Wyoming Long Term Care Reimbursement System

Wyoming Department of Health

Wyoming Long Term Care Reimbursement System

The following is a list of the enclosed forms and instructions for use in submitting your Financial Report for Long Term Care. Use of any substitute forms must have the prior approval of the Department. See Section 5(e) of Chapter VII, Wyoming Nursing Home Reimbursement System for the proper procedures to follow.

Schedules

A Statistical Data (beds, days, occupancy), and Certification Statement (signature required)

B Specific Cost & Revenue Detail

C Ancillary Charge Information

D Analysis of Financing

E Analysis of Leased Property

F Analysis of Management Fees

G Analysis of Home Office Expense and Home Office Allowable Expense Allocation

H Schedule of Revenues (complete only if not required to file a Medicare cost report)

I Schedule of Expenses (complete only if not required to file a Medicare cost report)

Instructions for electronic filing

Completion of an electronic form is the preferred method of filing your Financial Report for Long Term Care. To ensure you have the most current and proper version, please download the blank cost report template at http://www.mslc.com/Wyoming/ each filing period. The Financial Report for Long Term Care Form is set up in an Excel workbook. You will need Excel version 2000 (or higher) to use the electronic report. To obtain an earlier version of this file, please contact Myers and Stauffer at (800) 336-7721. There are 6 worksheets within the workbook (Schedules A-G), as seen by the corresponding tabs along the bottom of your screen. To access each worksheet, click on the appropriate tab with your mouse.

Every worksheet requires that some information be keyed. All cells available for input are designated with a yellow background.

The file is password protected, as no text, formatting, or other changes are allowed. For this reason, information can only be keyed into the yellow cells. A copy of the file can be used for data entry, as the password protection will be retained. If you require additional lines on a worksheet, please contact Myers and Stauffer to request a modified version of the file. After all forms have been completed, re-save the file to the disk and mail it back to Myers and Stauffer or email to , along with the other required items listed on the checklist.

For certification purposes, a signed copy of page one of the form must be submitted along with the electronic file.

User Tip: Using the "Tab" and "Shift Tab" keys during data entry will move you quickly between valid data cells. This will help to avoid navigating through locked cells (and thereby reduce the number of pop-up messages you receive). If you need assistance in using the electronic form, you may contact Myers and Stauffer directly.

General Submission Instructions

All enclosed forms must be completed and submitted. For any form not applicable to your facility, a notation should be made on the form stating that it does not apply.

Certification is required in the form of a signature on Schedule A.

This cost report must be submitted by the end of the fifth month following the provider's fiscal year end. Other required information must also be submitted. This information includes:

· Medicare cost report (including the electronic version submitted to Medicare – SN or EC format)

· Working trial balance actually used to prepare the Medicare cost report with line number tracing notations or similar identification

· Audit, review or compilation statement prepared by an independent accountant, including disclosure statements and management letter or SEC Form 10-K

· Home office cost statement (if applicable)

· Contracts or agreements involving the purchase of facilities and equipment during the last seven years

· Contracts or agreements with owners or related parties

· Lease agreements regarding property

· Management contracts

· Mortgages and loan agreements

A cover letter should accompany each submission of a cost report. It should list the contents of the current filing and provide an explanation for any omitted information.

General Preparation Instructions

These instructions are not comprehensive. In completing the forms, providers should rely on the Nursing Home Reimbursement Rule for guidance. The Nursing Home Reimbursement Rule requires adherence to generally accepted accounting principles (GAAP) unless the Rule language is to the contrary. An important principle of GAAP in presenting information is full disclosure. In completing the forms, attach additional schedules and explanations, where necessary, to accomplish full disclosure. Full disclosure requires that a knowledgeable financial reader, after reviewing the completed forms and attachments, is not misled. GAAP requires accurate classification of expenses. Report all data on appropriate lines and schedules of the form. The reporting of expense amounts on inappropriate lines may tend to be misleading to the financial reader. It is particularly important to record expenses in the correct cost center and lines. Since the rule sets forth different reimbursement treatment for different costs, incomplete or omitted data will result in additional information requests which can delay the completion of a provider's rate review.

Boxes that are shaded on the form should not be used in reporting data.

Detailed workpapers involving several pages normally should not be submitted with the cost report. However, they should be available to the Department and its auditors upon request.

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Specific Instructions

Most schedules and lines of the cost report are self-explanatory. The following items deserve extra clarification.

Provider Name and Identification Data

Lines 110(01), 110(02) should contain the beginning and ending date of the financial and statistical data. This is normally 12 months. In those cases involving less than 12 months, calculate the actual number of days in the period. Base the required statistical and other data upon the fraction of a year involved.

Lines 121(06), 121(08) should be the same period.

Lines 132(01) through 132(09) are for use by the Department.

Schedule A Statistical Data

This section must be completed and must account for all beds in the facility.

Line 143 When the number of beds is the same at the beginning of the period and the end of the period, total bed days available is simply the number of beds times the number of days in the period. Usually this is 365 days, or 366 days if the period includes leap year (February 29). If there was a change in the number of beds during the period, line 143 must be time weighted. It should agree with Schedule F - History of Bed Changes.

Lines 144- 148 The number of reported days should agree to the amounts reported on Worksheet S-3 of the Medicare cost report.

Certification Statement

After adequate review of the completed form, the certification statement must be signed by an authorized person.

Schedule B Specific Cost & Revenue Detail

For each item identified, record the amounts from the general ledger and the corresponding cost report line number.

