Instructions for Form DHCS3099 "Home Office Cost Report Form" - California

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State of California—Health and Human Services Agency
Department of Health Services
INTERMEDIATE CARE FACILITIES HOME OFFICE
(HABILITATIVE OR NURSING)
INSTRUCTIONS FOR COMPLETING HOME OFFICE COST REPORT FORM
(USE PDF VERSION (05/2016) OR
USE EXCEL VERSION (04/2017) WITH PDF VERSION (05/2016))
Home Office Costs: A chain organization consists of two or more facilities which are owned, leased, or by
some other devise, controlled by one organization. A chain organization may include more than one type of
program in addition to the ICF/DD (H or N) program, i.e. day program, workshops, etc.
The home office of a chain organization is not a provider of participant care. The relationship of the home office
to the ICF/DD (H or N) home is that of a related organization to a participating provider. Home offices usually
furnish central
management
and
administrative
services
such
as
centralized
accounting,
purchasing, personnel services, management direction and control, and other services. To the extent
the
home
office furnishes services to a facility related to participant care, the reasonable costs of such
services are included in the facility’s cost report. Where the home office provides services not related to client
care, these costs may not be recognized as allowable costs to the ICF/DD (H or N) facility.
SCHEDULE 1
Home Office General Information: The general information section is intended to provide the auditor with data on
the home office.
1. Enter the name of the home office. If there was a change in name during the reporting period, indicate the
former name in parentheses.
2. Enter the present address of the home office, include ZIP code.
3. Enter the telephone number of the home office, including area code.
4. Enter the period covered by the cost report. This will indicate whether a full year or lesser period cost report is
submitted.
5. Enter the name and telephone number of the report contact person. The auditors may contact the individual
indicated here regarding information contained in the cost report.
6. Enter the type of home office organization. If using Excel form, select from drop down box.
7. Enter the names of key officers of the home office and board members.
8. Certification must be signed by either the administrator, controller, corporate officer, or member of the board of
directors. The official signing the report must have the legal capacity to make commitments for the
organization. If using Excel form, a PDF certification page must be signed and submitted with the Excel form.
E-signatures are not acceptable.
9. Indicate if the report is being filed as a result in change in ownership. If using Excel form, select from drop down
box.
10. Cost Reports must be prepared using the PDF version (with signed certification statement) or the Excel version.
The Excel version must include a PDF copy of the Excel file (with signed certification statement.) Submit
completed cost reports to
ICFDDHN.Submissions@dhcs.ca.gov.
Home Office Name_FYE_HO_Submission Date
a. Submission:
ABCXYZ Home Office_123116_HO_053017
Example:
DHCS 3099i (10/17)
Page 1 of 4
State of California—Health and Human Services Agency
Department of Health Services
INTERMEDIATE CARE FACILITIES HOME OFFICE
(HABILITATIVE OR NURSING)
INSTRUCTIONS FOR COMPLETING HOME OFFICE COST REPORT FORM
(USE PDF VERSION (05/2016) OR
USE EXCEL VERSION (04/2017) WITH PDF VERSION (05/2016))
Home Office Costs: A chain organization consists of two or more facilities which are owned, leased, or by
some other devise, controlled by one organization. A chain organization may include more than one type of
program in addition to the ICF/DD (H or N) program, i.e. day program, workshops, etc.
The home office of a chain organization is not a provider of participant care. The relationship of the home office
to the ICF/DD (H or N) home is that of a related organization to a participating provider. Home offices usually
furnish central
management
and
administrative
services
such
as
centralized
accounting,
purchasing, personnel services, management direction and control, and other services. To the extent
the
home
office furnishes services to a facility related to participant care, the reasonable costs of such
services are included in the facility’s cost report. Where the home office provides services not related to client
care, these costs may not be recognized as allowable costs to the ICF/DD (H or N) facility.
SCHEDULE 1
Home Office General Information: The general information section is intended to provide the auditor with data on
the home office.
1. Enter the name of the home office. If there was a change in name during the reporting period, indicate the
former name in parentheses.
2. Enter the present address of the home office, include ZIP code.
3. Enter the telephone number of the home office, including area code.
4. Enter the period covered by the cost report. This will indicate whether a full year or lesser period cost report is
submitted.
5. Enter the name and telephone number of the report contact person. The auditors may contact the individual
indicated here regarding information contained in the cost report.
6. Enter the type of home office organization. If using Excel form, select from drop down box.
7. Enter the names of key officers of the home office and board members.
8. Certification must be signed by either the administrator, controller, corporate officer, or member of the board of
directors. The official signing the report must have the legal capacity to make commitments for the
organization. If using Excel form, a PDF certification page must be signed and submitted with the Excel form.
E-signatures are not acceptable.
9. Indicate if the report is being filed as a result in change in ownership. If using Excel form, select from drop down
box.
