Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106

CHAPTER 32

HOME HEALTH AGENCY COST REPORT

FORM CMS-1728-94

Section

General. 3200

Rounding Standards for Fractional Computations. 3201

Recommended Sequence for Completing Form CMS-1728-94. 3202

Worksheet S - Home Health Agency Cost Report. 3203

Part I - Certification by Officer or Administrator of Provider(s). 3203.1

Part II - Settlement Summary. 3203.2

Worksheet S-2 - Home Health Agency Complex Identification Data. 3204

Worksheet S-3 - Home Health Agency Statistical Data. 3205

Worksheet A - Reclassification and Adjustment of Trial

Balance of Expenses. 3206

Worksheet A-1 - Compensation Analysis - Salaries and Wages 3207

Worksheet A-2 - Compensation Analysis - Employee

Benefits (Payroll Related). 3208

Worksheet A-3 - Compensation Analysis - Contracted

Services/Purchased Services. 3209

Worksheet A-4 - Reclassifications. 3210

Worksheet A-5 - Adjustments to Expenses. 3211

Worksheet A-6 - Statement of Costs of Services from

Related Organizations. 3212

Worksheet A-7 - Analysis of Changes in Capital Asset Balance. 3213

Worksheet B - Cost Allocation - General Service Costs

and Worksheet B-1 - Cost Allocation - Statistical Basis. 3214

Worksheet C - Apportionment of Patient Service Costs 3215

Part I - Aggregate Agency Cost Per Visit Computation 3215.1

Part II - Computation of the Aggregate Medicare Cost and the

Aggregate of the Medicare Limitation 3215.2

Part III - Supplies and Drugs Cost Computation 3215.3

Part IV - Comparison of the Lesser of the Aggregate Medicare Cost, the

Aggregate of the Medicare Per Visit Limitation and the Aggregate Per

Beneficiary Cost Limitation 3215.4

Part V - Outpatient Therapy Reduction Computation 3215.5

Worksheet D - Calculation of Reimbursement Settlement -

Part A and Part B Services. 3216

Part I - Computation of Lesser of Reasonable Cost or

Customary Charges. 3216.1

Part II - Computation of Reimbursement Settlement 3216.2

Worksheet D-1 - Analysis of Payments to Home Health Agencies for

Services Rendered to Program Beneficiaries. 3217

Worksheets F, F-1, and F-2 - Financial Statements. 3218

W orksheet A-8-3 - Reasonable Cost Determination for Therapy Services

Furnished by Outside Suppliers 3219

Part I - General Information. 3219.1

Part II - Salary Equivalency Computation. 3219.2

Part III - Travel Allowance and Travel Expense Computation -

HHA Services. 3219.3

Part IV - Overtime Computation. 3219.4

Part V - Computation of Therapy Limitation and Excess

Cost Adjustment. 3219.5

Rev. 6 32-1

CHAPTER 32

Section

W orksheet S-6 - HHA-Based CORF Statistical Data. 3220

W orksheet J-1 - Allocation of General Service Costs

to CORF Cost Centers. 3221

Part I - Allocation of General Service Costs to CORF Cost Centers. 3221.1

Part II - Computation of Unit Cost Multiplier for Allocation of CORF

Administrative and General Costs. 3221.2

Part III - Allocation of General Service Costs to CORF Cost

Centers - Statistical Basis. 3221.3

W orksheet J-2 - Computation of CORF Costs. 3222

Part I - Apportionment of CORF Cost Centers. 3222.1

Part II - Apportionment of Cost of CORF Services Furnished by

Shared HHA Departments. 3222.2

Part III - Total CORF Costs. 3222.3

W orksheet J-3 - Calculation of Reimbursement

Settlement - CORF Services. 3223

Part I - Computation of Customary Charges for CORF Services. 3223.1

Part II - Computation of Reimbursement Settlement 3223.2

W orksheet J-4 - Analysis of Payments to Provider-Based

CORF for Services Rendered to Program Beneficiaries. 3224

W orksheet CM-1 - Allocation of General Service Costs

to CMHC Cost Centers. 3225

Part I - Allocation of General Service Costs to CMHC Cost Centers. 3225.1

Part II - Computation of Unit Cost Multiplier for Allocation of

