ࡱ> ]{M mPbjbj== PWWJl 4ZwZwZwhwxB{^S`AAAAAAA$UD uFvB Bi BDiii, x AiAii_ng* X 6{ q&JiZw߶"16 YBHB1Fo F6i STATE OF MICHIGAN  DEPARTMENT OF COMMUNITY HEALTH MEDICAL SERVICES ADMINISTRATION MICHIGAN NURSING FACILITY AND SPECIAL CARE UNIT -- TITLE XIX ELECTRONIC COST REPORT PREPARATION INSTRUCTIONS AND DEFINITIONS Table of Contents  TOC \o "1-2" Table of Contents  PAGEREF _Toc105512389 \h i Introduction  PAGEREF _Toc105512390 \h 1 Cost Report Versions  PAGEREF _Toc105512391 \h 1 Installing the Electronic Cost Report  PAGEREF _Toc105512392 \h 3 Cost Report CD Contents  PAGEREF _Toc105512393 \h 3 Windows 2000 / XP CD Installation  PAGEREF _Toc105512394 \h 3 Using the Electronic Cost Report  PAGEREF _Toc105512395 \h 4 Recent Changes to the Electronic Cost Report  PAGEREF _Toc105512396 \h 4 Microsoft Excel Security Settings and the Cost Report Workbook  PAGEREF _Toc105512397 \h 4 Opening the Cost Report Workbook  PAGEREF _Toc105512398 \h 5 Cost Report Utilities  PAGEREF _Toc105512399 \h 5 Loading Cost Report Data  PAGEREF _Toc105512400 \h 6 Entering Data  PAGEREF _Toc105512401 \h 7 Calculating the Cost Report  PAGEREF _Toc105512402 \h 8 Validating the Cost Report  PAGEREF _Toc105512403 \h 9 Saving Cost Report Data for Provider and LTC Use  PAGEREF _Toc105512404 \h 9 Saving the Cost Report Workbook - for Provider Use  PAGEREF _Toc105512405 \h 11 Clearing Cost Report Data  PAGEREF _Toc105512406 \h 11 Submitting the Electronic Cost Report  PAGEREF _Toc105512407 \h 11 Completing the Electronic Cost Report  PAGEREF _Toc105512408 \h 12 Basic Steps  PAGEREF _Toc105512409 \h 12 Prior Period Audit Adjustments  PAGEREF _Toc105512410 \h 12 Protest Cost Report  PAGEREF _Toc105512411 \h 12 Sequence For Completing Form MSA-1579 (Rev 9-95)  PAGEREF _Toc105512412 \h 12 Individual Worksheet Instructions  PAGEREF _Toc105512413 \h 14 Checklist  PAGEREF _Toc105512414 \h 14 Worksheet A  PAGEREF _Toc105512415 \h 14 Worksheet B  PAGEREF _Toc105512416 \h 16 Worksheet C  PAGEREF _Toc105512417 \h 18 Worksheet 1  PAGEREF _Toc105512418 \h 20 Worksheet 1-A  PAGEREF _Toc105512419 \h 27 Worksheet 1-B  PAGEREF _Toc105512420 \h 27 Worksheet 1-C  PAGEREF _Toc105512421 \h 29 Worksheet 1-D  PAGEREF _Toc105512422 \h 31 Worksheet 1-E-1  PAGEREF _Toc105512423 \h 32 Worksheet 1-E  PAGEREF _Toc105512424 \h 32 Worksheet 1-F  PAGEREF _Toc105512425 \h 33 Worksheet 1-G  PAGEREF _Toc105512426 \h 34 Worksheet 2  PAGEREF _Toc105512427 \h 34 Worksheet 2-A  PAGEREF _Toc105512428 \h 35 Worksheet 2-B  PAGEREF _Toc105512429 \h 35 Worksheet 2-C  PAGEREF _Toc105512430 \h 35 Worksheet 2-D  PAGEREF _Toc105512431 \h 35 Worksheet 2-E  PAGEREF _Toc105512432 \h 36 Worksheet 2-F  PAGEREF _Toc105512433 \h 36 Worksheet 2-G  PAGEREF _Toc105512434 \h 36 Worksheet 2-H  PAGEREF _Toc105512435 \h 36 Worksheet 3  PAGEREF _Toc105512436 \h 36 Worksheet 3-Lessor  PAGEREF _Toc105512437 \h 39 Worksheet 3-A  PAGEREF _Toc105512438 \h 39 Worksheet 3-B  PAGEREF _Toc105512439 \h 40 Worksheet 4  PAGEREF _Toc105512440 \h 40 Worksheet 5  PAGEREF _Toc105512441 \h 40 Worksheet 6  PAGEREF _Toc105512442 \h 41 Worksheet 7  PAGEREF _Toc105512443 \h 41 Worksheet 8  PAGEREF _Toc105512444 \h 44  Introduction Form MSA-1579 (Rev 9-95) must be used by all Long Term Care nursing facilities and information reported must conform to the requirements and principles set forth in the Provider Reimbursement Manual, Part I (CMS Pub. 15-1), except as provided under the Michigan Medical Assistance State Plan and Medicaid Provider Manual, Nursing Facility Chapter, Cost Reporting and Reimbursement Appendix and Program Bulletins for allowable costs. Facilities claiming home office costs must submit a home office cost statement (Form HCFA-287) for chain operations. A chain operation consists of a group of two or more health care facilities or at least one health care facility and any other business or entity, which are owned, leased, or through any other device controlled by one organization. The home office cost statement form and related instructions can be obtained from the Medical Services Administration if the home office has not previously received the forms from the Medicare intermediary. The completion of all statistical and financial information in the cost report forms must be factual and based upon readily available, reliable, and auditable records of the facility. Generally accepted accounting principles must be followed by providers of care under the Medical Assistance Program. The accrual method of accounting is mandated for all providers. Appropriate audits, utilizing generally accepted auditing standards, will be conducted by the Department to verify accuracy and reasonableness of information and cost contained in all financial and statistical reports. The Michigan Medicaid State Plan provides that Long Term Cares audit objectives are limited to ensuring that expenses attributable to allowable items of cost were accurately reported in accordance with Medicaid principles and guidelines. Cost Report Versions Due to changes in the Medicaid Program reimbursement policies, different versions of the electronic cost reporting templates are available. It is possible that more than one cost reporting period will use the same cost report template file especially when one of the periods is less than twelve months. Example: The first cost reporting period is November 1 through June 30. The second cost reporting period is July 1 through June 30. Both periods use the same cost reporting template version. Version CR199509.XLT: Use this cost report template file for cost reporting periods that begin prior to September30,1997. Version CR199710.XLT: Use this cost report template file for cost reporting periods that begin on or after October1,1997 and prior to September 30, 1998. Version CR199810.XLT: Use this cost report template file for cost reporting periods that begin on or after October1, 1998 and prior to September 30, 1999. At this time, the above prior years cost report text file can be loaded into any of the above versions. However, once the data is saved using either CR199710.XLT or CR199810.XLT, it cannot be loaded in an earlier version (CR199509.XLT). For example, a cost report text file saved using CR199810.XLT cannot be loaded into the CR199710.XLT or CR199509.XLT files. Version CR199910.XLT: Use this cost report template file for cost reporting periods that begin on or after October 1, 1999 and prior to September 30, 2000. Version CR200010.XLT: Use this cost report template for cost reporting periods that begin on or after October 1, 2000 and prior to September 30, 2001. Version CR200110.XLT: Use this cost report template for cost reporting periods that begin on or after October 1, 2001 and prior to October 31, 2003. Version CR200311.XLT: Use this cost report template for cost reporting periods that begin on or after November 1, 2003 and prior to February 29, 2004. Version CR200403.XLT: Use this cost report template for cost reporting periods that begin on or after March 1, 2004. A prior years cost report text file cannot be loaded into the CR200403.XLT or later cost report template version. Due to increased individual cell data validation, changes to the columns or additional rows added to some worksheets, it is not possible to open prior years cost report text files into a current years cost report template. Installing the Electronic Cost Report  EMBED Word.Picture.8 Effective with the mailing of the February 28, 2005 fiscal period end cost report template, all versions of the Medicaid electronic cost report will be specifically formatted to be used with Microsoft Excel 2000/XP for Windows. The electronic cost report is not formatted to be used with Office 2003.  EMBED MS_ClipArt_Gallery Upon receipt of the cost report CD, the following steps must be followed to install the cost report onto your computer. The installation will ask for a directory in which to install the cost report workbook. A default location of C:\COST_RPT\CR200403 will be shown during the installation. You may change this to any directory you want. It will then copy the cost report to your hard drive. This process should not affect any previous years cost reports. Cost Report CD Contents 200403 Cost Report: The CD (Compact Disk) that you receive will contain: 1 SETUP.EXE file, which will contain: 1 Cost Report Instruction Manual; 1 Cost Report Template 200403.xlt; 1 Provider Self Review Checklist; 1 Cost Report Submission Checklist; 1 Marshall Swift Index Table; 1 Instructions on use of Marshall Swift Index Table. The SETUP.EXE file holds a compressed version of the cost report workbook to use to complete your electronic cost report. This information is also available at http://www.michigan.gov/mdch/0,1607,7-132-2945_5100_8693-20345--,00.html OR HYPERLINK "http://www.michigan.gov/mdch"http://www.michigan.gov/mdch | Providers | Information HYPERLINK "http://www.michigan.gov/mdch | Providers | Information"  for Medicaid Providers | Long Term Provider Forms. Windows 2000 / XP CD Installation Insert the CD into CD drive of the computer. A window should appear prompting the user to unzip file to C:\ . . . If not, open Windows Explorer. Click on the CD drive icon in the left-hand pane of the Explorer window. Double-click on the SETUP.EXE file in the right-hand pane of the Explorer window. Double Click on the InstructionManual_CR200403.doc file to view directions on completing the cost report.Using the Electronic Cost Report Recent Changes to the Electronic Cost Report Files There are two files that make up the Electronic Cost Report the cost report WORKBOOK (may be referred to as the cost report template) and the cost report DATA FILE. The cost report workbook is for the preparers use and is a standard template that can be saved for the preparers and providers records. The cost report data file is the file that should be submitted to the Department of Community Health. The cost report workbook is on the CD you receive. The cost report data file is generated in the process of completing a cost report; it will have an .fcr extension and be named based on the county code, license number and period end date, i.e., 01-401 2004-12-31.fcr. PC Parameters Data Collection A new feature has been added to the 200403 cost report. This feature will collect information regarding the operating environment of the preparers or providers personal computer. This information will be used for guidance when determining future enhancements and or technology upgrades of the electronic cost report. The following variables will be captured: Operating System Version Microsoft Office (Excel) Version Microsoft Internet Explorer Version Current Default Web Browser Name and Version Microsoft Data Access Component (MDAC) Version (if available) Extensible Markup Language (XML) Version (if available) Note: These parameters will be captured automatically when the cost report data file is saved. Cost Report Filed Under Protest Another new feature has been added to the 200403 cost report. This feature allows the provider to file a cost report under protest. A Filed Under Protest checkbox has been added to Worksheet A. When the preparer places a checkmark in the box, the words FILED UNDER PROTEST will appear under the signature of the Officer or Administrator and the cost report data file will be saved with a .FCPR or .FCPA extension as opposed to a .FCR or .FCA extension. For further explanation regarding filing protested cost reports, please see section Protest Cost Report later in this document. Microsoft Excel Security Settings and the Cost Report Workbook In order for the cost report to work properly, you must set the security setting within Excel to Medium. This will allow you to Enable Macros when you open the cost report template. Without the macros enabled, the cost report will not work. To set the security within Excel, open Excel and click on the Tools menu and then select Macros and Security. Once the Security dialog box has opened, set the security to Medium and click OK. Now close Excel and re-open the cost report. Excel should now prompt you to Disable or Enable Macros. Choose Enable Macros.  Security Settings Caution It is recommended that if you lowered or changed the security settings within Excel in order to use the cost report, that you change the setting back once you have completed the work on the cost report. This will prevent malicious code or viruses from other Excel templates from executing. Microsoft also recommends that the Low setting not be used, as this will automatically enable all macros, which would make the users PC more vulnerable to attacks from viruses. Opening the Cost Report Workbook You can open the cost report workbook in the same manner as you open any other Excel file: In Excel, click on the Open command on the File menu. Locate the cost report workbook, and then click on it to select it. Click on the OK button in the File Open dialog box. When prompted, click the Enable Macros button. The cost report will not work if the macros are disabled. See Microsoft Excel Security Settings section above. Then the cost report workbook opens with the cost report toolbar being displayed, see below. Because the cost report workbook is a template, a copy of the original file is opened. You may save a copy of this workbook for your own records (which you may wish to do after entering data) using the instructions in the  REF Save_Cost_Report_Workbook \h  \* MERGEFORMAT Saving the Cost Report Workbook - for Provider Use section (note that this will not save to the cost report data file). Cost Report Utilities Cost Report Menu The Cost Report menu has 6 different items on it. The first section of the menu deals with Loading, Saving, Clearing, and Submitting the cost report data. The last two items are the standard Calculate and Validate commands that have been available in previous versions of the cost report. See the sections following for more information on  REF Load_CR \* MERGEFORMAT Loading Cost Report Data,  REF Save_Cost_Report_Data \* MERGEFORMAT Saving Cost Report Data for Provider and LTC Use,  REF _Ref409844115 \* MERGEFORMAT Clearing Cost Report Data, and  REF Submitting_the_CR \* MERGEFORMAT Submitting the Electronic Cost Report. Cost Report Toolbar When the cost report is opened a toolbar is added to the toolbars that Excel displays. The buttons on the toolbar provide the same functionality as the cost report menu options. The toolbar may appear either docked or floating on your screen. See the following pictures:   Loading Cost Report Data Once the cost report workbook is open, you can load data from a previously saved cost report. The cost report template will load the data from an original cost report or a cost report that was marked as Filed Under Protest (a .fcpr file). If this is the first time you are working with the cost report, simply begin filling in the data, otherwise, follow these instructions: Click the Load Data command on the Cost Report menu or the Load Data button on the Cost Report toolbar. If you were working on a cost report, Excel will ask you to save your data before loading a new cost report file. In the Load Cost Report dialog box, locate the name of the cost report data file to load, then click on it to select it. You may select an original or protested cost report to load.  Click on the Open button to load the data. Excel will save any data you had in the workbook (if you chose to have the data saved in Step 2, above), and then clear all the worksheets in the cost report workbook to ensure a fresh start, and then load the new cost report data. The cost report workbook will then be calculated TWICE. Note: Monitor the status bar in the lower left corner of Excel to see the loading process in progress. Also, the title bar at the top of the screen will display both the path and name of the data file you loaded, i.e.,  Entering Data Entries can be made only in the yellow shaded (or lightly shaded on non-color screens) cells. All information pertaining to a particular item must be entered into a single cell. Even though the entire text entry cannot be seen on the screen or printed out, use of multiple rows to enter text will cause validation errors. Cell Validation Effective with the change to Excel 97, the cost report template files will contain individual cell comment boxes and cell validation. When a yellow cell is clicked on to input data a comment box will appear on the screen. The comment box will provide useful instructions on the type and format of the data to be entered. Individual cell validation will not permit incorrect data to be entered. An error message will immediately appear. For example, on Worksheet A, if there is an attempt for input "N/A" in the Medicare Number, an error message will appear indicating the data must be numeric and input as "12-34567". If on Worksheet 5, "cents" are attempted to be input, an error message will appear indicating that "only whole numbers" can be entered. Rounding Standards All entries should be rounded to nearest whole number, unless specifically instructed on the worksheet. The electronic cost report will perform all calculation functions and display the results in the appropriate reporting format. Date and Year Entries Dates entered into the cost report should be in the format month/day/year (i.e., enter 1/1/95 for 01/01/1995 to appear). Key encoding of year entries into the cost report should be in four-digit calendar year format (i.e., 1996). Name Entries Names of individuals, corporations, management services, and other organizations must be entered into the cost report on all worksheets using identical spelling. When one individual fulfills several different positions in the operation of the nursing home, his/her name must be identical in all locations on all worksheets. For example, John Smith is the owner, resident agent, administrator, and provides related party services to a facility. Using John Smith as the owner, J Smith as the resident agent, JB Smith II as the administrator, and J B Smith as the related party is NOT acceptable. Enter the full name, i.e. John B Smith II, in all cells required. Do not use punctuation marks in the name or use abbreviations in names; exceptions are "INC" or "LLC". The Copy and Paste Special commands (see below) can be used to be sure identical names are entered into subsequent cells on a worksheet. Copying and Pasting Data To copy data from one cell