CMS-10839.Instructions for Worksheet S2

04-23

FORM CMS-2552-10

4004.

4004.1

WORKSHEET S-2 - HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX
IDENTIFICATION DATA

This worksheet consists of two parts:
Part I - Hospital and Hospital Health Care Complex Identification Data
Part II - Hospital and Hospital Health Care Complex Reimbursement Questionnaire
4004.1 Part I - Hospital and Hospital Health Care Complex Identification Data.--The
information required on this worksheet is needed to properly identify the provider. The responses
to all lines are Yes or No unless otherwise indicated.
Line descriptions
Lines 1 and 2--Enter the street address, post office box (if applicable), the city, state, ZIP code,
and county of the hospital.
Lines 3 through 18--Enter on the appropriate lines and columns indicated the component names,
CMS certification numbers (CCN), core based statistical area (CBSA) codes of the physical
location of the provider’s primary operations (non-CBSA (rural) codes are assembled by placing
the digits “999” in front of the two-digit state code, e.g., for the State of Maryland the non-CBSA
code is 99921), provider type, and certification dates of the hospital and its various components,
if any. Indicate for each health care program (titles V, XVIII, or XIX), the payment system
applicable to the hospital and its various components by entering P, T, O, or N in the appropriate
column to designate PPS, TEFRA, OTHER, or NOT APPLICABLE, respectively. The “PPS”
payment systems include the Inpatient Prospective Payment System (IPPS), the Inpatient
Psychiatric Facility Prospective Payment System (IPF PPS), the Long Term Care Hospital
Prospective Payment System (LTCH PPS) and the Inpatient Rehabilitation Facility Prospective
Payment System (IRF PPS), and the Rural Emergency Hospital (REH) Outpatient Prospective
Payment System (OPPS). The “TEFRA” payment system includes long term care hospitals
(LTCH) classified as extended neoplastic disease care hospitals (previously referred to as
“subclause (II)” LTCHs), children’s hospitals, cancer hospitals, Religious Non-Medical Health
Care Institutions (RNHCIs), and hospitals located outside the 50 States, the District of Columbia,
and Puerto Rico (i.e., hospitals located in the U.S. Virgin Islands, Guam, the Northern Mariana
Islands, and American Samoa). The “OTHER” payment system includes cost reimbursed
hospitals such as critical access hospitals (CAHs) and new TEFRA hospitals exempt from the rate
of increase limits.
Column 4--Indicate, as applicable, the number listed below which best corresponds with the type
of services provided.
1
2
3
4
5
6

= General Short Term (includes CAHs)
= General Long Term
= Cancer
= Psychiatric
= Rehabilitation
= Religious Non-Medical Health Care Institution

7 = Children
8 = Reserved for future use
9 = Other
10 = Extended Neoplastic Disease Care
11 = Indian Health Service
12 = Rural Emergency Hospital

If your hospital services various types of patients, indicate “General - Short Term” or “General Long Term,” as appropriate.
NOTE: LTCHs are hospitals organized to provide long term treatment programs with average
lengths of stay greater than 25 days. Some hospitals may be certified as other than LTCHs, but
also have average lengths of stay greater than 25 days.
If your hospital cares for only a special type of patient (such as cancer patients), indicate the special
group served. If you are not one of the hospital types described in items 1 through 8 above,
indicate 9 for “Other.”
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Line 3--This is an institution which meets the requirements of §1861(e) or §1861(mm)(1) of
the Act and participates in the Medicare program or is a federally controlled institution approved
by CMS.
Line 4--The distinct part IPF is a portion of a hospital which has been issued a subprovider CCN
because it offers a clearly different type of service from the remainder of the hospital with such
services reimbursed under inpatient psychiatric PPS. Effective for cost reporting periods
beginning on or after October 1, 2019, an IPF is permitted to have an IRF subunit, however, an
IPF may not have an IPF subunit. (See 42 CFR 412.25(d).)
Line 5--The distinct part IRF is a portion of a hospital which has been issued a subprovider CCN
because it offers a clearly different type of service from the remainder of the hospital with such
services reimbursed under inpatient rehabilitation PPS. Effective for cost reporting periods
beginning on or after October 1, 2019, an IRF is permitted to have an IPF subunit, however, an
IRF may not have an IRF subunit. (See 42 CFR 412.25(d).)
Line 6--This is a portion of a general hospital defined as non-Medicare certified and not included
in lines 4 through 18, which offers a clearly different type of service from the remainder of the
hospital.
Line 7--Medicare swing-bed services are paid under the skilled nursing facility (SNF) PPS system
(indicate payment system as “P”). CAHs are reimbursed on a cost basis for swing-bed services
and should indicate “O” as the payment system. Rural hospitals with fewer than 100 beds may be
approved by CMS to use these beds interchangeably as hospital and skilled nursing facility beds
with payment based on the specific care provided, as authorized by §1883 of the Act. (See
CMS Pub. 15-1, chapter 22, §§2230-2230.6.)
Line 8--Swing-bed NF services are not payable under the Medicare program but are payable under
State Medicaid programs if included in the Medicaid State plan. Rural hospitals with fewer than
100 beds that have a Medicare swing-bed agreement approved by CMS and that are approved by
the State Medicaid agency to use these beds interchangeably as hospital and other nursing facility
beds, with payment based on the specific level of care provided, as authorized by §1913 of the Act.
Line 9--This is a distinct part SNF (including a distinct part SNF based in a REH) that has been
issued an SNF identification number and which meets the requirements of §1819 of the Act. A
hospital complex cannot contain more than one hospital-based SNF (includes a composite distinct
part) or hospital-based NF. (See 42 CFR 483.5(2)(v).)
Line 10--This is a distinct part nursing facility which has been issued a separate identification
number and which meets the requirements of §1905 of the Act. (See 42 CFR 441.400 for
standards for other nursing facilities, for other than facilities for individuals with intellectual
disabilities, and for facilities for individuals with intellectual disabilities.) If your State recognizes
only one level of care (i.e., skilled), do not complete any lines designated as NF and report all
activity on the SNF line for all programs. The NF line is used by facilities having two levels of
care (i.e., either 100 bed facility all certified for NF and partially certified for SNF or 50 beds
certified for SNF only and 50 beds certified for NF only). The contractor will reject a cost report
attempting to report more than one nursing facility.
If the facility operates an intermediate care facility for individuals with intellectual disabilities
(ICF/IID), subscript line 10 to 10.01 and enter the data on that line. Note: Subscripting is allowed
only for the purpose of reporting an ICF/IID.
Line 11--This is any other hospital-based long term care facility not listed above. The beds in this
unit are not certified for titles V, XVIII, or XIX. The data on this line cannot be used for Medicare
reimbursement. Treat this as a nonreimbursable cost center since it is not part of the Medicare
certified hospital.

