Instructions for Form DHCS3076 "Supplemental Cost Report for Intermediate Care Facilities (Habilitative or Nursing)" - California

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This document contains official instructions for Form DHCS3076, Supplemental Cost Report for Intermediate Care Facilities (Habilitative or Nursing) - a form released and collected by the California Department of Health Care Services. An up-to-date fillable Form DHCS3076 is available for download through this link.

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State of California-Health and Human Services Agency
Department of Health Care Services
INTERMEDIATE CARE FACILITIES
(HABILITATIVE OR NURSING)
INSTRUCTIONS FOR COMPLETING COST REPORT FORMS
(USE PDF VERSION (05/2016) OR
USE EXCEL VERSION (04/2017) WITH PDF COPY)
Submit an e-File cost report for each licensed facility within 5 months after the close of the
1.
facility’s fiscal year.
2.
All required pages must be completed in accordance with the instructions below.
3.
Do not change the line or column descriptions under any circumstances. If an item does not
conform to the cost centers specified, include the item in the “Other” category.
4.
All dollar amounts are to be reported in whole dollars. Do not include cents.
5.
All financial records supporting the report should follow generally accepted accounting
principles and rules, CMS Publication 15-1, California Administrative Code, Title 22
requirements, and Medi-Cal Provider Manual for Long-Term Care.
Cost reports must be prepared using the PDF version (with signed certification statement) or
6.
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.
7.
8.
A separate e-File submission cover letter is required for each facility and a home office. The
subject line includes the facility name, NPI number, and the reported FYE. If an amended
cost report is submitted, the subject line also includes the word “Amended” and the amended
date.
Provider Name_NPI_FYE_CR_Submission Date
a. Submission:
ABCXYZ Care_0000000000_123116_CR_053017
Example:
e-File Submission Requirements
1. The e-File submission methodology does not affect the reporting requirements, criteria,
or submission schedule outlined on the DHCS website at
DHCS.ca.gov.
2. The date when e-File submissions are received will be used in lieu of the postmark
date for establishing the beginning of the 36-month audit limitation period in accordance
with Section 14170 of the Welfare and Institutions Code.
3. All cost reports must be submitted as an individual, stand-alone file document.
For assistance/questions, please contact ARAS at
ICFDDHN.Questions@dhcs.ca.gov
or
(916) 650-6696.
Page 1 of 7
DHCS 3076i (10/17)
State of California-Health and Human Services Agency
Department of Health Care Services
INTERMEDIATE CARE FACILITIES
(HABILITATIVE OR NURSING)
INSTRUCTIONS FOR COMPLETING COST REPORT FORMS
(USE PDF VERSION (05/2016) OR
USE EXCEL VERSION (04/2017) WITH PDF COPY)
Submit an e-File cost report for each licensed facility within 5 months after the close of the
1.
facility’s fiscal year.
2.
All required pages must be completed in accordance with the instructions below.
3.
Do not change the line or column descriptions under any circumstances. If an item does not
conform to the cost centers specified, include the item in the “Other” category.
4.
All dollar amounts are to be reported in whole dollars. Do not include cents.
5.
All financial records supporting the report should follow generally accepted accounting
principles and rules, CMS Publication 15-1, California Administrative Code, Title 22
requirements, and Medi-Cal Provider Manual for Long-Term Care.
Cost reports must be prepared using the PDF version (with signed certification statement) or
6.
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.
7.
8.
A separate e-File submission cover letter is required for each facility and a home office. The
subject line includes the facility name, NPI number, and the reported FYE. If an amended
cost report is submitted, the subject line also includes the word “Amended” and the amended
date.
Provider Name_NPI_FYE_CR_Submission Date
a. Submission:
ABCXYZ Care_0000000000_123116_CR_053017
Example:
e-File Submission Requirements
1. The e-File submission methodology does not affect the reporting requirements, criteria,
or submission schedule outlined on the DHCS website at
DHCS.ca.gov.
2. The date when e-File submissions are received will be used in lieu of the postmark
date for establishing the beginning of the 36-month audit limitation period in accordance
with Section 14170 of the Welfare and Institutions Code.
3. All cost reports must be submitted as an individual, stand-alone file document.
For assistance/questions, please contact ARAS at
ICFDDHN.Questions@dhcs.ca.gov
or
(916) 650-6696.
