CMS-2552-10. Response_To_Comments

SUMMARY OF COMMENTS AND RESPONSES
WORKSHEET S-2
Comment - Commenters questioned the need for the long-standing requirement to report Medicaid days
in six categories on Worksheet S-2, Part I, lines 24 and 25. The commenters suggested reducing the
reporting requirement to one column of Medicaid days. Alternately, some commenters requested that
CMS clarify reporting out-of-state HMO days and HMO-eligible but unpaid days.
Response - We made no substantive changes to the policy for data required to be reported on
Worksheet S-2, Part I, lines 24 and 25. Instead, we proposed clarifications to the instructions to provide
guidance to providers to report accurate data on those lines. In response to the commenter’s request that
we clarify reporting of HMO-eligible but unpaid days, we note that the proposed clarification already
instructs providers to report HMO-eligible but unpaid days in column 5.
Comment - A commenter appreciated the clarity and specificity of the revised instructions Worksheet S2, Part I, lines 24 and 25, instructions related to DSH eligible days, and the layout of Exhibit 3A. A
commenter suggested that CMS modify the proposed instructions for Worksheet S 2, Part I, lines 24 and
25, columns 1, 2, 3, and 4, to clarify that days not eligible for Medicaid but regarded as such under a 1115
waiver do not require a determination of DSH eligibility since neither the statute nor the regulations
require an eligibility determination.
Response - We agree that days not eligible for Medicaid but regarded as such under a 1115 waiver do
not require a determination of DSH eligibility under the statute or the regulations. Therefore, we modified
the proposed instructions for Worksheet S-2, Part I, lines 24 and 25, columns 1, 2, 3, and 4.
Comment - Several commenters suggested that CMS clarify what is meant by permanent adjustments in
the proposed instructions for Worksheet S-2, Part 1, line 88, and line 89. One commenter suggested that
we cite a reference for permanent adjustments in order to enhance the cost report instructions.
Response - We agree with the commenters and modified the proposed instructions for Worksheet S-2,
Part I, lines 88 and 89, by adding "See CMS Pub. 15-1, chapter 30, §3004.1 and §3004.2 for clarification
on permanent adjustments."
Comment – Commenters suggested that CMS modify the Worksheet S-2, part I, line 89, by deleting the
proposed column 2, the effective date of the permanent adjustment. Commenters noted that some
hospitals may not know the date given the time passed since approval.
Response – We agree that identifying the effective date of a permanent adjustment for the proposed line
89 on Worksheet S-2, Part I may be difficult for some providers. We note that calculating the updated
permanent adjustment amount for Worksheet D-1, Part II, line 55.01, requires the effective date in order
to apply the proper update factor to the adjustment amount. As some providers may be able to provide
the information requested on Worksheet S-2, Part I, line 89, column 2, we modified proposed instruction
as follows: In column 1, enter the Worksheet A line number upon which the approval of the permanent
adjustment to the TEFRA target amount per discharge was based; in column 2, enter the cost reporting
period beginning date that the permanent adjustment to the TEFRA target amount per discharge was
effective, if available; and in column 3, enter the amount of the approved permanent adjustment to the
TEFRA target amount per discharge approved as of the date in column 2.
Additionally, we modified the proposed instructions for Worksheet D-1, Part II, line 55.01, as follows: If
Worksheet S-2, Part I, line 88, column 1, is “Y”, enter the amount of the permanent adjustment to the
TEFRA target amount per discharge from Worksheet S-2, Part I, line 89, column 3, after applying the
proper update factor (see 42 CFR 413.40) as obtained from your contractor. If the contractor approved
more than one permanent adjustment to the TEFRA target amount per discharge (Worksheet S-2, Part I,
line 88, column 2, is greater than 1), enter the sum of all permanent adjustments, i.e., the sum of the
amounts entered on Worksheet S-2, Part I, line 89 and subscripts, column 3, after applying the proper
update factors (see 42 CFR 413.40) as obtained from your contractor.

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Comment: Several commenters questioned the need for the proposed line 123 on Worksheet S-2, Part
I, stating that the question adds significant administrative burden without improving the quality of data
collected by the cost report. In general, the commenters opposed adding this proposed line and
requested that CMS remove it from the cost report. Several commenters stated that almost all hospitals
use purchased legal, accounting, tax preparation, bookkeeping, payroll, and management consulting
services, and that hospitals do not track the percentage of services purchased from unrelated
organizations outside the main hospital CBSA. The commenters stated that even determining this
percentage is a complex undertaking. A few commenters stated that the firms providing these services
are either regional or national. The commenters pointed out that in many instances, organizations
providing these services may have a local office in the main hospital’s CBSA but, in light of the complexity
of the tax, accounting, and legal rules applicable to providers, will leverage staff resources outside the
CBSA to provide the requisite level of expertise on individual projects. The commenters stated that this
adds significant complexity to determining what percentage of purchased administrative services from
unrelated organizations the hospital procured from outside of the hospital’s CBSA. Several commenters
stated that the proposed line 123 on Worksheet S-2, Part I, appears to be informational in nature and
CMS does not provide any rationale for collecting this data. One commenter stated that the costs
imposed by this data element would be vastly disproportionate to the value of the data collected. In the
alternative, the commenter stated that if there is any rationale for collecting this data, it has not been
presented to stakeholders for comment.
Response: We acknowledge the difficulty for hospitals to determine the exact percentage of professional
services purchased outside the main hospital’s CBSA. We note that the question does not request that
hospitals report this exact percentage, but rather select the appropriate range (1% to 50%, 51% to 99%,
or 100%). However, we acknowledge that this proposal may appear to suggest that hospitals calculate
an actual percentage in order to answer this question. Therefore, we modified the proposed Worksheet
S-2, Part I, line 123, as follows:
Line 123--Did the facility and/or its subproviders (if applicable) purchased professional services, e.g.,
legal, accounting, tax preparation, bookkeeping, payroll, advertising, and/or management/consulting
services, from an unrelated organization? In column 1, enter "Y" for yes or "N" for no. If column 1 is yes,
were the majority of the expenses, i.e., greater than 50% of the total professional services expenses, for
services purchased from unrelated organizations located outside of the main hospital’s local area labor
market? In column 2, enter “Y” for yes or “N” for no.
With this revised question, hospitals need only answer a yes/no question indicating whether the hospital
purchased professional services from an unrelated organization and, if so, a yes/no question on whether
the hospital purchased the majority of these professional services outside of the main hospital’s local
labor market. Modifying the proposed question reduces the burden on hospitals compared to our initial
proposal as the revised question requires informed responses based on the hospital’s accounting
records, but does not require a separate detailed calculation. At the same time, the revised question
collects more current information on the proportion of professional fees for labor-related services the
hospital purchased outside of the local labor market, which will help ensure more accurate Medicare
payments.
We disagree that the question is informational in nature. The requested information ultimately impacts
the labor-related share of the wage index for IPPS hospitals, as well as the labor-related share for
inpatient rehabilitation facility, inpatient psychiatric facility, and long-term care hospitals. We
acknowledge that we did not thoroughly explain the need for the information. The rationale for the
proposed line 123 on Worksheet S-2, Part I, is to obtain a more recent estimate of the proportion of legal,
accounting and auditing, engineering, and management consulting services that meet our definition of
labor-related services. As described in the FY 2018 IPPS/LTCH final rule, our current estimate of laborrelated professional services is derived using a 2008 CMS survey of hospitals (82 FR 38167). A
discussion of the composition of the survey and post-stratification can be found in the FY 2010

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IPPS/LTCH PPS final rule (74 FR 43850 through 43856). Based on the weighted results of the survey,
we determined that hospitals purchase, on average, the following portions of contracted professional
services outside of their local labor market:
●
●
●
●

34 percent of accounting and auditing services;
30 percent of engineering services;
33 percent of legal services; and
42 percent of management consulting services.

Ultimately, in the 2014-based IPPS market basket, nonmedical professional fees that were subject to
allocation based on these survey results represent 4.9 percent of total operating costs (and are limited to
those fees related to Accounting & Auditing, Legal, Engineering, and Management Consulting services).
Based on our survey results, we apportioned 3.1 percentage points of the 4.9 percentage point figure into
the Professional Fees: Labor-Related share cost category and designate the remaining 1.8 percentage
points into the Professional Fees: Nonlabor-Related cost category (82 FR 38167). With the proposed
line 123, we intend to derive updated estimates of these percentages using data from Medicare cost
reports submitted by all hospitals, as opposed to relying on the limited sample of 108 hospitals in the
2008 survey.
In fact, as discussed in the FY 2018 IPPS/LTCH final rule, we received several public comments where
the commenters expressed concern about the methodology CMS used to remove a portion of
professional fees from the labor-related share (82 FR 38167). Several commenters believed the
information gathered for the Professional Fees Survey in 2008 is outdated and that the survey should be
updated. In addition, a few commenters stated that they did not believe the survey could be statistically
representative because it was based on 108 hospitals. Several commenters urged CMS to continue to
investigate alternative methodologies for determining the proportion that is labor-related before
implementing any changes. We provided detailed responses to these comments in the FY 2018
IPPS/LTCH final rule and indicated that we would continue to explore options for updating the
Professional Fees Survey to reflect more recent data for incorporation into future market basket rebasing
and labor-related share determinations (82 FR 38168).
In summary, we propose to collect purchased services information because it impacts the labor-related
shares used in the geographic adjustments for the hospitals’ Medicare prospective payment systems.
The proposed line 123, modified as noted in the response to comments about the complexity of
determining the percentage, will provide CMS with updated estimates for the labor-related professional
services provided to all hospitals submitting the Medicare cost report.
WORKSHEET S-10
Comment - One commenter suggested that CMS modify the proposed Worksheet S-10 instructions to
clarify that a provider must include explicit verbiage detailing the charity care eligibility criteria in the
written charity care policy or financial assistance policy.
Response - We note that the FY 2021 IPPS/LTCH final rule (85 FR 58826) published September 18,
2020, stated “… CMS does not set charity care criteria policy for hospitals, and within reason, hospitals
can establish their own criteria for what constitutes charity care in their charity care and/or financial
assistance policies.”
Comment - Commenters claimed the Worksheet S-10, line 20, language, “if such inclusion is specified in
the hospital’s charity care policy or FAP,” as written, could prompt some auditors to erroneously interpret
and extend this language to require unreasonably specific and granular provisions in charity care and
financial assistance policies. The commenters requested that we remove the language from instructions
for Worksheet S-10, line 20, and from Exhibit 3B to reduce the risk of arbitrary disallowances and