Schedule C Ancillary Charge Information

Amounts reported should agree with your Medicare PS&R report and working trial balance for the cost report period. If amounts are different, please provide a reconciliation and indicate the correct amounts.

Line 300, Credit Balance, is used to report Medicaid funds that are owed to the Department for any reason. The amount of the credit balance must be remitted to the Department within 60 days after the identification of the credit balance.

Schedule D Analysis of Financing

Identify each financing arrangement entered into to acquire patient related property or provide patient related working capital. Each financing arrangement should be reported in a separate column. If a financing arrangement provides both permanent financing and working capital, attach a detailed allocation sufficient to identify the interest expense associated with each type of financing.

Schedule E Analysis of Leased Property

If a lease has been reported on a prior cost report and none of the items on lines 778 through 786 have changed, these items do not need to be reported. Identify each leasing arrangement used to lease/rent patient related property. Property leased through a related party lease (line 762 is Yes) should be included on Schedule F at the lower of cost to the related lessor or fair market value at the date of lease. The cost of property acquired through capital leases with unrelated parties should also be included on Schedule F. To determine the type of lease, refer to Financial and Accounting Standards Board Statement of Standards No. 13 and subsequent pronouncements.

Schedule F Analysis of Management Fees

List all management fees with unrelated parties. Related party management fees should be reported on Schedule K.

Schedule G Analysis of Home Office Expense

Report all pooled or home office expenses that service more than one facility. Care should be taken to identify and allocate expenses to other business activities and out of state facilities. Allocated home office expenses should be properly reported on Schedule E, line 546 and line 547. (Note: Do not complete this schedule if you are submitting a Home Office Cost Report.)

Schedule H Revenues (Complete only if not required to file a Medicare cost report)

All revenues must be properly classified and recorded in the general ledger. They must also be included in this schedule. If a provider does not maintain adequate cost segregation or if such accounts cannot reasonably be subjected to normal audit procedures, then the related revenue on Schedule H shall be used as an adjustment to patient expense, provided the related revenue amount is reasonably equal to or greater than cost reported on Schedule I.

Schedule I Expenses (Complete only if not required to file a Medicare cost report)

Particular attention should be paid to the correct classification of expenses. Expenses should be classified to the proper cost component, cost center within the cost component, line within the cost center, and column for each line. Other lines are provided in each cost center for these items not specifically identified (i.e., consultants) in Schedule I. These lines are as follows:

Cost Center Line to Report Other Costs

Nursing and Nursing Services 422

Dietary 464

Laundry & Housekeeping 513

Plant Operations 535

Administration 576

Column 1 Hours Paid: The hours paid column should include all hours paid and reported in the general ledger. This should include applicable vacation, sick leave and holidays.

Column 2 Provider Adjustment: Should be the number of hours required to adjust hours paid to hours worked.

Column 3 Hours Worked: Should include all hours personnel actually worked in the facility. Inservice training, continuing education and nurse's aide training should be reported on the proper lines in the Nursing & Nursing Service cost center.

Column 4 Personnel: Should contain all salaries, wages and contractual amounts paid for services performed by employees or owners. Costs associated with inservice training, continuing education and nurse aide training should be reported separately on the proper lines in the Nursing & Nursing Service cost center. If personnel costs are reported for a line item in column 4, then hours must be reported in column 1 and 3. (Note: In certain instances, such as director's fees, the accounting records may not accumulate hours. Report the expense in column 4 and indicate, with an N/A (use zero in electronic file), that hours are unavailable.)

Column 5 Other: All expenses not classified as personnel costs should be reported on the appropriate expense lines of column 5. Expense amounts should come from the general ledger. If unlabeled other lines are used, identify the nature of the item reported. If more than one item is reported on another line, attach a schedule identifying the elements and dollar amounts of the items reported on the line.

Column 6 Provider Adjustments: This column provides for the removal of non-allowable costs which are not reasonably related to services included in the Medicaid per diem rate, or which are against public policy. The amount removed should be the related expenses recorded in the general ledger or the associated revenue reported on Schedule H to offset the costs reported on Schedule I. A schedule supporting the adjustments reported in this column identifying how the adjustment was determined is required.

Column 7 Reported Cost: This column is the sum of columns 4, 5, and 6.

Lines 434, 435, 436, 441 The expense and hours associated with inservice training, continuing education, nurses' aide training and attendant travel should be reported on these lines.

Line 442 This line is for use by Intermediate Care Facilities for the Mentally Retarded only.

Line 455 The expense and hours associated with food service training should be reported on this line.

Line 481 Interest on Facilities and Equipment: Should agree with the interest expense on Schedule D, line 742 for those financing arrangements identified as property financing on Schedule D, line 713.

Line 485 and 486 Should agree with lease expense associated with building components (line 485) and moveable equipment (line 486) reported on Schedule E, line 775. Executory costs arising from lease or rent agreements should be reported on the lines that are most descriptive. They should not be reported on lines 485 or 486 even if included in the lease/rent payment. Examples of executory costs include insurance, line 534; repairs and maintenance, lines 529 and 531; real estate taxes, line 532; and personal property taxes, line 533.

Lines 545, 574 Should agree with management personnel and other cost contract fees reported on Schedule F, line 929(03).

Line 546, 547 Should agree with the amount allocated on Schedule G, page 7.

Line 568 Should agree with the interest expense reported on Schedule D, line 742 for those financing arrangements identified as working capital on Schedule D, line 713.

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