Instructions for "Mainecare Cost Report for Multilevel Nursing Facilities With 1 Rcf Unit and Community Based Specialty (Cbs) Unit" - Maine

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Updated 3/1/2022
STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
INSTRUCTIONS FOR COMPLETING THE COST REPORT
FOR NURSING CARE FACILITIES – MULTI-LEVEL WITH 1 RCF AND CBS UNIT
All Nursing Facilities in the State of Maine are required to submit an annual cost report and
financial statements within five (5) months of the end of each fiscal year to the State of Maine
Department of Health and Human Services, Division of Audit. Please utilize the file transfer
program, MOVEit, to upload the completed cost report in .xlsx format, along with the required
supporting documents. If you have not been setup with a MOVEit account yet, email the
information to DHHS.Audit@maine.gov. If you do not have access to email, please mail the
information to the State of Maine DHHS, Division of Audit, 11 State House Station, Augusta,
Maine 04333-0011. If a provider fails to file an acceptable cost report by the due date, the
Division of Audit may send the provider a notice by certified mail advising the provider that all
payments are suspended until an acceptable cost report is filed. These instructions are intended
to offer guidance in completing the cost report. These instructions are not intended to offer
interpretation or clarification of the Principles of Reimbursement for Nursing Facilities (10-144
Chapter 101, MaineCare Benefits Manual (MBM), Chapter III, Section 67), the Private Non-
Medical Institution (PNMI) Services Principles of Reimbursement (MBM, Chapter III, Section
97, Appendices C and F) or the Principles of Reimbursement for Residential Care Facilities
Room and Board Costs (10-144 Chapter 115). If any conflict arises out of the interpretation
of these instructions versus the interpretation of the Principles of Reimbursement, the
Principles of Reimbursement will take precedence.
The annual cost report must be completed and filed on forms prescribed by the Division of
Audit. These forms will not be acceptable if they are changed in any way without prior approval
by the Department or if they are not completed in accordance with these instructions. The
Principles of Reimbursement in effect during the fiscal year of the cost report will determine
allowable cost. Providers are required to file cost reports using the accrual basis of accounting,
unless the Provider is a State or municipal institution that operates on a cash basis. All schedules
must be filled out completely and legibly in accordance with these instructions. Failure to
complete all forms could result in an unacceptable cost report.
A copy of the provider's financial statements must be submitted with the cost report, along with a
copy of the financial statements of any related real estate entity or any other type of related
organization involved in transactions with the facility.
Index of Cost Report Schedules
General Info
Cost Report/Facility/Ownership Information
Attestation
Certification by Officer or Administrator of Provider
Error Report
Schedule A
Calculation of Final Settlement for a Nursing Facility
Page 1 of 13
Updated 3/1/2022
STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
INSTRUCTIONS FOR COMPLETING THE COST REPORT
FOR NURSING CARE FACILITIES – MULTI-LEVEL WITH 1 RCF AND CBS UNIT
All Nursing Facilities in the State of Maine are required to submit an annual cost report and
financial statements within five (5) months of the end of each fiscal year to the State of Maine
Department of Health and Human Services, Division of Audit. Please utilize the file transfer
program, MOVEit, to upload the completed cost report in .xlsx format, along with the required
supporting documents. If you have not been setup with a MOVEit account yet, email the
information to DHHS.Audit@maine.gov. If you do not have access to email, please mail the
information to the State of Maine DHHS, Division of Audit, 11 State House Station, Augusta,
Maine 04333-0011. If a provider fails to file an acceptable cost report by the due date, the
Division of Audit may send the provider a notice by certified mail advising the provider that all
payments are suspended until an acceptable cost report is filed. These instructions are intended
to offer guidance in completing the cost report. These instructions are not intended to offer
interpretation or clarification of the Principles of Reimbursement for Nursing Facilities (10-144
Chapter 101, MaineCare Benefits Manual (MBM), Chapter III, Section 67), the Private Non-
Medical Institution (PNMI) Services Principles of Reimbursement (MBM, Chapter III, Section
97, Appendices C and F) or the Principles of Reimbursement for Residential Care Facilities
Room and Board Costs (10-144 Chapter 115). If any conflict arises out of the interpretation
of these instructions versus the interpretation of the Principles of Reimbursement, the
Principles of Reimbursement will take precedence.
The annual cost report must be completed and filed on forms prescribed by the Division of
Audit. These forms will not be acceptable if they are changed in any way without prior approval
by the Department or if they are not completed in accordance with these instructions. The
Principles of Reimbursement in effect during the fiscal year of the cost report will determine
allowable cost. Providers are required to file cost reports using the accrual basis of accounting,
unless the Provider is a State or municipal institution that operates on a cash basis. All schedules
must be filled out completely and legibly in accordance with these instructions. Failure to
complete all forms could result in an unacceptable cost report.
A copy of the provider's financial statements must be submitted with the cost report, along with a
copy of the financial statements of any related real estate entity or any other type of related
organization involved in transactions with the facility.