on a worksheet to another, or from one worksheet to another IN the cost report workbook: Select the cell to copy. Click on the Copy command on the Edit menu. Select the cell to receive the data. Click on the Paste Special command on the Edit menu. Note: DO NOT use the Paste command! This may alter the cost report in such a way that it may not calculate or validate correctly. Select the Values option in the dialog box and then click on the OK button. Note: Control v (paste shortcut has been disabled.) To copy data from another cost report, the cost report you are copying from must first be saved as a workbook (see the  REF Save_Cost_Report_Workbook \* MERGEFORMAT Saving the Cost Report Workbook - for Provider Use section). Open the cost report you want to copy into in the normal manner, and then follow the steps below to open the cost report workbook you want to copy from. In Excel, select the Open command from the File menu. Click on the cost report file name. Hold down the Shift key on the keyboard, and then click on the Open button in the File Open dialog box. You can release the Shift key as soon as the dialog box disappears from the screen. Note: the cost report menu will not be available in the cost report workbook opened in this way Copy and Paste Special data as needed. When you are finished, save and close the cost report you are copying into before closing the cost report you are copying from. You must only copy and paste data from/to a yellow cell or a range of yellow cells. If the cell is non-yellow or the range contains a non-yellow cell, attempting to paste data will result in an error. Calculating the Cost Report The electronic cost report format has been designed with calculation set to Manual mode. This means that calculations and data flow to subsequent worksheets do not occur until a manual calculation is performed. This design feature has been made to speed up data input. The preparer may calculate at any time during cost report completion. It is suggested that after each worksheet is completed, a calculation and save of the cost report are done. To calculate the cost report, do one of the following: Click on the Calculate command on the Cost Report menu. Click the Calculate command on the Cost Report toolbar. Hit the F9 function key at the top of your keyboard. Validating the Cost Report Validation permits the user to check the acceptability of the cost report. This Validation check must be run by the provider before submission of the cost report. The cost report will automatically be recalculated every time the Validation process is run. The Validation procedure may also be run at any time during completion of the cost report. To validate a cost report, do one of the following: 1. Click on the Validation command on the Cost Report menu. 2. Click on the Validation button on the Cost Report toolbar. To monitor the validation process, watch the status bar in the lower left corner of Excel. When the validation process is finished, a message box will appear that will inform you of the number of errors that have been detected in the cost report. You may view the errors, and even print them if you wish. If you view the cost report errors, Notepad will open and the cost report errors will be displayed for you to read them. In order to isolate the errors on specific pages, click on the Show Headers button or Show Headers command from the Cost Report menu to view the row and column headings. Note: The screen may flash momentarily when Notepad opens, as the headers and footers are added to the cost report error document. These show up at the top and bottom of the printed error report. Submission of a cost report with any unresolved Validation error(s) may cause the cost report to be rejected. Saving Cost Report Data for Provider and LTC Use When you want to save the data you have entered into the cost report template, you can use the Save Data command on the Cost Report menu. This generates the cost report data file (.fcr file) mentioned in the above sections. If the cost report has been marked as Filed Under Protest, then a .fcpr file extension will be used for the cost report data file as opposed to the .fcr extension. To save your cost report data for the first time: Click on Save Data command on the Cost Report menu or the Save Data button on the Cost Report toolbar. In the Save Cost Report dialog box, enter a name for the cost report data file, or accept the default name.  Click on Save. Excel will calculate the cost report first, then save all the data entered by the preparer into the cost report data file. If you have saved the cost report data previously, Excel will ask if you want to save the data to the same file again. Once you have saved the cost report data to a file, Excel will display the path and name of the cost report data file in the upper left hand section of the title bar, i.e., . If you have previously saved your cost report data, you will get the following message when you save your data: Click on the Save Data command on the Cost Report menu. When the Save dialog box appears do one of the following: a. Click YES if you would like to save your cost report data to the same file you have been saving it to. b. Click NO if you want to save the data to a new file name (similar to the Save As command in Excel). Follow the steps above on saving the cost report data for the first time if you choose this option. c. Click CANCEL if you dont want to continue with the Save Data process.  Saving the Cost Report Workbook - for Provider Use If you would like to save an Excel workbook version of the cost report, you may do so by using the normal means of saving a workbook in Excel: If this is the first time saving the workbook, click on the Save As command on the File menu. Enter the file name and determine the path in which to save the workbook. Click on the OK button in the dialog box. Once you have given the workbook a name, you can click on the Save command on the File menu or the Save button on the Standard toolbar along the top of the Excel window to save it again later. Please note that this method DOES NOT save the cost report in a format that should be sent to Long Term Care! Follow the instructions for  REF Save_Cost_Report_Data \* MERGEFORMAT Saving Cost Report Data for Provider and LTC Use and  REF Submitting_the_CR \* MERGEFORMAT Submitting the Electronic Cost Report for the proper methods of saving the cost report data for LTC use.Clearing Cost Report Data If you would like to clear all the data from the cost report workbook, you can use the Clear Data command on the Cost Report menu or the Clear Data button on the Cost Report toolbar. This command will check if you want to save any data currently in the workbook and then proceed to clear EVERY worksheet in the cost report workbook. Submitting the Electronic Cost Report To submit the electronic cost report data file to LTC Reimbursement and Rate Setting Section (RARSS): Place a blank diskette in the A:\ drive. Click on the Submit Data command on the Cost Report menu or the Submit Data button on the toolbar. Excel will do the rest it first calculates the data, then saves it to the removable media. The electronic cost report data must be submitted with the completed label on removable media such as a CD, floppy diskette or memory key. Identify the facility name and the cost report period From and To dates on the label. In addition to the electronic cost data, Medicaid providers are required to file a paper copy of the Worksheet A, which includes a Certification Statement, which is produced by the electronic cost report. In signing this report, it must be understood that the administrator/owner or officer takes full responsibility for the factual information presented. The cost report shall not be considered complete and properly filed unless the report includes the signed certification. Make sure to print out the entire WSA worksheet and submit it with the cost report data file diskette.Completing the Electronic Cost Report Basic Steps The basic steps for working with the electronic cost report are as follows: Install the cost report. Open the cost report workbook. Enter data, following the  REF Sequence \* MERGEFORMAT Sequence For Completing Form MSA-1579 (Rev 9-95) instructions. Submit the data to RARSS. When working with the cost report over a period of time, you can save the cost report at any time without performing the Submission process (see  REF Save_Cost_Report_Data \* MERGEFORMAT Saving Cost Report Data for Provider and LTC Use and  REF Save_Cost_Report_Workbook \* MERGEFORMAT Saving the Cost Report Workbook - for Provider Use for more details). Also, once you have saved your cost report data, you can re-load it at any time to work with it (see  REF Load_CR \* MERGEFORMAT Loading Cost Report Data for more details). Prior Period Audit Adjustments The current period cost report must be filed in accordance with prior year(s) audit adjustment determinations for like costs or cost reporting issues per Medicaid Provider Manual, Nursing Facility Chapter, Cost Reporting and Reimbursement Appendix, Section 4.4. A provider that receives a Preliminary Summary of Audit Adjustments notice, dated at least 60 calendar days prior to the filing of the annual cost report, must include those audit adjustments that are applicable to the current reporting period and the provider is in agreement, in the completion of the current periods cost report. A copy of the letter requesting an Area Office Conference, which details those audit adjustments that the provider has requested additional review must be filed with the current periods cost report, if the provider does not incorporate those audit adjustments into the current periods cost report filing. A provider that receives a Final Summary of Audit Adjustments notice, dated at least 60 calendar days prior to the filing of the annual cost report, must include all audit adjustments that are applicable to the current reporting period, in the completion of the current periods cost report. Protest Cost Report An on-going provider may dispute a Medicaid regulatory or policy interpretation related to the completion of their annual Medicaid cost report. The provider must submit a separate cost report, referred to protest cost report to establish their reporting of the dispute issue per Medicaid Provider Manual, Nursing Facility Chapter, Cost Reporting and Reimbursement Appendix, Section 4.12. The provider must follow all of the instructions for completion and submission of Worksheet A including clicking the Protest checkbox. The provider must submit a letter, signed by an authorized representative of the provider, with the protest cost report identifying the issue(s) and respective dollar amount(s) for the basis of the protest cost report filing. The protest cost report electronic data file should be saved onto the same diskette that contains the original cost report. It is not necessary to complete a separate Medicaid Submission Checklist or other attachments required with the original cost report filing. The Protest cost report is NOT utilized for rate determination or reimbursement, but will provide information for audit consideration relative to the disputed issue(s). Protest cost report filing is not for general disagreement with promulgated Medicaid policy. The RARSS will not accept protest cost reports filings that include items considered as disagreement or dissatisfaction with promulgated Medicaid policy. Sequence For Completing Form MSA-1579 (Rev 9-95) The following table is a general guideline for the steps to take to complete the Medicaid Electronic Cost Report. See the following pages for more details concerning the completion of each worksheet in the cost report. StepWorksheetQuick InstructionsPageCHECKLISTComplete yellow shaded cells. PAGEREF Checklist 14WS AComplete worksheet through Type of Control Section. PAGEREF _Ref409843730 14WS AComplete remaining sections of worksheet. PAGEREF _Ref409843972 14WS BComplete the entire worksheet. PAGEREF _Ref409843739 16WS CAnswer questions A and B. Complete the applicable sections. PAGEREF _Ref409843755 18WS 1Complete the entire worksheet. PAGEREF Worksheet_1 20WS 1-AComplete the entire worksheet. PAGEREF _Ref409843858 27WS 1-BComplete the entire worksheet. PAGEREF _Ref409843894 27WS 1-CComplete the entire worksheet. PAGEREF Worksheet_1_C 29WS 1-DComplete the entire worksheet. PAGEREF _Ref409843810 31WS 1-E-1Complete the entire worksheet. PAGEREF _Ref409843823 32WS 1-EComplete the entire worksheet PAGEREF _Ref409843823 32WS 1-FComplete the entire worksheet. PAGEREF _Ref409843883 33WS 2Complete the entire worksheet. PAGEREF Worksheet_2 34WS 3Complete the entire worksheet. PAGEREF _Ref409843792 36WS 3-AComplete the entire worksheet. PAGEREF _Ref409843918 39WS 4Complete the entire worksheet. PAGEREF _Ref409843931 40WS 3-LESSORComplete the entire worksheet. PAGEREF Worksheet_3_Lessor \* MERGEFORMAT 39WS 5Complete the entire worksheet or submit substitute statements. PAGEREF _Ref409843941 40WS 6Complete the entire worksheet. PAGEREF _Ref409843953 41WS 7Complete the entire worksheet. PAGEREF _Ref409843964 41WS 8Complete the entire worksheet. PAGEREF Worksheet_8 44Individual Worksheet Instructions Checklist The purpose of the Checklist worksheet is to identify each worksheet that is being completed or is not applicable as a part of the cost report. Each worksheet must be marked Completed or Not Applicable on the upper left side of the worksheet. This information will automatically flow to the Checklist page. Main Section Enter the County Code, License No., and the reporting period. The 2 digit County Code (Must include a 0 before single digit county number, i.e., 09) and 3 digit License Number will be sent with the cost report filing request. The reporting period must identify both the From and To dates. Provider Facility Section Enter the facilitys legal name on the first line. Enter the facilitys name under which the provider commonly does business, if different from the legal name, on the second line prefaced by d/b/a. Enter the mailing address of the facility in the street address box of the Provider Facility. If a P.O. Box or Suite is also a part of the mailing address, enter this information in the appropriate box. The telephone and fax numbers, including area code for the facility, must be entered. Preparer Section Enter the name of the individual preparing the cost report in the appropriate box. If the individual that prepares the cost report does so as a member of an accounting firm, management or consulting firm, or home office, enter the organizations name in the name of firm box. Separate boxes are provided and must be used to report the street address and if applicable the P.O. Box or Suite for the preparer. Telephone and fax numbers must include area code. Note: Address and Names should NOT be all upper case characters, nor include punctuation. Worksheet A Information and Certification Federal I.D. Number, Names and Addresses, Provider Numbers and Dates Certified Enter on appropriate lines: the Federal I.D. number, nursing unit names and exact street address (if different from Checklist Worksheet), provider type, Medicaid Provider number, dates certified, and Medicare Provider number. The following provider type definitions will apply when completing these cost report forms: Medicare Only (SNF Unit) An institution meeting the requirements of Section 1861(j) of the Social Security Act and participating in the Medicare Program only. The facility, or distinct part thereof, is licensed by the Michigan Department of Community Health (Bureau of Health Systems) to provide nursing care. Medicaid (NF) (NF/SNF) Routine Care Unit #1 and #2 An institution meeting the requirements of Section 1861 (j) of the Social Security Act and participating in the Medicare/Medicaid Program, or federally, state or locally controlled institution approved by the Secretary. The facility, or distinct part thereof, is licensed by the Bureau of Health Systems to provide nursing care services, and enrolled in the Medical Assistance Program under a signed Medical Provider Direct Payment Application/Agreement (MSA-1625). Special Care Unit #1 The facility, or distinct part thereof, is licensed by the Bureau of Health Systems to provide special nursing care. The nursing unit is enrolled in the Medical Assistance Program under a signed Medical Provider Direct Payment Application / Agreement (MSA-1625). Indicate the type of special nursing services rendered in the name space provided in the space provided on the worksheet (i.e., Ventilator dependent, closed head injury, mental illness, etc.) Adult Daycare Program The facility operations include activities of rendering adult daycare program services. The facility conducts this activity and maintains distinct services activity cost accounting procedures to identify the cost associated with the provision of the services and maintains statistical records consistent with other nursing services cost centers for purposes of allocation of costs. Enter the name of the adult daycare program (or facility name if the same as the facility name) on the Names and Addresses column cell. Home for the Aged The facility, or distinct part thereof, is licensed by the Department of Human Services to provide Home for the Aged services. Provider Type The providers level of care (designated Medicaid provider type) should be entered: Type 60 indicates a nursing home, Type 61 indicates a county medical care facility, Type 62 indicates a hospital long term care unit, Type 63 indicates a ventilator dependent care unit, Type 71 indicates a Mental Health contract nursing home MR, Type 72 indicates a MENTAL HEALTH contract nursing home MI, Special care units without an assigned provider type and Home for Aged will leave this item blank. Medicaid Provider Numbers Enter the seven digit Medicaid Program payment identification number(s) for routine care nursing services. If the nursing facility is participating in the Medicaid Program with distinct part units and the units have separate routine care numbers, this should be entered on separate lines in this area. A summary listing of Medicaid provider numbers for long term care providers is available on the Sections web site  HYPERLINK "http://www.michigan.gov/documents/provider_list_11156._7.xls" http://www.michigan.gov/documents/provider_list_11156._7.xls