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Line 12--This is a distinct part HHA that has been issued an HHA identification number and which
meets the requirements of §§1861(o) and 1891 of the Act. If you have more than one hospitalbased HHA, subscript this line, and report the required information for each HHA.
Line 13--This is a distinct entity that operates exclusively for the purpose of providing surgical
services to patients not requiring hospitalization and which meets the conditions for coverage in
42 CFR 416, Subpart B. The ambulatory surgery center (ASC) operated by a hospital must be a
separately identifiable entity which is physically, administratively, and financially independent
and distinct from other operations of the hospital. (See 42 CFR 416.30(f).) Under this restriction,
hospital outpatient departments providing ambulatory surgery (among other services) are not
eligible. (See 42 CFR 416.120(a).)
Line 14--This is a distinct part hospice and separately certified component of a hospital which
meets the requirements of §1861(dd) of the Act. No payment designation is required in columns 6,
7, and 8.
Lines 15 and 16--Enter the applicable information for hospital-based rural health clinics (RHCs)
on line 15 and for hospital-based federally qualified health centers (FQHCs) on line 16. These
lines are used by hospital-based RHCs and/or FQHCs which have been issued a CCN and meet
the requirements of §1861(aa) of the Act. If you have more than one hospital-based RHC, report
them on subscripts of line 15. If you have more than one hospital-based FQHC, report them on
subscripts of line 16. Report the required information in the appropriate column for each.
Hospital-based RHCs and FQHCs may elect to file a consolidated cost report pursuant to
CMS Pub. 100-02 (Medicare Claims Processing Manual), chapter 13, §80.2. Do not subscript
lines 15 or 16 to report RHCs or FQHCs affiliated with the consolidated group that elects to file
under the consolidated cost reporting method; report only the hospital-based primary RHC and/or
hospital-based primary FQHC of the consolidated group on lines 15 and/or 16, as applicable. A
new RHC/FQHC that begins after the start of a cost reporting period cannot be added to the
consolidated worksheets until the subsequent full cost reporting period. A written request to
consolidate the new RHC/FQHC must be submitted to the contractor in advance of the reporting
period and must be approved by the contractor prior to the start of the reporting period to be
reported as consolidated. In order to qualify for consolidated reporting, all RHCs/FQHCs in the
group must be owned, leased, or through any other device, controlled by one organization. Once
the election to use a consolidated cost report is made, the RHC/FQHC may not revert to individual
reporting without the prior approval of the contractor. See §§4010 and 4010.1 for further
instructions.
Line 17--This line is used by hospital-based community mental health centers (CMHCs).
Subscript this line as necessary to accommodate multiple CMHCs (lines 17.00 through 17.09).
Also subscript this line to accommodate CORFs (lines 17.10 through 17.19), OPTs (lines 17.20
through 17.29), OOTs (lines 17.30 through 17.39) and OSPs (line 17.40 through 17.49). (See
§4095, Exhibit 2, Table 4, Part III.)
Line 18--If this facility operates a renal dialysis facility (CCN XX-2300 through XX-2499), a renal
dialysis satellite (CCN XX-3500 through XX-3699), and/or a special purpose renal dialysis
facility (CCN XX-3700 through XX-3799), enter in column 2 the applicable CCN. Subscript this
line as applicable.
Line 19--For any component type not identified on lines 3 through 18, enter the required
information in the appropriate column.
Line 20--Enter the inclusive dates covered by this cost report.
In accordance with
42 CFR 413.24(f), you are required to submit periodic reports of your operations which generally
cover a consecutive 12-month period of your operations. (See CMS Pub. 15-2, chapter 1,
§§102.1-102.3, for situations where you may file a short period cost report.)

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Line 21--Indicate the type of control under which the hospital operates:
1 = Voluntary Nonprofit, Church
2 = Voluntary Nonprofit, Other
3 = Proprietary, Individual
4 = Proprietary, Corporation
5 = Proprietary, Partnership
6 = Proprietary, Other
7 = Governmental, Federal

8
9
10
11
12
13

= Governmental, City-County
= Governmental, County
= Governmental, State
= Governmental, Hospital District
= Governmental, City
= Governmental, Other