Index of Cost Report Schedules
General Info
Cost Report/Facility/Ownership Information
Attestation
Certification by Officer or Administrator of Provider
Error Report
Schedule A
Calculation of Final Settlement for a Nursing Facility
Page 1 of 13
Updated 3/1/2022
Schedule B
Calculation of Allowable Direct Care Reimbursement
Schedule C
Calculation of Allowable Room & Board Reimbursement
Schedule D
Intentionally Omitted
Schedule E
Schedule of NF MaineCare Utilization Allowance
Schedule F
Schedule of Allowable Costs
Schedule G
Summary of Allowable NF Costs
Schedule H
Explanation of Adjustments to Schedule F
Schedule I
Schedule F / Trial Balance Reconciliation
Schedule J
NF Days and Payments for State Residents
Schedule K
Total NF Resident Days
Schedule L
Payroll Distribution – Salaries & Wages
Schedule M
Reconciliation of Payroll Wages and Taxes
Schedule N
Payroll Distribution – Payroll Taxes & Benefits
Schedule O
Intentionally Omitted
Schedule P
Semi-Private Charge to the General Public
Schedule Q
Intentionally Omitted
Schedule R
Schedule of Allocated Allowable Costs
Schedule S
Methods of Allocation
Schedule T
Allocation of Nursing Salaries
Schedule U
Allocation of Non-Nursing Hours
Schedule V
Calculation of Final Settlement for a Community-Based Specialty
Nursing Facility
Schedule W
Calculation of Fixed, Direct, PCS & Routine Costs for a Residential Care
Facility
Schedule X
Calculation of Room & Board (R&B) Settlement for a Residential Care
Facility
Schedule X-I
Calculation of PNMI Personal Care Services (PCS) Settlement for a
Residential Care Facility
Schedule Y
Calculation of Maximum Amount Allowed for Personal Care & Routine
Services Costs for a Residential Care Facility
Schedule Z
Calculation of Administrative and Management Allowance for a
Residential Care Facility
Schedule AA-R&B
RCF State Room & Board (R&B) Days, Payments & Total
Days
Schedule AA-PNMI RCF State PNMI Direct Days, Payments & Total Days
Schedule AA-PCS
RCF State PNMI Personal Care Service (PCS) Days, Payments &
Total Days
Schedule AB
NF-CBS State Days, Payments & Total Days
Schedule FF
Disclosure of COVID-19 Federal Funding
Schedule GG-NF
LTC Supplemental Payment Reconciliation – Nursing Facility
Schedule GG-RCF
LTC Supplemental Payment Reconciliation – Residential Care Facility
Schedule GG-CBS LTC Supplemental Payment Reconciliation – NF Community Based
Specialty
Page 2 of 13
Updated 3/1/2022
Specific Instructions
The following includes specific instructions for each cost report schedule in the order that they
appear in the cost report. It is important to note that this is not necessarily the order in which the
forms need to be completed. In general, cells highlighted in blue contain formulas. The
formulas in these cells should not be altered. A cell that is highlighted in yellow indicates
that the cost report preparer must enter that information manually into that particular
cell.
General Info – Cost Report/Facility/Ownership Information
This section of the cost report provides general information about the provider and the operating
period.
In Part I, enter the Facility Name, Facility Address, Telephone Number, Email Address, Cost
Report Status (as-filed or revised), the Fiscal Year Begin date, the Fiscal Year End date, the
RCF Level of Care (Geriatric, Alzheimer’s, or Private Pay), the facility’s 10-digit NPI+3 ID’s
used for Medicaid billing for all levels of care, and the Number of Licensed Beds.
In Part II, enter the name of the facility’s Corporation or Central Office, Corporate Address,
Telephone Number, and Email Address. Select the Ownership Type from the dropdown list.
List the names of all owners/corporate officers and provide their title and number of shares or
percentage of ownership.
In Part III, enter the name of the Accounting Firm providing accounting services to the facility,
the Firm’s address, Telephone Number, and Email Address.
In Part IV, list the names for all persons whom served as the facility’s administrator during the
fiscal period, including from/to dates, identify if the administrator served as an administrator at
another facility, and list the names for all persons whom participated in an Administrator in
Training program including the start/completion dates.
Note: It is necessary to answer the question regarding whether or not the administrator
served as an administrator for more than one level of care. This answer is referenced in
conditional statements in multiple formulas throughout the cost report template.
In Part V, list the Business Name, Address, Type, Service Rendered, Property Leased, Product
Supplied, Amount of Charges, Applicable Trial Balance Account, and the Actual Cost of the
service, property, or product to the related organization with which the facility conducts
business transactions. A supplemental schedule must be submitted to support the actual cost of
the service, product or property supplied by a related party.
In Part VI, list the names of all persons living in the facility who are not residents, and their
reason for living in the facility. Also, identify any buildings on the grounds or areas within the
facility that are not directly related to resident care, including a description of the
building/area, the associated square footage, and the functional use of the building/area.
