State of Maine s17
nf cst rpt instrt 9-01-10 & after.doc UPDATED 10/22/10
STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
INSTRUCTIONS FOR COMPLETING THE COST REPORT
FOR NURSING CARE FACILITIES
FOR PERIODS ENDING ON OR AFTER 09/01/10
All nursing facilities are required to submit cost reports and financial statements no later than five months after the close of their fiscal period. The reports are to be submitted to the State of Maine Department of Health and Human Services, Division of Audit, 11 State House Station, Augusta, Maine 04333-0011. If a provider fails to file an acceptable cost report by the due date, the Division of Audit may send the provider a notice by certified mail advising the provider that all payments are suspended until an acceptable cost report is filed.
These instructions are intended to offer guidance in completing the cost report. These instructions are not intended to offer interpretation or clarification of the Principles of Reimbursement for Nursing Facilities (10-144 Chapter 101, MaineCare Benefits Manual (MCBM), Chapter III, Section 67), the Private Non-Medical Institution (PNMI) Services Principles of Reimbursement (MCBM, Chapter III, Section 97, Appendices C and F) or the Principles of Reimbursement for Residential Care Facilities Room and Board Costs (10-144 Chapter 115). If any conflict arises out of the interpretation of these instructions versus the interpretation of the Principles of Reimbursement, the Principles of Reimbursement will take precedence.
The following instructions are pertinent to the completion of the cost report:
· Each facility shall complete and file a cost report with the Division of Audit on forms supplied by the Division of Audit. These forms will not be acceptable if they are changed in any way without prior approval by the Department or if they are not completed in accordance with these instructions. A copy of the provider's financial statements must be submitted with the cost report, along with a copy of the financial statements of any related real estate entity or any other type of related organization involved in transactions with the facility.
· The Principles of Reimbursement in effect during the fiscal year of the cost report will determine allowable cost. Providers are required to file cost reports using the accrual basis of accounting, unless the Provider is a State or municipal institution that operates on a cash basis.
· The owner, officer or administrator of the facility must sign the cost report. The preparer must also sign the cost report. If prepared by an accounting firm, the person responsible for the report must sign the cost report.
· All schedules must be filled out completely and legibly in accordance with these instructions. Make sure all schedules include the facility's name and the cost reporting period. If a schedule is not applicable, then put N/A on the schedule. Failure to complete all forms could result in an unacceptable cost report.
This is the index of the cost report schedules & pages:
Introductory Pages Pages 1 & 2 Certification and General Information
Schedule A Page 3 Calculation of Final Settlement for a Nursing Facility
Schedule B Page 4 Calculation of Allowable Direct Care Cost per Day
Schedule C Page 5 Calculation of Allowable Routine Cost per Day
Schedule D Page 6 Calculation of Administrative and Management Ceiling for NF
Schedule E Page 7 Computation of Return on Owner's Equity
Schedule F Pages 8 – 11 Schedule of Allowable Costs
Schedule G Page 12 Summary of Allowable NF Costs
Schedule H Page 13 Explanation of Adjustments to Schedule F
Schedule I Page 14 Schedule F/Trial Balance Reconciliation
Schedule J Page 15 NF Days and Remittances for State Residents
Schedule J-I Page 16 NF Adjustment of Interim Staff Enhancement Payments (SEP)
Schedule K Page 17 Total NF Resident Days
Schedule L Page 18 Payroll Distribution – Salaries & Wages
Schedule M Page 19 Reconciliation of Payroll Wages and Taxes
Schedule N Page 20 Payroll Distribution – Payroll Taxes & Benefits
Schedule O Page 21 Related Party Information
Schedule P Page 22 Semi-Private Charge to the General Public
Schedule Q Page 23 Non Reimbursable Residents & Space
Schedule R Pages 24 - 27 Schedule of Allocated Allowable Costs
Schedule S Pages 28 - 29 Methods of Allocation
Schedule T Page 30 Allocation of Nursing Salaries
Schedule U Page 31 Allocation of Non Nursing Hours