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unnecessary administrative burdens. One commenter also suggested removing the language from line
24. Some commenters also claimed that the important facts in determining whether an amount is
included on line 20 are that the patient has an outstanding balance related to services rendered and
meets the financial criteria set forth in the hospital’s charity care policy or FAP, not that the balance was
the result of a payer’s administrative policy. These commenters claimed that the instruction may result in
arbitrary disallowances and unnecessary administrative burdens.
Response - We understand that commenters may perceive the phrase “if such inclusion …” as new text
because it appeared as red italic text in the proposed information collection request. While we formatted
the text as red italic to highlight that we revised the instructions for line 20 by applicable time period, we
note that the phrase “… if such inclusion is specified in the hospital's charity care policy …” appears in the
Worksheet S-10 instructions since the issuance of Transmittal 1, published December 2010. This
language does not appear in line 24 instructions. We are not aware of any instances where auditors
erroneously interpreted this language.
We agree that amounts included on line 20 result from outstanding balances related to services rendered
to patients meeting the financial criteria set forth in the hospital’s charity care policy or FAP. In
consideration of the commenters’ requests, we modified the proposed instructions for Worksheet S-10,
line 20, to clarify that that amounts reported on line 20 are attributable to services specified in the
hospital’s charity care policy or FAP, as follows: “… if such inclusion is specified in the hospital’s charity
care policy or FAP and the patient meets the hospital's policy criteria.” We note this revision is consistent
with the instructions for Exhibit 3B.
Comment - One commenter suggested that CMS modify the instructions for the proposed
Worksheet S-10, §4012.7, paragraph A, to include amounts written off to charity care for any uninsured
portion of an insured patient’s hospital stay, for any insured patient who exhausted benefits, and for any
non-covered services.
Response - We appreciate the comment and incorporated this revision in the instructions.
Comment - A commenter asked CMS to clarify that a SCH or MDH paid on its hospital-specific rate is
exempt from the requirement to submit supporting documentation for Worksheet S-10, line 20, for an
acceptable cost report submission and need not submit the proposed Exhibit 3A.
Response - We agree with the commenter that completion of the Exhibit 3A as well as 3B and 3C may
be burdensome for a SCH paid on its hospital specific rate; therefore, we modified the instructions for
each exhibit to indicate that when a SCH (WS S-2, Part I, line 35, is greater than zero) where Worksheet
E, Part A, line 48, is greater than line 47, do not complete Exhibits 3A, 3B or 3C. However, an MDH must
complete each of the appropriate exhibits.
Comment - Commenters suggested that CMS redefine Worksheet S-10, line 20, column 1, to report
amounts subject to the CCR and redefine column 2 to report amounts not subject to the CCR.
Commenters proposed limiting column 2 to deductible, copayment, and coinsurance amounts for insured
patients that are written off to charity care; and limiting column 1 to gross charges written off to charity
care for uninsured individuals, insured individuals with charges for non-covered services or days that
exceed a length-of-stay limit, and gross charges other than deductible, copayment, or coinsurance
amounts. One commenter suggested we also make corresponding changes to Worksheet S-10, lines 21
through 23, if these line 20 revisions are accepted. One commenter suggested revising the Worksheet S10 to correspond with reporting on the new Exhibit 3B.
Response - Worksheet S-10, line 20, intentionally segregates charity care charges for uninsured patients
and insured patients for use by various stakeholders. Likewise, line 25 and the proposed line 25.01
intentionally segregate charity care charges for days exceeding a length-of-stay limit for insured patients’
liability other than deductible, coinsurance, and co-payment amounts, respectively. The current structure
with separated columns based on insurance coverage is important for determining the application of the
hospital CCR. When reporting insured patients’ charity care charges, we note line 25 and the proposed

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line 25.01 are subject the CCR, and are a subset of the amounts reported on line 20, column 2. The
proposed line 25.01 collects amounts other than deductible, coinsurance, and copayment amounts;
therefore, we are maintaining the revisions as proposed for lines 20, 21, 22, 23, 25, and 25.01, on
Worksheet S-10.
Comment - One commenter claimed that CMS proposed language in the Worksheet S-10 instructions
regarding “inferred contractual relationship” is not permissible, would rewrite contract law and eliminate
any value of a contract between a provider and a payor. This commenter requested the proposed
inferred contractual relationship provision be removed. One commenter requested an expanded
definition of the term inferred contractual relationship, with examples, to ensure accuracy and reliability of
the Worksheet S-10 data. Another commenter stated that the inferred contractual relationship proposal
suggests that providers can only claim deductible, coinsurance, and co-payments, on Worksheet S-10,
line 20, column 2; however, for many of these claims (such as auto insurances), providers cannot prove
the amounts of deductibles, coinsurance, and copayments because remittance advices may report one
patient responsibility amount, which can incorporate amounts other than deductibles, coinsurance, or
copayments. The commenter encouraged CMS to reconsider inclusion of this language under the
instructions for Worksheet S-10, line 20, column 2.
Response - We appreciate the commenters concerns and requests for clarification. We disagree with
the commenter who requested the proposed inferred contractual relationship provision be removed. We
received comments from stakeholders in the past asking whether hospitals could report charges for
insured patients when the insurer has an out-of-network status with the hospital, i.e., when there is the
absence of a contractual relationship between the hospital and the insurer. In such circumstances, for
Worksheet S-10 purposes, we’ve expanded the instructions to address when a hospital does not have a
contractual relationship with the insurer due to its out of network status. The instructions for Worksheet
S-10, line 20, are more inclusive by allowing hospitals to report amounts written off to charity care for total
charges, or the portion of total charges, for patients with coverage from an entity/insurer that does not
have a contractual or an inferred contractual relationship with the provider. However, we agree with
comments that the cost report instructions are not as clear as they could have been, so we defined an
“inferred contractual relationship” in the proposed instructions as follows: For Worksheet S-10 purposes,
a contractual relationship between an insurer and a provider will be inferred where a provider accepts an
amount from an insurer as payment, or partial payment, on behalf of an insured patient (for example,
payments from workman’s compensation funds, payments from an automobile insurer for medical
benefits, or payments from an insurer for out-of-network services). An inferred contractual relationship
can be more than a deductible, coinsurance or co-payment, contrary to commenters suggestions. In
situations where the provider accepts under an inferred contractual relationship, payment from the insurer
as payment in full with no patient liability or a patient liability limited to deductible, coinsurance or copayment, the patient liability amount is written off to charity care is reported on Worksheet S-10, line 20,
column 2; however, any balance beyond the patient liability is considered a contractual allowance and
may not be written off to charity care. On the other hand, in situations where the hospital receives only a
partial payment under an inferred contractual relationship and the hospital does not accept the amount as
payment in full, resulting in a patient liability, the hospital reports the amount written off to charity care on
Worksheet S-10, line 20, column 2. For example, an inferred contractual relationship exists and the
patient has a $1,000 deductible. Total charges were $20,000 and the insurer agrees to pay 60% of
charges. The patient has a liability for 40% of the charges plus a $1,000 deductible. If the patient liability
amount is written off to charity care the hospital would report $9,000 on Worksheet S-10, line 20, column
2 ($20,000 times 40%=$8,000 plus the patient’s $1,000 deductible) and the hospital would also report
$8,000 ($9,000 patient liability minus $1,000 deductible) on Worksheet S-10, line 25.01. The amount on
line 25.01 identifies the amount on line 20, column 2, that is subject to the cost to charge ratio.
Comment - A commenter requested that Medicaid shortfalls be included in uncompensated care cost
calculations. The commenter also suggested revising the Worksheet S-10, lines 2 through 8, instructions
to include GME-related costs, intergovernmental transfers (IGTs), and certified public expenditures
(CPEs).

