System Rate (After BAF) > Prior System Rate
($13.14) Corridor Minimum Allowable Corridor Prior System Rate Maximum Allowable Corridor ($6.00) $0.00 $7.98 $214.24 $220.24 $228.22 Current System Rate (After BAF) $241.36 ‐$13.14 Phase‐In Adjustment to Current System Rate Current Rate After BAF (Prior to Phase‐In) 241.36 $ Phase‐In Adjustment (13.14) $ Rate After BAF and Phase‐In Adjustment 228.22 $
104
PHASE-IN ADJUSTMENT
Example 3: Current System Rate (After BAF) is Within Corridor
Corridor Minimum Allowable Corridor Prior System Rate Maximum Allowable Corridor Rate ($6.00) $0.00 $7.98 Current System Rate (After BAF) $214.24 $220.24 $228.22 $0.00 Phase‐In Adjustment to Current System Rate $221.75 Current Rate After BAF (Prior to Phase‐In) 221.75 $ Phase‐In Adjustment ‐ $ Rate After BAF and Phase‐In Adjustment 221.75 $
53
Questions and Answers
106
ADL ADL ADL ADL Yes Yes Yes Yes Yes Yes No No No No No Rehabilitation Extensive Services Special Care High/Low Clinically Complex Behavioral Symptoms & Cognitive Performance Reduced Physical Function
RUG-IV 48-Group Classification Model Schematic
ES3 ES2 ES1 1 5
6 11-14 6-10 1 1
4 0-1
Category II III & IV V VI VII
Depressed Depressed Depressed CC2 CC1 Yes No CB2 CB1 Yes No CA2 CA1 Yes No
ADL ADL
15-16 6-10 2-5 Restorative Nursing Restorative Nursing Restorative Nursing PE2 PE1 2+ 0-1 PD2 PD1 PC2 PC1 2
0-1 Restorative Nursing Restorative Nursing BB2 BB1 2+ 0-1 BA2 BA1 2+ 0-1 Restorative Nursing Restorative Nursing 2+ 0-1 2+ 0-1 PB2 PB1 2+ 0-1 PA2 PA1 2+ 0-1 Trach AND Vent Trach OR Vent Isolation 1 5
6 6-10 Depressed Depressed Depressed HE2 HE1 Yes No HD2 HD1 Yes No HC2 HC1 Yes No Depressed HB1 Yes No HB2 Depressed Depressed Depressed LE2 LE1 Yes No LD2 LD1 Yes No LC2 LC1 Yes No Depressed LB1 Yes No LB2
ADL HIGH LOW
1 5
6 11-14 6-10 2-5 2-5 Depressed Depressed CE2 CE1 Yes No CD2 CD1 Yes No 2-5 0-1 2-16 2-16 2-16
I HE2 1.88 RAE 1.65 RAD 1.58 RAC 1.36 RAB 1.10 ES3 3.00
1 5
6 11-14 6-10 RAC RAB RAA RAE RAD 2-5 0-1
RAA 0.82 HE1 1.47 HD2 1.69 HD1 1.33 HC2 1.57 HC1 1.23 HB2 1.55 HB1 1.22 LE2 1.61 LE1 1.26 LD2 1.54 LD1 1.21 LC2 1.30 LC1 1.02 LB2 1.21 LB1 0.95 CE2 1.39 CE1 1.25 CC2 1.08 CC1 0.96 CB2 0.95 CB1 0.85 CA2 0.73 CA1 0.65 CD2 1.29 CD1 1.15 BB2 0.81 BB1 0.75 BA2 0.58 BA1 0.53 PE2 1.25 PE1 1.17 PC2 0.91 PC1 0.85 PB2 0.70 PB1 0.65 PA2 0.49 PA1 0.45 PD2 1.15 PD1 1.06
Ultra High V e r y H i g h High Medium L
11-14
LB2 1.21 LB1 0.95 ES2 2.23 ES1 2.22 III IV Prepared by Myers and Stauffer LC 2012
Start Case Record Target RUG Start Date End Mix Type Date Class Date Field Date Days Index NC/01/99/0/99 09/02/2017 LD1 10/01/2017 10/30/2017 30 1.21 NQ/02/99/0/99 10/31/2017 PE1 10/31/2017 A2300 12/11/2017 42 1.17 NC/04/99/0/99 12/12/2017 PE1 12/12/2017 A2300 12/14/2017 3 1.17 ND/99/99/0/10 12/15/2017 12/15/2017 A2000 12/15/2017 75 NQ/02/99/0/99 08/17/2017 PC1 10/01/2017 10/30/2017 30 0.85 NC/03/99/0/99 10/31/2017 RAC 10/31/2017 A2300 12/04/2017 35 1.36 NC/03/99/0/99 10/31/2017 PC1 12/05/2017 A2300 12/31/2017 27 0.85 92 NP/99/03/0/99 09/13/2017 RAC 10/01/2017 10/05/2017 5 1.36 NP/99/04/0/99 10/06/2017 RAB 10/06/2017 A2300 10/11/2017 6 1.10 ND/99/99/0/10 10/12/2017 10/12/2017 A2000 10/12/2017 11 NT/99/99/0/01 12/15/2017 12/15/2017 A1600 12/15/2017 NC/01/99/0/99 12/20/2017 RAC 12/15/2017 A1600 12/31/2017 17 1.36 17 NQ/02/99/0/99 08/01/2017 PD1 10/01/2017 11/01/2017 32 1.06 NQ/02/99/0/99 11/02/2017 PE1 11/02/2017 A2300 12/31/2017 60 1.17 92 NT/99/99/0/01 10/23/2017 10/23/2017 A1600 10/23/2017 NC/01/99/0/99 10/30/2017 RAB 10/23/2017 A1600 11/22/2017 31 1.10 NC/01/99/0/99 10/30/2017 PB1 11/23/2017 A1600 11/24/2017 2 0.65 ND/99/99/0/10 11/25/2017 11/25/2017 A2000 11/25/2017 33 NQ/02/99/0/99 08/13/2017 PB1 10/01/2017 10/11/2017 11 0.65 NQ/02/99/0/99 10/12/2017 BB1 10/12/2017 A2300 12/31/2017 81 0.75 92 NT/99/99/0/01 12/19/2017 12/19/2017 A1600 12/19/2017 NC/01/01/0/99 12/23/2017 RAC 12/19/2017 A1600 12/31/2017 13 1.36 13 NQ/02/99/0/99 09/22/2017 PC1 10/01/2017 12/11/2017 72 0.85 NC/03/99/0/99 12/12/2017 PC1 12/12/2017 A2300 12/31/2017 20 0.85 92 NQ/02/99/0/99 09/29/2017 PC1 10/01/2017 11/27/2017 58 0.85 NQ/02/99/0/99 11/28/2017 PB1 11/28/2017 A2300 12/31/2017 34 0.65 92
Tennessee Division of Health Care Finance & Administration Time-Weighted CMI Resident Roster Report Final RUG IV - 48 Grouper Time-Weighted Resident Listing for the Quarter 10/01/2017-12/31/2017 Records Received as of 02/28/2018
Provider Number: Provider Name: Resident Payment Resident Name ID Source Resident #1 00000001 Medicaid Other Medicaid Resident #2 00000002 Medicaid Total Days Medicaid Medicaid Resident #3 00000003 Medicare Total Days Medicare Resident #4 00000004 Total Days Other Total Days Resident #5 00000005 Medicaid Medicaid Total Days Resident #6 00000006 Other Other Total Days Resident #7 00000007 Medicaid Medicaid Total Days Resident #8 00000008 Medicare Total Days Resident #9 00000009 Medicaid Medicaid Total Days Total Days Resident #10 00000010 Other Other Prepared by Myers and Stauffer LC Myers and Stauffer Help Desk: (800) 773-8609
Tennessee Division of Health Care Finance & Administration Time-Weighted CMI Resident Roster Report Final RUG IV - 48 Grouper Time-Weighted Resident Summary for the Quarter 10/01/2017-12/31/2017 Records Received as of 02/28/2018
CMI Points Days CMI CMI Points
Provider Number: Provider Name:
(b) (c = a x b) (d) (e) Medicaid Residents All Residents RUG-III Days CMI (f = d x e) Group (a) 2.23 0.00 ES3 3.00 0.00 3.00 2.22 0.00 2.22 0.00 ES2 2.23 0.00 0.00 RAE 1.65 0.00 1.65 0.00 ES1 1.36 95.20 RAD 1.58 0.00 1.58 1.10 0.00 37 1.10 0.00 RAC 35 1.36 47.60 70 40.70 RAA 0.82 0.00 0.82 0.00 RAB 1.47 0.00 HE2 1.88 0.00 1.88 1.69 0.00 1.69 0.00 HE1 1.47 0.00 0.00 HD1 1.33 0.00 1.33 0.00 HD2 1.23 0.00 HC2 1.57 0.00 1.57 1.55 0.00 1.55 0.00 HC1 1.23 0.00 0.00 HB1 1.22 0.00 1.22 0.00 HB2 1.26 0.00 LE2 1.61 0.00 1.61 1.54 0.00 1.54 0.00 LE1 1.26 0.00 0.00 LD1 30 1.21 36.30 30 1.21 36.30 LD2 1.02 0.00 LC2 1.30 0.00 1.30 1.21 0.00 1.21 0.00 LC1 1.02 0.00 0.00 LB1 0.95 0.00 0.95 0.00 LB2 1.25 0.00 CE2 1.39 0.00 1.39 1.29 0.00 1.29 0.00 CE1 1.25 0.00 0.00 CD1 1.15 0.00 1.15 0.00 CD2 0.96 0.00 CC2 1.08 0.00 1.08 0.95 0.00 0.95 0.00 CC1 0.96 0.00 0.00 CB1 0.85 0.00 0.85 0.00 CB2 0.65 0.00 CA2 0.73 0.00 0.73 0.81 0.00 0.81 0.00 CA1 0.65 0.00 0.00 BB1 81 0.75 60.75 81 0.75 60.75 BB2 0.53 0.00 BA2 0.58 0.00 0.58 0.00 BA1 0.53 0.00 Prepared by Myers and Stauffer LC Myers and Stauffer Help Desk: (800) 773-8609
Tennessee Division of Health Care Finance & Administration Time-Weighted CMI Resident Roster Report Final RUG IV - 48 Grouper Time-Weighted Resident Summary for the Quarter 10/01/2017-12/31/2017 Records Received as of 02/28/2018