or  HYPERLINK "http://www.michigan.gov/mdch" www.michigan.gov/mdch | Providers | Information for Medicaid Providers | Nursing Facility Cost Reporting Information | Provider List. Dates Certified Indicate the time periods within the current reporting period the nursing care services provider was certified for participation in the respective Program(s), (i.e., 10/01/1996 to 09/30/1997). The Dates Certified for the Medicare Only (SNF) Unit relate to the Medicare program certification time periods. The remaining Dates Certified relate to Medicaid program certification. If the nursing facility conducts an Adult Daycare Program, enter the date that the facility began providing these services. Medicare Provider Number Enter the facilitys Medicare Program I.D. number. The facility number is required for the Medicare Only (SNF) Unit. If the facility participates both in Medicaid and Medicare, the Medicare number must be entered in the respective Medicaid unit line. Do not make any entry in this cell if the provider does not have a Medicare provider number. Type of Control Select the type of ownership or auspices under which the business is conducted. Complete the remaining portions of this worksheet after all other worksheets in the cost report have been completed.Provider Cost Verification Section This section will verify that the data on Worksheets 2-G, 2-H, and 7 contained on the providers submitted diskette agrees to the signed certification page. If the data on the signed certification page does not agree with the diskette on the worksheet listed above, the cost report will not be accepted and the diskette will be returned to the provider. Cost Report Type An option button to indicate what type of cost report is being submitted. Original Check the button to indicate that the cost report for the reporting period is being submitted for the first time. Corrected Check the button to indicate that the previously submitted cost report had been returned by the Medicaid Program Office due to errors that must be corrected by the Provider, and is now being resubmitted. Amended Check the button to indicate that the cost report submission is subsequent to the "Original" cost report submission and/or corrected submission, which was accepted by the Medicaid Program Office. This indicator will be used regardless of whether the cost report is an initial filing of an amended report or to correct a previously filed amended report. Protest Check the button to indicate that the additional cost report submission is being filed under Protest. The protest cost report preserves the nursing facility claim for the disputed issues that remain under appeal or are subject to an appeal by the nursing facility. Certification Statement The name of the individual signing the certification statement, their title, and the date the individual signs the statement must be input into the electronic cost report file on the line provided. The signature of the individual signing the statement must be legible. Worksheet A is mandatory; therefore, mark the Completed box.Worksheet B Statistical And Fiscal Data Part I Nursing Facility License/Certification and Statistics Entry of the Nursing Unit data in Part I must be in the same line (row) sequence as was used in Worksheet A (use of Routine Nursing Care Unit #1 on W/S A, also requires the use of Routine Nursing Care Unit #1 on W/S B, etc. for any additional nursing units reported in W/S A). Type of Certification Type of certification refers to the level of care for which the nursing beds are certified for participation in the Medicaid Program. In addition to the definition of types in the  REF _Ref409846444 \* MERGEFORMAT Worksheet A section above, the following definitions apply: Non Available Beds An area of the facility which the provider has made application to and received advance approval from the Medicaid Program for temporary removal of beds from being considered available for patient care. A facility with non-available beds must report the number of beds information on this line category. The number of beds identified in the Total line must equal the total licensed beds in the facility. A facility during a renovation project of an entire wing or unit of the facility, and the rooms are deemed non-inhabitable for occupancy during the renovation project by the Bureau of Health Systems, Division of Health Facilities and Services, should report the beds in those rooms, during the limited time period of the renovation as nonavailable beds for cost reporting purposes. The facility must submit the notice from the Division of Health Facilities and Services, permitting reoccupancy of the rooms, with the cost report submission and submit a summary schedule of the room numbers and period of time of the rooms being noninhabitable. The facility should provide a written notice to RARSS, PRIOR to beginning of the renovation project. Apartment/Housing Unit An area of the facility used for individual residences that is supplying minimum services. It is a revenue producing cost center not shown elsewhere. Note: Customary rental units where no nursing services are provided should not be included because beginning and ending numbers of beds are not applicable. Non-LTC Nursing Services Unit Areas of the hospital used for non long term care hospital services. The number of beds in this area must be entered in order to account for all licensed beds in the facility. This would include the various hospital classified beds. Licensed Only Nursing facilities having a distinct part nursing portion of the facility that is licensed only and not participating in the Medicaid or Medicare Program. These beds must also be reported as a distinct part nursing unit in the subsequent cost report work sheets as a licensed only unit. The total amounts reported should not exceed the number of licensed beds in the facility. Beds at Beginning and End of Fiscal Period Enter the number of beds available for use by patients at the beginning and at the end of the cost reporting period. Enter the number of available beds by each area or component separately licensed in the facility. If the facility conducts Adult Daycare Program activity, enter the number of beds designated for this activity if such designation exists. These beds are not inclusive in the facilitys licensed bed number for other nursing areas. If no beds are designated as Adult Daycare Program activity, enter zero (0) in the beginning and ending cells. Total Bed Days Available Enter the total bed days available. Beds days are computed by multiplying the number of beds available throughout the period by the number of days in the period. If there is an increase or decrease in the number of beds available during the period, the number of beds available for each part of the cost reporting period should be multiplied by the number of days for which that number was available. Enter the total number of inpatient days in each respective area. A patient day is defined as the period of measurement for lodging (room and board) provided and services rendered to one in-patient between the census taking hour (zero hour at midnight) on two successive days. In computing patient days, the day of admission is counted but the day of discharge is not. However, should a patient be admitted and discharged the same day, this period is counted as one patient day. Where a total Ban on Admissions has been imposed by the Bureau of Health Systems during the reporting period, the number of bed days available is limited to the actual inpatient census for each day of the ban time period. A copy of the Bureau of Health Systems Ban on Admission notice and EXCEL spreadsheet must be submitted with the cost report filing. The spreadsheet must identify: each day during the cost reporting period that the ban is in effect, and the number of residents in the facility on each day. If the ban is amended to permit limited admissions, contact this office for directions on how to calculate the bed days available. A Denial of Payment for New Medicare/Medicaid Admissions is an action imposed by DCH. The bed is available to admit residents from other payor sources, therefore the bed is included in the bed days available calculation. The Denial of Payment is Medicaid payment control that will not allow payment for services provided during the denial time period for a resident who is admitted after the effective begin date of the denial on Medicaid payments. If the facility conducts Adult Daycare Program activity, enter the number of daycare days of services rendered during the cost report period. A daycare day is considered to be a day or portion of a day, in which an individual is rendered daycare services in the facility. Enter the same number in both days available and inpatient days for this activity. Enter 0 in the Title XIX data for the Adult Daycare Program area. The policies that must be used for Medicaid purposes for determining patient census are in the Medicaid Provider Manual, Nursing Facility Chapter, Cost Reporting and Reimbursement Appendix, Section 3 Definitions. Percent Occupancy The percentage of occupancy is the ratio of the total inpatient days to the bed days available during the cost reporting period. The percentage occupancy and 85% occupancy (if applicable) will be automatically calculated. Inpatient Days Health Care Programs Title V Enter the patient days statistics that are applicable to Title V (Crippled children) which are part of the total statistics on previous columns. Title XVIII Enter the patient days statistics that are applicable to Title XVIII (Medicare) which are part of the total statistics on previous columns. Providers participating in the Medicare Program must complete this information. Enter 0 (zero) if there is no participation in the Medicare Program. Title XIX Enter the routine nursing care inpatient days pertaining to Title XIX (Medicaid) Health Care Program. The Title XIX inpatient days should be reported by the nursing care unit in which the services were provided. Title XIX Special Care Days. Enter the special nursing care inpatient days pertaining to Title XIX (Medicaid) Health Care Program. Special care days defined - inpatient days rendered under a separate agreement (Memorandum of Understanding) between the facility and the Medical Services Administration. This agreement is patient specific and is for a limited time period. Part II Other Nursing Facility Data Question 1 must be answered. Examples of a yes would be any licensing, certification or approved unavailable bed changes. If yes, list each change occurring during the cost reporting period on separate lines as provided. This information is utilized in calculating total bed days available on Part I. Enter in the Place of Change column the reference to the nursing units indicated in Part I of this worksheet. Each separate nursing unit having a change must be reported in separate rows. Beds lost in one unit and gained in another unit must be reported as two separate row entries. A single row entry cannot have beds gained and lost even if the changes are in the same nursing unit. Worksheet B is mandatory; therefore, mark the Completed box.Worksheet C Ownership Information And Questionnaire Part A Proprietorship and partnership entities as indicated in the Type of Control section of Worksheet A, must report ownership information in Part A. Legal name and address of the entity, name of all owners and/or partners and their addresses must be entered. Enter officer position in the title column, or owner or partner should be entered if the individual is not an officer. Ownership percentage entries must be entered as decimal equivalent amounts (e.g. 90% must be entered as .9). Identify the individuals with the 12 highest ownership interests if more than 12 owners exist. Identify the entities resident agent if one exists. Begin name of owners and/or partners in the first yellow hi-lighted row. Part B All other Types of Control as indicated on Worksheet A, report ownership or board member information in Part B. Legal name and address of the entity, name of all officers and/or board of director members and their addresses must be entered. If the provider is a long-term care unit of a hospital, the legal name and officers and directors of the hospital should be identified. Enter officer position in the title column. Members of the board of directors, not holding office should be identified as member for their title. Multiple titled individuals should include all applicable titles in the Title column. Begin identifying the names of owners, partners, or board members in the first yellow hi-lighted row. For voluntary non-profit and government entities, complete all lines in Part B, except Resident Agent line and all lines in the area titled Name of Stockholders Owning at Least 10%. If the entitys board of directors exceed 31 officers and members, attach a separate printed listing. Ownership percentage entries must be entered as decimal equivalent amounts (e.g. 90% must be entered as .9). If the facility is owned and operated as a corporation, officers, directors and shareholders only need to be identified once in Part B. Officers and directors owning at least 10% of stock must not be listed in the portion of Part B, titled Name of Stockholders Owning at Least 10%". If the entity Type of Control on Worksheet A is Voluntary Non-Profit or Government, percentage of ownership column does not need to be completed. The name and address of the corporate resident agent must be entered in Part B on the line indicated. If the Resident Agent is also an officer or shareholder of the company and has a percentage of ownership already identified on a line prior to the Resident Agent line, DO NOT again include an amount in the Pct. of Shares . . . column. Identify 0% in the Resident Agent percentage column so that the persons ownership is not counted twice. If the Resident Agent individual is not listed in the prior lines, then it is proper to identify the persons percentage of ownership on the Resident Agent line. If the resident agent owns less than 10%, the resident agent is not listed again in the portion of Part B, titled Name of Stockholders Owning at Least 10%. If there are no owners having at least 10%, leave the lower section blank. PART C Answers to the two questions are required for all providers. The first question relates to owners and officers receiving compensation directly and/or indirectly from the nursing facility. The answer to the question is yes if either of the following situations exist: Owner(s) and/or officers of the nursing facility are employed by the facility, in addition to also being employed by another entity, regardless of whether such entity provides service to the facility; Owner(s) and/or officers of the nursing facility are not employed by the facility, however do have ownership, are employed by or have other compensatory affiliation with another entity providing service to the nursing facility. The existence of second situation described above will require further disclosure of related entity purchases on Worksheet 1-C of the cost report. Part D If either question in Part C is yes, further disclosure of the data is required in Part D. The second question relates to owners and officers of the nursing facility also having ownership interests or control in any other long term care facility (ies). If additional ownership(s) exists, the related facilities must be identified in Part D. Nursing homes operated as part of a chain organization must first individually list those facilities located in Michigan. If the number of related ownership facilities does not exceed fifty, identify the individual facilities in this worksheet. If the number of related ownership facilities exceeds fifty, list all the facilities located in Michigan, and the number of facilities owned and/or operated in other states along with the State name. Additional printed pages should be attached if necessary. Facility Name/Entity The d/b/a (doing business as) name of the facility should be input for all facilities located in Michigan. For multi- state organizations listing their non-Michigan facilities, enter the word Various. Location (City) - The city the facility is located in should be input for all facilities located in Michigan. For multi-state organizations listing their non-Michigan facilities, enter the word Various. Location (State) - The two digit postal abbreviation code should be used for all entries. Relationship - A brief description of the legal relationship between the provider and related entity listed. Facility ID - The county code and license number (Example 01-401) is entered for each individual Michigan facility listed. For each related Michigan non-nursing facility listed enter 00-001. For multi-state organizations, the total number of related facilities operated in that state should be indicated as 00-100, where 100 indicates the number of related facilities in that particular state. Report information applicable to each individual state on separate lines. Worksheet C is mandatory; therefore, mark the Completed box.Worksheet 1 Statement Of Revenues And Expenses Standardized accounting procedures are required for management information, budgeting, responsible reporting and internal control. Uniform classification of accounting input is also necessary to obtain valid statistical data for uniform reporting. Worksheet 1 is a statement of revenues and expenses incurred by the facility for the cost reporting period. The Medicaid reimbursement methodology requires separate identification of Plant, Base and Support costs. The cost reporting worksheets provide for the reporting of costs in these separate classifications. The Plant/Base/Support reference column is included in Worksheet 1 that cannot be changed. Base/Support Ratio for Contract Services The Contractor Services - Base account amount must only include those specific purchased services costs identified as 100% base cost (see section  REF Worksheet_1 \* MERGEFORMAT Worksheet 1,  REF BSP_Classes \* MERGEFORMAT Base/Support/Plant Classes). A provider purchasing services from an outside supplier, as an alternative to employing base cost facility personnel to perform such services is eligible to apportion the contract services costs between base and support. The total