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Response - We refer readers to the 2021 IPPS proposed rule (85 FR 58432 at 58825), wherein we
explained compelling arguments for excluding such shortfalls from the definition of uncompensated care.
We also refer readers to the 2020 IPPS final rule (84 FR 42044 at 42374), wherein we explained that a
stay exceeding the length-of-stay limit imposed on patients covered by Medicaid or other indigent care
program does not mean a length of stay that just happens to be longer than an individual hospital's
average length of stay, but is one that exceeds a Medicaid or other indigent care program's length of stay
limit. We further explained that a DRG-based Medicaid payment that is less than the cost of the services
furnished to a Medicaid patient is considered a Medicaid shortfall. A Medicaid shortfall, or a Medicaid
contractual allowance, must not be re-characterized as charity care and must not be reported on
Worksheet S-10, line 20. We continue to define uncompensated care costs as the amount on Worksheet
S-10, line 30, which is the cost of charity care (line 23) and the cost of non-Medicare bad debt and nonreimbursable Medicare bad debt (line 29). The comment requesting revision to Worksheet S-10, lines 2
through 8, instructions to include GME-related costs, IGTs, and CPEs are outside of the scope of the
proposals for the Worksheet S-10 in the PRA.
Comment - One commenter agreed with the CMS revisions to Worksheet S-10, line 20, instructions
limiting reporting of costs and charges to those for services provided to patients within the acute care
portion of hospital. Other commenters disagreed with our proposal to exclude charity care charges for
services provided in IPPS-exempt units within the hospital, such as skilled nursing facilities, inpatient
psychiatric units, and substance abuse services, from the amounts reported on Worksheet S-10, line 20.
One commenter suggested that CMS include the cost of providing physician and other professional
services when calculating uncompensated care. Commenters suggested this change reverses CMS’
longstanding policy, understates charity care and bad debt cost for certain hospitals, requires breaking
out uncompensated care costs for a patient for a given admission by the unit of the hospital where the
patient received care, violates the principle of mental health parity, and inappropriately excludes
substance abuse services amid the opioid crisis.
Response - We appreciate the commenters concerns and requests for clarification. Section 3133 of the
Patient Protection and Affordable Care Act, which added section 1886(r)(2) of the Act, authorizes an
additional payment for uncompensated care costs (UCC) for eligible section (d) hospitals
(disproportionate share hospitals). In light of the comments received, CMS will not finalize the proposed
changes to Worksheet S-10, lines 20 through 29. Instead we will re-designate the Worksheet S-10, to
include Parts I and II. On Worksheet S-10, Part I, we will retain the original collection of UCC data, and in
order to separately identify the UCC for the general short-term hospital inpatient and outpatient services
billable under the hospital CCN, we will require hospitals to identify this data on Worksheet S-10, Part II.
The Worksheet S-10, Part II data will be collected so that CMS may consider the general short-term
hospital inpatient and outpatient detailed information, in future years, in determining the scope of the UCC
data for purposes of the uncompensated care payment methodology.
Comment - A few commenters requested that CMS create an auditing threshold for amounts reported on
Worksheet S-10, line 20, column 2, that are greater than 25% of total hospital charges. Commenters
suggested that if CMS accepts this change, CMS also delete lines 24, 25, and 25.01 from
Worksheet S-10. One commenter recommended that CMS propose a threshold to determine when an
insured charity amount is likely a charity coinsurance and deductible amount as compared to other charity
charges for the insured patient. The commenter stated that not all hospital systems capture patient
coinsurance and deductible amounts from other liability amounts.
Response - Comments regarding a recommended threshold approach for audit purposes are outside the
scope of the hospital cost report PRA. As discussed in past IPPS/LTCH PPS final rules, Worksheet S-10
audit protocols are for CMS and MAC use only and we continue to hold the audit protocols as
confidential.
Comment - Many commenters opposed including the phrase “medically necessary” health care services
to the Worksheet S-10 proposed revised definition of charity care and uninsured discounts and requested

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the removal of the reference. However, some commenters agreed that uncompensated care costs
reported on Worksheet S-10 should only be “medically necessary” care. A commenter requested further
clarification of what constitutes “medically necessary care.” The majority of commenters expressed
concerns that there would be disallowances of charity care claimed on Worksheet S-10 due to differences
of opinion between auditors and hospitals. A commenter stated that Medicare cost report auditors are not
clinicians and will not know the underlying clinical details of a case, and the commenter expressed
concern that this additional phrase could give rise to inappropriate reviews of medical necessity, diverting
both hospital and auditor resources, without improving the accuracy of the data reported on Worksheet S10. One commenter stated there are separate medical necessity audits that occur today, for which such
determinations require medical records and medical expertise that Medicare cost report auditors simply
do not possess, and which require more patient information than is necessary to perform the S-10 audits.
The same commenter stated that their existing charity care policy provides that charity care is only offered
with respect to charges related to medically necessary charges and the commenter stated that Medicare
hospital cost report auditors are supposed to be auditing for adherence to such policy. A separate
commenter asked for confirmation that this proposed revised definition for “medically necessary” health
care services was not intended to re-adjudicate necessity determinations. One commenter suggested
“medically necessary” be replaced with “health care services.” Other commenters stated the terminology
was not necessary because many providers already exclude cosmetic and other elective services from
their charity care policies, and few, if any, hospitals charity care/financial assistance policies provide relief
for health care that is not medically necessary, therefore adding the phrase “medically necessary” is
redundant.
Response - In the past, CMS received questions from stakeholders asking whether there is a
requirement that medically necessary care be reported on the Worksheet S-10. Pursuant to section
1862(a)(1)(A) of the Social Security Act, no payment may be made under Part A or Part B for any
expenses incurred for items or services not reasonable and necessary for the diagnosis or treatment of
illness or injury or to improve the functioning of a malformed body member. The revised definition is
consistent with this statutory requirement because the Worksheet S-10 data is part of the DSH
uncompensated care payment calculations. We note that the Worksheet S-10 proposed definition
clarification addresses a potential contradiction that could arise if a hospital’s charity care policy were to
specify that non-medically necessary services would be eligible for charity care and/or financial
assistance at the hospital. Providers must only report medically necessary health care services on the
Worksheet S-10; we recognize that the majority of hospitals already follow the clarified definition in their
hospital specific charity care policy. The Worksheet S-10 audits review a provider's compliance with their
own documented charity care and financial assistance policies (FAP) in effect during the cost reporting
period. Regarding the concern of potential disallowances in future Worksheet S-10 audits and concern
on re-adjudicating necessity determination, the revised definition clarifies that even if a hospital’s charity
care policy allows charity care for non-medically necessary services, those services are not allowed for
Worksheet S-10 reporting of charity care.
Comment - Some commenters supported CMS’ addition of the language on Worksheet S-10 which
provides, “CMS does not mandate the eligibility criteria that a hospital uses under its financial assistance
policy.” Commenters recommended that CMS clarify that hospitals may qualify individuals as being
eligible for their charity care/financial assistance policies using a presumptive eligibility tool, if the use of
that tool is specifically referenced in the hospital’s charity care/financial assistance policy.
Response - We appreciate the commenters who supported our addition of certain proposed language on
Worksheet S-10. We disagree with commenters’ request to revise the instructions to state that hospitals
may qualify individuals as being eligible for their charity care/financial assistance policies using
presumptive eligibility tools. We note that the FY 2021 IPPS/LTCH final rule (85 FR 58826) published
September 18, 2020, stated “With regard to the comments regarding the use of presumptive eligibility
tools to determine charity care, we note that CMS does not set charity care criteria policy for hospitals,
and within reason, hospitals can establish their own criteria for what constitutes charity care in their
charity care and/or financial assistance policies.”

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Comment - One commenter suggested that CMS remove line 24, line 25, and the proposed line 25.01,
and treat length-of-stay limits in the same manner as any other partially covered stay. Another
commenter suggested CMS modify the Worksheet S-10 to remove line 24, line 25, and the proposed line
25.01, and report the charity care charges for days exceeding a length-of-stay limit on either line 20 or a
subscript of line 20. Another commenter supported CMS’ proposal to create line 25.01 on
Worksheet S-10 to distinguish charges that represent the insured patient’s liability for medically
necessary hospital services, other than deductible, coinsurance, and co-payment amounts from other
charity care charges reported on Worksheet S-10, line 20, column 2.
Response - We appreciate the commenters concerns. Worksheet S-10, line 20, intentionally segregates
uncompensated care data for uninsured patients and for insured patients’ reporting charity care. We note
line 25 and the proposed line 25.01 must be included in the amount on line 20, column 2, and are subject
to the CCR. The proposed line 25.01 collects amounts other than deductible, coinsurance, and
copayment amounts, subject to the CCR that are also included on line 20; therefore, we propose to
maintain the revisions as proposed for lines 20, 25, and 25.01, on Worksheet S-10.
Comment - Commenters stated that the line 29 instructions contain a flawed calculation because line 28
(non-Medicare bad debt) includes amounts for deductibles, coinsurance, and copayments, that should not
be subject to the CCR when calculating line 29. Some commenters suggested CMS create separate
columns for lines 26 through 29 to report charges for insured and uninsured patients and apply the CCR
only to the charges reported in the uninsured patients’ column. Another commenter suggested not
applying the CCR when calculating the amount of bad debt for uncompensated care. One commenter
requested CMS clarify the instructions for bad debt expenses to treat all coinsurance and deductibles for
non-Medicare bad debt the same—not multiplying them by the hospital CCR. A commenter disagreed
with the instruction to multiply non-Medicare bad debt expense (line 28) by the hospital’s CCR (line 29)
because the non-Medicare bad debt expense includes deductibles, coinsurance and copayment amounts
and are not hospital charges, but are amounts a hospital reasonably expected a patient to pay. The
commenter requested that only bad debt charges (not deductibles, coinsurance and copayment amounts)
be multiplied by the hospital’s CCR.
Response - Bad debt for the hospital is not limited to deductibles and coinsurance as is Medicare bad
debt. Bad debt for the hospital is comprised of components such as amounts that patients have not paid
for an entire self-pay hospital stay, a non-covered service, and/or deductibles and coinsurance. The
Medicare cost report does not identify bad debt for the hospital by components and collecting it would
impose additional unnecessary burden on the hospitals and our Medicare contractors.
WORKSHEET S-12
Comment - Several commenters requested that CMS withdraw the market-based MS DRG relative
weight data collection requirement, and subsequently withdraw or postpone the market-based MS DRG
relative weight methodology, as finalized in the FY 2021 IPPS/LTCH PPS final rule, effective for FY 2024.
These commenters requested that, if CMS continues the market-based MS DRG relative weight data
collection requirement, CMS delay the effective date of the market-based MS DRG relative weight
methodology until additional stakeholder engagement and provider education can be completed.
Additional commenters raised a number of issues with the instructions provided for calculating and
reporting the median payer-specific negotiated charge and that further information was needed in order to
account for the various contract arrangements hospitals use to negotiate payments with MA organization
payers, such as, but not limited to, per diem contracts, percentage of contract arrangements, quality
based add-on payments and adjustments, capitated payment arrangements, and shared risk contract
arrangements. These commenters asserted that without additional clarification, CMS would collect data
that was not reliable, valid or standardized across hospitals. Several commenters also noted that CMS
underestimated the administrative burden associated with the market-based MS-DRG relative weight