CMI Points Days CMI CMI Points
Provider Number: Provider Name:
(b) (c = a x b) (d) (e) Medicaid Residents All Residents RUG-III Days CMI (f = d x e) Group (a) 0.00 122.85 PE2 1.25 0.00 1.25 PE1 63 1.17 73.71 105 1.17 0.00 33.92 PD2 1.15 0.00 1.15 PD1 32 1.06 33.92 32 1.06 0.00 175.95 PC2 0.91 0.00 0.91 PC1 149 0.85 126.65 207 0.85 0.00 30.55 PB2 0.70 0.00 0.70 PB1 11 0.65 7.15 47 0.65 0.00 0.00 PA2 0.49 0.00 0.49 PA1 0.45 0.00 0.45 0.00 0.00 AAA 0.45 0.00 0.45 BC1 0.45 0.00 0.45 Totals 401 386.08 609 596.22 Medicaid Average CMI 0.96 All Average CMI 0.98 Total Medicare Days 24 Total Other Days 184 Medicare Average CMI 1.30 Other Average CMI 0.97 Prepared by Myers and Stauffer LC Myers and Stauffer Help Desk: (800) 773-8609
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 RECLASSI FI CATI O N AND ADJUSTM ENT O F TRI AL BALANCE O F EXPENSES Cost Cent er Descr i pt i on Sal ar i es O t her Tot al ( col . 1 + col . 2) Recl assi f i cat i ons I ncr ease/ Decr ease ( Fr W kst A- 6) Recl assi f i ed Tr i al Bal ance ( col . 3 +- col . 4)
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES 304, 943 304, 943 304, 943
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS 360, 301 360, 301 360, 301
00400 ADM I NI STRATI VE & G ENERAL 436, 711 495, 101 931, 812 931, 812
00500 PLANT O PERATI O N, M AI NT. & REPAI RS 113, 064 599, 200 712, 264 712, 264
00600 LAUNDRY & LI NEN SERVI CE 46, 841 46, 841 46, 841
00700 HO USEKEEPI NG 232, 890 232, 890 232, 890
00800 DI ETARY 259, 268 291, 103 550, 371 550, 371
00900 NURSI NG ADM I NI STRATI O N 311, 367 141, 615 452, 982 452, 982
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY 4, 119 4, 119 4, 119
01200 M EDI CAL RECO RDS & LI BRARY 75, 000 20, 000 95, 000 95, 000
01300 SO CI AL SERVI CE 35, 085 4, 366 39, 451 39, 451
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES 54, 575 16, 572 71, 147 71, 147
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 1, 407, 420 260, 289 1, 667, 709 1, 667, 709
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 384, 145 10, 140 394, 285 394, 285
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y 60, 000 60, 000 1, 245 61, 245
04100 LABO RATO RY 50, 000 50, 000 2, 043 52, 043
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY 298, 634 298, 634
188, 364
04500 O CCUPATI O NAL THERAPY 50, 000 50, 000 106, 639 156, 639
04600 SPEECH PATHO LO G Y 3, 632 3, 632
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS 14, 468 14, 468
11, 179
04900 DRUG S CHARG ED TO PATI ENTS 67, 645 67, 645 67, 645
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
3, 076, 635 3, 328, 227 6, 404, 862 6, 404, 862
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN
09100 BARBER AND BEAUTY SHO P 9, 628 9, 628 9, 628
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG 450, 000 160, 000 610, 000 610, 000
TO TAL 3, 526, 635 3, 497, 855 7, 024, 490 7, 024, 490 100. 00 EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 RECLASSI FI CATI O N AND ADJUSTM ENT O F TRI AL BALANCE O F EXPENSES Cost Cent er Descr i pt i on Adj ust m ent s t o Expenses ( Fr W kst A- 8) Net Expenses For Al l ocat i on ( col . 5 +- col . 6)
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES
4, 936
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS 360, 301
00400 ADM I NI STRATI VE & G ENERAL
702, 448
00500 PLANT O PERATI O N, M AI NT. & REPAI RS
673, 654
00600 LAUNDRY & LI NEN SERVI CE 46, 841
00700 HO USEKEEPI NG 232, 890
00800 DI ETARY
540, 432
00900 NURSI NG ADM I NI STRATI O N 452, 982
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY 4, 119
01200 M EDI CAL RECO RDS & LI BRARY 95, 000
01300 SO CI AL SERVI CE 39, 451
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES 71, 147
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 1, 667, 709
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 394, 285
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y 61, 245
04100 LABO RATO RY 52, 043
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY 188, 364
04500 O CCUPATI O NAL THERAPY 156, 639
04600 SPEECH PATHO LO G Y 3, 632
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS 11, 179
04900 DRUG S CHARG ED TO PATI ENTS 67, 645
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
5, 826, 942
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN
09100 BARBER AND BEAUTY SHO P 9, 628
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG 610, 000
TO TAL
6, 446, 570
EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 RECLASSI FI CATI O NS I ncr eases Cost Cent er Li ne # Sal ar y Non Sal ar y
( 1) A - RECLASSI FY ANCI LLARY EXPENSES
RADI O LO G Y
1, 245
LABO RATO RY
2, 043
O CCUPATI O NAL THERAPY
106, 639
SPEECH PATHO LO G Y
3, 632
TO TALS
Tot al Recl assi f i cat i ons ( Sum
ns 4 and 5 m ust equal sum
ns 8 and 9) 113, 559 100. 00 EXAM PLE FACI LI TY ( 1) A l et t er ( A, B, et c. ) m ust be ent er ed on each l i ne t o i dent i f y each r ecl assi f i cat i on ent r y. ( 2) Tr ansf er t o W
M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 RECLASSI FI CATI O NS Decr eases Cost Cent er Li ne # Sal ar y Non Sal ar y
( 1) A - RECLASSI FY ANCI LLARY EXPENSES
M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS
3, 289
PHYSI CAL THERAPY
110, 270
TO TALS
113, 559 100. 00 EXAM PLE FACI LI TY ( 1) A l et t er ( A, B, et c. ) m ust be ent er ed on each l i ne t o i dent i f y each r ecl assi f i cat i on ent r y. ( 2) Tr ansf er t o W
M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 RECO NCI LI ATI O N O F CAPI TAL CO STS CENTERS Acqui si t i ons Descr i pt i on Begi nni ng Bal ances Pur chases Donat i on Tot al Di sposal s and Ret i r em ent s
ANALYSI S O F CHANG ES I N CAPI TAL ASSET BALANCES
Land
Land I m pr ovem ent s
Bui l di ngs and Fi xt ur es
Bui l di ng I m pr ovem ent s 645, 479 21, 914 21, 914
Fi xed Equi pm ent
M
ent 551, 635 59, 152 59, 152
Subt ot al ( sum
1, 197, 114 81, 066 81, 066
Reconci l i ng I t em s
Tot al ( l i ne 7 m i nus l i ne 8) 1, 197, 114 81, 066 81, 066
Descr i pt i on Endi ng Bal ance Ful l y Depr eci at ed Asset s
ANALYSI S O F CHANG ES I N CAPI TAL ASSET BALANCES
Land
Land I m pr ovem ent s
Bui l di ngs and Fi xt ur es
Bui l di ng I m pr ovem ent s 667, 393
Fi xed Equi pm ent
M
ent 610, 787
Subt ot al ( sum
1, 278, 180
Reconci l i ng I t em s
Tot al ( l i ne 7 m i nus l i ne 8) 1, 278, 180
EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 ADJUSTM ENTS TO EXPENSES Expense Cl assi f i cat i on on W
To/ Fr om W hi ch t he Am
Descr i pt i on ( 1) ( 2) Basi s For Adj ust m ent Am
Cost Cent er Li ne No.