cost of services will be reclassified into base and support costs for proper reporting purposes using the Medicaid policy reporting percentage identified on this line. These reclassifications apply only to base cost services purchased instead of employing facility personnel to perform such services and reported in Account Reference # 253, 308, 340, 441, 469, and 977. The total purchased services amount will be entered in the yellow shaded areas of the respective accounts. The base and support apportionment will be automatically calculated and entered. Cost Center Descriptions Worksheet 1 mainly pertains to the reporting of general services costs properly classified to plant, base and support costs elements reimbursable under the program. It provides for recording the Trial Balance of expense accounts from the providers accounting books and records. The cost centers on this worksheet are listed in a manner which facilitates the transfer of various cost center data to the cost finding worksheets. Where the cost elements of a cost center are separately maintained on the providers books, a reconciliation of the costs per accounting books and records to those on this worksheet must be maintained by the provider. Providers Corresponding Account No. The facilitys corresponding account number(s) should be cross-referenced in the appropriate column on this worksheet. All account numbers should be entered even if they do not appear to fit in the cell. Account Reference # The account numbers identified in the column Account Reference # must be referenced in subsequent worksheets when adjustments or reclassifications are made to this specific account. No lines can be added, deleted or modified. . Account Description The account description provides for the classification of all assets, liabilities, income and expense necessary for preparation of the Medicaid electronic cost report. The provider must match its specific expenses as closely as possible to the descriptions provided. Base/Support/Plant Classes Cost descriptions are guideline to provide consistency in Provider cost reporting for Medicaid cost report filing and identification of reimbursement classifications for specific cost categories. Reimbursable cost classifications are identified for the individual cost elements in accordance with the provisions of the Medicaid State Plan and Policy Manual. The Medicaid Provider Manual, Nursing Facility Chapter, Cost Reporting and Reimbursement Appendix, Section 14 provides the definitions of the Medicaid Program cost classifications for reimbursement. Plant 1, 2 and 3 Plant 1 Depreciation of building and improvement costs which are normally allocated on square footage basis only. Plant 2 Depreciation of equipment/moveable including furniture and fixtures and transportation equipment, which are normally allocated based on square footage or dollar value. Plant 3 Interest expense, property taxes, allowable lease rental components and interest related amortization normally allocated based on square footage. Providers Trial Balance Expenses listed in this column must be in accordance with the providers accounting books and records detailed among plant, base and support costs. After recalculation with the F9 key, the total in this column must equal the total of expenses in the general ledger. Enter the appropriate amounts in the yellow shaded cells. Minor Equipment Several cost centers in the worksheet have the accounts titled Minor Equipment - Less Than $5,000 and Minor Equipment - More Than $5,000. The following guidelines should be used in reporting the costs in these accounts. Minor Equipment More Than $5,000. If a depreciable asset has at the time of its acquisition an estimated useful life of at least 2 years and a historical cost of at least $5,000, its cost must be capitalized and written off ratably over the estimated useful life of the asset using one of the approved methods of depreciation. If the Provider has expensed capital asset costs in excess of the minimum amount allowed for Program minor equipment expense, this expense must be separately reported in this account and will be removed from current year allowable cost. See cost reporting instruction, Capital Asset Values for related cost reporting instructions. Minor Equipment Less Than $5,000. If a depreciable asset has a historical cost of less than $5,000, or if the asset has a useful life of less than 2 years, its cost is allowable in the year it is acquired. The cost of asset acquisition meeting this requirement is reported in this account. The provider may establish a capitalization policy with lower minimum criteria, but under no circumstances may the above minimum limits be exceeded. For example, a provider may elect to capitalize all assets with an estimated useful life of at least 18 months and a historical cost of at least $4,000. However, it may not elect to capitalize only those assets with a useful life of at least 3 years and a historical cost of more than $6,000. When items are purchased as an integrated system, all items must be considered as a single asset when applying the capitalization threshold. Items that have a stand-alone functional capability may be considered on an item-by-item basis. For example, an integrated system of office furniture (interlocking panels, desktops that are supported by locking into panels) must be considered as a single asset when applying the threshold. Stand alone office furniture (e.g., chairs, and freestanding desks) will be considered on an item-by-item basis. Plant Costs Depreciation, interest, property taxes, leases, and amortization treated as interest are reported as plant costs. If the provider directly identifies plant costs to specific cost centers, these costs should be reported in the appropriate cost centers. This identification will be directly identified plant cost in subsequent worksheets for cost allocation. The provider must assure that there is not an unreasonable or inequitable allocation of total costs not directly identified. Account Reference #125 is for recording Interest Expense from the Mortgage and Bonds related to the current ownerships acquisition of the facility. Account Reference #126 is for recording all Other Interest Expense incurred by the facility. In the case of a refinancing of the original acquisition loan, the provider must identify that portion of the new loan interest expense attributable to the portion of the loan that is the original acquisition loan amortization and report that Interest Expense in Account Reference #125. The difference between the interest expense attributed to the original acquisition principle balances and the refinanced loans total interest expense and all other interest expense would be reported in Account Reference #126. Account Reference #118 through 123 will be entered as the result of completing W/S 1-D. Account Reference #130 through 132 will be entered as the result of completing W/S 3. Items directly identified to a specific cost center should be posted on W/S 1 and not on W/S 3. Employee Health and Welfare This cost center includes all fringe benefits such as employer contributions to FICA, FUTA, MESC, employee life and health insurance, workers compensation, retirement, physicals and all other insurance provided to employees as fringe benefits. Expenses related to payroll taxes and employee health and welfare are classified by the reference B/S. Since the Medicaid Program classifies certain salaries and wages as Base costs, and other salaries and wages as Support costs, the related payroll taxes and employee health and welfare expenses will also be separated to Base and Support as appropriate. If the facilitys accounting records separately reflect the payroll taxes and employee health and welfare expenses for Base and Support personnel, the individual cost center accounts should be used in the Worksheet 1. If the facilitys accounting records do not separately reflect the payroll taxes and employee health and welfare expenses for Base and Support personnel, by cost center identification, the total amount of these costs must be reported on W/S 1 in the Employee Health and Welfare cost center, Account Reference # lines 139 through 146. The necessary reclassification of these costs based upon payroll distribution will be automatically completed on W/S 1-G. If the provider has a more equitable allocation method to allocate these costs than based upon payroll distribution, the allocation must be reflected as a cost reclassification on Worksheet 1-A. The balance of the Account Reference # lines 139 through 141 and 143 through 146 must be zero after this reclassification. Worksheet 1-G must not be used to re-class these costs. Account Reference # 142 is for recording the total Workers Compensation premium costs where the provider does not have accountings records that separately identify this cost by individual cost center. Workers Compensation cost will be allocated on Worksheet 2 based upon payroll distribution. If a direct identification of Workers Compensation premium costs by individual cost center is available, the individual cost center Workers Compensation account must be used; individual cost centers without a Workers Compensation account should use the Employee Benefits account. Administrative and General This cost center includes but is not limited to office supplies, printing, postage, legal and accounting, telephone, travel, advertising, public relations, general insurance and other such support materials incurred in the general administrative services of the facility. Account Reference #154 through 156 will be automatically entered as a result of completion of W/S 1-E-1. Account Reference #157 will be automatically entered as a result of completion of W/S 1-E. The quarterly Quality Assurance Assessment fees billed to the nursing facility for the calendar quarters included in the cost reporting period must be reported as an expense in the facilitys financial records and reported in the cost reports Account 203. If a change of ownership occurs during a calendar quarter and both nursing facility entities prorates the assessment fee between the entities, supporting documentation must be submitted by each entity when filing their respective cost report. The supporting documentation must include entity sales document showing the proration. Account Reference 204 Provider Donation for Outstationed Workers would be utilized by the nursing facility that has a signed agreement with the Department of Human Services (DHS) for the salary costs of an onsite eligibility specialist worker. The costs reported for the worker, cannot exceed the amount stated in the contract agreement. A copy of the signed agreement must be submitted with the facilitys cost report. If the nursing facility has entered into an agreement(s) with other nursing facility(ies), to share the outstationed worker services, an individual Worksheet 1B adjustment must be made for the amount of services purchased by each facility. Documentation must be submitted by the facility that entered into the agreement with DHS, that details the facility(ies) using the outstationed worker services, and the amount of services purchased by each facility. Plant Operation and Maintenance This cost center contains cost of ordinary repairs and maintenance, maintenance supplies and materials, maintenance service contracts for equipment, elevators, carpet cleaning, other service contracts such as snow and trash removal, etc. Maintenance and repair costs that are applicable to the housekeeping, dietary, laundry and other cost centers but not readily identified in the providers accounting books and records, may be included in this cost center. See the instructions on  REF _Ref410630020 \h  \* MERGEFORMAT Worksheet 2 for special note on statistics for Worksheet 2. Account Reference #209 will be automatically entered as a result of completion of W/S 1-E-1 and W/S 1-E. Utilities This cost center includes utilities, i.e., heat, fuel, electricity, water. See the instructions on  REF _Ref410629842 \h  \* MERGEFORMAT Worksheet 2 for special note on statistics for Worksheet 2. Laundry This cost center includes laundry and linen supplies, repairs of laundry equipment, outside laundry services, linen and bedding. If any miscellaneous base costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #266. Account Reference #246 will be automatically entered as a result of completion of W/S 1-E-1 and W/S 1-E. Housekeeping This cost center includes housekeeping supplies, services, housekeeping equipment repair, outside housekeeping services, etc. Account Reference #276 will be automatically entered as a result of completion of W/S 1-E-1 and W/S 1-E. Dietary This cost center contains all supplies, disposable tableware, raw food, repair of equipment and dietitian contractual services, etc., including the costs of the separately operated cafeteria for employees and/or guests. If any miscellaneous base costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #321. If any miscellaneous support costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #322. Account Reference #301 will be automatically entered as a result of completion of W/S 1-E-1 and W/S 1-E. Nursing Administration This cost center normally should include only the cost of nursing administration. The salary cost of direct nursing services, including the salary cost of nurses who render direct services in more than one patient care area, should be directly assigned to the various patient care cost centers in which services were rendered. If any miscellaneous base costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #353. If any miscellaneous support costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #354. Account Reference #331 will be automatically entered as a result of completion of W/S 1-E-1. Account Reference #332 will be automatically entered as a result of completion of W/S 1-E-1 and W/S 1-E. Central Supplies All supplies and materials, not included anywhere else, should be included in this cost center. Account Reference #360 will be automatically entered as a result of completion of W/S 1-E Medical Supplies Chargeable and non-chargeable supplies should be reported in this cost center. Chargeable supplies (those items for which a separate billing is submitted to the beneficiary or other third party) should be reclassified to Medical supplies charged to patients, Account Reference #s 641 through 649. Account Reference #384 will be automatically entered as a result of completion of W/S 1-E. Medical Records Library This cost center reflects the cost of medical records activity. Account Reference #408 through 409 will be automatically entered as a result of completion of W/S 1-E-1 and W/S 1-E. Social Services This cost center reflects the costs of maintaining social services activity. If any miscellaneous base costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #451. If any miscellaneous support costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #452. Account Reference #433 will be automatically entered as a result of completion of W/S 1-E-1 and W/S 1-E. Diversional Therapy Activities All diversional therapy activities expenses should be included in this cost center. If any miscellaneous base costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #479. If any miscellaneous support costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #480. Account Reference #461 will be automatically entered as a result of completion of W/S 1-E-1 and W/S 1-E. Radiology, Laboratory, Intravenous Therapy, Inhalation Therapy (Oxygen), Physical Therapy, Speech Therapy, Occupational Therapy, Electroencephalography, Medical Supplies Charged to Patient, Pharmacy Physician Services These are ancillary cost centers. Salaries and wages will be automatically entered as a result of completion of W/S 1-E. Medicare SNF Unit, Medicaid Routine Care Unit #1 and #2, Medicaid Special Care Unit #1 and #2, Home for Aged Unit, Non-LTC Apartment/Housing Unit, Non-Medicare and Non-Medicaid Licensed Only, and Non-LTC Nursing Services These were previously defined. Salaries and wages will be automatically entered as a result of completion of W/S 1-E. If any miscellaneous base costs cannot be identified with any other Account Reference #, the amount can be entered on the Miscellaneous - Base line. If any miscellaneous support costs cannot be identified with any other Account Reference #, the amount can be entered on the Miscellaneous - Support line. Non-Available Beds This cost center is available for the step-down and any specifically identified cost. Nurse Aide Training & Testing LTC Training Program Approval Requirement Only costs incurred relative to a Bureau of Health Professions approved Nurse Aide Training Program may be claimed on this schedule. An approved program may be conducted by the provider facility or by a separate entity from the provider. Accounting Records and Allowable Costs Accounting records must be maintained to document the allowable costs incurred in providing the training and testing. Allowable costs must be determined in accordance with the requirements and principles set forth in the Provider Reimbursement Manual, Part I (-CMS Pub. 15-1), except as provided under the Michigan Medical Assistance State Plan and Medicaid Provider Manual, Nursing Facility Chapter, Cost Reporting and Reimbursement Appendix and Program Bulletins. Training and testing program costs claimed for services and supplies furnished to or purchased by the facility from organizations related to the provider by common ownership or control must adhere to the related party allowable cost principles. Expenses for such transactions should not exceed expenses for like items or services in an arms-length transaction with other non-related organizations, or the cost to the related organization, whichever is lower. Cost reporting of related party transactions must be coordinated with the reporting of cost adjustments on Worksheet 1-C related party expenses. Administrative overhead costs and space costs in nursing facilities conducting in-house training are not considered training and testing program costs. The costs reported must be specifically incurred in conducting the approved nurse aide training and testing program. Supporting accounting records such as class attendance rosters or training participation