Line 22--Does your facility qualify and is it currently receiving payments for disproportionate
share (DSH) hospital adjustment, in accordance with 42 CFR 412.106? Enter in column 1, “Y”
for yes or “N” for no. Is this facility subject to the provisions of 42 CFR 412.106(c)(2)
(Pickle Amendment hospitals)? Enter in column 2, “Y” for yes or “N” for no.
Line 22.01--For cost reporting periods that overlap or begin on or after October 1, 2013, did this
hospital receive interim uncompensated care payments (UCPs), including supplemental UCPs as
described in 42 CFR 412.106(h)? Enter in column 1, “Y” for yes or “N” for no, for the portion of
the cost reporting period prior to October 1. Enter in column 2, “Y” for yes or “N” for no, for the
portion of the cost reporting period beginning on or after October 1. For cost reporting periods
that begin on October 1, enter “N” for no in column 1 and complete column 2; however, when the
cost reporting period begins on October 1 and overlaps October 1 of the subsequent year, complete
column 1 for the first period (October 1 through September 30) and complete column 2 for the
remainder of the cost reporting period.
Line 22.02--Is this a newly merged hospital that requires final UCPs to be determined at cost report
settlement? Enter in column 1, “Y” for yes or “N” for no, for the portion of the cost reporting
period prior to October 1. Enter in column 2, “Y” for yes or “N” for no, for the portion of the cost
reporting period on and after October 1. For a newly merged hospital as defined in the IPPS
FY 2015 final rule, 79 FR 50022 (August 22, 2014), the final Factor 3 would be recalculated based
on the Medicaid days and SSI days reported on the cost report used for the applicable fiscal year
since the Factor 3 that was published in the final rule did not reflect the merger. For example, for
a newly merged hospital that merged in FY 2015, the numerator of its Factor 3 would be
recalculated based on the FY 2015 SSI days and the Medicaid days reported on its 2015 cost report.
See 79 FR 50021 (August 22, 2014).
For the purpose of this question, a merger is defined as an acquisition where the Medicare provider
agreement of one hospital is subsumed into the provider agreement of the surviving provider. We
would not consider a merger to be an acquisition where a new owner voluntarily terminates the
provider agreement of the hospital it purchased by rejecting assignment of the previous owner’s
provider agreement.
Line 22.03--For cost reporting periods ending on or after October 1, 2014, and before
October 1, 2016, 42 CFR 412.102 provides for a 2-year transition to a rural DSH payment amount
from an urban DSH payment amount, for hospitals that received a geographic reclassification from
urban to rural under the OMB standards for delineating statistical areas adopted by CMS in
FY 2015. Impacted hospitals whose DSH payment adjustment exceeds 12 percent will receive 2/3
of the difference between the urban and rural operating DSH for FY 2015 and 1/3 of the difference
between the urban and rural operating DSH for FY 2016. Did this hospital receive a geographic
reclassification from urban to rural as a result of the OMB standards for delineating statistical areas
adopted by CMS in FY 2015? Enter in column 1, “Y” for yes or “N” for no for the portion of the
cost reporting period prior to October 1. Enter in column 2, “Y” for yes or “N” for no for the
portion of the cost reporting period occurring on or after October 1. Does this hospital contain at
least 100, but not more than 499 beds (as counted in accordance with 42 CFR 412.105)? Enter in
column 3, “Y” for yes or “N” for no.
Line 22.04--For cost reporting periods ending on or after October 1, 2020, and before
October 1, 2022, the FY 2021 IPPS final rule (CMS-1735-F; 85 FR 58746, September 18, 2020)
provides for a 2-year transition (in accordance with 42 CFR 412.102) to a rural DSH payment
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amount from an urban DSH payment amount, for hospitals that received a geographic
reclassification from urban to rural under the OMB standards for delineating statistical areas
adopted by CMS in FY 2021. Impacted hospitals whose DSH payment adjustment exceeds
12 percent will receive 2/3 of the difference between the urban and rural operating DSH for
FY 2021 and 1/3 of the difference between the urban and rural operating DSH for FY 2022. Did
this hospital receive a geographic reclassification from urban to rural as a result of the OMB
standards for delineating statistical areas adopted by CMS in FY 2021? Enter in column 1, “Y”
for yes or “N” for no for the portion of the cost reporting period prior to October 1. Enter in
column 2, “Y” for yes or “N” for no for the portion of the cost reporting period occurring on or
after October 1. Does this hospital contain at least 100, but not more than 499 beds (as counted in
accordance with 42 CFR 412.105)? Enter in column 3, “Y” for yes or “N” for no.
Line 23--Indicate in column 1 the method used to capture Medicaid (title XIX) days reported on
lines 24 and/or 25 of this worksheet during the cost reporting period by entering a “1” if days are
based on the date of admission, “2” if days are based on census days (also referred to as the day
count), or “3” if days are based on the date of discharge. Is the method of identifying the days in
the current cost reporting period different from the method used in the prior cost reporting
period? Enter in column 2, “Y” for yes or “N” for no.
NOTE FOR LINES 24 AND 25: Columns 1 through 6 are mutually exclusive. For example, if
patient days are entered in column 1, those days may not be entered in any other column.
Effective for cost reporting periods beginning on or after October 1, 2018, a cost report
will be rejected when submitted without listings supporting the DSH eligible days
reported on lines 24 and 25 (42 CFR 413.24(f)(5)). Exhibit 3A presents the standardized
format for the information required for cost reporting periods beginning on or after
October 1, 2022, to support the DSH eligible days reported (see 42 CFR 412.106(b)(4),
and exhibit for instructions and listing presented at the end of §4004.1.) Submit separate
listings for the DSH eligible days reported on lines 24 and 25. Report days for each
column as follows:
Column 1: Enter the number of in-state Medicaid paid days. An in-state Medicaid paid
day is an in-state day of inpatient care furnished to a patient eligible for inpatient
benefits under an approved State Medicaid plan or eligible for inpatient
benefits, or regarded as such, under a waiver authorized under
section 1115(a)(2) of the Act on that day and for which the hospital received
payment from Medicaid. These patients cannot also be entitled to Medicare
Part A.
Column 2: Enter the number of in-state Medicaid eligible unpaid days. An in-state
Medicaid eligible unpaid day is an in-state day of inpatient care furnished to a
patient eligible for inpatient benefits under an approved State Medicaid plan or
eligible for inpatient benefits, or regarded as such, under a waiver authorized
under section 1115(a)(2) of the Act on that day and for which the hospital has
not received payment from Medicaid. These patients cannot also be entitled to
Medicare Part A. Reasons for non-payment could be related to the provider not
billing timely, days that are beyond the number of days for which a State will
pay, days that are utilized by a Medicaid beneficiary prior to an admission
approval but for which a valid enrollment is determined within the prescribed
period, and days for which payment is made by a third party.
Column 3: Enter the number of out-of-state Medicaid paid days. An out-of-state Medicaid
paid day is an out-of-state day of inpatient care furnished to a patient eligible
for inpatient benefits under an approved State Medicaid plan or eligible for
inpatient benefits, or regarded as such, under a waiver authorized under
section 1115(a)(2) of the Act on that day and for which the hospital received
payment from Medicaid. These patients cannot also be entitled to Medicare
Part A.
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Column 4: Enter the number of out-of-state Medicaid eligible unpaid days. An out-of-state
Medicaid eligible unpaid day is an out-of-state day of inpatient care furnished
to a patient eligible for inpatient benefits under an approved State Medicaid
plan or eligible for inpatient benefits, or regarded as such, under a waiver
authorized under section 1115(a)(2) of the Act on that day and for which the
hospital has not received payment from Medicaid. These patients cannot also
be entitled to Medicare Part A. Reasons for non-payment could be related to
the provider not billing timely, days that are beyond the number of days for
which a State will pay, days that are utilized by a Medicaid beneficiary prior to
an admission approval but for which a valid enrollment is determined within
the prescribed period, and days for which payment is made by a third party.
Column 5: Enter the number of Medicaid health maintenance organization (HMO) days,
both in-state and out-of-state. A Medicaid HMO day is a paid and/or eligible
but unpaid day of inpatient care furnished to a Medicaid beneficiary who is
eligible for Medicaid under a State plan approved under title XIX through a
HMO or a managed care organization (MCO). These patients cannot also be
entitled to Medicare Part A.
Column 6: Enter other Medicaid days. Other Medicaid days are only labor and delivery
days reported on Worksheet S-3, Part I, column 7, line 32.
Line 24--If line 23, column 1, is “3” and this is an IPPS provider, enter the in-state Medicaid paid
days in column 1 (report these days on Worksheet S-3, Part I, column 7, line 1, and lines 8
through 13, as applicable), the in-state Medicaid eligible but unpaid days in column 2 (report these
days on Worksheet S-3, Part I, column 7, line 2, for adult and pediatric patients and line 13 for
nursery patients, as applicable), the out-of-state Medicaid paid days in column 3 (report these days
on Worksheet S-3, Part I, column 7, line 2, for adult and pediatric patients and line 13 for nursery
patients, as applicable), the out-of-state Medicaid eligible but unpaid days in column 4 (report
these days on Worksheet S-3, Part I, column 7, line 2, for adult and pediatric patients and line 13,
for nursery patients, as applicable), the in-state and out-of-state Medicaid HMO paid and in-state
and out-of-state Medicaid HMO eligible but unpaid days in column 5 (report these days on
Worksheet S-3, Part I, column 7, line 2, for adult and pediatric patients and line 13, for nursery
patients, as applicable). Enter only labor and delivery days (reported on Worksheet S-3, Part I,
column 7, line 32) as “Other Medicaid days” in column 6. If line 23, column 1, is “1” or “2”, enter
the Medicaid days based on each column description; however, these days may not equal the
Medicaid days reported by discharge on Worksheet S-3, Part I. Do not include swing-bed,
observation or hospice days in any columns on this line. See 42 CFR 412.106(a)(1)(ii) and
412.106(b)(4).
Line 25--If line 23, column 1, is “3” and this provider is an IRF or contains an IRF unit, enter the
in-state Medicaid paid days in column 1, (report IRF days on Worksheet S-3, Part I, column 7,
line 1, or IRF unit days on Worksheet S-3, Part I, column 7, line 17), the in-state Medicaid eligible
but unpaid days in column 2 (report IRF days on Worksheet S-3, Part I, column 7, line 2, or IRF
unit days on Worksheet S-3, Part I, column 7, line 4), the out-of-state Medicaid paid days in
column 3 (report IRF days on Worksheet S-3, Part I, column 7, line 2, or IRF unit days on
Worksheet S-3, Part I, column 7, line 4), the out-of-state Medicaid eligible but unpaid days in
column 4 (report IRF days on Worksheet S-3, Part I, column 7, line 2, or IRF unit days on
Worksheet S-3, Part I, column 7, line 4), the in-state and out-of-state Medicaid HMO paid and
in-state and out-of-state Medicaid HMO eligible but unpaid days in column 5 (report IRF days on
Worksheet S-3, Part I, column 7, line 2, or IRF unit days on Worksheet S-3, Part I, column 7,
line 4). Do not enter any days in column 6 for cost reporting periods beginning on or after
October 1, 2012. If line 23, column 1, is “1” or “2”, enter the Medicaid days based on each column
description; however, these days may not equal the Medicaid days reported by discharge on
Worksheet S-3, Part I. Do not include swing-bed, observation or hospice days in any columns on
this line.