10. Cost Reports must be prepared using the PDF version (with signed certification statement) or the Excel version.
The Excel version must include a PDF copy of the Excel file (with signed certification statement.) Submit
completed cost reports to
ICFDDHN.Submissions@dhcs.ca.gov.
Home Office Name_FYE_HO_Submission Date
a. Submission:
ABCXYZ Home Office_123116_HO_053017
Example:
DHCS 3099i (10/17)
Page 1 of 4
Department of Health Services
State of California-Health and Human Services Agency
The following pages pertain to home office expenses and consists of schedules two through six and are intended to
provide auditors with:
a.
A detailed analysis of allowable home office costs (Schedule 2)
b.
Medi-Cal adjustments to those costs (Schedule 3)
c.
Allocation of the home office costs (Schedules 4 and 5)
d.
A summary of direct and pool costs (Schedule 6)
SCHEDULE 2
Statement of Allowable Home Office Costs: Enter the home office name and the fiscal year of the cost report.
Column 1—Account Description and Column 2—Expenses Per Home Office Books: Enter the home office
expenses as shown in the home office general ledger. Use audited data if available.
Note: If you are a Home Office by definition, but have determined that you have the exceptional situation
whereby there are no Expenses per Home Office Books, then you must do the following:
1. On Schedule 2, mark not applicable (N/A) across the face of Schedule 2.
2. Skip Schedules 3, 4, and 5.
3. On Schedule 6, complete Columns 1 and 2. Mark “N/A” across the face of Columns 3, 4, and 5.
4. Submit a transmittal letter with the cost report filing and provide the explanation for why No Home Office
Expenses is reported.
Column 3—Adjustments Increase: Enter the adjustment from Schedule 3, Column 3. If two or more adjustments
are made to the same expense, adjustments must be summarized and the figure transferred to Schedule 2,
Column 3. Note that Column 3, Line 35 must agree with the total of Schedule 3, Column 3, Line 21.
Column 4—Allowable Expenses: Enter the balance by adding or subtracting Column 3 from Column 2.
Column 5—Direct Allocations: Enter the home office direct allocation of expenses to chain components from
Schedule 4, Line 11. Note that Schedule 2, Column 5, Line 35 must agree with Schedule 4, Column 7, Line 11.
Column 6—Pool Costs: The pool costs are computed by subtracting Column 5 from Column 4. The Column 6,
Line 35 amount should be carried forward to Schedule 5, Part 1, Column 3, Line 11, if the single allocation method
is required. See instructions for Schedule 5 to determine which allocation method should be used.
SCHEDULE 3
Medi-Cal Adjustments to Expenses:
Column 1—Description: Enter a description of the adjustment. Some common adjustment descriptions have been
included on Lines 1–9.
Column 2—Basis of Adjustment: Indicate in Column 2 the basis for each adjustment listed. Use a letter “A” if the
basis is cost. Use a letter “B” if revenue received is used as a cost recovery of the expenses.
It is recommended that all adjustments be made on the basis of costs rather than revenue abatement. If related
costs are unknown or the amounts immaterial, then revenue abatement may be used.
Refer to CMS 15-1 for identification of adjustments that should be made. A written schedule supporting each
adjustment may be attached to Schedule 3 to facilitate the auditor’s review of the cost report.
Column 3—Amount: Enter the amount of each adjustment. Note that Column 3, Line 21, must agree with Line 35
of Schedule 2, Column 3.
Column 4—Line Number: For each adjustment, indicate the line number of the expense account on Schedule 2
that will be adjusted.
Column 5—Account to be Adjusted, Account Name: For each adjustment, indicate the expense account title on
Schedule 2 that will be adjusted.
Page 2 of 4
DHCS 3099i (10/17)
Department of Health Services
State of California-Health and Human Services Agency
SCHEDULE 4
Direct Allocation of Expenses: The purpose of this schedule is to identify all of the home office organization’s
expenses that are directly identifiable with specific facilities. These types of expenses are incurred primarily on
behalf of specific facilities and, therefore, must be allocated directly to them. If no expenses are directly allocable,
then Schedule 4 should be marked not applicable (N/A).
Column 1—Facility (Chain Component): Enter the names of the facilities of the chain organization.
Columns 2–6: A through E—Type of Expense: Enter the expense account title above each column and show the
distribution of the amount of direct allocation to each affected chain facility. The total in Column 7 on Schedule 4,
Line 11, must agree with the amount shown on Schedule 2, Column 5, Line 35. The home office may attach
supporting documentation to explain the allocations made in each category.Column 7: F—Total: Enter the sum of
Columns 2 through 6 for all expenses directly allocable for each chain component. Transfer the sum for the
facility to Schedule 6, Column 3.
Additional columns may be added or supplementary schedules may be prepared by the home office to reflect all
directly allocable expenses.