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data collection requirement and the steps necessary to crosswalk the data to report it by MS DRG on the
Medicare cost report, specifically during the COVID-19 public health emergency.
Response - We agree with commenters that additional clarification is necessary for the proposed
Worksheet S 12 to assure that CMS collects reliable and usable data under the market-based MS DRG
relative weight data collection requirement for use in the market-based MS DRG relative weight
methodology effective in FY 2024. We agree with commenters that a delay is necessary to assure we
are able to meaningfully consider and review public comments. As such, in conjunction with the proposal
in the FY 2022 IPPS/LTCH PPS proposed rule to repeal the market-based MS DRG relative weight data
collection policy and the market-based MS DRG relative weight methodology, we are holding in abeyance
the requirement that hospitals complete the S-12 worksheet. Therefore, we removed the proposed
Worksheet S 12 and instructions from the Form CMS 2552 10. We may publish additional changes, as
necessary.
WORKSHEET A
Comment - Several commenters requested CMS clarify the instructions for Worksheet A, line 78. One
commenter noted the changes are an important first step to ensuring appropriate calculation of CAR Tcell acquisition costs, and will help inform future rate setting and other policies relative to CAR T-cell
therapy. Commenters asked if CMS intends to isolate the direct purchase cost of the CAR T-cell
manufactured biologic on Worksheet A, line 78, and one commenter specified line 78 on Worksheets A,
B, B-1, and C. Some commenters asked if CMS meant to exclude from Worksheet A, line 78, the
expense of non-CAR T cell drugs, (e.g., ocilizumab, a drug used for CAR T-cell therapy complications),
furnished to patients receiving CAR T-cell therapy. Several commenters requested CMS confirm that
Worksheet A, line 78, is appropriate for reporting other direct, purchased services costs related to the cell
collection, laboratory storing and processing of the cells.
Response - We appreciate the commenter who noted the importance of capturing CAR T-cell acquisition
costs on the Medicare cost report Worksheet A, line 78. We agree with commenters’ request to clarify the
instructions and modified the Worksheet A, line 78, proposed instructions as follows: Effective for cost
reporting periods beginning on or after October 1, 2022, enter the hospital acquisition costs for procuring,
storing, and processing chimeric antigen receptor T cells (CAR T-cell) for immunotherapy infusion (FDA
approved CAR T-cell immunotherapies only). This includes the cost of the CAR T-cell manufactured
biologic, i.e., the cost paid to the manufacturer. Do not include costs for CAR T-cell immunotherapy
transplants or the medication cost of the non-CAR T-cell drugs used for CAR T-cell therapy
complications, e.g., Cytokine Release Syndrome, on this line.
We originally proposed to capture CAR T-cell acquisition costs on Worksheet D-6. After consideration of
public comments, we propose to capture Medicare CAR T-cell acquisition costs on Worksheet D-3 and
Worksheet D, Part V, as these amounts are billed on the claim, as opposed to determining the acquisition
cost of all CAR T-cell transplants on the proposed Worksheet D-6. Therefore, we modified Worksheet D3 to capture the Medicare inpatient ancillary CAR T-cell acquisition costs and modified Worksheet D, Part
V, to capture the outpatient ancillary CAR T-cell acquisition costs. We modified the proposed Worksheet
D-6 and instructions to remove references to CAR T-cell therapy so that Worksheet D-6 only captures
acquisition costs for all allogeneic hematopoietic stem cell transplants to determine the Medicare
acquisition cost.
Comment - A commenter suggested CMS clarify the proposed instructions for Worksheet A, line 102, for
reporting opioid treatment program costs and specify whether to include the costs for Medicare patients.
Response - We added the proposed Opioid Treatment Program (OTP) cost center to the Medicare cost
report to ensure that a hospital’s OTP receives its appropriate share of hospital general service costs,
e.g., capital costs. Furthermore, we do not intend to capture ancillary costs for services provided by the
OTP nor calculate a settlement in the Medicare cost report for the OTP services because those services
are paid bundled payment rates under the Medicare Part B benefit.

9

In response to the commenter’s request that we clarify the description for the OTP cost center proposed
on Worksheet A, line 102, we modified the proposed instruction as follows: Effective for cost reporting
periods ending on or after January 1, 2021, enter the cost of providing services for the treatment of Opioid
Use Disorder furnished by a Medicare-enrolled Opioid Treatment Programs as defined in §1861(jjj) of the
Act and as described in CMS Pub. 100-02, Medicare Benefit Policy Manual, chapter 17.
WORKSHEET D-4
Comment - Commenters requested clarification of the phrase, "dates of service" on Worksheet D-4, line
63.01. Some commenters requested the instructions for line 63.01 be revised to state, "kidney
transplants occurring on or after January 1, 2021," to align with line 75.02 instructions. Several
commenters questioned if CMS intends for hospitals to report kidneys based on the patient’s admission
date, discharge date, or the organ transplantation date, during the transition year.
Response - The reasonable costs for procuring a kidney are reimbursable when billed in connection with
a Medicare covered transplant. Therefore, CMS intends for transplant hospitals to report kidney
acquisition costs based on the date the MA transplant occurs. We removed line 63.01 and included
instructions for line 63 to include kidneys transplanted into MA beneficiaries effective for transplants
occurring on or after January 1, 2021. We revised the proposed instruction for Worksheet D-4, line 63
and removed line 63.01. Line 75.02 will continue to identify the kidneys transplanted in MA beneficiaries
that are reported on line 63.
Comment - A commenter requested that CMS use only one definition of "usable" in regards to research
organs. This commenter suggested that research organs be included in the counts of both Medicare
usable organs and total usable organs or excluded from both counts.
Response - In the FY 2022 IPPS final rule (86 FR 73416 at 73518) we codified under 42 C.F.R.
413.412(c), for Medicare cost allocation purposes, organs used for research are not counted as Medicare
usable organs in Medicare’s share of organ acquisition costs, with the exception of pancreata for islet cell
transplants. Any further changes to the counting of research organs will need to go through notice and
comment rulemaking.
Comment - One commenter stated that the proposed instruction for Worksheet D-4, line 66, improperly
reduces the provider’s reimbursement and suggested revising the proposed instruction by removing the
parenthetical reference to Worksheet E, Part A, line 60, to avoid reducing the provider’s reimbursement
with no corresponding increase for Medicare’s full DRG payment if Medicare had been primary.
Response - To clarify, when Medicare has a secondary payor liability for an organ transplant, the hospital
must reduce the Medicare organ acquisition cost by the amounts received from the primary insurer for the
cost to acquire organs (not the transplant). When a hospital submits a claim to Medicare, the primary
payor payment amount is reflected on the provider’s PS&R. This primary payor amount may be an
amount for just the transplant or may be an amount for the transplant and the organ acquisition
cost. Inpatient primary payor amounts are reported on Worksheet E, Part A, line 60. The amount
pertaining to organ acquisition cost must not be used to reduce payments based on a DRG; this amount
must be reduced from Worksheet E, Part A, line 60, and reported on Worksheet D-4, Part III, line 66 or
66.01 (as applicable). The remaining amount applicable to the organ transplant and reported on
Worksheet E, Part A, line 60, must be reflected for informational purposes on Worksheet D-4, Part III, line
66.02. We refer the commenters to 42 CFR 413.414 for further information.
Comment - A commenter thanked CMS for including detailed instructions regarding Worksheet D-4 lines
62, 63, 66.01 and 66.02. This commenter stated that the addition of lines 66.01 and 66.02 provides a
clearer cost report submission and audit process for stakeholders.
Response - We thank the commenter for their support.