I nvest m ent i ncom e on r est r i ct ed f unds ( chapt er 2) B
STS - BLDG S & FI XTURES
Tr ade, quant i t y, and t i m e di scount s ( chapt er 8)
Ref unds and r ebat es of expenses ( chapt er 8)
Rent al of pr ovi der space by suppl i er s ( chapt er 8)
Tel ephone ser vi ces ( pay st at i ons excl uded) ( chapt er 21)
Tel evi si on and r adi o ser vi ce ( chapt er 21)
Par ki ng l ot ( chapt er 21)
Rem uner at i on appl i cabl e t o pr ovi der - based physi ci an adj ust m ent A- 8- 2
Hom e of f i ce cost ( chapt er 21)
Sal e of scr ap, wast e, et c. ( chapt er 23)
Nonal l owabl e cost s r el at ed t o cer t ai n Capi t al expendi t ur es ( chapt er 24)
Adj ust m ent r esul t i ng f or m t r ansact i ons wi t h r el at ed or gani zat i ons ( chapt er 10) A- 8- 1
Laundr y and l i nen ser vi ce
Revenue - Em pl oyee m eal s B
Cost of m eal s - G uest s
Sal e of m edi cal suppl i es t o ot her t han pat i ent s
Sal e of dr ugs t o ot her t han pat i ent s
Sal e of m edi cal r ecor ds and abst r act s
Vendi ng m achi nes B
PERATI O N, M AI NT. & REPAI RS
I ncom e f r om i m posi t i on of i nt er est , f i nance
I nt er est expense on M edi car e over paym ent s and bor r owi ngs t o r epay M edi car e
ent s
Ut i l i zat i on r evi ew- - physi ci ans' com pensat i on ( chapt er 21) 0 UTI LI ZATI O N REVI EW
Depr eci at i on- - bui l di ngs and f i xt ur es 0 CAP REL CO STS - BLDG S & FI XTURES
Depr eci at i on- - m
ent 0 CAP REL CO STS - M O VABLE EQ UI PM ENT
M I SC. I NCO M E B
I NI STRATI VE & G ENERAL
RESI DENT TRAVEL I NCO M E B
I NI STRATI VE & G ENERAL
PUBLI C RELATI O NS AND M ARKETI NG A
I NI STRATI VE & G ENERAL
NO N ALLO W ABLE CO NTRI BUTI O N EXPENSE A
I NI STRATI VE & G ENERAL
PRO VI DER ASSESSM ENT A
I NI STRATI VE & G ENERAL
t o W
( 1) Descr i pt i on - al l chapt er r ef er ences i n t hi s col um n per t ai n t o CM S Pub. 15- 1. ( 2) Basi s f or adj ust m ent ( see i nst r uct i ons) .
i ned.
i ned. EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
Par t s I - I I 2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 STATEM ENT O F CO STS O F SERVI CES FRO M RELATED O RG ANI ZATI O NS AND HO M E O FFI CE CO STS Li ne No. Cost Cent er Expense I t em s
PART I . CO STS I NCURRED AND ADJUSTM ENTS REQ UI RED AS A RESULT O F TRANSACTI O NS W I TH RELATED O RG ANI ZATI O NS O R CLAI M ED HO M E O FFI CE CO STS:
STS - BLDG S & FI XTURES LEASE
I NI STRATI VE & G ENERAL PRO PERTY EXPENSE
TO TALS ( sum
n 6, l i ne 100 t o W
n 3, l i ne 12.
Am
Al l owabl e I n Cost Am
I ncl uded i n W kst . A, col . 5 Adj ust m ent s ( col . 4 m i nus col . 5)
PART I . CO STS I NCURRED AND ADJUSTM ENTS REQ UI RED AS A RESULT O F TRANSACTI O NS W I TH RELATED O RG ANI ZATI O NS O R CLAI M ED HO M E O FFI CE CO STS:
300, 000
1, 031 1, 031
TO TALS ( sum
n 6, l i ne 100 t o W
n 3, l i ne 12. 1, 031 301, 031
EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
Par t s I - I I 2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 STATEM ENT O F CO STS O F SERVI CES FRO M RELATED O RG ANI ZATI O NS AND HO M E O FFI CE CO STS Sym bol ( 1) Nam e Per cent age of O wner shi p
PART I I . I NTERRELATI O NSHI P TO RELATED O RG ANI ZATI O N( S) AND/ O R HO M E O FFI CE: The Secr et ar y, by vi r t ue of t he aut hor i t y gr ant ed under sect i on 1814( b) ( 1) of t he Soci al Secur i t y Act , r equi r es t hat you f ur ni sh t he i nf or m at i on r equest ed under Par t B of t hi s wor ksheet . Thi s i nf or m at i on i s used by t he Cent er s f or M edi car e and M edi cai d Ser vi ces and i t s i nt er m edi ar i es/ cont r act or s i n det er m i ni ng t hat t he cost s appl i cabl e t o ser vi ces, f aci l i t i es, and suppl i es f ur ni shed by or gani zat i ons r el at ed t o you by com m
i ned under sect i on 1861 of t he Soci al Secur i t y Act . I f you do not pr ovi de al l or any par t of t he r equest i nf or m at i on, t he cost r epor t i s consi der ed i ncom pl et e and not accept abl e f or pur poses of cl ai m i ng r ei m bur sem ent under t i t l e XVI I I .
B SNUG HARBO R M G M
B SNUG HARBO R M G M
. O t her ( f i nanci al or non- f i nanci al ) speci f y:
( 1) Use t he f ol l owi ng sym bol s t o i ndi cat e i nt er r el at i onshi p t o r el at ed or gani zat i ons:
i ni st r at or , or key per son of pr ovi der or r el at i ve of such per son has f i nanci al i nt er est i n r el at ed or gani zat i on.
i ni st r at or , or key per son of pr ovi der and r el at ed or gani zat i on.
i ni st r at or , or key per son of r el at ed or gani zat i on or r el at i ve of such per son has f i nanci al i nt er est i n pr ovi der . Rel at ed O r gani zat i on( s) and/ or Hom e O f f i ce Nam e Per cent age of O wner shi p Type of Busi ness
PART I I . I NTERRELATI O NSHI P TO RELATED O RG ANI ZATI O N( S) AND/ O R HO M E O FFI CE: The Secr et ar y, by vi r t ue of t he aut hor i t y gr ant ed under sect i on 1814( b) ( 1) of t he Soci al Secur i t y Act , r equi r es t hat you f ur ni sh t he i nf or m at i on r equest ed under Par t B of t hi s wor ksheet . Thi s i nf or m at i on i s used by t he Cent er s f or M edi car e and M edi cai d Ser vi ces and i t s i nt er m edi ar i es/ cont r act or s i n det er m i ni ng t hat t he cost s appl i cabl e t o ser vi ces, f aci l i t i es, and suppl i es f ur ni shed by or gani zat i ons r el at ed t o you by com m
i ned under sect i on 1861 of t he Soci al Secur i t y Act . I f you do not pr ovi de al l or any par t of t he r equest i nf or m at i on, t he cost r epor t i s consi der ed i ncom pl et e and not accept abl e f or pur poses of cl ai m i ng r ei m bur sem ent under t i t l e XVI I I .
SNUG HARBO R PAR
PERTY
SNUG HARBO R PAR
PERTY
. O t her ( f i nanci al or non- f i nanci al ) speci f y:
( 1) Use t he f ol l owi ng sym bol s t o i ndi cat e i nt er r el at i onshi p t o r el at ed or gani zat i ons:
i ni st r at or , or key per son of pr ovi der or r el at i ve of such per son has f i nanci al i nt er est i n r el at ed or gani zat i on.
i ni st r at or , or key per son of pr ovi der and r el at ed or gani zat i on.