logs, purchase orders, vendor invoices, contracts, documentation verifying amounts reimbursed to employees for approved training program expense incurred by the employee prior to employment at the facility (canceled check, training program receipt), etc. must be maintained for audit purposes. Supporting materials should be readily identifiable as training related cost documentation and must indicate the type of training involved. If the facility maintains separate cost center reporting for the training program, enter the appropriate costs as Identified. Nurse Aide Training and Testing Cost Definitions: Facility Training Staff Payroll related costs for facility employees, incurred for the approved program direct training time or nurse aide training program preparation time. Nurse Aide Training Consultants Costs incurred for non-facility staff engaged to provide instruction or consultation for the facilitys approved nurse aide training program. Student Staff Payroll costs for facility employees incurred while the student is actually engaged in the approved training program or traveling to and from the off-site approved training location, or engaged in off-site testing or traveling to and from the off-site testing location. Training Program Supplies Cost incurred for supplies and materials used in conducting an approved training program. Training Program Transportation Travel or transportation cost incurred by facility staff in conducting approved training program activity and testing, or for off-site nurse aide training and testing. Identify costs separately for training and student staff. Outside Contracted Approved Nurse Aide Training Program Paid Directly By Facility Costs incurred to obtain nurse aide training through an outside entity approved training program. Payment for subject training is made directly from the nursing facility to the training entity and the nurse aide trainees are employed by the nursing facility. Reimbursed To Employee Staff Costs incurred to reimburse a facility employee who had personally paid for approved nurse aide training program participation prior to becoming an employee at the facility. Reasonable and necessary expenses incurred by the prospective employee through participation and completion of a Bureau of Health Professions approved training program, for which the aide has made payment, are eligible for remuneration. Only cost of tuition and books are reimbursed. The aide must be hired by a facility within 12 months after incurring this expense. The facility must obtain receipts and retain documentation from the employee to verify the expense. Nurse Aide Testing Fees a. Paid Directly By Facility Cost incurred for State-run testing. Payment for subject testing fees is made directly from the nursing facility to the testing authority for aides employed at the facility. b. Reimbursed To Employee Staff Cost incurred to reimburse a facility employee who had personally paid for State-run testing prior to becoming an employee at the facility. The aide must be hired by a facility within 12 months after paying the testing fee. The facility must obtain receipt and retain documentation from the employee to verify the expense. Miscellaneous Cost incurred that are not classified in the identified cost categories. Rental costs for space located off-site of the facility are reimbursable under training and testing only if the space is used solely for the training and testing program. Space costs not meeting this requirement are reimbursable within the plant cost component of Michigans prospective reimbursement system. Reasonable rental expense for training equipment necessary to the approved training program is an eligible cost. The detail listing of these expenditures must be reported in Worksheet 8, Miscellaneous. Refer to the  REF Worksheet_8 \* MERGEFORMAT Worksheet 8 instructions. Account Reference #964, Miscellaneous, will be automatically entered from data reported on W/S 8. Note: If the facility does not maintain separate cost center reporting, appropriate cost reclassifications must be made on Worksheet 1-A for Account Reference #951, and #955 - #964. Special Dietary Special dietary reimbursement outside the routine nursing care per diem for special dietary needs of religious non-profit nursing facilities requires completion of account reference #970 through #991. Note: Account Reference # 970 will be automatically entered as a result of completion of W/S 1-E for those providers that directly identify salary costs. If the provider does not directly identify salary costs on the Worksheet 1-E, a reclassification must be made on Worksheet 1-A for the salary and wages of special dietary staff. Note: A reclassification of related payroll taxes and fringe benefits must be made on Worksheet 1-A, if the provider directly identifies payroll taxes and fringe benefits by cost center. Reclassification of related payroll taxes and fringe benefits will automatically be calculated on Worksheet 1-G for providers that do not directly identify payroll taxes and fringe benefits. (see section  REF Worksheet_1 \* MERGEFORMAT Worksheet 1,  REF Employee_Health_and_Welfare \* MERGEFORMAT Employee Health and Welfare) If any miscellaneous base costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #990. If any miscellaneous support costs cannot be identified with any other Account Reference #, the amount can be entered on Account Reference #991. If the facility does not maintain separate cost center reporting, appropriate cost reclassifications must be made on Worksheet 1-A. Beauty & Barber Shop, Gift, Flower, Coffee Shop & Canteen, Physicians Private Office, Non-paid Workers, & Other These cost centers are available for the step-down and any specifically identified costs. NO MANUAL ENTRIES CAN BE MADE IN THE REMAINING COLUMNS OF WORKSHEET 1Reclass There are no direct entries to this column. All entries to this column will automatically flow from subsequent worksheets. Adjustments There are no direct entries to this column. All entries to this column will automatically flow from subsequent worksheets. Medicaid Trial Balance There are no direct entries to this column. The column entries are automatically entered as the result of all of the provider's trial balance adjustments and reclassifications. The Medicaid trial balance amounts will be automatically carried forward to subsequent worksheets for the allocation process. Worksheet 1 is mandatory; therefore, mark the Completed box.Worksheet 1-A General Reclassifications The purpose of this worksheet is to identify cost reclassifications in the reclass column on Worksheet 1, of certain amounts to effect proper cost classification for Medicaid reimbursement and cost allocation under cost finding. A reclassification will transfer the specified cost from one designated Account Reference # to another designated Account Reference #. The first seven lines of Worksheet 1-A are reserved for information posting from W/S 1-D. Entries in the Explanation of Reclassification column can be of any length. Although it may not print, the information is available electronically. All reclassifications are to be assigned a letter in the Code column. Start with adjustment b on the first shaded line. The cost center must be entered in the Cost Center column and the Account Reference # from within that cost center must be entered in the Account Reference # column as shown on the first seven lines. It is recommended a printed copy of the partially completed W/S 1 would be helpful as a reference in completing cost reclassifications. Reclassify costs reported on Worksheet 1 to reflect proper classification per Medicaid reimbursement policy. This action is necessary where a certain cost has been reported in an inappropriate cost center or Account Reference # on Worksheet 1, Provider Trial Balance column. Worksheet 1-A is NOT mandatory. Mark the Completed box if you have entered data; if there are no entries, mark the Not Applicable box.Worksheet 1-B Adjustments To Expenses Provider Prepared Adjustments Worksheet 1-B provides for the adjustments to the expenses listed on Worksheet 1. These adjustments, which are required under the Medicaid Principles of Reimbursement, are to be made on the basis of cost, or amount received (revenue) only if the cost (including direct cost and all applicable overhead) cannot be determined. If the total direct and indirect cost can be determined, enter the cost. Once an adjustment to an expense is made on the basis of cost, the provider cannot make the required adjustment to the expense on the basis of revenue in future cost reporting periods. The following symbols must be entered in column 1 to indicate the basis for adjustments: A for cost; and B for amount received. Line descriptions indicate the more common activities, which affect allowable costs, or results in costs incurred for reasons other than patient care and thus require adjustments. Types of items to be entered on Worksheet 1-B are: (1) those needed to adjust expenses to reflect actual expenses incurred; (2) those items which constitute recovery of expense through sales, charges, fees, grants, gifts, etc.; (3) those items needed to adjust expenses in accordance with the Medicaid Principles of Reimbursement; and (4) those items which are provided for separately in the cost apportionment process. Where an adjustment to an expense affects more than one cost center, the provider must record the adjustment to each cost center on a separate line on Worksheet 1-B. Yellow shaded lines may be used for such adjustments. The number entry in the amount column can be either plus or minus. Minus amounts are displayed in ( ). Entries to reduce the account amount reported in Worksheet 1 must be entered as a minus amount. If the adjustment reported on Worksheet 1-B is based on revenue received from the sale of a service or item, the adjustment to reduce costs in Worksheet 1 should be in that specific cost center in which the cost of the service or item is reported. Use the specific Account Reference # if available; otherwise, use the miscellaneous line. If miscellaneous base and support are both available, use miscellaneous base cost account reference #. Normally the sum total of adjustments to expenses is a negative amount. If the sum total is a positive amount, a validation error message will occur. The purpose of the message is to alert the preparer to verify the adjustment amounts have been properly entered in Worksheet 1-B. Adjustments To Remove Special Services Costs The cost of certain special services that are not considered part of the Medicaid Program routine nursing care per diem cost may be removed from total costs. The removal of the cost from the facility total costs removes the cost allocation requirement of administrative costs to those services for which the nursing facility is limited to recovery of the direct cost of providing the service. The cost of these services may be adjusted on Worksheet 1-B to exclude these costs from the administrative cost allocation. The adjustment will exclude the costs from being included in the accumulated cost statistical basis used in the Worksheet 2 cost allocation. If the nursing facility recovers revenue in excess of the direct cost of the services the adjustment of cost on Worksheet 1-B may be based on the revenue dollar amount received. The revenue amount exceeding the direct cost will be considered the overhead expense that should be reflected as an adjustment to the Miscellaneous expense in the Administrative and General cost center. This adjustment is in addition to the adjustment to exclude the direct cost of the service. This adjustment process applies only to the service items where the billing process for those services is limited to recovery of the direct cost of the service. Certain pharmacy services and Clintron bed costs are examples of this type of service. This process may not be applied to other services activity if that particular activity normal billing process or practice includes billing of overhead or mark up costs. Automatically Entered Adjustments The following adjustments are automatically entered by the cost reporting format for compliance with Medicaid reimbursement policies. Any remaining cost in the identified accounts after reclassifications and adjustments will appear as a Worksheet 1-B adjustment to zero out the account. Account Reference #156 - Owner/Administrator compensation in excess of Medicaid guidelines from Worksheet 1-F. Account Reference #123 - Other non-allowable costs from Worksheet 1-D and Worksheet 1. Account Reference #199 - Penalties on Worksheet 1. Account Reference #201 - Bad debts on Worksheet 1. Account Reference #203 - Quality Assurance Assessment tax on Worksheet 1. Account Reference #192, #217, #257, #284, #312, #347, #369, #393, #419, #445, #473, #499, #518, #537, #555, #572, #592, #611, #628, #643, #661, #686, #714, #741, #768, #795, #822, #848, #874, #900, #926, #981 Minor Equipment More Than $5,000 on Worksheet 1. The appropriate depreciation and capital asset cost entries must be made on Worksheet 3, Statement of Capital Asset Values on Financial Records of Nursing Facility in order to properly report these items for Medicaid reimbursement. Enter all of the text information on the same line as the adjustment dollar and account reference information. Entry of text information on multiple lines will cause a validation error because there are no dollar or account number entries to correspond with the additional text lines. Worksheet 1-B is NOT mandatory. Mark the Completed box if you have entered data; if there are no entries, mark the Not Applicable box.Worksheet 1-C Statement Of Costs Of Services From Related Organizations The purpose of this worksheet is to identify the cost claimed for services and supplies furnished to or purchased by the facility from organizations related to the provider by common ownership, control, central or interlocking directorates. Expenses for such transactions should not exceed expenses for like items or services in an arms-length transaction with other non-related organizations, or the cost to the related organization, whichever is lower. Related to the provider means that the provider to a significant extent is associated or affiliated with or has control of or is controlled by the organization furnishing the services, facilities or supplies. [Refer to 42 CFR, Sec. 413.157(b)(1)] Common ownership exists when an individual or individuals possess significant ownership or equity in the provider and the institution or organization serving the provider. [Refer to 42 CFR, Sec. 413.157(b)(2)] For purposes of Worksheet 1-C, common ownership of 5% or more ownership or equity must be reported. Control exists where an individual or an organization has the power, directly and indirectly, significantly to influence or direct the actions or policies or an organization or institution. [Refer to 42 CFR, Sec. 413.157(b)(3)] Interlocking directorate refers to situations where entities are under the control of officers, directors or board of directors who are related by marriage or not necessarily by marriage, but become engaged or interrelated with one another. ITEMS A. AND B. OF THIS WORKSHEET MUST BE COMPLETED BY ALL PROVIDERS. THIS IS MANDATORY.ITEM A. Related Organization Lease/Rental This question is specific to costs claimed in Worksheet 1 that result from lease/rental agreement with related organizations. A yes answer to this question requires completion of Items C and D of this worksheet and Worksheet 1-D. ITEM B. Related Organization Other Costs This question is specific to costs claimed on Worksheet 1 that resulted from business transactions, other than lease/rental, with related organizations. A yes answer to this question requires further completion of Items C and D of this worksheet. ITEM C. Interrelationship of Provider to Related Organization(s) This item is used to show the interrelationship of the provider to organizations furnishing services, facilities or supplies to the provider. The requested data relative to all individuals, partnerships, corporations or other organizations having either a related interest to the provider, a common ownership of the provider, or control over the provider as referenced above in section  REF Worksheet_1_C \* MERGEFORMAT Worksheet 1-C, must be shown in columns 1 through 6, as appropriate. Column 1 If the symbols A, D, E, F, or G are entered in column 2, enter the name of the related individual in column 1. If the symbols B or C is entered in column 2 enter the name of related company or organization in column 1. Enter the name of the individual, organization or business entity (i.e.: related party), which owns, controls or has business association with the related party entity/organization that is providing the transaction services to the nursing home. Column 2 Enter the appropriate symbol that describes the inter-relationship of the provider nursing home to the related party listed in column 1. (Note: only one symbol should be identified. If more than one interrelationship applies, enter the predominant relationship). Column 3 If the individual or entity identified in column 1 has a financial interest in the provider, enter in this column the percentage of ownership the individual or organization has in the provider. Column 4 Enter in this column the name of the related individual corporation, partnership or other entity/organization. Column 5 If the individual or entity/organization in column 1 has a financial interest in the related entity/organization, enter in this column the percentage of ownership in such organization. Column 6 Enter in this column the type of business in which the related entity engages (e.g., medical drugs and/or supplies, laundry and linen service). ITEM D. Related Organization Cost Data The purpose of this section is to determine cost adjustments to Worksheet 1, necessary to report expenses in accordance with the limitation identified in the  REF Worksheet_1_C \* MERGEFORMAT Worksheet 1-C instructions, above. Lines 1 and 2 are specifically identified for lease/rental costs, if applicable. Columns 1 through 5 identify the costs reported in Worksheet 1. The data entered on this page relative to related party leases is informational. No adjustments to expenses is made from this worksheet for underlying costs of such