10

WORKSHEET D-6
Comment - One commenter asked that CMS clarify the instructions for Worksheet D-6, lines 1 through 6,
column 3, with examples, regarding what would constitute an inpatient day of care before the inpatient
admission.
Response - In response to the commenter’s request that we clarify the instructions for reporting inpatient
days on Worksheet D-6, we modified the proposed instructions for Worksheet D-6, Part I, lines 1 through
7, column 3, as follows: An allogeneic hematopoietic stem cells acquisition day is an inpatient day of care
rendered to a potential recipient or donor, before admission for the actual transplant, solely for a medical
evaluation for an anticipated allogeneic hematopoietic stem cells transplant; or rendered to an allogeneic
hematopoietic stem cells donor patient who is hospitalized for the allogeneic hematopoietic stem cells
acquisition procedure.
Comment - Several commenters suggested expanding the Worksheet D-6, lines 8 through 40, to
calculate both inpatient and outpatient costs related to hematopoietic stem cell acquisition costs and
requested more detailed instructions.
Response - In response to commenters suggesting that CMS clarify the instructions for calculating
inpatient and outpatient hematopoietic stem cell acquisition costs on the proposed Worksheet D-6, we
modified the proposed Worksheet D-6 and instructions to calculate the inpatient and outpatient
acquisition costs. In particular, we note that we modified the proposed instructions for Worksheet D-6,
Part III, to compute shared costs in addition to ancillary costs for both inpatient and outpatient service.
We also not that only inpatient service costs will be transferred to the appropriate worksheet for
reimbursement under reasonable cost principles.
Comment - One commenter questioned whether the expenses calculated on the proposed Worksheet D6 are included as allowable Medicare costs on the E worksheets. This commenter suggested that while
there is no separate or cost-based reimbursement of CAR T-cell services, the calculated expense should
allow for inclusion as Medicare allowable costs, and asked that CMS make changes in the E worksheets
to include in Medicare allowable costs the costs from the Worksheet D-6 for CAR T-cell therapy.
Response - In response to public comments, we modified the proposed Worksheet D-6 and instructions
to remove references to CAR T-cell therapy so that Worksheet D-6 only captures acquisition costs for all
allogeneic hematopoietic stem cell transplants to determine the Medicare acquisition cost. That costs
associated with CAR T-cell will be collected on Worksheet A and apportioned to Medicare on Worksheets
D-3, and D Part V.
Comment - Some commenters expressed disagreement with utilization of the Worksheet D-6 for CAR-T
cell acquisition costs because there is no cost settlement and the acquisition costs are reported for
informational purposes only. One commenter cited provider burden in completing the worksheet and
expressed that CMS has data to support the current DRG payment for CAR T-cell transplants because
the manufacturer charges for CAR T-cells are well known in the industry. Another commenter expressed
that the informational CAR T-cell cost acquisition data collection was not addressed in the proposed or
final IPPS rules regarding reimbursement for CAR T-cell therapies, and requested that CMS propose and
finalize the data collection through notice-and-comment rulemaking.
Response - We agree with the commenters and will only capture CAR T-cell acquisition costs on
Worksheet D-3 and Worksheet D, Part V, to determine the Medicare’s costs associated with CAR T-cell
acquisition cost. We modified Worksheet D-3 to capture the Medicare inpatient ancillary CAR T-cell
acquisition charges and modified Worksheet D, Part V, to capture the outpatient ancillary CAR T-cell
acquisition charges. We also modified the proposed Worksheet D-6 and instructions to remove
references to CAR T-cell therapy so that Worksheet D-6 only captures acquisition costs for all allogeneic
hematopoietic stem cell transplants to determine the Medicare acquisition cost.
WORKSHEET E-3

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Comment - Commenters suggested that CMS clarify the difference in the permanent adjustments to be
reported on the proposed Worksheet S-2, Part 1, line 88, and line 89; and the adjustments that may be
reported on Worksheet E-3, Part 1, line 17. Commenters further requested that CMS clarify the proposed
instructions for Worksheet E-3, Part 1, line 17, to define the type of adjustments reported on line 17,
specifically in light of the 2019 Medicare Administrative Contractors' (MACs') instructions to use this line
to report acquisition cost of CAR-T for Medicare patients. Commenters further asked that CMS also allow
subscripting of line 17 for other adjustments.
Response - We appreciate the commenters request to clarify the instructions for S-2 Part I L. 88 and L.
89. Line 88 was added to identify a provider’s permanent adjustment to their TEFRA target amount.
Because this can be more than one added permanent adjustment over the years, line 89 was added to
track each individual adjustment that the provider may have received. This information is needed to
ensure when calculating the adjustment amount on Worksheet D-1, Part II, line 55.01 that all permanent
adjustment amounts are included in the calculation. This historical data does not currently exist in the
cost report and it has been difficult at times to determine amounts that may have been approved in
previous years or from previous contractors. We added additional instructions to these lines for further
clarification. We also acknowledge that MACs have been using Worksheet E-3, Part I, line 17, for TEFRA
adjustments, such as for the timely issuance of reimbursement for critical CAR T-cell therapy. Worksheet
D-1, Part II, line 55.02 has been added to address the proper reimbursement calculation and to track the
adjustment amount associated with the cost reporting period. We revised the instructions for line 17 to
include the statement: Do not report adjustments resulting from permanent or other adjustments to the
TEFRA target amount per discharge on this line.
WORKSHEET E-5
Comment - A commenter requested that the CMS Pub. 100-04, Chapter 3, §20.1.2.5, be updated to
reflect the requirements for the outlier reconciliation amounts at tentative settlement, since the current
instruction manual only references outlier requirements at final settlement. The commenter believed
updating the manual would ensure contractors and providers understand the requirement.
Response - We removed the references to CMS Pub. 100-04, chapter 3, §§20.1.2.5, from the Worksheet
E-5 instructions as the manual section applies to final settlement, not tentative settlement.
Comment - A commenter supporting the addition of Worksheet E-5 requested that CMS apply the outlier
reconciliation adjustment at the time of cost report tentative settlement to eliminate interest accruals on
outlier reconciliations.
Response - We thank the commenter for their support of Worksheet E-5 and their recommendation. We
may consider the recommendation for future rulemaking.
Comment - A commenter urged CMS to make this worksheet available for use by providers.
Response - The contractor completes Worksheet E-5 to report outlier reconciliation amounts during the
cost report tentative settlement if the hospital meets the criteria based on information available at
tentative settlement. We continue to require that contractors complete the worksheet.
EXHIBIT 2A
Comment - We received numerous comments on the proposed Exhibit 2A. One commenter suggested
revising the Exhibit 2A instructions to permit modifying the prescribed format of the template and allow
entry of alternate data. Another commenter stated that column 12 of the proposed Exhibit 2A is
unnecessary and suggested that CMS remove it from the exhibit. The commenter suggested that,
alternately, CMS modify the instructions to clarify what is reported in column 12. Several commenters
suggested column 16 (Collection Effort Cease Date) of the proposed Exhibit 2A is unnecessary and

12

suggested that CMS remove it from the exhibit. Additional commenters requested CMS modify
instructions to clarify that the dates reported in columns 14, 15, 16, and/or 17 can be the same date. One
commenter requested column 19 (FYE date of recoveries), be optional since only providers that seek to
limit recoveries would complete this field. A commenter suggested consolidating columns 20 and 21
(Medicare Deductibles and Medicare Coinsurance, respectively). A commenter suggested deleting
columns 22 and 23 (Current Year Payments Received Amount and Source, respectively) to reduce
providers' reporting burden. Commenters requested CMS combine, modify, and/or eliminate columns
from the proposed Exhibit 2A to streamline the exhibit and reduce burden. Commenters suggested
removing columns 10, 11, 12, 14, 15a, 16, 17, 18, 19, 22, and 23; combining columns 20 and 21; and
revising instructions. Another commenter suggested removing columns with HIPPA-related data, i.e.,
columns 1, 2, 3, and 7, and instructing providers to submit the information to the MAC during review. One
commenter suggested modifying the instructions for column 23 to permit the entry of multiple payment
sources.
Response: The proposed Exhibit 2A is a compilation of data elements that are currently reported on the
Exhibit 2, with the addition of data elements that are historically requested by MACs in order to facilitate
review of bad debts claimed in the Medicare cost report. The Exhibit 2A supporting documentation is
often requested by the contractor, and must be submitted by the provider in order to assure proper
payment, not delay payments, or prolong audits. In the 2019 IPPS final rule 83 FR 41681 (August 17,
2018) commenters suggested that a standardized format be established and required for the submission
of the bad debt listing that corresponds to the bad debt amounts claimed in the provider’s cost report. We
developed the Exhibit 2A using internal and external stakeholders, including Medicare contractors and
hospital providers. We believe that providing this added information on the bad debt listing will reduce the
numerous data requests through the review process and will expedite the cost report settlement process.
Exhibit 2A, columns 1, 2, 3, 4, 6, 7, 8, 9, 13, 16, 20, and 21, are columns that exist on the current Exhibit
2, and have been longstanding data requests. Column 5 was added as an additional source to identify a
patients account. Columns 1 through 7, some of which a commenter suggested removing from Exhibit
2A, collect data identifying the Medicare beneficiary and the specific dates of service for whom the
provider claims Medicare bad debt. In response to public comment we reorganized columns 1 through 7
so that all of the proposed exhibits collect this patient related information consistently. The data collected
in columns 1 through 7 is needed to support Medicare bad debts claimed on the Medicare cost report.
Column 10, was an added field to collect the Medicaid remittance advice date for dually eligible
beneficiaries, if applicable; column 11, was an added field to collect the secondary payer remittance
advice received date, if applicable; and column 12 of the proposed Exhibit 2A, while some commenters
indicated that it was unnecessary, collects the deductible and coinsurance amounts for which a Medicare
beneficiary that is dually eligible may have a state cost sharing responsibility. We clarified the instructions
for column 12 to explain when this column is completed. Columns 12 is a subset of the amounts reported
in columns 20 and 21, and the amount reported may be used to reduce the bad debt for a dually eligible
beneficiary that has a state cost sharing liability. Several commenters noted that columns 14, 15, 16 and
17 were not necessary and that the same date may be reported in those columns. We agree with the
commenters that the same date may be reported in these columns; however, it is important to provider
the various columns in situation where they are not the same date. Providers have various write off dates
for instance column 14 collects the date the Medicare beneficiary’s liability was written off of the accounts
receivable (A/R) in the provider’s financial accounting system. This account may have been written off for
financial purposes but for Medicare purposes collection effort continues until the debt met Medicare
guidelines. Column 15 collects the date a collection agency ceases efforts and is used to determine the
year in which the bad debt is eligible for reimbursement. If accounts are not sent to a collection agency
this column would be blank. Column 16 is the date that all collection efforts ceased and column 17 is the
date a beneficiary’s deductible and coinsurance amounts are written off as Medicare bad debt. We
modified the proposed instructions for columns 14, 15, 16, and 17, to clarify that the dates may be the
same in each of those columns. While the dates may be the same, if they are different the date in column
17 must be greater than the dates in columns 14 through 16. Column 18 collects the amount of any
recoveries to assist in identifying amounts that are used to reduce allowable bad debt and column 19
identifies the cost reporting period associated with the recovery amounts reported in column 18. This
column was made option at commenters request, but in order to limit the amount of recoveries must be
completed. In response to a commenter’s request to combined columns 20 and 21 into one column, we