i ni st r at or , or key per son of r el at ed or gani zat i on or r el at i ve of such per son has f i nanci al i nt er est i n pr ovi der . EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
Par t I 2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 CO ST ALLO CATI O N - G ENERAL SERVI CE CO STS CAPI TAL RELATED CO STS Cost Cent er Descr i pt i on Net Expenses f or Cost Al l ocat i on ( f r om W kst A col . 7) BLDG S & FI XTURES M O VABLE EQ UI PM ENT EM PLO YEE BENEFI TS Subt ot al
3A G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES 4, 936 4, 936
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS 360, 301 360, 301
00400 ADM I NI STRATI VE & G ENERAL 702, 448 418 44, 617 747, 483
00500 PLANT O PERATI O N, M AI NT. & REPAI RS 673, 654 404 11, 551 685, 609
00600 LAUNDRY & LI NEN SERVI CE 46, 841 46, 841
00700 HO USEKEEPI NG 232, 890 232, 890
00800 DI ETARY 540, 432 172 26, 488 567, 092
00900 NURSI NG ADM I NI STRATI O N 452, 982 31, 811 484, 793
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY 4, 119 4, 119
01200 M EDI CAL RECO RDS & LI BRARY 95, 000 7, 662 102, 662
01300 SO CI AL SERVI CE 39, 451 60 3, 584 43, 095
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES 71, 147 5, 576 76, 723
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 1, 667, 709 1, 441 143, 790 1, 812, 940
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 394, 285 1, 402 39, 247 434, 934
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y 61, 245 61, 245
04100 LABO RATO RY 52, 043 52, 043
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY 188, 364 29 188, 393
04500 O CCUPATI O NAL THERAPY 156, 639 29 156, 668
04600 SPEECH PATHO LO G Y 3, 632 3, 632
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS 11, 179 11, 179
04900 DRUG S CHARG ED TO PATI ENTS 67, 645 67, 645
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
5, 826, 942 3, 955 314, 326 5, 779, 986
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN 48 48
09100 BARBER AND BEAUTY SHO P 9, 628 12 9, 640
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG 610, 000 921 45, 975 656, 896
Cr oss Foot Adj ust m ent s
Negat i ve Cost Cent er s
TO TAL 6, 446, 570 4, 936 360, 301 6, 446, 570 100. 00 EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
Par t I 2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 CO ST ALLO CATI O N - G ENERAL SERVI CE CO STS Cost Cent er Descr i pt i on ADM I NI STRATI V E & G ENERAL PLANT O PERATI O N, M AI NT. & REPAI RS LAUNDRY & LI NEN SERVI CE HO USEKEEPI NG DI ETARY
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS
00400 ADM I NI STRATI VE & G ENERAL 747, 483
00500 PLANT O PERATI O N, M AI NT. & REPAI RS 89, 923 775, 532
00600 LAUNDRY & LI NEN SERVI CE 6, 144 52, 985
00700 HO USEKEEPI NG 30, 545 263, 435
00800 DI ETARY 74, 379 32, 448 11, 022 684, 941
00900 NURSI NG ADM I NI STRATI O N 63, 584
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY 540
01200 M EDI CAL RECO RDS & LI BRARY 13, 465
01300 SO CI AL SERVI CE 5, 652 11, 242 3, 819
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES 10, 063
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 237, 786 271, 481 31, 840 92, 217 386, 616
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 57, 045 264, 342 21, 145 89, 792 256, 763
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y 8, 033
04100 LABO RATO RY 6, 826
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY 24, 709 5, 498 1, 868
04500 O CCUPATI O NAL THERAPY 20, 548 5, 498 1, 868
04600 SPEECH PATHO LO G Y 476
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS 1, 466
04900 DRUG S CHARG ED TO PATI ENTS 8, 872
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
660, 056 590, 509 52, 985 200, 586 643, 379
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN 6 9, 136 3, 103
09100 BARBER AND BEAUTY SHO P 1, 264 2, 352 799
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG 86, 157 173, 535 58, 947 41, 562
Cr oss Foot Adj ust m ent s
Negat i ve Cost Cent er s
TO TAL 747, 483 775, 532 52, 985 263, 435 684, 941 100. 00 EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
Par t I 2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 CO ST ALLO CATI O N - G ENERAL SERVI CE CO STS Cost Cent er Descr i pt i on NURSI NG ADM I NI STRATI O N CENTRAL SERVI CES & SUPPLY PHARM ACY M EDI CAL RECO RDS & LI BRARY SO CI AL SERVI CE
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS
00400 ADM I NI STRATI VE & G ENERAL
00500 PLANT O PERATI O N, M AI NT. & REPAI RS
00600 LAUNDRY & LI NEN SERVI CE
00700 HO USEKEEPI NG
00800 DI ETARY
00900 NURSI NG ADM I NI STRATI O N 548, 377
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY 4, 659
01200 M EDI CAL RECO RDS & LI BRARY 116, 127
01300 SO CI AL SERVI CE 63, 808
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 342, 898 3, 310 69, 783 38, 343
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 205, 479 1, 349 46, 344 25, 465
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y
04100 LABO RATO RY
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY
04500 O CCUPATI O NAL THERAPY
04600 SPEECH PATHO LO G Y
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS
04900 DRUG S CHARG ED TO PATI ENTS
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
548, 377 4, 659 116, 127 63, 808
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN
09100 BARBER AND BEAUTY SHO P
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG
Cr oss Foot Adj ust m ent s
Negat i ve Cost Cent er s
TO TAL 548, 377 4, 659 116, 127 63, 808 100. 00 EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
Par t I 2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 CO ST ALLO CATI O N - G ENERAL SERVI CE CO STS O THER G ENERAL SERVI CE Cost Cent er Descr i pt i on NURSI NG AND ALLI ED HEALTH EDUCATI O N PATI ENT ACTI VI TI ES Subt ot al Post St epdown Adj ust m ent s Tot al
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS
00400 ADM I NI STRATI VE & G ENERAL
00500 PLANT O PERATI O N, M AI NT. & REPAI RS
00600 LAUNDRY & LI NEN SERVI CE
00700 HO USEKEEPI NG
00800 DI ETARY
00900 NURSI NG ADM I NI STRATI O N
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY
01200 M EDI CAL RECO RDS & LI BRARY
01300 SO CI AL SERVI CE
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES 86, 786
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 52, 151 3, 339, 365 3, 339, 365
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 34, 635 1, 437, 293 1, 437, 293
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y 69, 278 69, 278
04100 LABO RATO RY 58, 869 58, 869
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY 220, 468 220, 468
04500 O CCUPATI O NAL THERAPY 184, 582 184, 582
04600 SPEECH PATHO LO G Y 4, 108 4, 108
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS 12, 645 12, 645
04900 DRUG S CHARG ED TO PATI ENTS 76, 517 76, 517
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
86, 786 5, 403, 125 5, 403, 125
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN 12, 293 12, 293
09100 BARBER AND BEAUTY SHO P 14, 055 14, 055
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG 1, 017, 097 1, 017, 097
Cr oss Foot Adj ust m ent s
Negat i ve Cost Cent er s
TO TAL 86, 786 6, 446, 570 6, 446, 570 100. 00 EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 CO ST ALLO CATI O N - STATI STI CAL BASI S CAPI TAL RELATED CO STS Cost Cent er Descr i pt i on BLDG S & FI XTURES ( SQ UARE FEET) M O VABLE EQ UI PM ENT ( SQ UARE FEET) EM PLO YEE BENEFI TS ( G RO SS SALARI ES) Reconci l i at i o n ADM I NI STRATI V E & G ENERAL ( ACCUM . CO ST)
4A
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES 110, 000
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS 3, 526, 635
00400 ADM I NI STRATI VE & G ENERAL 9, 320 436, 711
5, 699, 087
00500 PLANT O PERATI O N, M AI NT. & REPAI RS 8, 998 113, 064 685, 609
00600 LAUNDRY & LI NEN SERVI CE 46, 841
00700 HO USEKEEPI NG 232, 890
00800 DI ETARY 3, 836 259, 268 567, 092
00900 NURSI NG ADM I NI STRATI O N 311, 367 484, 793
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY 4, 119
01200 M EDI CAL RECO RDS & LI BRARY 75, 000 102, 662
01300 SO CI AL SERVI CE 1, 329 35, 085 43, 095
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES 54, 575 76, 723
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 32, 094 1, 407, 420 1, 812, 940
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 31, 250 384, 145 434, 934
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y 61, 245
04100 LABO RATO RY 52, 043
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY 650 188, 393
04500 O CCUPATI O NAL THERAPY 650 156, 668
04600 SPEECH PATHO LO G Y 3, 632
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS 11, 179