leases. Providers with related party leases must complete Worksheet 1-D and must report the lease expense and resulting adjustments on that worksheet. Lines 3 through 39 are open for the provider to enter the information relative to services and goods purchased from a related entity or party. Columns 1 through 5 relate to information where such costs were claimed on Worksheet 1. Briefly describe in column 1 the expense item or services purchased. Column 2 is the reference to the Item C information row(s) that identifies that "related organization" for that expense. Column 6 identifies the allowable costs applicable to services, facilities and supplies furnished to the provider by the related organization. These costs must not exceed the amount a prudent and cost-conscious buyer would pay for comparable services, facilities or supplies that could be purchased elsewhere. Column 7 reflects the adjustment, by Account Reference #, necessary to Worksheet 1 reported costs. The amount in column 7 is automatically calculated and entered in Worksheet 1. Note: Services purchased from a related party or entity are viewed the same as unrelated party purchases as to the consideration of base and support account classifications. If the purchased services from the related party are a purchased service cost that was split between base and support on Worksheet 1, two lines must be used on Worksheet 1-C for the purchased service to maintain the allocation of base and support cost and adjustment thereto. For example, if laundry contracted services was originally entered in line 253 and automatically split between lines 252 and 253, adjustments must be made to both lines 252 and 253. Providers that have costs allocated from a home office operation or purchases of management services, laundry, or any other type of services from a related party entity/organization must prepare and file detailed supporting documentation identifying these expenses and the allocation basis to the individual nursing facility (ies). The required cost report format is a Medicare Home Office Cost Statement, Schedules A through J, HCFA 287-82. Worksheet 1-C is mandatory; therefore, mark the Completed box.Worksheet 1-D Statement Of Leased Capital Assets The purpose of this worksheet is to identify all lease expenses including pass-through leases reported on Worksheet 1. ITEM A. Leased Capital Assets This question is specific to costs claimed in Worksheet 1 that result from any lease/rental agreement. A yes answer to this question requires completion of item B of this worksheet. ITEM A OF THIS WORKSHEET MUST BE COMPLETED BY ALL PROVIDERS.ITEM B. Lease Rental Cost Incurred and Adjustment Required This section provides for the determination of the necessary adjustments to lease/rental costs reported on Worksheet 1. Enter the following information for each individual lease arrangement: Identify the Lessors information. Enter the appropriate information in each of the first three cells for each lease arrangement. Entries can be of any length. Although it may not print, the information is available electronically. Entry of Various or leaving any of the cells blank is not proper disclosure, and will cause return of the cost report. Account #Procedure118Enter the dollar amount of the lease expense for the specific identified lease recorded in the providers accounting general ledger.119Enter the dollar amount of the underlying allowable depreciation expense incurred by the Lessor.120Enter the dollar amount of the underlying allowable interest expense incurred by the Lessor.121Enter the dollar amount of the underlying allowable property taxes expense incurred by the Lessor.200Enter the dollar amount of the allowable Lessors repair costs, maintenance expense, insurance, etc. 122Lease Rental Component - Minor Equipment Leases. The Medicaid Program allows certain minor equipment leases as pass through plant costs without adjustment to underlying costs. Reference should be made to the Medicaid Provider Manual, Nursing Facility Chapter, Cost Reporting and Reimbursement Appendix, Section 8.9.C and applicable policy bulletins for such items. Such leases should be reported on Worksheet 1-D. Enter the same amount to Account Reference # 122, Lease Rental Component. Account Reference # 123 will equal 0.123This amount will be automatically calculated as the difference between Account Reference # 118 and the sum of Account Reference # 119, 120, 121, 200, and 122.Enter description of item(s) leased. Entries can be of any length. Although it may not print, the information is available electronically. Entry of Various or leaving any of the cells blank is not proper disclosure, and will cause return of the cost report. The sum of the individual Account Reference # amounts for all leases will be automatically calculated and entered in the Totals cells on this worksheet. These totals will flow to Worksheet 1-A and then to Worksheet 1 automatically. A lease of any facility asset, which meets any of the conditions in CMS Pub. 151, Section 110.B.1.b establishes the lease agreement as a virtual purchase. The lease of a facility asset must be considered and treated, for Medicaid cost reporting, as a virtual purchase if any of the conditions set forth in CMS Pub. 151, Section 110.B.1.b is satisfied. This is applicable to assets that meet the Medicaid definition for treatment as a passthrough lease asset(s) and nonpass through leased asset(s). Worksheet 1-D is mandatory; therefore, mark the Completed box.Worksheet 1-E-1 Salary Information of Owners, Officers, Administrators, and Department Heads The purpose of this worksheet is to identify the individuals working in the position of Owners, Officers, Administrators, and Department Heads and report their salary, wages, and hours for actual payroll hours within the specific nursing or service area or cost center in accordance with the column heading. The worksheet should be completed from the facilitys accounting and payroll records. If the facility maintains one salary and wage account or has various cost center payroll data combined for accounting purposes, the payroll data must be separately identified on Worksheet 1E1 by each cost center as indicated. If an identified cost center did not have an individual staffing the position during the reporting period, click the check box I certify that the position was not staffed during the reporting period. Name of Individual Enter the first and last name of the individual employed in the position during the reporting period. If more than one individual, enter the name(s) of all employees that were employed in the position during the reporting period. Contract Service or Related Party Enter yes, when a related party pays the individuals salary and the salary has been reported on Worksheet 1C, enter no when the salary amount reported for the individual was reported on the nursing facilitys records. Number of Hours Per Week Devoted to this Function Enter the number of hours devoted to this position by each employee listed. Do not make adjustments to the hours to account for overtime hours adjustment as requested for Worksheet 7 reporting. The number of hours should be entered as a whole number. Total Hours Worked Per Report Period The number of work hours reported for payroll reporting for employees during the cost report time period. This amount should correspond to the number of hours worked or the number of hours on which the employee payroll is determined. Do not make adjustments to the hours to account for overtime hours adjustment as requested for Worksheet 7 reporting. The number of hours should be entered as a whole number. Months Worked Per Reporting Period Enter the number of months each employee listed worked in this position during the reporting period. The number of months should be entered as a whole number. Total Salary Cost Per Report Period The salary and wage amounts should agree with the general ledger since they are automatically will be posted to Worksheet 1, via the Worksheet 1E1. The entry should be a whole number. Information from this worksheet will automatically flow to the appropriate line on Worksheet 1F. If the Contract Service or Related Party was answered no, then the information for that employee will automatically flow to the appropriate line on Worksheet 1-E. Worksheet 1E1 is mandatory; therefore, mark the Completed box.Worksheet 1-E Statement Of Salaries And Wages The purpose of this worksheet is to report salary, wages, and hours for actual payroll hours within the specific nursing or service area or cost center in accordance with the column heading. The worksheet should be completed from the facilitys accounting and payroll records. The records necessary to determine the appointment of salary cost between two or more cost centers must be maintained by the provider and must adequately substantiate the method used to apportion the salary cost. If the facility maintains one salary and wage account or has various cost center payroll data combined for accounting purposes, the payroll data must be separately identified on Worksheet 1-E by each cost center as indicated. The wage and salary information for Owners, Officers, Administrators, and Department Heads is reported on Worksheet 1 E 1 and will automatically flow to the appropriate cells on this worksheet (see above). Total No. of Staff The number of staff should be reported in this column as numeric entry. The entry should be a whole number. The entry should not be the number of full time equivalence staff employed during the reported period. Total Hours Worked Per Report Period The number of work hours reported for payroll reporting for employees during the cost report time period. This amount should correspond to the number of hours worked or the number of hours on which the employee payroll is determined. Do not make adjustments to the hours to account for overtime hours adjustment as requested for Worksheet 7 reporting. The number of hours should be entered as a whole number. Total Salary Cost Per Report Period The salary and wage amounts should agree with the general ledger since they are automatically posted to Worksheet 1. The entry should be a whole number. Worksheet 1-E is mandatory; therefore, mark the Completed box.Worksheet 1-F Salary Information Of Owners, Administrators, Assistant Administrators And Relatives The purpose of this worksheet is to identify the reported compensation applicable to owners, administrators, assistant administrators and relatives to the owner. The worksheet provides for the computation of any needed adjustments to these costs for amounts reported in excess of compensation limits allowed under the Medicaid policy. The information required on this worksheet must provide for, in the aggregate, owners, administrators, assistant administrators total compensation paid for the services, furnished in determining the reasonableness and allowable costs under the Medicaid guidelines. Compensation includes: Salary amounts paid for managerial, administrative, professional, and other services. Amounts paid by the facility for the personal benefit of the owner to the extent the cost is allowable as salary and wages. The cost of assets and services which the proprietor receives from the institution. Deferred compensation. (Refer to 42 CFR, Sec. 413.102). Directors fees paid to owners. Do not enter text or symbol information in the hours cells. If it is necessary to enter text information to explain the individuals employment status or other pertinent data, enter the text in the job description cell in the line (row) for that individual. Line 33 a, Maximum Medicaid owner/administrator compensation amounts applicable to nursing care facilities will be provided by the Medical Assistance Program and entered by the preparer. The maximum compensation limit is based upon the number of "available beds" for nursing care in the facility. If the facility has a Medicaid Program non-available bed plan in effect for the entire cost reporting time period or has operated under a ban on admissions for the entire cost reporting time period, the reduced number of beds available for nursing care must be considered. The appropriate compensation limit is the limit corresponding with the highest number of "available beds" for any specific date during the subject cost report period. If the subject cost reporting period is less than twelve months, the compensation limit must be prorated to reflect the limitation for less than a full year. The prorated amount is equal to: (number of months in the cost report period divided by 12) times the respective facility bed size compensation limit amount. Amounts in excess of the limit will automatically be adjusted on line 33 b and posted to Worksheet 1-B. Section I, II, III, and IV. The name of the individual(s)and their respective salary amount reported on Worksheet 1E1 are automatically forwarded to the appropriate columns on Worksheet 1F. For each individual listed, the number of hours devoted weekly to this function, their job title and description, and other compensation amounts, if applicable, must be reported on this schedule. Section V. The name of individual(s) employed in and / or paid by the facility whom are owners and / or relatives of facility ownership and their respective salary amounts, earned from non administrative duties and other compensation received must be reported in this section. For each individual listed in this section, in addition to reporting their salary and other compensation, the number of hours devoted to this function, the job title and description, must be identified on this schedule. Worksheet 1-F is mandatory; therefore, mark the Completed box.Worksheet 1-G Employee Health & Welfare Base/Support Reclassifications NO MANUAL ENTRIES CAN BE MADE IN THE WORKSHEET 1-G. This worksheet allocates those Employee Health & Welfare Benefits which are not directly identified to the appropriate account reference # (i.e., Employee Health & Welfare account lines 139 through 141 and 143 through 146). The reclassification to the appropriate account reference # is computed automatically using the adjusted salaries from Worksheet 1. Worksheet 2 Cost Allocation: Statistical Basis ALL FACILITIES ARE REQUIRED TO USE THE STEP-DOWN PROCESS.Worksheet 2 provides for the proration of statistical data needed to equitably allocate expenses of the general service cost centers through the remaining cost report worksheets where necessary. Cost Allocations The Medicaid Program for long term nursing care reimbursement includes determination of reimbursement rates based on various cost categories. It is necessary to separate the allocation of costs by Plant cost (1, 2, and 3), Base Cost and Support Cost categories as defined in the completion of worksheet 1 and related worksheets. This separation is required to preserve the identification of the type (Plant, Base and Support) of cost in the total costs allocated to the facilitys revenue producing cost centers. The provider should contact the Medicaid intermediary regarding the necessary worksheet preparation if further clarification is needed for cost finding statistics. A written request must be made to the Medical Services Administration, LTC Reimbursement and Rate Setting Section (RARSS), for approval of any deviation from standard cost finding statistics. The request must be made prior to the beginning of the cost reporting period in which the change is to apply. . (See CMS Pub. 15-1, chapter 23 for adequate cost data and cost finding and Section 9.6.B of the Medicaid Provider Manual, Nursing Facility Chapter, Cost Reporting and Reimbursement Appendix.) A written explanation and supporting documentation (if applicable) of any changes (except the statistical basis, see above); to the statistics used in the prior cost reporting period must be submitted with the cost report. Examples would include: remeasurement of the facility square footage, weighted average square footage, square footage changes due to renovation or new construction, the elimination of a cost center. The Worksheet 2 series of cost reporting schedules provide for the allocation of total expenses of each general service cost center to those cost centers which receive the services. These worksheets also provide for presentation of statistics used for allocating costs and automatically perform the mathematical calculations of the allocation process. The cost centers serviced by the general service cost centers include all cost centers within the provider organization; that is, other general service cost centers, ancillary cost centers, inpatient routine service cost centers, out-patient service cost centers and other reimbursable cost centers and non-reimbursable cost centers. These forms include the step-down method of cost finding for the allocation of the cost of services rendered by each general service cost center to other cost centers which utilize such services. Once the costs of a general service cost center have been allocated, that cost center is considered closed. Being closed it will not receive any of the costs that are subsequently allocated from the remaining general service cost centers. The statistical basis shown at the top of each column on Worksheet 2 is the recommended basis of allocation of the cost center indicated. A yellow data entry cell is provided in the column heading in Columns 5 through 15, to allow for the preparer to enter a statistical basis other than the standard basis. The Provider must have prior approval to use an alternative basis (see above). Indicate the statistic basis used to allocate the identified cost center expenses. Most cost centers are allocated on different statistical bases. However, for those cost centers where the basis is the same (e.g., square feet), the total statistical base over which the costs are to be allocated will differ because of the prior elimination of cost centers that have been closed. If the basis is the same, the statistic used in each cost center must be identical. Special Note for Allocation Statistics for Plant 1 + 3 (column 1) and Plant 2 (column 2). Line 8 - Plant Operations and Maintenance. Enter the square footage applicable to the plant operations and maintenance cost center area in column 1 and 2 as applicable. Line 9 - Utilities. If the facility does not operate its own utility power plant or