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Line 26--For the Standard geographic classification (not wage), what is your status at the
beginning of the cost reporting period. Enter “1” for urban or “2” for rural.
Line 27--For the Standard geographic classification (not wage), what is your status at the end of
the cost reporting period. Enter “1” for urban or “2” for rural. If applicable, enter the effective
date of the geographic reclassification in column 2.
Lines 28 through 34--Reserved for future use.
Line 35--If this is a sole community hospital (SCH), enter the number of periods (0, 1, or 2) within
this cost reporting period that SCH status was in effect.
Line 36--Enter the beginning and ending dates of SCH status during this cost reporting period.
Subscript line 36 if more than one period is identified for this cost reporting period and enter
multiple dates. Multiple dates are created where there is a break in the date between SCH status
(i.e., for calendar year provider SCH status dates are 1/1/2010 through 6/30/2010 and 9/1/2010
through 12/31/2010).
Line 37--If this is a Medicare-dependent, small rural hospital (MDH), enter the number of periods
within this cost reporting period that MDH status was in effect.
Line 37.01--Did this hospital lose their MDH status because they are no longer in a rural area due
to the implementation of the new OMB delineations in FY 2015, and they did not reclassify from
urban to rural under the regulations at §412.103 before January 1, 2016? Enter “Y” for yes or “N”
for no. If yes, calculate the MDH transition payment on Worksheet E, Part A, for portions of the
current cost reporting period that overlap or fall within January 1, 2016, and September 30, 2017.
Do not respond to this question for cost reporting periods that begin on or after October 1, 2017.
Line 38--If line 37 is 1, enter the beginning and ending date of MDH status during this cost
reporting period. If line 37 is greater than 1, subscript this line and enter the applicable beginning
and ending dates accordingly.

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Line 39--For cost reporting periods that overlap or begin on or after October 1, 2010, does the
hospital qualify for the inpatient hospital adjustment for low-volume hospitals for a portion of the
cost reporting period? Enter in column 1 “Y” for yes or “N” for no. If column 1 is “Y”, does the
facility meet the mileage requirements in accordance with 42 CFR 412.101(b)(2)(i), (ii), or (iii)?
Enter in column 2, “Y” for yes or “N” for no. Hospitals are required to request low-volume status
in writing to their contractor and provide documentation that they meet the mileage criteria.
The response to these questions determines the completion of the low-volume calculation
adjustment.
NOTE: 42 CFR 412.101(c)(1) provides for a low-volume adjustment for qualifying hospitals for
federal fiscal years (FFYs) 2005 through 2010, and FFY 2025 and subsequent federal fiscal years.
Qualifying hospitals, those hospitals more than 25 road miles from the nearest subsection (d)
hospital and with fewer than 200 total discharges, receive a payment adjustment of an additional
25 percent for each Medicare discharge.
42 CFR 412.101(c)(2) provides for a temporary change in the low-volume adjustment for
qualifying hospitals for FFYs 2011 through 2018:
•
•

Those hospitals with 200 or fewer Medicare discharges will receive an adjustment of
an additional 25 percent for each Medicare discharge; and,
Those with more than 200 and fewer than 1,600 Medicare discharges will receive an
adjustment of an additional percentage for each Medicare discharge. This adjustment
is calculated using the formula [(4/14) - (Medicare discharges/5600)].