04900 DRUG S CHARG ED TO PATI ENTS 67, 645
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
88, 127 3, 076, 635
5, 032, 503
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN 1, 080 48
09100 BARBER AND BEAUTY SHO P 278 9, 640
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG 20, 515 450, 000 656, 896
Cr oss Foot Adj ust m ent s
Negat i ve Cost Cent er s
Cost t o be al l ocat ed ( per W kst . B, Par t I ) 4, 936 360, 301 747, 483 102. 00
Uni t cost m ul t i pl i er ( W kst . B, Par t I )
Cost t o be al l ocat ed ( per W kst . B, Par t I I ) 418 104. 00
Uni t cost m ul t i pl i er ( W kst . B, Par t I I )
EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 CO ST ALLO CATI O N - STATI STI CAL BASI S Cost Cent er Descr i pt i on PLANT O PERATI O N, M AI NT. & REPAI RS ( SQ UARE FEET) LAUNDRY & LI NEN SERVI CE ( TO TAL PATI ENT DAYS) HO USEKEEPI NG ( SQ UARE FEET) DI ETARY ( M EALS SERVED) NURSI NG ADM I NI STRATI O N ( DI RECT NRSI NG HRS)
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS
00400 ADM I NI STRATI VE & G ENERAL
00500 PLANT O PERATI O N, M AI NT. & REPAI RS 91, 682
00600 LAUNDRY & LI NEN SERVI CE 23, 158
00700 HO USEKEEPI NG 91, 682
00800 DI ETARY 3, 836 3, 836 73, 962
00900 NURSI NG ADM I NI STRATI O N 90, 151
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY
01200 M EDI CAL RECO RDS & LI BRARY
01300 SO CI AL SERVI CE 1, 329 1, 329
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 32, 094 13, 916 32, 094 41, 748 56, 371
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 31, 250 9, 242 31, 250 27, 726 33, 780
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y
04100 LABO RATO RY
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY 650 650
04500 O CCUPATI O NAL THERAPY 650 650
04600 SPEECH PATHO LO G Y
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS
04900 DRUG S CHARG ED TO PATI ENTS
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
69, 809 23, 158 69, 809 69, 474 90, 151
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN 1, 080 1, 080
09100 BARBER AND BEAUTY SHO P 278 278
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG 20, 515 20, 515 4, 488
Cr oss Foot Adj ust m ent s
Negat i ve Cost Cent er s
Cost t o be al l ocat ed ( per W kst . B, Par t I ) 775, 532 52, 985 263, 435 684, 941 548, 377 102. 00
Uni t cost m ul t i pl i er ( W kst . B, Par t I )
Cost t o be al l ocat ed ( per W kst . B, Par t I I ) 454 3 17 233 35 104. 00
Uni t cost m ul t i pl i er ( W kst . B, Par t I I )
EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 CO ST ALLO CATI O N - STATI STI CAL BASI S Cost Cent er Descr i pt i on CENTRAL SERVI CES & SUPPLY ( TO TAL PATI ENT DAYS) PHARM ACY ( CO STED REQ UI S. ) M EDI CAL RECO RDS & LI BRARY ( TO TAL PATI ENT DAYS) SO CI AL SERVI CE ( TO TAL PATI ENT DAYS) NURSI NG AND ALLI ED HEALTH EDUCATI O N ( ASSI G NED TI M E)
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS
00400 ADM I NI STRATI VE & G ENERAL
00500 PLANT O PERATI O N, M AI NT. & REPAI RS
00600 LAUNDRY & LI NEN SERVI CE
00700 HO USEKEEPI NG
00800 DI ETARY
00900 NURSI NG ADM I NI STRATI O N
01000 CENTRAL SERVI CES & SUPPLY 23, 158
01100 PHARM ACY 1, 361, 994
01200 M EDI CAL RECO RDS & LI BRARY 23, 158
01300 SO CI AL SERVI CE 23, 158
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 13, 916 967, 709 13, 916 13, 916
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 9, 242 394, 285 9, 242 9, 242
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y
04100 LABO RATO RY
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY
04500 O CCUPATI O NAL THERAPY
04600 SPEECH PATHO LO G Y
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS
04900 DRUG S CHARG ED TO PATI ENTS
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
23, 158 1, 361, 994 23, 158 23, 158
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN
09100 BARBER AND BEAUTY SHO P
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG
Cr oss Foot Adj ust m ent s
Negat i ve Cost Cent er s
Cost t o be al l ocat ed ( per W kst . B, Par t I ) 4, 659 116, 127 63, 808 0 102. 00
Uni t cost m ul t i pl i er ( W kst . B, Par t I )
Cost t o be al l ocat ed ( per W kst . B, Par t I I ) 7 70 0 104. 00
Uni t cost m ul t i pl i er ( W kst . B, Par t I I )
EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
I n Li eu of For m CM S- 2540- 10 Heal t h Fi nanci al Syst em s Dat e/ Ti m e Pr epar ed: W
2/ 16/ 2018 11: 20 am Per i od: To Fr om 01/ 01/ 2015 12/ 31/ 2015 Pr ovi der No. : 445999 CO ST ALLO CATI O N - STATI STI CAL BASI S O THER G ENERAL SERVI CE Cost Cent er Descr i pt i on PATI ENT ACTI VI TI ES ( TO TAL PATI ENT DAYS)
G ENERAL SERVI CE CO ST CENTERS
00100 CAP REL CO STS - BLDG S & FI XTURES
00200 CAP REL CO STS - M O VABLE EQ UI PM ENT
00300 EM PLO YEE BENEFI TS
00400 ADM I NI STRATI VE & G ENERAL
00500 PLANT O PERATI O N, M AI NT. & REPAI RS
00600 LAUNDRY & LI NEN SERVI CE
00700 HO USEKEEPI NG
00800 DI ETARY
00900 NURSI NG ADM I NI STRATI O N
01000 CENTRAL SERVI CES & SUPPLY
01100 PHARM ACY
01200 M EDI CAL RECO RDS & LI BRARY
01300 SO CI AL SERVI CE
01400 NURSI NG AND ALLI ED HEALTH EDUCATI O N
01500 PATI ENT ACTI VI TI ES 23, 158
I NPATI ENT RO UTI NE SERVI CE CO ST CENTERS
03000 SKI LLED NURSI NG FACI LI TY 13, 916
03100 NURSI NG FACI LI TY
03300 O THER LO NG TERM CARE 9, 242
ANCI LLARY SERVI CE CO ST CENTERS
04000 RADI O LO G Y
04100 LABO RATO RY
04200 I NTRAVENO US THERAPY
04300 O XYG EN ( I NHALATI O N) THERAPY
04400 PHYSI CAL THERAPY
04500 O CCUPATI O NAL THERAPY
04600 SPEECH PATHO LO G Y
04700 ELECTRO CARDI O LO G Y
04800 M EDI CAL SUPPLI ES CHARG ED TO PATI ENTS
04900 DRUG S CHARG ED TO PATI ENTS
05000 DENTAL CARE - TI TLE XI X O NLY
05100 SUPPO RT SURFACES
05200 CO M PLEX M EDI CAL EQ UI PM ENT
O UTPATI ENT SERVI CE CO ST CENTERS
06000 CLI NI C
06100 RURAL HEALTH CLI NI C
06200 FQ HC
06300 O THER O UTPATI ENT SERVI CE CO ST CENTER
O THER REI M BURSABLE CO ST CENTERS
07000 HO M E HEALTH AG ENCY CO ST
07100 AM BULANCE
07200 CO RF
07300 CM HC
07400 O THER REI M BURSABLE CO ST
SPECI AL PURPO SE CO ST CENTERS
08000 M ALPRACTI CE PREM I UM S & PAI D LO SSES
08100 I NTEREST EXPENSE
08200 UTI LI ZATI O N REVI EW
08300 HO SPI CE
08400 O THER SPECI AL PURPO SE CO ST CENTERS
SUBTO TALS ( sum
23, 158
NO NREI M BURSABLE CO ST CENTERS
09000 G I FT, FLO W ER, CO FFEE SHO PS & CANTEEN
09100 BARBER AND BEAUTY SHO P
09200 PHYSI CI ANS PRI VATE O FFI CES
09300 NO NPAI D W O RKERS
09400 PATI ENTS LAUNDRY
09500 I NDEPENDENT LI VI NG
Cr oss Foot Adj ust m ent s
Negat i ve Cost Cent er s
Cost t o be al l ocat ed ( per W kst . B, Par t I ) 86, 786
Uni t cost m ul t i pl i er ( W kst . B, Par t I )
Cost t o be al l ocat ed ( per W kst . B, Par t I I ) 6
Uni t cost m ul t i pl i er ( W kst . B, Par t I I )
EXAM PLE FACI LI TY M CRI F32 - 7. 16. 164. 0
Line Description Column Adjustment Amount Allowable Cost Per Medicaid (b) (c) (d) (e) (f) (g) 1.00 Owner's Compensation Limitation 200,000 $ 4.00 Administrative and General Salary (55,000) $ 145,000 $ 2.00 Payroll Tax (Related to Salary Limitations) 3.00 Employee Benefits Other (5,500) $ 3.00 Employee Benefits (Related to Salary Limitations) 3.00 Employee Benefits Other (7,500) $ 4.00 165,000 $ 4.00 Administrative and General Salary (20,000) $ 145,000 $ 5.00 Payroll Tax (Related to Salary Limitations) 3.00 Employee Benefits Other 6.00 Employee Benefits (Related to Salary Limitations) 3.00 Employee Benefits Other 7.00 Allocation of Medicaid Only Home Office Adjustment 9.00 Nursing Administration ‐ $ 8.00 Allocation of Medicaid Only Home Office Adjustment 12.00 Medical Records ‐ $ 9.00 Allocation of Medicaid Only Home Office Adjustment 30.00 SNF ‐ $ 10.00 Other (Specify): 2,000 $ 44.00 PT Other (2,000) $ ‐ $ 11.00 Other (Specify): 500 $ 45.00 OT Other (500) $ ‐ $ 12.00 Other (Specify): 150 $ 95.00 Independent Living Other (150) $ ‐ $ 13.00 Other (Specify): 1,700 $ 30.00 SNF Salary (1,700) $ ‐ $ 31.00 TOTALS 369,350 $ (92,350) $ Other Adjustment # 1 Other Adjustment # 2 Other Adjustment # 3 Other Adjustment # 4 Example Facility 7449999 (NF1) 445999 (NF2) Compensation Limits for Relatives of Owners or Administrators Tennessee Comptroller of the Treasury Division of State Audit Nursing Facility Medicaid Cost Report Adjustments to allowable 2540/2552 MEDICARE cost report expenses to comply with MEDICAID allowable cost guidelines for the nursing facility. Note: Reductions in expense that are input into Col. (f) "Adjustment Amount" must be entered as a negative number. (a) SCHEDULE D - Medicare/Medicaid Cost Reconciliation 445999 Description of Adjustment Medicare Cost Report Worksheet A Printed: 5/3/2018 7449999 ‐ Example Facility ‐ 20151231 Cost Report TN NF
TN Case Mix Reimbursement System