building, do not enter any square footage statistic on line 9, columns 1 and 2. If the facility has a separate building or physical plant area for utility production, then enter square footage of that building area on line 9, columns 1 and 2 as applicable. This note does not apply to the Utilities statistic column. Square footage statistics must be entered in that column. On Worksheet 2, enter the appropriate cost finding statistics in the yellow shaded cells. All cost center totals and unit cost multipliers will be computed automatically. The Medicaid Nursing Unit % (percentage) is calculated by dividing the respective care unit line by the sum of Ancillary Service and Nursing Service Cost Centers (line 21 - 43). This percentage is used in calculating the Medicaid Nursing Unit % on Worksheet 7, Wage Pass-Through Cost Reporting Summary. The Medicaid Nursing Unit % reported in Column 4 is based on the same data as Column 5. Worksheet 2 is mandatory; therefore, mark the Completed box. NO MANUAL ENTRIES CAN BE MADE IN THE REMAINING WORKSHEET 2 SERIESWorksheet 2-A Cost Allocation: General Service Costs Worksheet 2-B Cost Allocation: General Service Costs, Excluding Depreciation Worksheets 2-A and 2-B provide for the allocation of expenses of each general service cost center to those cost centers that receive the services. These worksheets are automatically calculated after completion of Worksheet 2 by calculating the cost report. The calculations are made by multiplying the unit cost multiplier times the applicable statistical unit for each respective cost center. Worksheet 2-C Computation Of Inpatient Base Cost Worksheet 2-D Computation Of Inpatient Base Cost, Excluding Depreciation Worksheets 2-C and 2-D are provided to compute the amount of allocated base costs that are part of the general inpatient routine service cost. Only the general service cost centers and general inpatient routine service cost centers are displayed because they are the cost centers needed in determining the base cost applicable to general inpatient routine service cost centers. These worksheets provide for the computation of the allocated base costs utilizing the unit cost multipliers and cost finding statistics from Worksheet 2. These worksheets were automatically calculated after completion of Worksheet 2 by calculating the cost report. Worksheet 2-E Computation Of Inpatient Plant Costs Worksheet 2-F Computation Of Inpatient Plant Costs, Excluding Depreciation Worksheets 2-E and 2-F are provided to compute the amount of allocated plant costs that are part of the general inpatient routine service cost. Only the general service cost centers and general inpatient routine service cost centers are displayed because they are the cost centers needed in determining the plant cost applicable to general inpatient routine service cost centers. These worksheets provide for the computation of the allocated plant costs utilizing the unit cost multipliers and cost finding statistics from Worksheet 2. These worksheets were automatically calculated after completion of Worksheet 2 by calculating the cost report. Worksheet 2-G Determination Of Support Costs: Per Patient Day Costs And Support/Base Cost Ratio Worksheet 2-G calculates the support costs, per patient day costs, and support to base ratio as defined per Medicaid reimbursement policy. Completion of this worksheet utilizes the information from Worksheets 2, 2-A, 2-C, and 2-E. These worksheets were automatically calculated after completion of Worksheet 2 by calculating the cost report. Worksheet 2-H Determination Of Support Costs: Per Patient Day Costs And Support/Base Cost Ratio, Excluding Depreciation Worksheet 2-H calculates the support costs, per patient day costs, and support to base ratio as defined per Medicaid reimbursement policy. Completion of this worksheet utilizes the information from Worksheets 2, 2-B, 2-D, and 2-F. These worksheets were automatically calculated after completion of Worksheet 2 by calculating the cost report. Worksheet 3 Statement Of Capital Asset Values Capital Asset Values General Worksheet 3 series schedules are provided to identify capital asset value information necessary for the plant reimbursement determinations for the Medicaid Program. Capital asset values will be allocated to the appropriate cost center serviced by such assets. The capital assets owned by the facility are reported on Worksheet 3, Statement of Capital Assets Values on Financial Records of Nursing Facility. The capital assets leased by the facility are reported on Worksheet 3-Lessor, Statement of Capital Asset Values on Financial Records of Lessor. Either one or both worksheets may be applicable. Costs in Minor Equipment - More than $5,000 accounts will automatically be adjusted out of Worksheet 1 through the use of a Worksheet 1-B adjustment. The asset acquisition cost and depreciation must be reported in the appropriate asset section of Worksheet 3. If an asset is being leased, and the lease meets the criteria as a virtual purchase as described previously (see Worksheet 1D instructions) and the lessee becomes the owner of the leased asset, the historical asset cost of the asset is determined by the sum of the assets original fair market value, plus any deferred charges (if applicable) less the annual lease rental expense claimed. The asset year of acquisition is the current year. Entering Capital Asset Values Enter the data in yellow shaded cells. Worksheet 3, Sections A, B, C, and D provide for the detailed identification of capital asset values by asset category, acquisition cost of such assets, activity relative to asset disposition and depreciation. If there are no assets in the asset category, a zero (0) must be entered in the Asset Cost Beginning Balance cell. After a zero (0) is entered in the cell, a - will appear in the cell. Separate sections of Worksheet 3 exist for reporting the following asset cost categories: Land, Land Improvements, Building, Building Improvements, Leasehold Improvements (Building), Departmental Equipment, Furniture and Fixtures, and Transportation. Section A Asset Cost Beginning Balance and Asset Cost Ending Balance For the purpose of reporting asset value data for the current reporting period. Enter the beginning balance for each asset cost category. The beginning balance (for an ongoing provider) for each asset category must agree with the ending balance of the prior cost reporting period. In the first reporting period by a new ownership of the asset cost categories, the assets beginning balance is the Medicaid allowable purchase values. The dollar amount of asset costs reported in Section A must be the allowable cost basis of the asset for Medicaid Program reimbursement. The "ASSET COST BEGINNING BALANCE" beginning balance in the current cost report period should equal the Section A, "ASSET COST ENDING BALANCE" for the prior cost report period. The "ASSET COST ENDING BALANCE" is an automatic calculated amount. The Asset Cost Ending Balance is calculated as follows: Section A, "ASSET COST BEGINNING BALANCE" plus Section A, "NEW ASSET ACQUISITION ALLOWABLE COST TOTAL" minus Section A, "PRIOR ASSET ACQUISTION ALLOWABLE COST TOTAL". New Asset Acquisition and Prior Asset Acquisition For new asset acquisition, first enter an identifiable description. Enter the four digit year of the current cost reporting period end date in which the asset was placed into service. For example: A provider with a June 30, 1999 fiscal year end, would use 1999 for all assets placed into service between July 1, 1998 and June 30, 1999. If the asset acquisition represents a replacement of a prior asset, enter the original acquisition year (four digit entry see previous example) and allowable cost of the replaced asset. Assets disposed of during the current reporting period but not replaced would also be included in this area. If the cost reporting period is the final cost report period for a terminating provider, only those assets disposed during the reporting period are reported. Do not report the asset values of those assets which are included as a part of the sales transaction. Enter in the Notes any additional information regarding this asset transaction. Numeric entry data is required in the amount columns. Do not use symbols or text in the amount columns. See the related Asset Cost Reporting and Marshall Valuation Index cost reporting instructions for asset disposals. This data should only reflect the allowable cost of the purchase in accordance with Federal regulations 42 CFR 413.13(b). (Provider Reimbursement Manual, CMS Pub 15-1, Part I, Section 104) Section B The purpose of Section B is to report asset cost information only for those assets reported in the facility financial records at a value that is not equal to the Medicaid Program allowable value reported in Section A of the worksheet. Adjustments are required if the provider has recorded asset values on the facilitys financial records that are different from those values reported in Section A. The dollar amounts reported on the first line of the Section should be the Section B ending "TOTALS" from the prior cost report period. The first line description column indicates that these amounts are the beginning balances carried over from prior period reported adjustments, and no entry is required by the preparer. The "code" column has been entered "b" as a standard entry and no entry id required by the preparer. Enter the amounts in the yellow cells under the "ASSET COST PER FIN. REC. BALANCE" column and "MEDICAID ALLOWABLE COST BALANCE" column first line as applicable. If there are no previous period adjustment amounts, the entry may remain blank or a zero may be entered. The remaining rows in this section are for reporting adjustments applicable to new asset acquisitions that are reported for the current cost report period. Briefly describe the type of assets involved and the nature of the adjustment in the DESCRIPTION column. Enter the code as indicated on the worksheet. Enter in the ASSET COST PER FIN. REC. BALANCE column and MEDICAID ALLOWABLE COST BALANCE column the appropriate amounts. Examples of asset cost entries in Section B are: The cost of an asset continues to be reported in the facility financial records but a portion or all of cost of that asset has been reported in the Section A, "PRIOR ASSET ACQUISITION" category (a roof replacement). The financial statement asset value is reported in the "ASSET COST PER FIN. REC. BALANCE column. The amount entered in "MEDICAID ALLOWABLE COST BALANCE column will be zero. The cost of an asset reported in the facility financial records exceeds the dollar amount of that asset item reported in Section A. The amount reported in the "ASSET COST PER FIN. REC. BALANCE column will equal the value of the asset in the facility financial records; the amount entered in "MEDICAID ALLOWABLE COST BALANCE" will be equal to the "NEW ASSET ACQUISITION" amount reported for that asset item in Section A. The cost of an asset does not appear in the facility financial records as an asset, however a "NEW ASSET ACQUISITION" amount has been reported in Section A for that asset item (asset purchase that was expensed in the facility financial records, but the asset cost must be reported as a capital asset expenditure for the Medicaid Program). The entry in the "ASSET COST PER FIN. REC. BALANCE column is zero; the amount entered in the "MEDICAID ALLOWABLE COST BALANCE" column will equal the "NEW ASSET ACQUISITION ALLOWABLE COST" amount reported for that asset item in Section A. The Section B "TOTALS" line is the sum of the first line amount (which is the prior year cumulative amount) plus the current cost report period reported amounts. This "TOTALS" line should be the first line entry amounts in Section B of the subsequent cost report period cost report. Innovation Award Asset Purchases. Report the dollar amount of the capital asset cost recorded in the facility financial records in the "ASSET COST PER FIN. REC. BALANCE column. The dollar amount entry in the "MEDICAID ALLOWABLE COST BALANCE" column must equal the dollar amount reported in Section A for that asset item during a prior reporting period. If the asset allowable cost is greater than the Innovation Award revenue amount, enter the dollar amount in excess of the revenue amount. This latter amount should be equal to the amount reported in Section A for the asset item. Section C The beginning and ending balances will be automatically calculated and agree with the historical cost asset values reported in the facility financial statement. The Asset Cost Beginning Balance amount is calculated as follows: Section A, "ASSET COST BEGINNING BALANCE" plus Section B, first line entry amount "ASSET COST PER FIN. REC. BALANCE" minus Section B, first line entry amount "MEDICAID ALLOWABLE COST BALANCE" equals Section C, "ASSET COST BEGINNING BALANCE". The Asset Cost Ending Balance amount is calculated as follows: Section A, "ASSET COST BEGINNING BALANCE" plus Section A, "NEW ASSET ACQUISITION ALLOWABLE COST TOTAL" plus Section B, "ASSET COST PER FIN. REC. BALANCE TOTAL" minus Section A, "PRIOR ASSET ACQUISITION ALLOWABLE COST TOTAL" minus Section B, "MEDICAID ALLOWABLE COST BALANCE TOTAL" equals Section C, "ASSET COST ENDING BALANCE". Section D Provided for reporting of allowable asset depreciation. This section must be completed based on asset depreciation as an allowable cost item in accordance with Medicaid Program allowable cost principles. Complete the lines in accordance with line descriptions. The Prior Years Asset Purchases column is used for reporting current period depreciation relative to assets purchased in reporting periods prior to the current cost reporting period. The Current Year Asset Purchases column is used for reporting current period depreciation relative to new assets purchased in the current reporting period. The Adjustment to depreciation reserve for asset disposals line is used to record any adjustment necessary to correct the accumulated depreciation reserve balance for that asset category. The amount in the sum column for the Current year depreciation line automatically will flow to Worksheet 1, Plant Costs, account reference # 130, 131, or 132 dependent on the asset category. The sum column for the depreciation reserve ending balance line is calculated as follows: Depreciation reserve balance beginning of year SUM column amount plus Current year depreciation SUM column amount plus Adjustment to depreciation reserve for asset disposals SUM column amount equals Depreciation reserve ending balance SUM column amount.  EMBED Word.Picture.8 Worksheet 3 is mandatory; therefore, mark the Completed box.Worksheet 3-Lessor Statement Of Capital Asset Values - Lessor This Worksheet should not include any minor equipment leases (expensed) or pass-through leases. Note: Section D is not applicable because depreciation is not reported in this worksheet since it has been previously reported in Worksheet 1-D. Section A In addition to the instructions above for Worksheet 3 Section A, the lessors name and four digit calendar year the lessor purchased the assets must be included for Land, Land Improvements, Building, and Building Improvements. Section B and C Follow the corresponding instructions above for Worksheet 3, Statement of Capital Asset Values. Worksheet 3-Lessor is NOT mandatory. Mark the Completed box if you have entered data; if there are no entries, mark the Not Applicable box.Worksheet 3-A Statement Of Directly Identified Asset Values Worksheet 3-A is for the purpose of allocating allowable asset values reported on Worksheet 3, to applicable cost centers. This data will be carried forward to Worksheet 3-B for the allocating of asset values to cost centers. The information is necessary for determining Medicaid reimbursement return on current asset value portion of the plant cost component. The totals from Worksheet 3 series will automatically flow to Worksheet 3-A by asset category to line 41 C by use of the F9 key. Those asset values that can be directly identified to an individual cost center should be entered in the yellow shaded cells. Line 1 can be calculated by use of the F9 key after directly identified assets have been entered. The provider must directly allocate those new assets that be identified to a specific cost center to the appropriate cost center. An ongoing provider must continue to directly allocate assets, which were directly allocated on a prior periods cost report. Worksheet 3-A is mandatory; therefore, mark the Completed box.Worksheet 3-B Allocation Of Capital Asset Values And Determination Of Relative Percentages NO MANUAL ENTRIES CAN BE MADE IN WORKSHEET 3-B. Worksheet 3-B provides for the allocation of capital asset values to those cost centers which utilize such assets. Capital asset values will be allocated to specific cost centers. The cost centers utilizing such assets include all cost centers within the provider organization; that is, other general service cost centers, ancillary cost centers, inpatient routine cost centers, outpatient service cost centers, other reimbursable and non-reimbursable cost centers. The main objective of this worksheet is to determine the relative percentages of asset values applicable to the cost centers. The cost finding statistics flow from Worksheet 2. This worksheet was automatically calculated after completion of Worksheet 2 and Worksheet 3 by calculating the cost report. Worksheet 4 Apportionment Of Ancillary Services To Health Care Programs Worksheet 4 is provided for the reporting of nursing facility ancillary services cost to the Medicaid Program. The cost data for those services cost settled by the Medicaid Program will be utilized in the cost settlement determination. Services reimbursed by the Medicaid Program on a fee for service basis are not subject to cost settlement. Refer to the Medicaid policy manual for ancillary service reimbursement policies. Column 1 Charges automatically flow from Worksheet 1 and column 1 costs flow from the Worksheet 2-A. Column 3 The amount of gross charges for Medicaid inpatient services of that cost center. Column 4 The amount of gross charges for Medicaid outpatient services of that cost center. The remaining cells will automatically be calculated by using the F9 key or clicking on the Calculate command on the Cost Report menu. Worksheet 4 is NOT