To qualify as a low-volume hospital, the hospital must meet both of the following criteria:
•
•

Be more than 15 road miles from the nearest subsection (d) hospital; and,
Have fewer than 1,600 Medicare discharges based on the latest available Medicare
Provider Analysis and Review (MedPAR) data as determined by CMS.

42 CFR 412.101(c)(3) provides for a temporary change in the low-volume adjustment for
qualifying hospitals for FFYs 2019 through FFY 2024 as follows:
•
•

Those hospitals with 500 or fewer total discharges will receive an adjustment of an
additional 25 percent for each Medicare discharge; and,
Those with more than 500 and fewer than 3,800 total discharges will receive an
adjustment of an additional percentage for each Medicare discharge. This adjustment
is calculated using the formula [(95/330) - (total discharges/13,200)].

To qualify as a low-volume hospital, the hospital must meet both of the following criteria:
•
•

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Be more than 15 road miles from the nearest subsection (d) hospital; and,
Have fewer than 3,800 total discharges based on the hospital’s most recently submitted
cost report.

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Line 40--Section 3008 of the Affordable Care Act (ACA 2010) established the Hospital Acquired
Condition (HAC) Reduction Program, beginning in FFY 2015. Enter in column 1, “Y” for yes or
“N” for no if your hospital is subject to the HAC reduction adjustment for discharges occurring
prior to October 1. For cost reporting periods that overlap October 1, 2014, enter “N” in column 1.
Enter in column 2, “Y” for yes or “N” for no if your hospital is subject to the HAC reduction
adjustment for discharges occurring on or after October 1.
Lines 41 through 44--Reserved for future use.
Line 45--Does your facility qualify and receive capital payments for disproportionate share in
accordance with 42 CFR 412.320? Enter “Y” for yes and “N” for no.
Line 46--Are you eligible for the exception payment for extraordinary circumstances pursuant to
42 CFR 412.348(f)? Enter “Y” for yes or “N” for no. If yes, complete Worksheets L, Part III,
and L-1.
Line 47--Is this a new hospital under 42 CFR 412.300(b) (PPS capital)? Enter “Y” for yes or “N”
for no for the respective programs.
Line 48--If line 47 is yes, do you elect full federal capital payment? Enter “Y” for yes or “N” for
no for the respective programs.
Lines 49 through 55--Reserved for future use.
NOTE: CAHs complete question 107 in lieu of question 57.
Line 56--Is this a hospital involved in training residents in approved graduate medical education
(GME) programs? For cost reporting periods beginning prior to December 27, 2020, enter “Y”
for yes or “N” for no in column 1. For cost reporting periods beginning on or after
December 27, 2020, under 42 CFR 413.78(b)(2), a hospital must enter “Y” for yes and report FTE
residents on Worksheet E-4 if the hospital trained at least 1.0 FTE in an approved program(s) in
the cost reporting period. Additionally, if the hospital trained less than 1.0 FTE residents in an
approved program(s) and this training resulted from the hospital’s participation in a Medicare
GME affiliation agreement (as defined under 42 CFR 413.75(b)), then the hospital must also enter
“Y” for yes and report FTE residents on Worksheet E-4. The BBRA provided that payments that
are made to teaching hospitals for costs of direct GME associated with services to Medicare
Advantage (MA) enrollees will be reduced by an estimated percentage in each calendar year (CY).
For column 2, if the response to column 1 is “Y”, or if this hospital was involved in training
residents in approved GME programs in the prior year or penultimate year, and you are impacted
by Change Request (CR) 11642 (or applicable CRs) MA direct GME payment reduction, enter
“Y” for yes; otherwise, enter “N” for no in column 2.
Line 57--For cost reporting periods beginning prior to December 27, 2020, if line 56, column 1, is
yes, is this the first cost reporting period in which you are training residents in approved programs?
Enter “Y” for yes or “N” for no in column 1. If column 1 is yes, were residents training during
the first month of the cost reporting period? Enter “Y” for yes or “N” for no in column 2. If
column 2 is yes, complete Worksheet E-4. If column 2 is “N”, complete Worksheets D,
Parts III and IV, and D-2, Part II, if applicable. For cost reporting periods beginning on or after
December 27, 2020, under 42 CFR 413.77(e)(1)(iv) and (v), regardless of which month(s) of the
cost report the residents were on duty, if the response to line 56, column 1, is “Y” for yes, enter
“Y” for yes in column 1, do not complete column 2, and complete Worksheet E-4.
Line 58--If line 56, column 1, is “Y” for yes, did you elect cost reimbursement for physician direct
medical and surgical services as defined in 42 CFR 415.160 and CMS Pub. 15-1, chapter 21,
§2148? Enter “Y” for yes or “N” for no. If yes, complete Worksheet D-5.
Line 59--Are you claiming costs of interns and residents (I&R) in unapproved programs on
Worksheet A, column 7, line 100? Enter “Y” for yes or “N” for no. If yes, complete
Worksheet D-2, Part I.
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Line 60--Are you claiming nursing and allied health education (NAHE) costs for any programs
approved in accordance with 42 CFR 413.85(e)? Enter “Y” for yes or “N” for no in column 1. If
your hospital does not have an approved NAHE program that meets the criteria in
42 CFR 413.85(e), or if all the NAHE costs are for educational activities treated as normal
operating costs as defined in 42 CFR 413.85(h)(6), enter “N” for no. Additionally, 42 CFR 413.87
provides for additional payments to hospitals for costs of NAHE services to MA enrollees. If the
response to column 1 is “Y”, are you impacted by CR 11642 (or applicable CRs) NAHE MA
payment adjustment? Enter “Y” for yes or “N” for no in column 2. If the response to line 60 is
no, do not complete subscripts for line 60.
Effective for cost reporting periods ending on or after September 30, 2017, if the response to
line 60, column 1, is yes, subscript this line for each program, beginning with line 60.01. Enter in
column 2, the Worksheet A line number on which the costs of the NAHE program were reported.
Enter in column 3, the appropriate code that identifies the criterion under which the NAHE
program costs qualify for pass-through payment or are treated as normal operating costs. Select
from the following list:
(1) - NAHE program is a provider operated program that meets the criteria under
42 CFR 413.85(f).
(2) - NAHE program is a nonprovider operated program that meets the criteria
under 42 CFR 413.85(g)(2). However, under 42 CFR 413.85(g)(2)(iii), the
pass-through costs are limited to the percentage of total allowable provider
cost attributable to NAHE clinical training costs reported in the most recent
cost reporting period ending on or before October 1, 1989.
(3) - NAHE program is a nonprovider operated program that meets the criteria
under 42 CFR 413.85(g)(3).
(4) - NAHE program is a nonprovider operated program where costs are treated as
normal operating costs under 42 CFR 413.85(h)(6).
For each subscript of line 60 beginning with line 60.01, if the entry in column 3 is “1”, “2”, or “3”,
report the NAHE program costs in the applicable column of Worksheet D, Parts III and IV, to
separately identify nursing program and allied health education costs from all other medical
education costs. For any subscript of line 60 where the entry in column 3 is “4”, do not transfer
the costs to Worksheet D, Part III, or Part IV.
Requirements During Five Year Period Following Implementation of Increases to Hospitals’ FTE
Resident Caps Under Section 5503 of the Affordable Care Act (ACA), Line 61 and Subscripts-Section 5503 of the ACA states that a hospital that receives an increase to its FTE resident cap
under section 5503 shall ensure, during the 5-year period beginning on July 1, 2011, that:
(I) The number of FTE primary care residents is not less than the average number of FTE
primary care residents during the three most recent cost reporting periods ending prior to
the date of enactment of section 5503; and,
(II) Not less than 75 percent of the positions attributable to such increase are in a primary
care or general surgery residency.
Failure to comply with either of these two requirements, known as the 3-year primary care average
requirement (I) and the 75 percent test (II), means permanent removal of all section 5503 slots
from the earliest applicable cost reporting period under the regulations at 42 CFR 413.79(n)(2).

