| |
Total Allowable Costs (including all Administrative Expenses) |
| 1) |
Total Visits (Therapy Services) or Hours (HHA) |
|
Sch. 5a.1 & 5a.2 Col 023 for Therapy and Col 024 for HHA; Nursing - lines 004, 015, 016; PT - line 002; Speech - lines 007, 010, OT - line 003, HHA - lines 001, 008, 011 - 014, 017, 018 |
| 2) |
Medical Social Services / Nutrition / Social & Environmental Support Units Reallocation |
|
Sch. 5a.1 & 5a.2 Col 023; lines 005, 006, 009 reallocated to therapy services based on service % of therapy (Nursing, PT, Speech, OT) visits |
| 3) |
Adjusted Allowable Visits (Therapy Services) or Hours (HHA) |
|
(1) + (2) |
| 4) |
Allowable Costs |
|
Sch. 3a, Col 003; lines 001, 002, 003, 004, 007, 008, 010, 011, 012, 013, 014, 015, 016, 017, 018 |
| 5) |
Medical Social Services / Nutrition / Social & Environmental Support Cost Reallocation |
|
Sch. 3a, Col 003; lines 005, 006, 009 reallocated to therapy services based on % of therapy (Nursing, PT, Speech, OT) costs |
| 6) |
Adjusted Allowable Costs |
|
(4) + (5) |
| 7) |
Cost/Visit or Cost/Hour for HHA |
|
(6) / (3) |
| 8) |
Initial Current Charges |
|
Sch. 7a, Col "Current Charges to the General Public" Nursing: line 004, PT: line 002, OT: line 003, Speech: lines 007 & 010, HHA: lines 001 & 008 |
| 9) |
Medical Social Services / Nutrition / Social & Environmental Support Current Charges Reallocation |
|
Sch. 7a, Col "Current Charges to the General Public" lines 005, 006, 009 reallocated to therapy services based on % of therapy (Nursing, PT, Speech OT) current charges |
| 10) |
Current Charges |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
(8) + (9) |
| |
Disallowed Administrative Expenses (Subject to Statewide Admin Cap): |
| 11) |
Total Allowable Costs (All Services) |
|
Sch. 3a, Col 003, line 019 |
| 12) |
Capital Related - Buildings & Fixtures |
|
Sch. 4a, Col 004, lines 002,005,006,008,009,015 |
| 13) |
Capital Related - Moveable Equipment |
|
Sch. 4a, Col 004, lines 003,007,010,011 |
| 14) |
Total Capital Costs |
|
(12) + (13) |
| 15) |
Total Operating Costs |
|
(11) - (14) |
| 16) |
Total Admin & General Costs |
|
Sch. 4a, Col 004, lines 014, 016, 019 |
| 17) |
Agency Admin & General Cost Percentage |
|
(16) / (15) |
| 18) |
Statewide Average Cap Admin & General Cost Percentage |
|
See #41 in Statewide Average Cap Support table below for calculation |
| 19) |
Allowable Admin & General Cost Percentage |
|
Lower of (17) or (18) |
| 20) |
Total Agency & Admin General Cost |
|
Page 1 - CHHA #4 * (17) |
| 21) |
Allowable Admin & General Cap |
|
Page 1 - CHHA #4 * (19) |
| 22) |
Disallowed A&G |
|
(21) - (20) |
| Group Ceiling Support |
Nursing |
Physical Therapy |
Speech Therapy |
Occupational Therapy |
Home Health Aide |
Cost Report Reference / Formula |
| |
Cost/Visit or Cost/Hour (All Agencies in Regional Group) |
| 23) |
Total Visits / Hours (All Agencies in Regional Group) |
|
Sch. 5a.1 & 5a.2 Col 023 for Therapy and Col 024 for HHA; Nursing - lines 004, 015, 016; PT - line 002; Speech - lines 007, 010, OT - line 003, HHA - lines 001, 008, 011 - 014, 017, 018 |
| 24) |
Medical Social Services/Nutrition/Social & Environmental Support |
|
Sch. 5a.1 & 5a.2 Col 023; lines 005, 006, 009 reallocated to therapy services based on service % of therapy (Nursing, PT, Speech, OT) visits |
| 25) |
Adjusted Allowable Visits (All Agencies in Regional Group) |
|
(23) + (24) |
| 26) |
Allowable Costs (All Agencies in Regional Group) |
|
Sch. 3a, Col 003; lines 001, 002, 003, 004, 007, 008, 010, 011, 012, 013, 014, 015, 016, 017, 018 |
| 27) |
Medical Social Services/Nutrition/Social & Environmental Support Allowable Cost Reallocation (All Agencies in Regional Group) |
|
Sch. 3a, Col 003; lines 005, 006, 009 reallocated to therapy services based on % of therapy (Nursing, PT, Speech, OT) costs |
| 28) |
Adjusted Allowable Costs (All Agencies in Regional Group) |
|
(26) + (27) |
| 29) |
Cost / Visit or Cost / Hour (All Agencies in Regional Group) |
|
(28) / (25) |
| |
Group Ceiling Calculation |
| 30) |
Service Cap |
|
(29) * (125% ceiling percent) |
| 31) |
Service Base |
(29) * (75% base percent) |
| 32) |
Service Centered Costs |
Sum for all agencies in regional group: [ Agency-Specific step (3) ] * [ Agency-Specific step (7) capped at step (30) and floored at step (31) ] |
| 33) |
Service Centered Average Rate |
(32) / (25) |
| 34) |
Group Ceiling |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
(33) * (110% high percent) |
| Statewide Average Cap Support
| Nursing |
Physical Therapy |
Speech Therapy |
Occupational Therapy |
Home Health Aide |
Cost Report Reference / Formula |
| Build-Up (All Agencies Statewide) |
| 35) |
Total Allowable Costs (All Agencies Statewide) |
|
Sch. 3a, Col 003, line 019 |
| 36) |
Capital Related - Buildings & Fixtures (All Agencies Statewide) |
|
Sch. 4a, Col 004, lines 002,005,006,008,009,015 |
| 37) |
Capital Related - Moveable Equipment (All Agencies Statewide) |
|
Sch. 4a, Col 004, lines 003,007,010,011 |
| 38) |
Total Capital Costs (All Agencies Statewide) |
|
(36) + (37) |
| 39) |
Total Operating Costs (All Agencies Statewide) |
|
(35) - (38) |
| 40) |
Total Admin & General Costs (All Agencies Statewide) |
|
Sch. 4a, Col 004, lines 014,016,019 |
| 41) |
Agency Admin & Costs Percentage |
0.00% |
(40) / (39) |