Example of Summary Allocation of Rate Components Page 1
Rate Component Cost Center Description 30.00 IC SKILLED NURSING FACILITY 174,711 IC 118,285 IC 1,392 EX 189 PAS 8,436 DCA 8,076 DCN 59,414 IC
30.00 DCN Reconcile DON Salaries 81,003 DCN 178,513 DCN 15 EX
6,942 DCA 7,978 DCN 6,915 IC
30.00 DCA Reconcile RN Salaries 1,095,502 DCA 15,504 DCA 66 EX 7 PAS 100,942 DCA
8,522 IC
30.00 IC Reconcile MDS Coord. Salaries 173,008 IC 49,913 IC 13 EX 1 PAS
14,057 IC
30.00 PAS Reconcile Property Taxes
10,509 PAS
30.00 EX Reconcile Provider Assessment
24,001 EX 1 EX
208 EX 31.00 IC NURSING FACILITY
33.00 EX OTHER LONG TERM CARE 384,145 EX 10,140 EX 1,309 EX 178 EX
78,996 EX 40.00 EX Other Ancillary
447,532 EX 73 EX 8 PAS
4,315 IC
90.00 EX Other Non-Reimbursable 331,496 EX 123,757 EX 867 EX 117 EX
42,500 EX Totals 2,239,865 978,154 3,736 500 116,320 16,054 93,223 121,704
Rate Component Cost Center Description 30.00 IC SKILLED NURSING FACILITY 134,763 IC 25,498 EX 257,595 IC 28,147 IC 89,055 IC 140,734 IC 97,527 IC 261,962 DCN 30.00 DCN Reconcile DON Salaries 24,822 IC 4,707 EX
30.00 DCA Reconcile RN Salaries 113,133 IC 21,448 EX
30.00 IC Reconcile MDS Coord. Salaries 22,269 IC 4,222 EX
30.00 PAS Reconcile Property Taxes 974 IC 184 EX
30.00 EX Reconcile Provider Assessment 2,563 EX 486 EX
31.00 IC NURSING FACILITY
33.00 EX OTHER LONG TERM CARE 117,930 EX 22,313 EX 244,079 EX 18,694 EX 84,381 EX 93,466 EX 58,442 EX 188,801 EX 40.00 EX Other Ancillary 42,598 IC 8,073 EX 9,552 IC
3,302 IC
90.00 EX Other Non-Reimbursable 69,095 EX 13,070 EX 162,428 EX
56,152 EX 15,129 EX
Totals 528,147 100,001 673,654 46,841 232,890 249,329 155,969 450,763
Rate Component Cost Center Description 30.00 IC SKILLED NURSING FACILITY 85,666 DCA 89,334 IC 39,546 IC 30.00 DCN Reconcile DON Salaries
Rate Component Totals 30.00 DCA Reconcile RN Salaries
Direct Care CMI Adjusted 1,312,992 DCA 30.00 IC Reconcile MDS Coord. Salaries
Direct Care Non-CMI Adjusted 537,532 DCN 30.00 PAS Reconcile Property Taxes
Indirect Care 1,702,491 IC 30.00 EX Reconcile Provider Assessment
Cost Based 10,714 PAS 31.00 IC NURSING FACILITY
Excluded 2,790,491 EX 33.00 EX OTHER LONG TERM CARE 51,335 EX 55,678 EX 25,511 EX 6,354,220 40.00 EX Other Ancillary
90.00 EX Other Non-Reimbursable
Totals 137,001 145,012 65,057 (1) Employee benefits represent pooled employee benefits expense contained in the employee benefits cost center of the Medicare cost reporting form. Directly assigned employee benefits through Schedule C of the Medicaid cost report would be included with the direct costs of the appropriate cost center. (2) Medicare cost report Worksheet A, Column 1, "Salary" and Column 2, "Other", represent the direct costs for these cost centers, after accounting for both the Medicare and Medicaid supplemental cost reports. All remaining categories represent the end result of the Medicare cost-finding (step-down) appropriation process of allocating overhead (general service) costs. 814,611 6,354,220 Tennessee Rate Setting Component Legend 11,667 27,259
515,453 Reconcile Licensed Registered Nurse Reconcile MDS Coordinator Social Service Total Adjusted Net Expense for 1,620,330 310,895 Pooled Employee Benefits Worksheet A - Salary Worksheet A - Other Capital - Bldg. & Fixtures Reconcile Property Taxes Employee Benefits (DC CMI) Employee Benefits (DC NCMI) Employee Benefits (Indirect) Employee Benefits (Excluded) Administrative and General Reconcile Provider Assessment Plant Operation, Maint., and Repairs Laundry and Linen Housekeeping Dietary Nursing Admin. Reconcile DON 1,355,124 263,483
TN Case Mix Reimbursement System
Example of Individual Cost Center Cost Finding Appropriation Process For Administrative and General Costs Page 2
Rate Component Cost Center Description Net Expense for Allocation Administrative and General Reconcile Provider Assessment Plant Operation, Maint., and Repairs Laundry and Linen Housekeeping Dietary Nursing Admin. Reconcile DON Reconcile Licensed Registered Nurse Reconcile MDS Coordinator Social Service Total 1.00 EX Capital - Bldg. & Fixtures 3,736
Reconcile Property Taxes 500
Employee Benefits 347,301
Administrative & General 528,147 528,147
Reconcile Provider Assessment 100,001 9,120 9,120
Plant Operation, Maint. & Repairs 673,654 62,490 1,100 63,590
Laundry & Linen Service 46,841 4,272 75
Housekeeping 232,890 21,240 374
Dietary 249,329 25,083 441
Nursing Administration 155,969 14,578 257
Reconcile DON Salaries 450,763 33,337 587
Reconcile RN Salaries 137,001 13,725
Reconcile MDS Coord. Salaries 145,012 23,510
Social Service 65,057 6,118 108 922
SKILLED NURSING FACILITY 292,996 28,437 1,201 23,260 2,612 8,468 15,120 9,276 19,569 7,709 14,586 4,525 134,763 30.00 DCN Reconcile DON Salaries 259,516 24,682 140
30.00 DCA Reconcile RN Salaries 1,111,006 111,177 1,956
30.00 IC Reconcile MDS Coord. Salaries 222,921 21,778 491
30.00 PAS Reconcile Property Taxes 10,509 958 16
30.00 EX Reconcile Provider Assessment 24,001 2,517 46
31.00 IC NURSING FACILITY
OTHER LONG TERM CARE 394,285 40,032 798 23,208 1,735 7,367 8,639 5,559 12,716 6,016 8,924 2,936 117,930 40.00 EX Other Ancillary 447,532 40,675 715 902
90.00 EX Other Non-Reimbursable 455,253 44,418 815 15,298
1,765
Totals 6,354,220 528,147 9,120 63,590 4,347 21,614 25,524 14,835 33,924 13,725 23,510 7,461 528,147 Inpatient Routine Service Cost Centers General Service (Overhead) Cost Centers Ancillary Service Cost Centers Non-Reimbursable Cost Centers
TN Case Mix Reimbursement System
Example of Individual Cost Center Cost Finding Appropriation Process For Provider Assessment Page 3
Rate Component Cost Center Description Net Expense for Allocation Administrative and General Reconcile Provider Assessment Plant Operation, Maint., and Repairs Laundry and Linen Housekeeping Dietary Nursing Admin. Reconcile DON Reconcile Licensed Registered Nurse Reconcile MDS Coordinator Social Service Total 1.00 EX Capital - Bldg. & Fixtures 3,736
Reconcile Property Taxes 500
Employee Benefits 347,301
Administrative & General 528,147
Reconcile Provider Assessment 100,001 100,001
Plant Operation, Maint. & Repairs 673,654 12,062 12,062
Laundry & Linen Service 46,841 822
Housekeeping 232,890 4,101
Dietary 249,329 4,836
Nursing Administration 155,969 2,818
Reconcile DON Salaries 450,763 6,437
Reconcile RN Salaries 137,001
Reconcile MDS Coord. Salaries 145,012
Social Service 65,057 1,184 175
SKILLED NURSING FACILITY 292,996 9,785 4,412 494 1,607 2,865 1,762 3,713
25,498 30.00 DCN Reconcile DON Salaries 259,516 4,707
30.00 DCA Reconcile RN Salaries 1,111,006 21,448
30.00 IC Reconcile MDS Coord. Salaries 222,921 4,222
30.00 PAS Reconcile Property Taxes 10,509 184
30.00 EX Reconcile Provider Assessment 24,001 486
31.00 IC NURSING FACILITY
OTHER LONG TERM CARE 394,285 10,521 4,402 328 1,398 1,637 1,056 2,413
22,313 40.00 EX Other Ancillary 447,532 7,844 171
90.00 EX Other Non-Reimbursable 455,253 8,544 2,902
334
Totals 6,354,220
12,062 822 4,101 4,836 2,818 6,437
100,001 Inpatient Routine Service Cost Centers General Service (Overhead) Cost Centers Ancillary Service Cost Centers Non-Reimbursable Cost Centers
Cost Center Category Medicare Cost Report Cost Center Description Fair Rental Value Component Direct Care Case Mix Adjusted Direct Care Non-Case Mix Adjusted Administrative and Operating Cost-Based Component Expense Excluded Capital Blds & Fixtures / Capital Moveable Equip X4 Employee Benefits X 1 X 1 X 1 X 1 Administrative and General X Plant Operations and Maintenance X Laundry and Linen X Housekeeping X Dietary X Nursing Administration X Central Services and Supply X Pharmacy X Medical Records X Social Service X Nursing and Allied Health Education X Other General Service Cost Centers X Skilled Nursing Facility X Nursing Facility X ICF - Mentally Retarded X Other Long Term Care X Radiology X2 Laboratory X2 Intravenous Therapy X2 Oxygen (Inhalation) Therapy X2 Physical Therapy X2 Occupational Therapy X2 Speech Pathology X2 Electrocardiology X2 Medical Supplies Charged to Patients X2 Drugs Charged to Patients X2 Dental Care - Title XIX Only X2 Support Surfaces X2 Other Ancillary Services X2 Other Outpatient Services Clinic X Non-NF Services X
Tennessee Division of Health Care Finance and Administration Nursing Facility Rate Component Crosswalk
WARNING: Medicaid will only recognize costs in a rate component based on the case mix cross-walk shown below. If a facility chooses to classify costs on the Medicaid cost report in a manner that excludes that cost from their direct care or administrative and operating rate components, then the cost will forever be excluded from the direct care and administrative and operating rate components, unless adjusted at audit or desk review.