Schedule V Page 32 Calculation of Final Settlement for a Community-Based Specialty
Nursing Facility (NF-CBS)
Schedule V-l Page 33 Calculation of Final Settlement for Brain Injury
Rehabilitation NF Services (NF-BI)
Schedule W Page 34 Calculation of Fixed, Direct, PCS & Routine Costs
for a Residential Care Facility
Schedule X Page 35 Calculation of Room & Board (R&B) and Combined Settlement
for a Residential Care Facility
Schedule X-I Page 36 Calculation of PNMI Personal Care Services (PCS) Settlement
for a Residential Care Facility
Schedule Y Page 37 Calculation of Maximum Amount Allowed for Personal Care
& Routine Services Costs for a Residential Care Facility
Schedule Z Page 38 Calculation of Administrative and Management Allowance
for a Residential Care Facility
Schedule AA-R&B Page 39 RCF State Room & Board (R&B) Days & Remittances
Schedule AA-PNMI Page 40 RCF State PNMI Direct Days & Remittances
Schedule AA-PCS Page 41 RCF State PNMI Personal Care Service (PCS) Days & Remittances
Schedule AB Page 42 NF-CBS State Days & Remittances
Schedule AC Page 43 NF-BI State Days & Remittances
Specific Instructions
The following are specific instructions for each schedule in the order that it appears in the cost report. However, it is important to note that this is not necessarily the order in which the forms need to be completed.
Pages 1 & 2
General Information
The first two pages of the cost report provide general information about the facility and the operating period.
Page 1:
Enter the reporting period, the facility's complete name, the complete address, and the telephone and fax numbers and e-mail address on the lines provided. Enter the facility's MaineCare billing numbers for all levels of care on the lines provided. On the facility ID No line, enter the facility's six digit Medicare number. Place a check mark next to the appropriate type(s) of ownership. Enter the total number of licensed beds in the space provided. In the section labeled "For the Period:”, enter the operating period and the number of licensed beds for each level of care in the appropriate columns for that operating period. If the facility has a change in licensed beds during the reporting period, enter the operating periods for each change of licensed beds on the additional lines, and the corresponding number of licensed beds for each level of care. Make sure that the preparer's name is printed or typed, that the preparer signs the cost report, and that the name and telephone number of the preparer's firm are included. Also, make sure that the Officer or Administrator's name is printed or typed, that the Officer or Administrator signs the cost report, and that the cost report is dated (a faxed or scanned copy of page 1 with the signatures is not acceptable).
Page 2:
Part I, Accounting Services: Enter the name of the provider’s accounting firm, the address, telephone and fax numbers, and e-mail address on the lines provided.
Part II, Ownership: Enter the facility’s corporate name, the address, the telephone and fax numbers, and e-mail address on the lines provided. Enter the names of all owners or corporate officers, their title, and their shares or percentage of ownership, if proprietary.
Part III, Administrator(s): Enter the name(s) of the administrator(s) and the period that they were the administrator during the cost reporting period. If reporting for a multi-level facility, indicate the administrator(s) for each level of care. If the administrator is also the administrator of another facility or facilities, please identify the facility or facilities. If the facility had an Administrator in Training (AIT) during the cost reporting period enter the name of the AIT and the starting and completion dates of the AIT program.
Schedule A, Page 3
CALCULATION OF FINAL SETTLEMENT
FOR A NURSING FACILITY
Schedule A is used to calculate the final settlement amount due to the Provider or the State for nursing facility services. This is a lead schedule incorporating information from Schedules B, C, G, J and J-I.
Enter the following on:
Line 1: the direct care cost per day from Schedule B, line 4.
Line 2: the fixed cost per day from Schedule G, the lesser of lines 2(a) or 2(b).
Line 3: the routine cost per day from Schedule C, line 7.
Line 4: the sum of lines 1 through 3.
Line 5: the State resident days from Schedule J, column 1, line 13.
Line 6: the product of line 4 times line 5.