mandatory. Mark the Completed box if you have entered data; if there are no entries, mark the Not Applicable box.Worksheet 5 Balance Sheet Enter the balances recorded in the providers books of accounts at the end of the reporting period. Dollar amount entries must be whole dollar amounts. Do not enter cents. The asset values reported must agree with the ending asset values of Section C of Worksheet 3. This worksheet must be completed or the facility must substitute prepared financial statements instead of preparing this worksheet; however, such statements must disclose the required data. The totals will automatically be calculated by using the F9 key or clicking on the Calculate command on the Cost Report menu. Either mark the Completed box or mark the Substitute box as applicable on Worksheet 5. Worksheet 6 Determination Of Average Borrowings Balance The average borrowings balance worksheet is necessary for the Medicaid Program per diem rate determination of the plant cost component. The data must cover the current cost reporting period coinciding with the cost report time period. The data is coordinated with the interest expense determined allowable during the period. The purpose of this worksheet is to coordinate borrowings balances with allowable interest expense. The Month Ending Dollar Balance Of Borrowings For The Time Period columns must be completed for allowable interest bearing loans applicable to the nursing home operations. The loan balances must be identified separately as to the liability on the facility financial records and liability on the financial records of a related party or lessor. The month ending balances of only mortgages and loans for which interest expense is being claimed and is allowable must be shown on this worksheet. If the provider or the other party has non-allowable borrowings, the non-allowable loan balance must not be included in the month ending balance amount. If the Providers outstanding borrowing balance is totally zero for the entire cost reporting period, enter zero (0) in the Beginning Balance and Month 1 lines in the Mortgage and Other columns. This also applies if no interest cost is being reported applicable to the Medicaid nursing unit. Mortgage Balance Include in this column the sum total of the month ending principle balance of the mortgage and land contract loan(s). Other Loans Balance Include in this column the sum total of the month ending principle balance of loans other than those identified above. These would include working capital loans, notes payable, equipment loans, vehicle loans, etc. The month ending balance (of an ongoing provider) of the prior period cost report must equal the current cost report period's Balance at Beginning of Fiscal Period for each loan. The month ending balances should be reflected as whole dollar amounts. If the loan balance at the end of a month is zero, then 0 should be entered. Entries should only be made in the "Balance beginning of fiscal period" line and the individual "Month (number)" lines that the cost report time period covers. Example: if the cost report time period only covers a nine month time period, only enter amounts through "Month 9". Do not make an entry in the line entitled "Month 13" unless this specific cost report is for a 13 month time period. The Portion Applicable to Nursing Home Operations percentage automatically flows from Worksheet 3-B. The Totals, Gross Average Borrowings Balance, Nursing Home Average Borrowing Balance will automatically be calculated by using the F9 key or clicking on the Calculate command on the Cost Report menu. Worksheet 6 is a mandatory worksheet for type 60 providers. Other provider types mark the Not Applicable box.Worksheet 7 Wage Cost Reporting Summary The purpose of the worksheet is to determine the cost of changes for wages, associated payroll costs, and benefits increases to routine nursing care unit employees and the amount of cost per inpatient day for these incurred cost changes for wages. This accounting of payroll data is different than the payroll information presented in Worksheet 1-E. This reporting is for purposes of evaluating wage rate levels of the routine nursing care unit employees. Employee benefit cost increase is included only when there is an actual increase in the benefits available to employees or a decrease in the employee contribution to the cost of the benefit package. Increased costs of existing benefit packages do not qualify. The provider is required to complete the wage reporting documentation worksheet in accordance with Medicaid Program policy previously issued in Medical Services Administration Bulletin LTC 01-02. Detail instructions and a facsimile worksheet for wage data reporting is provided in this bulletin based upon individual employee hours and wage compilation. The nursing facility may elect to compile the data by individual employee or may report the data based on cost center aggregate wage data. Effective with cost reporting periods that begin on or after October 1, 2000, an alternative wage data reporting method may be completed. The nursing facility is not required to compile the supporting detail of hours and wages by individual employee. Total employee hours and total wages may be reported for the entire cost center (employee group). The aggregate average hourly wage will be determined from this data. Regardless of the method selected for reporting the wage data, the same process must be utilized for both the benchmark time period and the cost report time period. Salary and wage data of staff pertaining to the Nurse Aide Training and Testing Program must not be included in this wage data reporting. Salary and wage data of staff related to the Nurse Aide Training and Testing Program is reported on Worksheet 8. Two wage cost reporting summary worksheets are provided for those providers with two Medicaid certified routine nursing care units. One worksheet must be completed for each Medicaid certified routine nursing care unit. If the facility has only one Medicaid certified routine nursing unit, use the first format on the worksheet; and leave the second format blank. Provider Information, Medicaid Provider Number, and Total Actual Patient Days flow from previous worksheets for the respective Medicaid certified routine nursing care unit. PART I. Benchmark Period The established benchmark period will be automatically entered based upon completion of the cost report period on the Checklist (see the  REF Checklist \* MERGEFORMAT Checklist instructions). Employee wage levels in the cost reporting period will be measured against the wage levels in benchmark period to determine the amount of change. The benchmark period for each provider will be employee payrolls ending during the month of September preceding the begin date of the cost report time period (Example: cost report period January through December 2002, benchmark month is September 2001). Wages and hours information must be separately reported for each employee group identified by the various operations departments of the facility. The objective is to measure the average hourly base wage rate for employee group during this time period. Wages - Enter the dollar amount of gross wages paid to employees in the payrolls ending during the month. This information will be primarily for September hours, however may include some hours from August due to payroll time periods extending beyond the last day of August. Wage dollar amounts will include holiday paid wages, therefore it is important to also include the associated paid hours in the "Hours Paid" category. Special attention is required in reporting wage dollar amounts for shift premium pay. Reporting of shift premium pay must be on a consistent basis for both the benchmark period and cost reporting period. The provider may choose either method of reporting of shift premium pay depending upon the availability of the individual nursing facility payroll reporting data: Shift premium pay is excluded in the wage reporting for both time periods. This is the recommended procedure since shift premium is not part of an employee's base wage rate. Payment of shift premium during the wage period is not considered a wage increase. Increased costs due to shift premium pay would only be considered wage increase if there were no shift premium pay program in the facility prior to the benchmark time period. If such a program was implemented after the benchmark period, method 2 must be used and include the shift premium pay in the wage period wages. OR Shift premium pay is included in the wage reporting for both time periods. The inclusion of shift premium pay may adversely impact the measurement of average hourly wage depending upon the nursing facility employee staffing assignments. Employees receiving shift premium pay in the benchmark period, but not in the pass-through period, or the reverse situation for employees not receiving shift premium in the benchmark period, but receiving it in the cost report period, would be impacted in the wage change measurement. Consistency of reporting applies to all employees. Shift premium pay reporting cannot be included for some employees receiving shift premium pay and not included for other employees who also receive shift premium pay in their wages. Hours Paid - Enter the number of paid hours for the payrolls in the benchmark time period. Paid hours are regular hours plus sick, vacation, or other leave paid plus overtime hours plus overtime premium hours. (Example: an employee is paid for 35 regular hours worked, 5 hours sick leave and 10 hours overtime at time-and-a-half, the hours paid for that employee are 55 hours.) Average Hourly Rate - Calculated as indicated. (NOTE: In the electronic format, this is calculated automatically.) Cost Reporting Period Report this information on the basis for the complete cost reporting period. Payroll information may be reported on the basis of payrolls ending during the cost reporting period if the nursing facility has maintained payroll time period reporting consistent with the previous year, or on the basis of paid hours and wages specific to the time period included in the annual cost reporting. The data must be consistent reporting for all employee groups. Wages - Enter the actual dollar amount of gross wages paid to the employees for the cost reporting time period. Gross wages reporting must be consistent with the benchmark period wages reporting. Hours Paid - Enter the actual number of paid hours for the reporting period. Paid hours are defined in the same manner as the benchmark period. Salaried employees are reported to a maximum of 2,080 hours, on an annual basis. Salaried employees employed less than the full year are reported for the prorated number of hours corresponding with the employment period. Average Hourly Rate Change - Calculated as indicated for each individual employee group identified. (NOTE: In the electronic format, this is calculated automatically.) Average Increase - Calculate for each individual employee group identified. (Column F minus column C.) Associated Cost - Calculated amount. (NOTE: In the electronic format, this is calculated automatically.) New Benefits Per Hour Cost incurred during the wage cost reporting year for new benefits must be determined if "new benefits" are being claimed for wage increase cost. New benefits are items that were not provided to employees prior to the benchmark period. Increased costs of existing benefits do not qualify. Examples of new benefits would be: added health care insurance coverage with corresponding cost increase; additional paid time off; reduction in employees share of health benefit premium; day care services; etc. The cost per employee paid hour should be reported in this column. The aggregate average hourly cost of the new benefits may be used by employee group. Total Per Hour - Calculated for each individual employee group identified. (NOTE: In the electronic format, this is calculated automatically. GROSS - Calculate Per Class for each individual employee group identified. (Column E times Column J). (NOTE: The maximum Gross per Class amount cannot exceed the reported hours paid times the maximum hourly wage increase currently $0.50 per hour). If the gross wage increase per employee group is determined from individual employee detail wage data, enter the sum total of wage increase for the respective employee group. Note: Wage and hours data reported for the employee groups for Registered Nurses, Licensed Practical Nurses and Nurse-Aides must only include the direct nursing staff for the respective Medicaid certified routine nursing care unit. PART I. A Wage change data applies to the employee wages applicable to routine nursing services. Gross reimbursable wage amounts will automatically be allocated to the applicable Medicaid certified nursing unit. The allocation will reflect the relative proportion of the applicable employee group cost center that is attributable to the routine nursing unit through normal cost reporting allocations. Column M flows automatically from Worksheet 2, Medicaid Nursing Unit %. Direct care nursing staff must be identified by unit on Worksheet 1-E, therefore these percentages are 100%. (See Note above.) Mark the form as Completed if wage data is being reported. Mark the form Not-Applicable only if the provider is reporting that wage increases were not granted in the cost report period subsequent to the referenced benchmark time period.Worksheet 8 Nurse Aide Training And Testing Program The purpose of this worksheet is for the provider to access Medicaid Program reimbursement outside the routine nursing care rate per diem for OBRA nurse aide training and testing programs. The worksheet must be completed as part of the annual cost report. Costs will be retrospectively settled to reflect the Medicaid Programs appropriate share of actual allowable training and testing costs. Enter the following data in the yellow shaded cells: Date Training Program Began Enter the date the facility began administering or participating in a Michigan Department of Community Health, Bureau of Health Professions approved Nurse Aide Training Program. Questionnaire And Statistical Data Number of Facility Staff Members Enter the appropriate numbers of nurse aide/orderly student staff for each Training and Testing category during the cost reporting period identified above. Medicare Program Certification Answer as applicable. 3. Mode of Training It is possible that providers may utilize both in-house staff and outside contractors. If a chain organization or group home ownership uses an approved central training program, indicate the training as in-house with the notation centralized training. If multiple outside contractors are used, indicate each of them and the time periods utilized. 4. Training Statistics Training Staff Hours. Indicate the work hours expended by training staff personnel for Bureau of Health Professions approved nurse aide/orderly training programs. This time may include direct class time and preparation time. Student Staff Hours. Indicate the work hours expended by nurse aide/orderly students while attending Bureau of Health Professions approved nurse aide/orderly training programs. Inpatient Days This information automatically flows from Worksheet B. Lockout Facility A facility identified by the Bureau of Health Systems, as a lockout facility cannot conduct an approved training and testing program, cannot be a training/clinical practice site for another approved program and cannot conduct clinical skills testing. The facility is notified of the lockout determination action by the Bureau of Health Systems. Answer question as applicable. The provider must not report and make claim for Medicaid Program reimbursement on this schedule for any costs incurred and associated with providing training by the lockout facility during the lockout time period. Nurse aide training program costs during the lockout time period are limited to the costs incurred in obtaining training and testing outside the facility from an approved nurse aide training program. Cost Information The specific allowable costs are described in the  REF Worksheet_1 \* MERGEFORMAT Worksheet 1,  REF NATAT_LTC \* MERGEFORMAT Nurse Aide Training & Testing LTC section. Items 1-7 The cost data entry for items 1 through 7 will automatically flow from the Worksheet 1 series. Item 8 Miscellaneous - Expenses incurred for an approved nurse aide training program cost that is not classified in cost categories items 1-7 explained above requires the completion of this section. A specific line has been established for reporting costs associated with original and biennial renewal Nurse Aide Registry fees paid by the facility for employees. Enter the detail description and cost of these individual expenses, in the yellow shaded cells. The total of these items will be automatically calculated by use of the F9 key. This total must equal the providers trial balance. The total automatically will flow to Worksheet 1, Account Reference 964. Item 9 Automatically completed when the cost report is calculated. Item 10 Training Program Equipment Use Allowance - An annual cost allowance is made for equipment purchased specifically for the Bureau of Health Professions approved nurse aide training program. Such equipment purchases are not included in the plant asset costs of the facility for routine nursing care. An annual allowance of 15% of the equipment purchase price is reported as a cost of the training program, for as long as the equipment is used in the program, but not to exceed seven years. The use allowance is an annual percentage; therefore an adjustment is made to the 15% amount if the cost report period differs from 12 months. Line 10.a. and Line 10.b. will automatically be calculated. Enter line 10.c. equipment purchase cost as required in the yellow shaded cells. The remainder of the worksheet will be completed by calculating the cost report. The Medicaid Program Percentage reflects Medicaid routine nursing care days divided by the total routine nursing care inpatient days in the facility as reported on Worksheet B. If the facility has not incurred any costs for this purpose, mark the Not Applicable box. Mark the Completed box on Worksheet 8, if Nurse Aide Training costs ARE being claimed. 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