Medicare 2540-10 (2552-10) Cost Center Crosswalk to Tennessee Case Mix Rate Components
Rate Component General Service Cost Centers 1 Ancillary Service Cost Centers Non- Reimbursable Cost Centers Routine Cost Centers
Cost Center Category Medicare Cost Report Cost Center Description Fair Rental Value Component Direct Care Case Mix Adjusted Direct Care Non-Case Mix Adjusted Administrative and Operating Cost Based Component Expense Excluded Director of Nursing (DON) X Assistant Director of Nursing (ADON) X Registered Nurse (RN) X Licensed Practical/Vocational Nurse (LPN/LVN) X Certified Nurse Aide (CNA) X Raw Food X Social Services X Recreational (Patient) Activities X Minimum Data Set (MDS) Coordinator X Quality Assurance (Infection Control) Coordinator X Inservice (Training) Coordinator X Ward Clerk (Unit Secretary) X Property Insurance X Property Taxes X Provider Assessment X Rate Component Medicaid Supplemental Cost Report Specific Cost Items (Sch. C)
2 Indirect Ancillary Cost: Costs from the Capital, Administrative and Operating, Direct Care Case Mix Adjusted, and Direct Care Non-Case Mix Adjusted rate components may have a portion of their costs attributable to ancillary cost centers through the Medicaid cost report cost allocation process. The indirect ancillary costs that are allocated to ancillary cost centers will be included in the same rate component as the routine portion of expense. Costs that are allocated to an excluded rountine, outpatient, or non-reimbursable cost center are excluded from reimbursable nursing facility expense. Hospital-based nursing facilities will only included indirect expense allocated to allowable routine cost centers in nursing facility allowable cost, all other indirect cost allocation will be excluded. 1 Employee Benefit Cost: Employee Benefit cost is allocated on the basis of salaries to all rate components. Employee Benefit expense allocated to excluded rate component salaries will be excluded from reimbursable nursing facility expense. 3 Direct Ancillary Cost: The direct cost of reimbursable ancillary cost centers is excluded from the allowable nursing facility expense 5 Allocation of Rate Component Expense: It is important to note that all expenses will be subject to the Medicare cost report step-down/cost-finding process (B series worksheets). During this allocation process, expenses that are stepped down to non-reimbursable areas will be excluded from rate setting. 4 Fair Rental Value: The FRV calculation replaces the cost in these cost centers. The capital cost is excluded from the development of the Fair Rental Value, and is not included in the rate setting process.Medicaid Supplemental Cost Center Crosswalk to Tennessee Case Mix Rate Components
: Reviewed : 1/1/2018 : 7.19080% : 7449999 : 42 : 445304 1/1/2015 to 12/31/2015 : 15,330 : 16,690 : 83.38% : 13,916 : 12,782 : 3,557 : 10.49% QUALITY COMPONENT INCENTIVES Quality Tier Rating Tier 1 Increase in Direct Care Non CMI Adjusted Price Due to Quality Tier Rating 5.00% Increase in FRV Maximum Square Footage Per Bed Due to Medicaid Private Room Occupancy Percentage $3,000 Stand-alone Quality Incentive Payment Per Diem $10.55 CASE MIX INDEX (CMI) VALUES Base Year Cost Report Period Total Facility (All Payers) Case Mix Index: 1.0784 Facility Medicaid Average Case Mix Index (As of 9/30/2017): 0.9928 CALCULATION OF FAIR RENTAL VALUE PER DIEM Appraisal Undepreciated Facility Replacement Cost $2,300,000 Calculated Depreciation Applied for Rate Setting (70.00% of Appraisal Depreciation) $665,000 Depreciated Net Facility Value for Rate Setting $1,635,000 Allowable Land Value $145,000 Facility Fixed Asset Additions (After Appraisal) $0 Total Facility Base Value $1,780,000 Maximum Allowable Base Value (42 Licensed Beds * ($75,000 Base Value + $3,000 Private Room Additional Value) $3,276,000 Lesser of Facility Base Value or Maximum Allowable Base Value $1,780,000 Allowable Base Value Add-on for Movable Equipment (42 Licensed Beds * $7,500) $315,000 Total Facility Value $2,095,000 Rental Rate 8.70% Annual Fair Rental Value $182,265 Divided by Greater of Total Annual Patient Days or 85.00% of Total Annual Bed Days Available 13,031 Fair Rental Value Per Diem $13.99
DIRECT CARE CASE MIX ADJ DIRECT CARE NON CASE MIX ADJ TOTAL
Price Calculation (Prior to Spending Floor Reduction) Statewide Price Per Provider $67.56 $18.79 $86.35 Times Direct Care Non CMI Median Cost Quality Incentive Factor N/A 105.00% Times the Facility Medicaid Average Case Mix Index 0.9928 N/A Facility Specific Total Direct Care Rate (Prior to Floor Adj.) $67.07 $19.73 $86.80 Spending Floor Requirement Calculation: Spending Floor Percentage of Total Direct Care Rate 82.50% Floor Spending Requirement $71.61 Spending Floor Adjustment Calculation: Base Year Per Diem Cost - C/R Period Ending 12/31/2015 $92.18 $40.17 Divided by the Facility Cost Report Period Case Mix Index 1.0784 N/A Facility Neutralized Direct Care CMI and Direct Care Non CMI Cost $85.48 $40.17 Times the Facility Medicaid Average Case Mix Index 0.9928 N/A Medicaid CMI Adjusted Inflated/Neutralized Direct Care Cost $84.86 $40.17 $125.03 Spending Floor Adjustment $0.00 Facility Specific Rate (After Spending Floor Adjustment): Facility Specific Total Direct Care Per Diem Rate [$86.80 + ($0.00)] $86.80 PRIOR SYSTEM REIMBURSEMENT RATE (Includes Consideration of Quality and Acuity Quarterly Payments) $220.24 Administrative and Operating Rate $83.22 Facility Specific Direct Care Case Mix and Direct Care Non Case Mix Adjusted Rate $86.80 Capital Rate (Fair Rental Value Per Diem) $13.99 Cost-Based Component Rate: Property Tax (Inflated from base year to 12/31/2017) $0.81 Nursing Facility Provider Assessment $13.04 Quality Incentive Payment Per Diem $10.55 Medicaid Reimbursement Rate Prior to BAF and Phase-In $208.41 Budget Adjustment Factor (BAF) 99.7744% Medicaid Reimbursement Rate After BAF and Prior to Phase-In $207.94 Corridor Phase-In Calculation $6.30 $214.24 Provider Number Level II NF. . . . . . . . . . . . . . . . . . . . Bed Days Available per Base Year Cost Report Period . . Resident Days per Base Year Cost Report Period . . . . . . Occupancy % per Base Year Cost Report Period . . . . . . . . . . . . . . . . Annual Resident Days per Base Year Occupancy % . . . . . . . . . . . . . . Base Year Cost Report Period . . . . . . : Annual Bed Days Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tennessee Division of Health Care Finance and Administration
JANUARY 1, 2018 SCHEDULE OF REIMBURSEMENT RATE
Provider Number Level I NF. . . . . . . . . . . . . . . . . . . . . . . 123 Anywhere Lane Nashville, TN 37201
Example Facility
Rate Effective Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12/31/2017 Inflation Factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cost Report Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Licensed Beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Base Year Private Room Medicaid Resident Days . . . . . . Medicaid Reimbursement Rate Effective January 1, 2018 CALCULATION OF FACILITY SPECIFIC DIRECT CARE CMI AND DIRECT CARE NON CMI ADJUSTED PER DIEM CALCULATION OF REIMBURSEMENT RATE Base Year Private Room Medicaid Resident Day Occupancy % . . . . Phase-In Adjustment (+$7.98/-$6.00 Corridor Applied From Prior System Rate)
Quality Informed Rate Components
Non-Case Mix Adjusted Facility Specific Medicaid Rate
Spending Floor Adjustment
Quality Tier Rental Factor Quality Tier 1 8.70% Quality Tier 2 8.35% Quality Tier 3 8.00% Quality Tier Multiplier Quality Tier 1 105.00 percent multiplier Quality Tier 2 102.50 percent multiplier Quality Tier 3 100.00 percent multipler
Effective Date of Quality Tier Floor Percentage Quality Tier 1 Quality Tier 2 Quality Tier 3 July 1, 2018 82.50% 85.00% 87.50% July 1, 2019 85.00% 87.50% 90.00% July 1, 2020 87.50% 90.00% 92.50% July 1, 2021 90.00% 92.00% 94.00%
Health Care Finance and Administration • 310 Great Circle Road • Nashville, TN 37243 tn.gov/hcfa • tn.gov/tenncare Page 1 STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION
BUREAU OF TENNCARE
310 Great Circle Road NASHVILLE, TENNESSEE 37243
Tennessee Medicaid Nursing Facility Case‐Mix Capital Improvement Update Requests
As identified in the proposed rulemaking from the Tennessee Division of Finance and Administration (TennCare), nursing facilities that will be reimbursed under the forthcoming case‐mix reimbursement system may now submit Capital Improvement Update Requests on a semi‐annual basis in years outside
Update Requests and supporting documentation must be received by TennCare’s contractor, Myers and Stauffer, no later than 3 months prior to a rate setting period. The Capital Improvement Update Request form must meet the following acceptance criteria: Cost included on the Capital Improvement Update Request must:
104.2 Buildings.‐‐Building includes, in a restrictive sense, the basic structure or shell and additions thereto. The remainder is identified as building equipment. 104.3 Building Equipment.‐‐Building equipment includes attachments to buildings, such as wiring, electrical fixtures, plumbing, elevators, heating system, air conditioning system, etc. The general characteristics of this equipment are: (a) affixed to the building, and not subject to transfer; and (b) a fairly long life, but shorter than the life of the building to which affixed. Since the useful lives of such equipment are shorter than those of the buildings, the equipment may be separated from building cost and depreciated over this shorter useful life.