Line 7: the remittances received, net of the staff enhancement payments, from Schedule J, column 5, line 15.
Line 8: the amount due the Provider/(State) - line 6 minus line 7. If negative, bracket the number.
Line 9: the NF adjustments due the Provider/(State) from Schedule J-I, line 5.
Line 10: the amount due the Provider/(State) after the line 9 NF adjustments - line 8 plus line 9. If negative,
bracket the number.
Line 11: if line 10 is negative, the product of line 10 times 50%. Enter the amount as a positive number. This
amount is due the State at the time the cost report is filed.
Line 12: the final amount due the Provider/(State) - the sum of lines 10 and 11.
Schedule B, Page 4
CALCULATION OF ALLOWABLE DIRECT CARE COST PER DAY
Schedule B is used to calculate the allowable direct care cost per day for the cost reporting period as well as any direct care disallowance. Historically, there were four direct care rates issued quarterly within a cost reporting period. Effective 09/01/10, an annual facility-specific direct care rate was established. This direct care rate is adjusted by 1 of 45 resident classification group case mix weights based on the individual resident’s classification.
Enter the period beginning and the period ending for each quarterly direct care rate posted in column 1. Enter the average direct care rate from 09/01/10 to the Provider’s fiscal year end (FYE) from Schedule J, line 18. In column 2, enter the total census days from Schedule K, column 6, that correspond to each rate period. Multiply each direct care rate in column 1 by the applicable days in column 2 and post the dollar amounts in column 3. Please note that the dollar amounts in column 3 do not represent actual dollars received. This is the method used to obtain the average direct care rate per day for the cost reporting period.
Add the census days for each period in column 2 to obtain the total days for the cost reporting period. Add the dollars for each period in column 3 to obtain the total dollars for the cost reporting period.
Enter the following on:
Line 1: the quotient of the total dollars in column 3 divided by the total days in column 2.
Line 2: the direct care cost per day from Schedule G, column 2, line 1.
Line 3: the result of line 2 minus line 1 if line 2 is greater than line 1. If line 2 is less than line 1 enter 0.
Line 4: the lesser of lines 1 or 2.
Schedule C, Page 5
CALCULATION OF ALLOWABLE ROUTINE COST PER DAY
The purpose of this schedule is to compare the prospective routine rate per day to the actual routine cost per day and allow the lesser of the two amounts. If there is any routine cost savings it is compared to the direct care disallowance and the lesser of the two amounts is allowed as routine cost savings.
Enter the following on:
Line 1: the prospective routine rate per day from the last quarterly rate slip issued for the cost reporting
period. If the prospective routine rate per day is not the same for all four quarters, calculate the
average rate, weighted by months, using a supplemental schedule.
Line 2: the actual routine cost per day from Schedule G, column 2, line 3.
Line 3: the lesser of lines 1 or 2.
Line 4: the result of line 1 minus line 2 if line 2 is less than line 1. If line 2 is greater than line 1 enter 0.
Line 5: the direct care disallowance from Schedule B, line 3.
Line 6: the lesser of lines 4 or 5
Line 7: the sum of lines 3 and 6.
Schedule D, Page 6
CALCULATION OF THE ADMINISTRATIVE AND MANAGEMENT CEILING FOR NF
Schedule D is used to calculate the administrative and management ceiling and to adjust for administrative costs that exceed the ceiling amount.
On line 1, enter the number of licensed beds for all levels of care within the facility. On line 2, enter the base ceiling amount. This amount will depend on a facility's bed size and fiscal year end. The amount of the ceiling and the bed size groupings, effective July 1, 1995, are listed in Section 43.42.2 of the Principles of Reimbursement. The base amount and the amount per bed in the excess of the base will be updated quarterly and provided upon request to facilities by the Division of Audit. On line 3, enter the number of beds in excess of the base, the ceiling amount per bed in excess of the base and the product of the two. On Line 4, enter the sum of lines 2 and 3. This is the total administrative and management ceiling for the cost report period.