Page 1 of 7
DHCS 3076i (10/17)
State of California-Health and Human Services Agency
Department of Health Care Services
ICF/DD (H OR N) COST REPORT INSTRUCTIONS
(USE PDF VERSION OR USE EXCEL VERSION)
COVER PAGE
Enter Facility Name. If using Excel form, no input necessary.
1.
Check the box for service level. If using Excel form, select from drop down box.
2.
Enter the NPI Number. If using Excel form, no input necessary.
3.
Enter the Reporting Period From and To. If using Excel form, no input necessary.
4.
PAGE 1—GENERAL INFORMATION AND CERTIFICATION: The purpose of this page is
to collect licensee information, the licensee mailing address, the name of the person to contact
for necessary information, and to have the contents of the report certified. A licensee is defined
as a legal entity, e.g., the organization to which the actual license is issued.
Enter Facility Name.
1.
Enter State License Number.
2.
Enter NPI Number.
3.
Enter facility street address.
4.
Enter facility city.
5.
Enter facility ZIP code.
6.
Enter mailing address where official correspondence is received if different from facility.
7.
Enter mailing address city.
8.
Enter mailing address ZIP code.
9.
Enter name of administrator. This should be the person who oversees the overall daily
10.
operations of one or more facilities.
Enter name of person to contact to answer questions about the cost report.
11.
Enter contact person’s e-mail address.
12.
Enter contact person’s phone number.
13.
Enter mailing address of contact person.
14.
Enter city of contact person.
15.
Enter ZIP code of contact person.
16.
Enter date reporting period began.
17.
Enter date reporting period ended.
18.
Enter name of home office, if applicable.
19.
Enter home office phone number.
20.
Certification must be signed and dated by the Administrator, Controller, Corporate Officer,
21.
or member of the Board of Directors. The official signing the report must have the legal
capacity to make commitments for the organization. E-Signatures are not acceptable.
Indicate if the report is being filed as a result of a change in ownership. If using Excel
22.
form, select from drop down box.
SECTION A - PAGE 2 — REQUEST FOR INFORMATION: Complete questions 1, 2, and 3 by
marking the appropriate box or ,if using Excel form, select from drop down boxes. If the
answer to question 3 is yes, then enter the requested trust fund information.
Page 2 of 7
DHCS 3076i (10/17)
Department of Health Care Services
State of California-Health and Human Services Agency
SECTION B – PAGE 2 — LICENSEE DESCRIPTION: Place an “X” in the appropriate column
indicating the type of control and the legal organization of the facility.
SECTION C – PAGE 2 — FACILITY CENSUS
Line 1: Enter total number of licensed beds at the beginning of report period.
Line 2: Enter total number of licensed beds at the end of the report period.
Line 3: Enter the total number of client days during the cost reporting period that were billed to
the Medi-Cal Fee for Service programs. If client days were billed to Medi-Cal Managed
Care during the cost reporting period, enter the total on the Medi-Cal Managed Care
colum n. In the column marked “Other,” enter the number of client days during the
cost reporting period that were billed to private pay or other insurance. (If not
completed, cost report may be considered incomplete and subject to rejection.)
Line 4: Enter the number of client discharges for Medi-Cal Fee For Service, Medi-Cal
Managed Care, and Other in the respective columns.
Line 5: Enter the number of admissions made during the reporting period for Medi-Cal Fee
For Service, Medi- Cal Managed Care and Other in the respective columns.
SECTION D — PAGE 3 - STATEMENT OF RELATED ORGANIZATIONS: Complete question by
marking the appropriate box or, if using Excel form, select from drop down box. If the answer to
Section D is yes, then enter the name of the “Home Office or Related Organization” and “Percent
of Ownership.”
SECTION E — PAGE 3 - STATEMENT OF HOME OFFICE COSTS: Complete question by
marking the appropriate box or, if using Excel form, select from drop down box. If the answer is
yes, then you are required to file a home office cost report.
Home Office is a chain organization consisting of two or more facilities which are owned, leased,
or by some device, controlled by one organization. Home offices usually furnish
central management and administrative services such as centralized accounting, purchasing,
payroll, personnel services, management direction and control, and other services.
The purpose
of the home office cost report is to allocate the home office cost to the facilities.
Filing of a home office cost report is required when related party home costs are included on the
facility cost report.
Enter the account, item, and amount of home office cost in the appropriate column. For example:
Account
Item
Amount
Other Gen. & Admin
H.O. overhead –rent, etc.
$4,500 utilities
Note: Allocated home office costs should also be reported on page 5. Reclassifications
and Adjustments of Revenues and Expenses—Section I of the cost report. Refer to the
home office cost report instructions for cost allocation guidelines.