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Line 61--Did your hospital receive FTE slots under section 5503 of the ACA? Enter “Y” for yes
or “N” for no in column 1. If “Y”, enter the number of IME section 5503 slots awarded in
column 4 and direct GME section 5503 slots awarded in column 5. The number of IME and/or
direct GME slots entered here should be the amounts on the award letter from CMS. Complete
the subscripts of line 61 for portions of cost reporting periods occurring on or after July 1, 2011,
and before July 1, 2016. If “N” for no, do not complete columns 4 or 5 and subscripts of line 61.
NOTE: Effective for portions of cost reporting periods occurring on or after July 1, 2011, do not
complete line 61, columns 2 and 3. This information is now reported on line 61.01,
columns 2 and 3.
Line 61.01--Effective for portions of cost reporting periods occurring on or after July 1, 2011, and
before July 1, 2016, enter the average unweighted number of primary care FTE residents from the
hospital’s three most recent cost reports ending and submitted to the contractor before
March 23, 2010. See 42 CFR 413.75(b) for the definition of “primary care resident”. Enter the
3-year primary care average for IME in column 2. The source of the primary care IME FTE
residents is the rotation schedules submitted by the provider to support its cost reports for the three
most recent cost reports ending and submitted to the contractors prior to March 23, 2010. Any
audit adjustments to these IME primary care FTE residents must be taken into account in
computing the 3-year average. Exclude OB/GYN and general surgery FTE residents. This
primary care average is based on the hospital’s total primary care FTE count that would otherwise
be allowable if not for the FTE resident cap for each year in the 3-year period. If any of the three
cost reports is not a 12-month cost report, enter the 12-month equivalent FTE count.
Enter the average unweighted number of primary care FTE residents for direct GME in column 3.
This primary care average is based on the hospital’s total unweighted primary care FTE count that
would otherwise be allowable if not for the FTE resident cap for each year in the 3-year period. If
the hospital did not train any OB/GYN residents in its three most recent cost reports ending and
submitted prior to March 23, 2010, convert the weighted primary care FTE counts from line 3.19
of Worksheet E-3, Part IV, of Form CMS-2552-96, to unweighted FTE counts, compute a 3-year
average, and report the average in column 3. If the hospital did train OB/GYN FTE residents in
its three most recent cost reports ending and submitted prior to March 23, 2010, subtract the
OB/GYN FTE counts from line 3.19 of Worksheet E-3, Part IV, of Form CMS-2552-96, convert
the remaining primary care FTE counts to unweighted FTE counts, compute a 3-year average, and
report the average in column 3. Exclude general surgery FTE residents. If any of the three cost
reports is not a 12-month cost report, enter the 12-month equivalent FTE count.
Line 61.02--Enter the current cost reporting period total unweighted primary care FTE count
(excluding obstetrics and gynecology and general surgery), which is used to determine compliance
with the 3-year primary care average requirement. In accordance with section 5503 of the ACA,
which states that the 3-year primary care average requirement must be met by “excluding any
additional positions” added as a result of the section 5503 FTE cap increase, also exclude from
this unweighted primary care FTE count any primary care FTEs added in the current cost reporting
period specific to new or expanded programs under section 5503 (see 75 FR 72198-72199 dated
November 24, 2010). Enter the unweighted IME FTE count in column 2 and the direct GME FTE
count in column 3. If the current cost report is not a 12-month cost report, enter the 12-month
equivalent FTE count. These current cost reporting period unweighted primary care FTE counts
are compared to the 3-year primary care average amounts in line 61.01.