Page 3 of 13
Updated 3/1/2022
Attestation – Certification by Officer or Administrator of Provider
Print this form after completing all other cost report schedules. Ensure that the name of the
facility and the reporting period are displayed correctly at the top of the form. Print the
provider’s name, license number and period beginning and end dates in the appropriate fields
within the certification statement. Print the Preparer’s Name, Accounting Firm, Telephone
Number, the Officer’s/Administrator’s Name and Title, and the Date completed. Both the cost
report preparer and Officer/Administrator must sign on the appropriate lines. This form bearing
original signatures must be mailed to the State of Maine DHHS, Division of Audit, 11 State
House Station, Augusta, Maine 04333-0011.
Error Report
The error report is used to flag errors on various schedules of the cost report. Once you have
completed the data entry on the other schedules of the cost report and before submitting the cost
report to the Division of Audit, check the error report for warnings. If a warning is visible, correct
the errors on the identified schedules. No manual entry is required on this schedule.
Schedule A – Calculation of Final Settlement for a Nursing Facility
Schedule A is used to calculate the final settlement amount due to the Provider or the State
for nursing facility services. No manual entry is required on this schedule.
Schedule B – Calculation of Allowable Direct Care Reimbursement
Schedule B is used to compare the average direct care rate paid to the allowable direct care cost
per day, determine the lesser of the two amounts, and calculate the allowable direct care
reimbursement. Schedule B also identifies any direct care disallowance for the cost reporting
period. An average direct care rate is calculated for the cost report period based on direct care
days paid and payments received.
In note ‘a’, enter the average direct care add-on and supplemental wage allowance from the rate
letter computation. The extraordinary circumstance allowance, also known as the temporary rate
increase (TRI), in the direct care add-on section of the rate letter does not get included on
Schedule B as these funds related to the COVID-19 pandemic will be settled separately from the
cost report. If there is more than one rate computation for the audit period, calculate the average
rate, weighted by the applicable NF total days from Schedule K, column 5.
Schedule C – Calculation of Allowable Room & Board Reimbursement
The purpose of this schedule is to compare the prospective routine rate per day to the actual
routine cost per day, determine the lesser of the two amounts, and calculate the allowable room
& board reimbursement. If there is any routine cost savings it is compared to the direct care
disallowance and the lesser of the two amounts is allowed as routine cost savings.
In note ‘a’, enter the prospective routine rate per day (a/k/a the routine cost component) and the
aggregate funding adjustment, if applicable, from the rate letter computation. If there is more
than one rate computation for the audit period, calculate the average rate, weighted by the
applicable NF total days from Schedule K, column 5.
Page 4 of 13
Updated 3/1/2022
Schedule D – Intentionally omitted
Schedule E – Schedule of NF MaineCare Utilization Allowance
The purpose of this schedule is to determine if a NF provider is eligible for a MaineCare
utilization payment. This is a two-part schedule. The first part is used to test for high MaineCare
utilization. The second part is used to determine if there is a savings or disallowance when
allowable combined direct care and routine costs are compared to the combined direct care and
routine cost caps.
Allowable combined direct care and routine costs must exceed the combined direct care and
routine cost caps in order to be eligible to receive and retain the MaineCare utilization
payments.
Answer the Yes/No question at the top of Schedule E. Answer “Yes” if the facility’s base year
direct and routine aggregate costs per day are less than the median aggregate direct and routine
costs for the facility’s peer group. Answer “No” if the aggregate costs are above the median
aggregate costs for the peer group. To find the median aggregate direct and routine costs per day,
divide the total of the direct and routine upper limits found on the facility’s rate letter by 1.1.
Schedule F – Schedule of Allowable Costs
The purpose of this schedule is to determine allowable costs. Expenses are entered from the
provider's records, and then adjusted to the Principles of Reimbursement. The primary source
for this schedule should be the trial balance of expenses that ties to the provider’s financial
statements. This trial balance must be submitted with the cost report.
Columns 1 and 2:
In column 2 labeled “Expenses per Provider’s Records”, enter each amount from the facility’s
trial balance (T/B). The T/B expense should correspond with the Schedule F expense line that
matches it the closest. Input each entry rounded to the nearest dollar. In column 1, enter the
T/B account number corresponding to the expense in column 2.
If more than one T/B account is included on an expense line in column 2, document this on
Schedule I and reference Schedule I in column 1. If one T/B account is allocated to more than
one expense line in column 2, document this on Schedule I and reference Schedule I in column
1 for each applicable expense line.
Complete the Salaries & Wages expense lines with the amounts from Schedule L, column 6.
Complete the expense lines for Payroll Taxes & Benefits with the amounts from Schedule N,
column 9. In column 1, reference Schedule L for all the Salaries and Wages lines, and
reference Schedule N for all the Payroll Taxes & Benefits lines.
Columns 3 and 4:
For any adjustment to the provider’s expenses in column 2, the adjustment number is entered in
column 3 and the amount of the adjustment is entered in column 4. For adjustments intended to
reduce the amount of the expense, enter a minus sign (-) before the number. The negative
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