Page 3 of 7
DHCS 3076i (10/17)
State of California-Health and Human Services Agency
Department of Health Care Services
SECTION F – PAGE 3 — STATEMENT OF COMPENSATION TO OWNERS: If the owner(s)
is/are employed by the facility and/or organization then enter the name(s) of the owners, their
title and function, percent of ownership, average number of hours worked per week, and
compensation paid for the current fiscal year, and for the prior fiscal year.
SECTION G – PAGE 3 — STATEMENT OF COMPENSATION PAID TO ADMINISTRATOR
(OTHER THAN OWNERS OR QMRP): Complete the schedule with requested information for
the administrator who is neither an owner nor QMRP.
SECTION H – PAGES 4 & 4.1 — STATEMENT OF INCOME AND EXPENSE WITH
RECLASSIFICATIONS AND ADJUSTMENTS: These pages are a summation of
an ICF/DD (H or N) facility’s income and expenses presented in income statement form.
Column 1—Description: This column is a description of each necessary line item account. The
costs and revenues contained in each of these numbered accounts are defined in the Chart of
Accounts.
Column 2—Amount: If you are using the recommended Chart of Accounts, list the fiscal year
end account balances from the general ledger. If you are not, you must group your costs to
agree with the cost report accounts. See the Description of Accounts for details of costs to be
included in each account.
Column 3—Reclassification and Adjustments: Post reclassifications and adjustments including
home office cost from page 5, column 1.
Column 4—Total Amount: Sum of columns 2 and 3.
PAGE 4
Lines 005-015:
Revenue must be reported at usual and customary charges. On line 006, report
the reimbursement for the Adult Day Services and Related Transportation as
detailed in the Welfare and Institutions Code 14132.925 (b) (1).
Line 025:
Contractual and other deductions are the differential, if any, between the
amounts of the facility’s gross charges and the amount received from third-party
agencies.
Include revenues such as earned interest, grants, regional center revenues,
Line 035:
donations, etc.
Report depreciation on owned homes and equipment, amortization of
Line 045:
leasehold improvements and start-up costs. Equipment includes tables and
chairs, kitchen equipment, and various other furnishings. Start-up costs
should be amortized over a five-year period. Note: This line item should not
include depreciation of a home-owned van which should be reported on line
090-Client Transportation. Generally, asset lives should conform to the
Page 4 of 7
DHCS 3076i (10/17)
Department of Health Care Services
State of California-Health and Human Services Agency
American Hospital Association estimated useful lives.
Include normal monthly lease or rental payments related to the physical property
Line 050:
of the facility.
Line 055:
Include real property taxes paid to a government agency.
Include personal property taxes paid to a government agency.
Line 060:
If the facility is making monthly payments for the building they
occupy,
Line 065:
report the amount of mortgage interest which is included in the payment.
Include cost of insurance payments for protection against property-related
Line 070:
liabilities. This includes fire, flood, earthquake, and liability insurance.
Include cost of facility gardening, minor repairs, and housekeeping supplies, e.g.
Line 080:
light bulbs, safety equipment, etc.
Include payments for gas, electricity, water, garbage, telephone, or any other
Line 085:
property-related utility.
Include costs associated with a facility-owned or leased vehicle, vehicle
Line 090:
insurance, gasoline, maintenance, vehicle interest, vehicle depreciation, and
purchased services and bridge tolls. These costs should be net of regional
center reimbursement. Exclude that portion of costs pertaining to personal
use. Documentation is required to establish the business use of a personal
vehicle. The minimum requirement is a log indicating the date, purpose, and
mileage of each trip.
Include costs associated with food, kitchen supplies, and the costs of facility
Line 095:
purchased meals.
Include costs associated with client haircuts (excluding perms and special
Line 100:
styling); weekend recreational outings and socialization experiences; and home
linens and regular laundering care of clients’ personal garments. Note: Do not
include dry cleaning or special treatment for garments needing this care when
the regular laundry services are not appropriate.
PAGE 4.1
Lines 115-215: This segment reports wages and benefits for the entire cost reporting period
for salaried and contracted staff. Benefits should include such items as
employer portion of taxes, unemployment insurance costs, health
insurance, sick leave and vacation, and other employer-paid benefits.
Line 220:
Include salaries of administrator, office assistants, secretary, billing clerk and
bookkeeper and/or accountant.
Page 5 of 7
DHCS 3076i (10/17)
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