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Line 61.03--Enter the baseline FTE count for primary care and/or general surgery residents that is
used for determining compliance with the 75 percent requirement. These primary care and/or
general surgery FTEs would be a part of the unweighted allopathic and osteopathic FTE count
from the hospital’s 12-month (or prorated equivalent) cost report that immediately precedes the
cost report that includes July 1, 2011. Report the IME primary care and/or general surgery
baseline FTE count in column 2 and the direct GME baseline primary care and/or general surgery
FTE count in column 3. (For example, the baseline cost report for June 30 providers would be
July 1, 2010 through June 30, 2011; for December 31 providers, this would be January 1, 2010,
through December 31, 2010; for September 30 providers, this would be October 1, 2009 through
September 30, 2010). (On the Form CMS-2552-96, the baseline FTE primary care and/or general
surgery count is included and commingled in the allopathic and osteopathic FTEs reported on
line 3.08 of Worksheet E, Part A, and on line 3.05 of Worksheet E-3, Part IV. On the
Form CMS-2552-10, the baseline primary care and/or general surgery FTE count is included and
commingled in the allopathic and osteopathic FTEs reported on line 10 of Worksheet E, Part A,
and on line 6 of Worksheet E-4). Use the rotation schedules from the hospital’s 12-month (or
prorated equivalent) cost report that immediately precedes the cost report that includes
July 1, 2011, as the source for the primary care and/or general surgery FTEs.
Line 61.04--Enter the total number of unweighted primary care and/or general surgery allopathic
and/or osteopathic FTEs in the current cost reporting period. If the cost report is not a 12-month
cost report, enter the 12-month equivalent FTE count. Exclude OB/GYN FTEs. (These FTEs are
part of the current year FTE count, and are included on Form CMS-2552-10, line 10 of
Worksheet E, Part A, and line 6 of Worksheet E-4). Report the unweighted IME FTE count in
column 2 and the direct GME FTE count in column 3.
Line 61.05--Determination of Compliance with 75 Percent Requirement--For portions of cost
reporting periods occurring on or after July 1, 2011, and before July 1, 2016, enter the difference
between the baseline primary care and/or general surgery FTE counts and the current year primary
care and/or general surgery FTE counts (line 61.04 minus line 61.03). Report the IME FTE count
difference in column 2 and the direct GME FTE count difference in column 3. (If the difference
is less than or equal to zero, enter a zero).
The section 5503 FTE cap slots reported on Worksheet E, Part A, line 8.01 (for IME), and
Worksheet E-4, line 4.01 (direct GME), are dependent upon this difference on line 61.05 (for
portions of cost reporting periods occurring on or after July 1, 2011, and before July 1, 2016),
because of the requirement that 75 percent of the section 5503 FTE cap award be used for primary
care and/or general surgery FTEs in new or expanded programs. If the difference on line 61.05 is
greater than zero, then it must be at least 75 percent of the section 5503 FTE cap award to be
reported on Worksheet E, Part A, line 8.01 (for IME), and Worksheet E-4, line 4.01 (for direct
GME). For example, if a hospital was awarded a total of 10 slots, but the difference reported on
line 61.05 is 5, then the section 5503 FTE slots reported on Worksheet E, Part A, line 8.01 (for
IME), and Worksheet E-4, line 4.01 (for direct GME), cannot be more than 6.67 (that is, 5 divided
by 75 percent). Therefore, determine that the difference on line 61.05 is at least 75 percent of the
section 5503 award amount that is reported on Worksheet E, Part A, line 8.01 (for IME), and
Worksheet E-4, line 4.01 (for direct GME).