13

will continue to collect this data similar to columns 8 and 9 of Exhibit 2. Deductible and coinsurance
amounts are reported separately on a provider’s remittance advice and in their PS&R. There is no added
burden to report these amounts separate, it provides for better comparison to the separate amounts that
appear on the provider’s PS&R, and it eliminates the need for adding the amounts together. Column 22
collects the payment amounts such as amounts received from a secondary payor, an individual or an
estate, that are associated with the deductible and coinsurance amounts reported in columns 20 and 21.
In column 23, some commenters suggested removing and one commenter requested clarifying the
instructions, we propose to collect the payment source of the amounts reported in column 22. A payment
source may payors such as a secondary payor, an individual, an estate or multiple payors. The
information is needed to ensure all payments are applied correctly prior to a bad debt determination and
more than one source may be listed.
EXHIBIT 3A
Comment - We received comments on the burden for Exhibit 3A and comments suggesting that we
streamline the listing by consolidating the reporting of Worksheet S-2 data to eliminate the requirement to
submit multiple listings; that we omit select data elements; that we clarify reporting State eligibility codes,
and reporting Medicaid days and identification numbers for newborns; that we require hospitals to report
the method used to determine the days reported on the listing; that we allow a hospital to update the
listing after submission; and that we allow hospitals to enter additional data elements.
Response - Numerous commenters stated that the proposed Exhibit 3A listing is burdensome. The
proposed Exhibit 3A listing provides the standardized format for a DSH eligible hospital to list the
Medicaid eligible days that correspond to the Medicaid eligible days claimed in the hospital’s cost report.
We developed the listing as a result of discussion in the FY 2019 IPPS Final Rule, 83 FR 41681 and
41684 (August 17, 2018), where we agreed to develop standard formats for supporting documentation
that correspond to amounts claimed in the provider’s cost report and required for an acceptable cost
report submission. As we stated in the FY 2019 IPPS Final Rule, 83 FR 41762 (August 17, 2018),
providers are required under §§ 413.20 and 413.24 to maintain data that substantiates their costs.
Requiring a provider to submit, as a supporting document with its cost report, a listing of the provider’s
Medicaid eligible days that corresponds to the Medicaid eligible days claimed in the DSH eligible
hospital’s cost report is consistent with the recordkeeping and cost reporting requirements of §§ 413.20
and 413.24. This listing does not require hospitals claiming a DSH payment adjustment to collect
additional data. Hospitals claiming a DSH payment adjustment already collect the data in order to report
the hospital’s Medicaid eligible days in the hospital’s cost report. Because the existing burden estimate
for a DSH eligible hospital’s cost report already reflects the requirement that these hospitals collect,
maintain, and submit this data when requested, requiring a DSH eligible hospital to submit this supporting
document along with the cost report, and to ensure the supporting documentation corresponds to the
days reported on the Worksheet S-2, Part I, line 24 or 25, in order to have an acceptable cost report
submission imposes no additional burden. Some commenters stated that reporting Medicare eligibility
information in the listing is unnecessary and burdensome because no Medicare days are included in the
days reported on Worksheet S-2, Part I, lines 24 or 25. We agree with the commenters that Worksheet
S-2, Part I, lines 24 or 25, should include no days for patients eligible for Medicare Part A. Therefore, the
columns for Medicare eligibility should be blank and instances where a hospital enters Medicare eligibility
should be rare; therefore, the columns impose no additional burden.
Several commenters suggested that we streamline the proposed listing to reduce the number of listings
submitted. We agree and revised the listing by adding the column titled “WS S-2 COL #” to identify, for
each listing entry, the Worksheet S-2, Part I, column number to which the days correspond, thereby
eliminating the need for a separate listing for each column and reducing the number of listings to one for
Worksheet S-2, Part I, line 24, and one for Worksheet S-2, Part I, line 25.
Some commenters suggested that we revise the listing so that columns common to the Exhibits 2A, 3A,
3B, and 3C listings, appear in the same order on each listing and one commenter suggested that we
combine the “Last Name” and “First Name” columns. We agree with the commenters’ suggestion to align
common columns among the listings and revised the format of the proposed listing to present the first five
columns in the same order and with the same column titles as presented on the proposed Exhibits 2A,

14

3B, and 3C listings; therefore, we could not accommodate the commenter’s suggestion that we combine
the “Last Name” and “First Name” columns.
Some commenters suggested that we omit select data elements, we eliminated the requirement to report
each patient’s date of birth and gender. All remaining data elements on the proposed listing are required
to validate the amounts reported on the cost report. We could not accommodate requests that we
remove the requirements to report state eligibility codes, Medicare eligibility information, or primary and
secondary insurer or other payer names, as these are required to determine whether the days reported
on the listing were Medicaid eligible days.
Some commenters suggested that we clarify reporting State eligibility codes. We revised the proposed
instructions to state that the provider enters the State eligibility code if available. Furthermore, we revised
the proposed instructions so that a provider reporting multiple State eligibility codes reports one code in
the State Eligibility Code column and additional codes in the Comments column.
Numerous commenters requested clarification for reporting Medicaid days of newborns. We revised the
listing to add the column “Newborn Baby Days” with instructions for reporting the number of newborn
baby days for babies born to Medicaid eligible mothers. Additionally, we revised the instructions for the
“Eligible Days” column for reporting the number of days for the newborn baby if the Medicaid eligible
mother is discharged and the newborn baby remains in the hospital.
Numerous commenters requested clarification for reporting Medicaid identification numbers for newborns.
We revised the instructions for the “Medicaid ID No” column of the proposed listing to be consistent with
the Children’s Hospital Insurance Program Reauthorization Act 2009 (Pub. L. 111-3) section (e), which
authorizes the use of the child health or medical assistance eligibility identification number of the mother
to also serve as the identification number of the child.
One commenter requested that we require hospitals to report the method used to determine the days
reported on the listing. We note that Worksheet S-2, Part I, line 23, requires the hospital to identify the
method for determining the days on Worksheet S-2, Part I, lines 24 and 25. The listing must correspond
to the days reported on Worksheet S-2, Part I, lines 24 or 25, the days for both Worksheet S-2, Part I, and
the listing must be determined on the same basis. Requiring a hospital to report the method on the listing
unnecessarily duplicates the information already reported on the cost report. Therefore, we did not revise
the proposed Exhibit 3A to include reporting the method used to determine the days reported on the
listing.
A few commenters requested the ability to update the listing after cost report submission. We note that in
the 2019 IPPS Final Rule, 83 FR 41683, we stated that the hospital is required to report on its cost report
the Medicaid eligible days known by the hospital at the time of the cost report submission. If the Medicaid
eligible days change once the hospital receives the documentation from the State, the hospital may
amend its cost report. The contractor must accept the amended cost report with the amended listing of
the Medicaid eligible days that substantiates the revised Medicaid eligible days reported in the amended
cost report if the amended cost report and amended listing are submitted within 12 months after the
hospital’s cost report is due.
A few commenters suggested that we expand the listing to allow reporting additional data elements such
as MCO-specific identification numbers in place of Medicaid numbers, date of birth and social security
numbers. We note that the proposed listing already provides the “Comment” column with instructions to
enter optional comments or additional information as needed and clarify that multiple entries are
permitted. Additionally, we revised the instructions for the “Comment” column to exclude a patient’s date
of birth or social security number in order to decrease patient’s vulnerability to identity theft.
Comment - A commenter requested that CMS clarify that sole community hospitals (SCHs) and Medicare
dependent hospitals (MDHs) are excluded from the requirement to submit the proposed Exhibit 3A. The
commenter claimed SCHs and MDHs are paid a hospital-specific rate and Medicaid eligible days have no
impact on their reimbursement. The commenter noted that CMS clarified such in the past.