104.4, Major Moveable Equipment is defined as:
104.4 Major Moveable Equipment.‐‐The general characteristics of this equipment are: (a) a relatively fixed location in the building; (b) capable of being moved as distinguished from building equipment; (c) a unit cost sufficient to justify ledger control; (d) sufficient size and identity to make control feasible by means of identification tags; and (e) a minimum life of approximately three years. Major moveable equipment includes such items as accounting machines, beds, wheelchairs, desks, vehicles, x‐ray machines, etc.
Health Care Finance and Administration • 310 Great Circle Road • Nashville, TN 37243 tn.gov/hcfa • tn.gov/tenncare Page 2
Improvement Update Request. An exception will be allowed for submissions prior to March 31, 2018 deadline. For the initial Capital Improvement Update Request period, items placed in service from the date of your last appraisal going forward may be included in the Capital Improvement Update Request form. Submissions after the March 31, 2018 deadline must adhere to the 12 month placed in service thresholds.
prior to the Capital Improvement Update Request.
expenses if the capital expenditures apply to both nursing and non‐nursing facility areas. Nursing facility services include direct care services, as well as the administrative and general expense, and other business operations expense necessary to support the functioning of the nursing facility. Supporting documentation relating to any allocation
improvement update form.
For example, if a nursing facility has leased space to a separate entity, improvements to the leased space (or leased spaces allocation of capital improvements) should be reported in the “Non‐Nursing Facility Related” section of the Capital Improvement Update Form, or can be excluded from the form altogether. Supporting documentation relating to any allocation of expense between nursing and non‐nursing areas must be submitted with the capital improvement update form. Additionally, the Capital Improvement Update Request must be submitted on the form designated by the department no later than 3 months prior to the applicable rate period. For the July 1 rate period, the Capital Improvement Update Request and all required supporting documentation must be submitted by end of day March 31, 2018. For the January 1 rate period, the Capital Improvement Update Request and all required supporting documentation must be submitted by end of day September 30, 2018. Supporting documentation should be the facility’s most recent depreciation schedule at the time of
the date placed in service, and show the cost of the item. All items included in the Capital Improvement Update Request should be clearly identified. Upon review and acceptance of a Capital Improvement Update Request, the qualifying capitalized fixed asset expenditures will be added to the total facility base value utilized for the fair rental value (FRV) per
Health Care Finance and Administration • 310 Great Circle Road • Nashville, TN 37243 tn.gov/hcfa • tn.gov/tenncare Page 3 diem calculation purposes. The qualifying capitalized fixed asset expenditures will not be inflated or depreciated. Please note that a NF statewide mandatory appraisal or voluntary reappraisal will eliminate all previously submitted and accepted Capital Improvement Update Requests expenditures in calculation of the FRV per diem. Additionally, no Capital Improvement Update Requests will be accepted during an appraisal year, as it is assumed the provider will have received credit for these items during the appraisal process. Provider Filing Information and Help Desk Support: To file a Capital Improvement Update Request, please download the required form from TennCare’s website or Myers and Stauffer’s website as shown below. This form should be fully completed with an Administrator/Management signature. The form and all supporting documentation should be submitted directly to Myers and Stauffer via email at TNCaseMix@mslc.com. If you have any questions concerning the above requirements and procedures, or about the required form, please contact Myers and Stauffer at 800‐374‐6858. To access the Capital Improvement Update Request form on TennCare’s Website: https://www.tn.gov/tenncare/providers/miscellaneous‐provider‐forms.html To access the Capital Improvement Update Request form on the Myers and Stauffer Website: http://www.mslc.com/tennessee/TN_Downloads.aspx
Tennessee Division of Health Care Finance and Administration Nursing Facility Capital Improvement Update Request Form
Provider Name: Medicaid NF Level 1 Number: Medicaid NF Level 2 Number: Date of Request: Notes:
A. 1. 2. 3. 4. 5. 6. B. 1. 2. C. D.Non-Nursing Facility Related
Submitted N/A
*Please place in "X" in the applicable areas below1. 2. 3. Administrator / Management Signature Title Date Administrator / Management (Print Name) Email
* Attn: Tennessee NF Myers and Stauffer, LC 700 W. 47th Street, Suite 1100 Kansas City, Missouri 64112 Phone: 1-800-374-6858 Fax: (816) 945-5301 e-mail: TNCaseMix@MSLC.COMMarch 31
Please complete all applicable "Green" input cells.Date of Last FRV Appraisal (Mandatory or Voluntary)
If capital expenditures apply to both nursing facility and non-nursing facility areas, an allocation factor (square feet, resident days, etc.) must be utilized to segregate the expenses. Nursing facility services include direct care services, as well as administrative and general expense, and other business operations expense necessary to support the functioning of the nursing facility. Non-nursing facility functions relate to non-allowable/non-nursing facility service areas. For example, if a nursing facility has leased space to a separate entity, improvements to the leased space (or the leased spaces allocation of capital improvements) should reported in the Non-Nursing Facility Related section of this form, or it can be excluded from this form altogether. Fixed assets must be capitalized in accordance with CMS Publication 15-1 section for inclusion on this form.Documentation of all insurance proceeds or government assistance payments (FEMA, etc.) received.
Tennessee Code §1200-13-02-.06.(5)(c)(8) details the requirements of an acceptable capital improvement update request, and should be reviewed for compliance prior to submission. The major acceptance provisions are as follows:Capitalized Improvements Totals Nursing Facility Related
Only fixed assets as defined in CMS Publication 15-1 section 104.2 (Building) and 104.3 (Building Equipment) may be submitted for Capital Improvement Update consideration. The submitted depreciation schedule must be the most recent version at the time of submission. The depreciation schedule should include all current items for the entire facility, and should also clearly identify which items are being requested for capital improvement update request purposes.Capitalized Fixed Assets
This form may not contain capital expenditures that occurred during a statewide mandatory appraisal period or a voluntary provider reappraisal period. Capital improvements must be segregated between improvements impacting nursing facility service areas and non-nursing facility service areas. Capital improvement expenditures must exceed $1,000 per licensed bed. Licensed beds shall be those determined as of the April 1 prior to submission of this form. Capital improvement expenditures must exclude all grant or insurance proceeds associated with the purchasing of the asset. Only capitalized items placed into service less than 12 months prior to the submission date of this form may be included. Electronic submissions for both the signed capital improvement update request form and all applicable supporting documents is the preferred submission method. A form that has be printed, signed, scanned, and emailed to the TNCaseMix@MSLC.com will satisfy the signature requirements. Should the provider prefer to transmit a hard copy of the signed report and/or supporting documentation, please use the information provider below:Oldest Placed in Service Date Brief Description of Capital Improvements
Depreciation schedule must identify date placed in service, total capitalized cost, and clearly indicate requested items Documentation supporting any allocation of improvement expense between nursing and non‐nursing areas. Description Rate Effective Date Due Date
Documentation Checklist Due Dates
January 1 September 30 July 1