Some facilities incur expenses for centralized dietary, housekeeping, maintenance, etc. These expenses should be
allocated directly to the individual homes using the following allocation bases:
Recommended Allocation Base
Type of Cost
Square Footage
Housekeeping
Square Footage
Plant Operation and Maintenance
Meals Served or Attended Client Days
Dietary
Square Footage
Depreciation—Building
Square Footage
Depreciation—Equipment
Phone Lines
Telephone
The allocation of expenses should only be used when the actual expenses can not be readily determined.
SCHEDULE 5
Allocation of Pool Expenses: It is presumed that prior to the completion of this page, all expenses that can be
directly identifiable to the chain’s facilities have been so assigned on Schedule 4.
Pool expenses represent expenses that cannot be directly identified with any given chain facility and, therefore,
must be allocated to components through an equitable allocation base.
If the home office incurs expenses for nonprogram services such as day programs, workshops, etc., then the pool
expenses should be allocated using the double allocation method. The first allocation is necessary to allocate costs
between program and nonprogram services. This is accomplished using accumulated costs as the allocation base.
After the program costs are determined via the first allocation, then the second allocation allocates program costs
to the facilities based upon client days. Use Schedule 5, Parts I and II, for the double allocationmethod.
If the home office incurs expenses only for the ICF/DD (H or N) program, then the costs should be allocated to the
facilities using the single allocation method. The single allocation method allocates program costs to facilities based
upon client days. Use Schedule 5, Part II for the single allocation method.
PART I
Column 1—Allocation Statistics Base: Accumulated Cost:
Line 1—Program Services: Enter the total costs applicable to ICF/DD (H or N) programservices.
Line 2—Nonprogram Services: Enter the total nonprogram costs
Line 3—Total: Compute and enter total of Lines 1 and 2.
Column 2—Percent:
Lines 1—Program Services and 2—Nonprogram Services: Compute and enter the percent of program and
nonprogram cost to the total cost. The sum of the Line 1 and Line 2 percent should equal 100 percent.
DHCS 3099i (10/17)
Page 3 of 4
Department of Health Services
State of California-Health and Human Services Agency
Column 3—Allocation Pool Expenses:
Line 3—Total: Enter the total pool cost to be allocated from Schedule 2, Column 6, Line 35.
Lines 1—Program Services and 2—Nonprogram Services: Multiply the amount on Line 3 by the percent in
Column 2. Enter the product. The sum of Lines 1 and 2 should agree with the amount on Line 3.
This completes the first allocation of the double allocation. The amount on
Line 1, Column 3, will be allocated to the ICF/DD (H or N) facilities.
The second step of the double allocation method is an allocation of the pool home office program costs to the
ICF/DD (H or N) facilities based upon client days.
PART II
Column 1—Facility: Enter the names of the facilities which are to receive home office costs.
Column 2—Allocation Statistics (Client Days): Enter the total client days which correspond to the facilities listed in
Column 1. Sum the column and enter the total on Line 11.
Column 3—Allocation Pool Expenses: Line 11—Total: Enter the home office costs which are to be allocated. This
is the amount computed in Part I, Line 1, Column 3 above, or if this is a single allocation, take the amount from
Schedule 2, Column 6, Line 35.
Column 1—Facility: Line 12—Unit Cost Multiplier: Divide the total pool costs figure (Line 11, Column 3) by the total
day figure (Line 11, Column 2). The product is the unit cost multiplier.
Column 3—Allocation Pool Expenses: Compute the pool cost allocation by multiplying the allocation statistic (client
days) in Column 2 by the unit cost multiplier (Line 12, Column 2). Enter the amounts in Column 3. The sum of the
Part II, Column 3 amounts should agree with the total home office costs on Schedule 2, Column 6, Line 35 if this
was a single allocation, or the amount on Schedule 5, Column 3, Line 1, if this was a double allocation.
SCHEDULE 6
Summary of Direct and Allocated Pool Costs: The purpose of this schedule is to summarize the direct and
allocated pool cost of each chain facility.
Columns 1 and 2—Facility and Medi-Cal Provider Number: Enter the names of the facilities which will receive
direct and allocated home office costs and the applicable facility Medi-Cal provider number. (If not completed,
cost report may be considered incomplete and subject torejection.)
Column 3—Home Office Expenses Directly to Facility: Enter the home office expenses directly allocated to the
facilities from Schedule 4, Column 7.
Column 4—Allocated Pool Expenses: Enter the allocated pool expense amounts from Schedule 5, Part II,
Column 3.
Column 5—Total Direct and Pool Facility Expense: Sum Columns 3 and 4 and enter the total in Column 5. The
Column 5 amounts represent the total home office cost allocation. The Column 5 amounts should be included on
the cost reports of the individual homes. In order to transfer the home office cost to the individual homes, an
adjustment should be made to page 5 of the facility cost report. The adjustment on page 5 of the facility cost report
for the home office costs should be made to Account Number 7080—Other General and Administrative Costs. The
adjustment amount should agree with the Schedule 6, Column 5 total direct and pooled facility expense.
DHCS 3099i (10/17)
Page 4 of 4