15

Response - As we stated in the 2019 IPPS Final Rule (83 FR 41683) published on August 17, 2018, the
requirement to submit a listing of the Medicaid eligible days that corresponds to the Medicaid eligible days
reported in the hospital’s cost report is not applicable to SCHs that are paid under the hospital-specific
rate and are not eligible to receive DSH payment adjustments. However, because MDHs are eligible to
receive DSH payment adjustments, this proposal applies to them if they are claiming a DSH payment
adjustment. Similarly, a SCH that is not paid under its hospital-specific rate and is eligible to receive a
DSH payment adjustment must submit a listing of the Medicaid eligible days that corresponds to the
Medicaid eligible days reported in the hospital’s cost report if it is claiming a DSH payment adjustment.”
To clarify that hospitals claiming a DSH payment adjustment must complete the proposed Exhibit 3A, we
modified the proposed instructions as follows: For hospitals claiming a DSH payment adjustment and
reporting Medicaid days on Worksheet S 2, Part I, line 24, or line 25, for a cost reporting period beginning
on or after October 1, 2022, complete Exhibit 3A to support the Medicaid days reported.
EXHIBIT 3B
Comment: We received numerous comments on the proposed Exhibit 3B Charity Care Listing, a listing
that supports charity care amounts a hospital reports on the Worksheet S-10. Commenters described the
listing as complex, attempting to capture a significant amount of extraneous information, and significantly
increasing administrative burden. Commenters suggested revisions, deletions, and additions, with many
of the suggestions designed to more closely match the proposed charity care listing currently required for
Worksheet S-10 audits. Some commenters recommended continuing to require that hospitals complete
the currently required listing rather than the proposed charity care listing. Other commenters requested
that CMS mandate that auditors use this proposed listing as the audit document for charity care. Several
commenters requested that CMS allow hospitals to update the listing to reflect subsequent changes in
patient’s insurance status prior to an audit. Another commenter suggested that CMS clarify that only
hospitals that reported DSH on Worksheet E, Part A, line 34, need complete the listing.
Some commenters suggested that CMS modify the proposed Exhibit 3B listing, as well as the proposed
Exhibits 2A, 3A, and 3C listings, to align common data elements for ease of completion and data
extraction from patient accounting systems while other commenters suggested that CMS permit hospitals
to modify the listing. Commenters suggested that CMS add a column to identify the patient’s insurance
status so that a hospital submits a single listing of all patients, with validations to ensure insured and
uninsured amounts correspond to amounts reported on Worksheet S-10, line 20. A commenter
recommended CMS specify that hospitals enter all dates using the MM/DD/YYYY format. A commenter
expressed concern about size constraints when submitting large electronic files with charity care and
uninsured discount data to contractors.
Commenters expressed concern about transmitting protected health information; some commenters
suggested limiting the listing to the patient’s name, dates of service, patient account number, payor name
or type, Medicare beneficiary identifier (MBI), Medicaid number or equivalent, total charity care amount,
write off date, and payments received, while other commenters suggested that CMS expand the listing to
include data elements such as a patient’s social security number, date of birth, payment transaction code,
secondary payor plan, patient gender, revenue code and total charges for revenue code for claim, service
indicator (inpatient or outpatient), and total third party payments. A commenter suggested that CMS
require an attestation that the hospital includes no professional fees in the patient accounting system
utilized to populate the listing.
Commenters suggested clarifying or removing the “Uninsured/Insured Not Covered,” “Name of Insurer,”
“Medicaid Number,” “Charity Care Determination - Approved,” “Charity Care Determination - Policy Under
Which Approved,” “Gross Charges,” and “Deductible/Coinsurance/Copayment,” “Non-Covered Charges
Covered by Medicaid,” “Physician/Professional Charges,” “Non-Covered Charges,” “Uninsured Discount
Amounts,” “Contractual Allowance,” “Courtesy Discount,” “Gross Charges Net of Reductions,” “Allowable
Charity Care Charges,” “Charity Care Approved Ratio,” “Write Off Date,” “Patient Responsibility Charges,”
and “Payments Received” columns as well as the duplicate “Uninsured Discount” column. One
commenter suggested renaming the “Approved Charity Care” column as “Approved Charity Care and
Uninsured Discounts.”

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Response: The proposed Exhibit 3B listing provides the standardized format for a DSH eligible hospital
to list the charity care and uninsured discount amounts that support the charity care amounts claimed on
the hospital’s cost report and replaces the currently required listing of charity care and uninsured discount
data. Significant efforts have been made to limit required data elements yet provide adequate support for
charity care charges and bad debts claimed in the hospitals uncompensated care cost calculation. The
purpose of the Exhibits is to create a nationwide standard template for consistent use by all hospitals.
Currently, exhibits referenced by commenters have slight variations and this published requirement is
intended to eliminate these slight differences. This will create consistency in Charity Care and Total
Hospital Bad Debt data utilized in the distribution of Uncompensated Care Payments and this is
something all stakeholders have requested. We developed the listing as a result of discussion in the FY
2019 IPPS Final Rule, 83 FR 41681 and 41684 (August 17, 2018), where we agreed to develop standard
formats for supporting documentation that correspond to amounts claimed in the hospital’s cost report
and required for an acceptable cost report submission. As we stated in the FY 2019 IPPS Final Rule, 83
FR 41762, providers are required under §§ 413.20 and 413.24 to maintain data that substantiates their
costs. Requiring a provider to submit, as a supporting document with its cost report, a listing of the
provider’s charity care and uninsured discount amounts that correspond to the amounts claimed in a
hospital’s cost report is consistent with the recordkeeping and cost reporting requirements of §§ 413.20
and 413.24. Hospitals already collect the data in order to report the hospital’s charity care and uninsured
discounts data in the cost report. Because the existing burden estimate for a DSH eligible hospital’s cost
report already reflects the requirement that these hospitals collect, maintain, and submit this data when
requested, requiring a DSH eligible hospital to submit this supporting document along with the cost report,
and to ensure the supporting documentation corresponds to the amounts reported on the hospital’s cost
report, in order to have an acceptable cost report submission imposes no additional burden.
To streamline the listing, we rearranged, redefined, revised, and removed proposed columns. Consistent
with revisions to the proposed listings in Exhibits 2A, 3A, and 3C, we rearranged columns so that those
columns common to all the listings, i.e., the Last Name, First Name, Date of Service-From, Date of
Service-To, and Patient Account Number, appear as the first five columns and in the same order on each
listing. To maintain the continuity of the common columns of the schedules, we did not accommodate
suggestions to allow hospitals to modify the listing. We revised the instructions for the listing to state that,
a SCH (Worksheet S-2, Part I, line 35, is greater than zero) where Worksheet E, Part A, line 48, is greater
than line 47, does not complete a listing. We revised the listing to encompass both uninsured and
insured patients on one listing, thereby eliminating the need for a hospital to submit separate listings, and
we added validations to ensure uninsured and insured amounts correspond to amounts reported on
Worksheet S-10, line 20. We revised the instructions to specify reporting dates in the MM/DD/YYYY
format.
In response to requests that CMS permit updates to the listing reflecting changes subsequent to cost
report submission but prior to audit, we note that the hospital is required to report on its cost report the
charity care and uninsured discounts data known by the hospital at the time of the cost report submission.
We anticipate few instances when the data would change. However, if the data changes, the hospital
may request to submit a revised listing with an amended cost report in accordance with 413.24(f). In
response to the concern about contractors’ ability to accept large listings electronically, we note that
Medicare Cost Report e-Filing System User Manual provides guidance on file size limits and recommends
that any individual file or total submission exceeding the limits specified be submitted via traditional
methods (mail or hand delivery).
To refrain from collecting extraneous information, we removed the “Uninsured/Insured Not Covered,”
“Medicare Beneficiary Identifier,” “Medicaid Number,” “Charity Care Determination - Approved,” “Charity
Care Determination - Policy Under Which Approved,” “Gross Charges,” “Courtesy Discount,” “Gross
Charges Net of Reductions,” “Allowable Charity Care Charges,” “Charity Care Approved Ratio,” and
“Patient Responsibility Charges” columns as well as the duplicate “Uninsured Discounts” column.
We did not revise the “Name of Insurer” column to report the type of payor because the payor name
provides a greater level of specificity; instead, to accommodate the request that we clarify reporting
multiple payors, we redefined the name of the column as “Primary Payor” and added the “Secondary

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Payor” column to report the names of the primary and secondary payers, respectively. We redefined the
“Non-Covered Charges Covered by Medicaid” as “Charity Care Non-Covered Charges” and revised the
instructions to include charges for non-covered services provided to patients eligible for Medicaid or other
indigent care programs, charges for non-covered days exceeding a length-of-stay limit for patients
covered by Medicaid or other indigent care programs, and the portion of charges where the patient has
exhausted their benefits.
We added the “Total Charges for Claim” column to report charges for both uninsured and insured patients
and to exclude physician/professional charges; we also revised the instructions for
“Physician/Professional Charges” to report any physician/professional charges included in the “Total
Charges for Claim” column. Therefore, we did not accommodate the suggestion to require an attestation
that the listing includes no physician/professional charges.
We revised the instructions for the “Uninsured Discount” column to clarify that the column does not apply
to insured patients. We revised the title for the “Contractual Allowance” column to be “Insured
Contractual Allowance Amount” and revised the instructions to clarify that hospitals report the sum of
contractual allowance amounts for primary and secondary payers, if applicable. We did not add
instructions for reporting sequestration adjustments as commenters requested because those amounts
are not includable on Worksheet S-10. We did not revise the instructions to remove the phrase “not
medically necessary” in the “Non-Covered Charges” column as commenters requested because those
charges must be considered when determining the amounts reported in columns 17, 18, and 19.
We redefined the “Total Allowable Charity Care Amount” column as “Amounts Written Off to Charity Care
and Uninsured Discounts” and revised the instructions to calculate the amount as the sum of uninsured
discounts, charity care non-covered charges, and other charity care charges. We revised the instructions
for the “Write Off Date” column to report multiple write-off dates within the cost reporting period of the
Worksheet S-10 that the listing supports by entering each date as MM/DD/YYYY separated by a semicolon. We redefined the “Payments Received” column as “Total Patient Payments” and revised the
instructions to specify that the hospital reports payments received prior to the determination of amounts
for charity care. We did not add a column to report payments received subsequent to the charity care
write off as commenters requested because those amounts are reported separately on Worksheet S-10,
line 22 and must not be netted against amounts reported on Worksheet S-10, line 20. We added the
“Other Charity Care Charges” column to report any other allowable charges written off as charity care
pursuant to the provider’s written charity care policy or FAP and not reported as uninsured discount
amounts or as charity care non-covered charges.
We did not add columns suggested by commenters to report a patient’s social security number, date of
birth, and gender, in order to decrease the vulnerability of identity theft; nor did we add columns to report
whether services were inpatient or outpatient or to collect payment transaction codes as these columns
would impose unnecessary burden. To avoid unnecessary burden, we did not add a column to report
revenue codes and total charges by revenue code for each patient; contractors can request revenue code
detail as needed when reviewing the listing. Neither did we accommodate the suggestion to require an
attestation that the listing includes no physician/professional charges; we require the
physician/professional charges data to validate that these charges are excluded from charity care and
uninsured discounts charges. We did not accommodate the request to remove the
“Deductible/Coinsurance/Copayment” column; we require this data to validate amounts reported on
Worksheet S-10, line 20.
EXHIBIT 3C
Comment - Some commenters stated that patients often submit payments but do not identify the account
or date of service to which the payment applies. In these circumstances, commenters recommended that
providers complete the proposed Exhibit 3C, column 12, by applying any payments received to the oldest
date of service first, as recommended in the Health Care Financial Management Association’s Best
Practices for Resolution of Medical Accounts Receivable, Best Practices for Resolution of Medical
Accounts (hfma.org).