CMHC Administrative and General Costs. 3225.2

Part III - Allocation of General Service Costs to CMHC Cost

Centers - Statistical Basis. 3225.3

W orksheet CM-2 - Computation of CMHC Costs 3226

Part I - Apportionment of CMHC Cost Centers. 3226.1

Part II - Apportionment of Cost of CMHC Services Furnished by

Shared HHA Departments. 3226.2

Part III - Total CMHC Costs. 3226.3

W orksheet CM-3 - Calculation of Reimbursement

Settlement - CMHC Services. 3227

Part I - Computation of Lesser of Reasonable Cost or Customary

Charges. 3227.1

Part II - Computation of Reimbursement Settlement 3227.2

W orksheet CM-4 - Analysis of Payments to Provider for

CMHC Services Rendered to Program Beneficiaries. 3228

W orksheet RH-1 - Allocation of General Service

Costs to RHC Cost Centers. 3229

Part I - Allocation of General Service Costs to RHC Cost Centers. 3229.1

Part II - Computation of Unit Cost Multiplier for Allocation of RHC

Administrative and General Costs. 3229.2

Part III - Allocation of General Service Costs to RHC Cost

Centers - Statistical Basis. 3229.3

32-2 Rev. 6

CHAPTER 32

Section

Worksheet RH-2 - Apportionment of RHC Costs 3230

Part I - Apportionment of RHC Cost Centers. 3230.1

Part II - Apportionment of Cost of RHC Services Furnished by

Shared HHA Departments. 3230.2

Part III - Total RHC Costs. 3230.3

Worksheet FQ-1 - Allocation of General

Service Costs To FQHC Cost Centers. 3231

Part I - Allocation of General Service Costs to FQHC Cost Centers. 3231.1

Part II - Computation of Unit Cost Multiplier for Allocation of FQHC

Administrative and General Costs. 3231.2

Part III - Allocation of General Service Costs to FQHC Cost

Centers - Statistical Basis. 3231.3

Worksheet FQ-2 - Computation of FQHC Costs 3232

Part I - Apportionment of FQHC Cost Centers. 3232.1

Part II - Apportionment of Cost of FQHC Services Furnished by

Shared HHA Departments. 3232.2

Part III - Total FQHC Costs. 3232.3

Worksheet S-4 - HHA-Based Rural Health Clinic/

Federally Qualified Health Center Provider Statistical Data 3233

Worksheet RF-1 - Analysis of HHA-Based Rural Health Clinic/

Federally Qualified Health Center Costs 3234

Worksheet RF-2 - Allocation of Overhead to RHC/FQHC Services 3235

Visits and Productivity 3235.1

Determination of Total Allowable Costs Applicable to RHC/FQHC

Services 3235.2

Worksheet RF-3 - Calculation of Reimbursement Settlement

for RHC/FQHC Services 3236

Determination of Rate for RHC/FQHC Services 3236.1

Calculation of Settlement 3236.2

Worksheet RF-4 - Computation of Pneumococcal and

Influenza Vaccine Cost 3237

Worksheet RF-5 - Analysis of Payments to Provider-Based RHC/FQHC

for Services Rendered to Program Beneficiaries 3238

W orksheet S-5 - Hospice Identification Data 3239

Part I - Enrollment Days 3239.1

Part II - Census Data 3239.2

W orksheet K - Reclassification and Adjustment of Trial

Balance of Expenses. 3240

W orksheet K-1 - Compensation Analysis - Salaries and Wages 3241

W orksheet K-2 - Compensation Analysis - Employee

Benefits (Payroll Related). 3242

W orksheet K-3 - Compensation Analysis - Contracted

Services/Purchased Services. 3243

W orksheet K-4, Part I - Cost Allocation - General Service Costs and

Worksheet K-4, Part II - Cost Allocation - Statistical Basis.. 3244

W orksheet K-5 - Allocation of General Service Costs to Hospice

Cost Centers 3245

Part I - Allocation of General Service Costs to Hospice Cost Centers 3245.1

Part II - Allocation of General Service Costs to Hospice Cost

Centers - Statistical Basis. 3245.2

Part III - Apportionment of Hospice Shared Services . 3245.3

W orksheet K-6 - Calculation of Per Diem Cost 3246

Exhibit 1 - Form CMS-1728-94 Worksheets 3290

Electronic Reporting Specifications for Form CMS-1728-94 3295

Rev. 10 32-3