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Response - In response to comments, the purpose of column 12 is to collect revenues received from
accounts previously written off as a bad debt. The amount reported in this column must be associated
with a bad debt write off amount that occurred in a previous or current cost reporting period. If there are
multiple dates of service for a patient account and those accounts were written off to bad debt, if the
payer did not identify the account or date of service to which the payment applies, apply the payment to
the oldest date of service first.
Comment - A commenter requested that the instructions for the proposed Exhibit 3C, column 14, be
clarified to specify that the amounts written off to charity care can relate to any year, and that it does not
relate solely to the years S-10 reporting. Another commenter requested confirmation that column 14
includes both charity care and uninsured discounts as reported on Worksheet S-10, line 20.
Response - In response to this comment we are clarifying that the amounts reported in column 14,
pertain to the charges reported in column 10. A provider may determine a portion of patient charges are
eligible for charity care or an uninsured discount and write them off in one year then subsequently
determine the patient’s liability to be uncollectible and the provider writes off the remainder of charges to
bad debt. The timing of the two write-offs may not be in the same cost reporting period; therefore, the
amount reported in this column is relative to the charges reported in column 10, and the dates of service
reported in columns 3 and 4, regardless of charity care write-off date. The charges reported in this
column are also used in determining the amount of eligible bad debt reported in column 17.
Comment - Commenters requested that CMS clarify the instructions for the proposed Exhibit 3C, column
15, by providing examples of other amounts a hospital would enter in this column. Commenters
specifically asked whether hospitals could include discounts to self-pay patients (e.g., uninsured discount)
regardless of whether the self-pay patients qualified for charity care or financial assistance discounts.
Response - In response to comments, we modified the instructions for the proposed Exhibit 3C to clarify
that column 15 includes amounts that represent discounts to self-pay patients (e.g., uninsured discount)
regardless of whether the patients qualified for charity care or financial assistance discounts. The amount
reported in this column is used in determining the amount of eligible bad debt reported in column 17.
Comment - Commenters requested that the proposed Exhibit 3C listing instructions define the accounts
receivable write-off date in column 16 not as the date that all collections activities cease but as the date
the account was written off the hospital’s financial accounting system (and financial statements).
Response - The accounts receivable write-off date for the proposed Exhibit 3C, column 16, is the date
that the provider writes off the account in the hospital’s financial accounting system (and financial
statements) following the collections pursuit activity.
Comment - Another commenter suggested that the Medicare bad debt requirement to write off bad debt
to a contra revenue account not be applied to the proposed Exhibit 3C listing.
Response - Hospitals must follow the Financial Accounting Standards Board’s (FASB) Accounting
Standards Update (ASU) 2014–09, Revenue from Contracts with Customers (Topic 606), (hereinafter
“ASU Topic 606”), when accounting for total bad debts and completing this listing. As we stated in the 85
FR 59004 (September 18, 2020), the ASU Topic 606, changed the national accounting standard for
revenue recognition of patient-related bad debts and uncollectible accounts. Under the ASU Topic 606,
an amount representing a bad debt would generally no longer be reported separately as an operating
expense in the provider’s financial statements, but would generally be treated as an ‘‘implicit price
concession,” and included as a reduction in patient revenue. Additionally, under the ASU Topic 606
standards, bad debts treated as “implicit price concessions” are now considered to be “reductions in
patient revenue” instead of “uncollectible accounts receivable and notes receivable” and the provider
should have the usual “accounting recordation for the reductions in revenue.”
Comment - Some commenters suggested that CMS revise the instructions for column 17 to report,
instead of calculating, the patient bad debt write-off amount, which will account for bad debt recoveries,
Medicare crossover claims for dual eligible beneficiaries, and discrepancies in data collected in columns
12 through 15, improving the accuracy of amounts reported in column 17.

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Response - We appreciate the comment; this instruction is intended to identify a portion related to
professional fees if it applies and should be considered. We modified the cost report instructions for
columns 12 and 13 to identify recoveries and payments from third party payors such as Medicare
crossover claims paid for dual eligible beneficiaries.
Comment - Commenters suggested that reporting primary and secondary payer information be optional
as some hospitals may not have this information for older bad debt accounts.
Response - As we stated in the FY 2019 IPPS Final Rule, 83 FR 41681 and 41684 (August 17, 2018),
where we agreed to develop standard formats for supporting documentation that correspond to amounts
claimed in the hospital’s cost report, providers are required under §§ 413.20 and 413.24 to maintain data
that substantiates their costs We revised the instructions for the listing to state that the hospital reports
the primary and/or secondary payor information for a claim with a date of service before January 1, 2021,
if available.
Comment - A commenter requested that CMS modify the instructions to recognize implicit price
concessions.
Response - We modified the listing instructions to recognize implicit price concessions as follows: For
cost reporting periods beginning on or after October 1, 2022, IPPS hospitals eligible for DSH and UCC
must complete an Exhibit 3C listing to support the amount of total bad debt, or implicit price concessions,
reported on Worksheet S-10, line 26.
Comment - Some commenters requested that CMS clarify that the proposed Exhibit 3C is an optional
submission or if failure to submit the Exhibit 3C will result in the rejection of the cost report.
Response - The proposed Exhibit 3C listing is not required for an acceptable cost report submission;
however, a hospital that receives uncompensated care payments must support the total hospital bad
debts claimed on Worksheet S-10. Submission of Exhibit 3C will help reduce requests from Medicare
auditors asking the hospital for supporting documentation when reviewing the Worksheet S-10.
Comment - One commenter suggested that the data requested on the listing be the same as the data for
the Worksheet S-10 audits while another commenter suggested that CMS abandon the proposed listing
and use the Worksheet S-10 bad debt schedules instead.
Response - The Exhibit 3C listing is optional at cost report submission, unlike the Exhibit 3A and Exhibit
3B listings which are required for an acceptable cost report submission, and replaces the listing currently
used for Worksheet S-10 audits. Currently, providers submit data in non-standard formats. The proposed
Exhibit 3C listing provides the standardized format for a DSH eligible hospital to list the total bad debts
that support the amounts claimed on the hospital’s cost report. We developed the listing as a result of
discussion in the FY 2019 IPPS Final Rule, 83 FR 41681 and 41684 (August 17, 2018), where we agreed
to develop standard formats for supporting documentation that correspond to the Medicaid eligible days
for a DSH-eligible hospital and the charity care and uninsured discount amounts claimed in the hospital’s
cost report. The listing represents significant effort to limit required data elements yet provide adequate
support for total bad debt amounts claimed in a hospital’s uncompensated care cost calculation. The
proposed listing calculates the total bad debt write off amounts, something not calculated in the
Worksheet S-10 audit bad debt schedules, providing a means to validate the total bad debts reported on
Worksheet S-10, line 26.
Comment - A commenter suggested that additional data fields be added such as social security number,
date of birth, revenue code and total charges for revenue code for the claim. However, the revenue code
could be eliminated if the provider could attest that there are no professional fees included.
Response - We did not add columns to report a patient’s social security number, date of birth, in order to
decrease the vulnerability of identity theft; nor did we add a column to report revenue codes and total
charges by revenue code for each patient as contractors can request revenue code detail as needed
when reviewing the listing. Neither did we accommodate the suggestion to require an attestation that the

20

listing includes no physician/professional charges; we require the physician/professional charges data to
determine the total bad debt amount.
Comment - A commenter requested that CMS format the proposed listing to organize data elements in
common with the proposed Exhibit 3B in the same order for ease of completion. The commenter also
suggested consolidating the proposed primary and secondary payor columns to report the patient’s
insurance status.
Response - Consistent with revisions to the proposed listings in Exhibits 2A, 3A, and 3B, we rearranged
columns so that those columns common to all the listings, i.e., the Last Name, First Name, Date of
Service-From, Date of Service-To, and Patient Account Number, appear as the first five columns and in
the same order on each listing. We did not combine the primary and secondary payor columns to report
the patient’s insurance status as the commenter suggested; instead, we clarified the instructions for the
insurance column for reporting uninsured and insured status.
Comment - A commenter suggested that CMS require date entries in the MM/DD/YYY format on Exhibit
3C.
Response - The instructions for the proposed Exhibit 3C already describe the required format for
entering dates as MM/DD/YYYY.
EXHIBITS 3A, 3B AND 3C
Comment - Commenters suggested that CMS specify that hospitals submit the proposed Exhibits 3A, 3B,
and 3C, in the Excel format for ease of data verification and to avoid duplication of data submissions.
Response - In response to comment, we recommend hospitals consult their MAC on the appropriate
format for submitting supporting documentation.
BURDEN
Comment - Commenters suggested minimizing burden by limiting Medicare cost report changes to only
those necessary and appropriate for efficient administration of the Medicare program. Commenters cited
the proposed Worksheet S 12 and the proposed Exhibits 2A, 3A, 3B, and 3C, as imposing significant
increased burden.
Response - We added exhibits for DSH, total bad debt and charity care pursuant to the amendments to
42 CFR § 413.24(f)(5) to allow providers a method to streamline submission of data required for an
acceptable cost report submission. The data required are data the provider already has available to them
for preparation of their cost reports. Facilitating providers’ acceptable cost report submissions will save
time and resources for providers and help ensure the cost report submission includes all data necessary
for the eventual review and cost report settlement process.
We removed the proposed Worksheet S-12 from Form CMS 2552 10.

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