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Line 61.06--Enter the amount of the ACA section 5503 award FTEs that are being used for cap
relief, if any, and/or that are nonprimary care or non-general surgery FTEs. Report the IME
amount in column 2 and the direct GME amount in column 3. For portions of cost reporting
periods occurring on or after July 1, 2011, and before July 1, 2016, the amount reported on this
line can be no more than 25 percent of the section 5503 FTE cap slots reported on Worksheet E,
Part A, line 8.01 (for IME), and Worksheet E-4, line 4.01 (for direct GME). If the amount on
line 61.05, columns 2 or 3, is greater than or equal to the section 5503 cap award reported on
line 61, columns 4 or 5, respectively, report zero on this line.
If the amount on line 61.05 is less than the section 5503 cap award, and the hospital either is
training FTE residents over its existing FTE cap or has added nonprimary care and non-general
surgery FTEs in the current cost reporting period, report on this line the difference of the
section 5503 cap slots on Worksheet E, Part A, line 8.01 (for IME), and Worksheet E-4, line 4.01
(for direct GME), and the amount reported on line 61.05. For example, if a hospital was awarded
a total of 10 slots, and 5 is reported on line 61.05, and the section 5503 FTE slots reported on
Worksheet E, Part A, line 8.01 (for IME), and Worksheet E-4, line 4.01 (for direct GME) is
6.67 FTEs, then the amount reported on line 61.06 cannot exceed 1.67 FTEs which is the
difference between the amount on line 61.05, and the amount reported on Worksheet E, Part A,
line 8.01 (for IME), and Worksheet E-4, line 4.01 (for direct GME). If 10 is reported on line 61.05,
then report 0 (zero) on line 61.06. If 8 is reported on line 61.05 and the hospital added 2 or more
nonprimary care FTEs in the current cost reporting period, then report 2 on this line.
Lines 61.07 through 61.09--Reserved for future use.
Line 61.10--Of the FTEs in line 61.05, specify each new primary care or general surgery program
specialty, if any, and the number of FTE residents for each new program. Use subscripted
lines 61.11 through 61.19 for each additional new program. Enter in column 1 the program name,
enter in column 2 the program code, enter in column 3 the IME FTE unweighted count and enter
in column 4 the direct GME FTE unweighted count.
Line 61.20--Of the additional FTEs in line 61.05, specify each expanded primary care or general
surgery program specialty, if any, and the number of FTE residents for each program expansion.
Use subscripted lines 61.21 through 61.29 for each additional program expansion. Enter in
column 1 the program name, enter in column 2 the program code, enter in column 3 the IME FTE
unweighted count and enter in column 4 the direct GME FTE unweighted count.
Lines 62 and 62.01--Provisions Affecting the Health Resources and Services Administration
(HRSA)--These provisions are effective for the Health Resources and Services Administration
(HRSA) Primary Care Residency Expansion (PCRE) program and the Teaching Health Center
(THC) program.
Line 62--Effective for services rendered on or after September 30, 2010, enter the number of FTE
residents that your hospital trained in this cost reporting period for which your hospital received
HRSA PCRE funding. (Sections 4002 and 5301 of the ACA.)
Line 62.01--Effective for services rendered on or after October 1, 2010, enter the number of FTE
residents that rotated from a THC into your hospital during this cost reporting period under the
HRSA THC program. (Section 5508 of the ACA and §301(c) of the Consolidated Appropriations
Act of 2021 (CAA 2021).)
Line 63--Has your facility trained residents in a nonprovider setting during this cost reporting
period?
Enter “Y” for yes or “N” for no in column 1.
(See 75 FR 72139-72140
(November 24, 2010).) If column 1 is “Y” for yes, complete lines 64 through 67 and applicable
subscripts. If “N” for no, but your facility trained residents in a nonprovider setting during the
base year period (cost reporting period that begins on or after July 1, 2009, and before
June 30, 2010), complete lines 64 and 65, and applicable subscripts effective for cost reporting
periods beginning on or after July 1, 2010.
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Lines 64 and 65--Section 5504 of the ACA Base Year FTE Residents in Nonprovider Settings-The base year is your cost reporting period that begins on or after July 1, 2009, and before
June 30, 2010.
Line 64--If line 63 is yes or your facility trained residents in the base year period, enter in
column 1, for cost reporting periods that begins on or after July 1, 2009, and before June 30, 2010,
the number of unweighted nonprimary care FTE residents attributable to rotations that occurred in
all nonprovider settings. Enter in column 2, the number of unweighted nonprimary care FTE
residents that trained in your hospital. Include unweighted OB/GYN, dental and podiatry FTEs
on this line. Enter in column 3, the ratio of column 1 divided by the sum of columns 1 and 2.
Line 65--If line 63 is yes or your facility trained residents in the base year period, enter from your
cost reporting period that begins on or after July 1, 2009, and before June 30, 2010, the number of
unweighted primary care FTE residents for each primary care specialty program in which you train
residents. (See 42 CFR 413.75(b) for the definition of “primary care resident.”) Use subscripted
lines 65.01 through 65.50 for each additional primary care program. Enter in column 1, the
program name. Enter in column 2, the program code. Enter in column 3, the number of
unweighted primary care FTE residents attributable to rotations that occurred in nonprovider
settings for each applicable program. Enter in column 4, the number of unweighted primary care
FTE residents in your hospital for each applicable program. Enter in column 5, the ratio of
column 3 divided by the sum of columns 3 and 4. If you operated a primary care program that did
not have FTE residents in a nonprovider setting, enter zero in column 3 and complete all other
columns for each applicable program.
NOTE: The sum of the FTE counts on line 64, columns 1 and 2, and line 65, columns 3 and 4,
should approximate the sum of the FTE counts on Form CMS-2552-96, Worksheet E-3,
Part IV, lines 3.05 and 3.11, for your cost reporting period that begins on or after
July 1, 2009 and before June 30, 2010.
Lines 66 and 67--Section 5504 of the ACA Current Year FTE Residents in Nonprovider
Settings--Effective for cost reporting periods beginning on or after July 1, 2010.
Line 66--If line 63 is yes, enter in column 1, the unweighted number of nonprimary care FTE
residents attributable to rotations occurring in all nonprovider settings. Enter in column 2, the
number of unweighted nonprimary care FTE residents in your hospital. Include unweighted
OB/GYN, dental and podiatry FTEs on this line. Enter in column 3, the ratio of column 1 divided
by the sum of columns 1 and 2.
Line 67--If line 63 is yes, then, for each primary care residency program in which you are training
residents, enter in column 1, the program name. Enter in column 2, the program code. Enter in
column 3, the number of unweighted primary care FTE residents attributable to rotations that
occurred in nonprovider settings for each applicable program. Enter in column 4, the number of
unweighted primary care FTE residents in your hospital for each applicable program. Enter in
column 5, the ratio of column 3 divided by the sum of columns 3 and 4. Use subscripted
lines 67.01 through 67.50 for each additional primary care program.
If you operated a primary care program that did not have FTE residents in a nonprovider setting,
enter zero in column 3 and complete all other columns for each applicable program.
NOTE: The sum of the FTE counts on line 66, columns 1 and 2, and line 67, columns 3 and 4,
should approximate the sum of the FTE counts on Worksheet E-4, lines 6 and 10, for
this current cost reporting period.
Line 68--For a cost reporting period beginning prior to October 1, 2022, did you obtain permission
from your MAC to apply the DGME formula in accordance with the FY 2023 IPPS final rule,
87 FR 49065-49072 (August 10, 2022)? Enter “Y” for yes; otherwise, enter “N” for no. Do not
complete the question for cost reporting periods beginning on or after October 1, 2022.
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Line 69--Reserved for future use.
Line 70--Are you an IPF or do you contain an IPF subprovider? Enter in column 1 “Y” for yes or
“N” for no.
Line 71--For column 1, if this facility is an IPF or contains an IPF subprovider (response to line 70,
column 1, is “Y” for yes), did the facility train residents in graduate medical education programs
in the most recent cost report filed on or before November 15, 2004? Enter “Y” for yes or “N”
for no.
For column 2, did the facility train residents in a new graduate medical education program in the
current cost reporting period, or in a prior cost reporting period, in accordance with
42 CFR 412.424(d)(1)(iii)(D)? Enter in column 2, “Y” for yes or “N” for no. (Note: If column 1
is “Y,” then column 2 must be “N.” Columns 1 and 2 cannot be “Y” simultaneously; however,
columns 1 and 2 can be “N” simultaneously.)
For column 3, if column 2 is yes, indicate which program year began in this cost reporting period.
New programs that began before October 1, 2012, have a 3-year new program growth period for
the first new program, while new programs that began on or after October 1, 2012, have a 5-year
new program growth period for the first new program. For new programs that began before
October 1, 2012 (see 42 CFR 413.79(e)(1)), enter a 1, 2, or 3, in column 3 to correspond to the
I&R academic year in the first 3 program years of the first new program’s existence that began
during the current cost reporting period, or enter a 6 to indicate this cost reporting period includes
the beginning of the program year following the 3-year new program growth period of the first
new program, or the program is beyond the new program growth period. For new programs that
began on or after October 1, 2012 (see 42 CFR 413.79(e)(1)), enter a 1, 2, 3, 4, or 5, in column 3
to correspond to the I&R academic year in the first 5 program years of the first new program’s
existence that began during the current cost reporting period, or enter a 6 to indicate this cost
reporting period includes the beginning of the program year following the 5-year new program
growth period of the first new program, or the program is beyond the new program growth period.
If column 2 is no, make no entry in column 3.
Lines 72 through 74--Reserved for future use.
Line 75--Are you an IRF or do you contain an IRF subprovider? Enter in column 1 “Y” for yes
or “N” for no.
Line 76--For column 1, if this facility is an IRF or contains an IRF subprovider (response to
line 75, column 1, is “Y” for yes), did the facility train residents in graduate medical education
programs in the most recent cost reporting period ending on or before November 15, 2004?
Enter “Y” for yes or “N” for no.
For column 2, did the facility train residents in a new graduate medical education program in the
current cost reporting period, or in a prior cost reporting period, in accordance with 70 FR 47929
(August 15, 2005)? Enter in column 2, “Y” for yes or “N” for no. (Note: If column 1 is “Y”, then
column 2 must be “N.” Columns 1 and 2 cannot be “Y” simultaneously; however, columns 1
and 2 can be “N” simultaneously.)
For column 3, if column 2 is yes, indicate which program year began in this cost reporting period.
New programs that began before October 1, 2012, have a 3-year new program growth period for
the first new program, while new programs that began on or after October 1, 2012, have a 5-year
new program growth period for the first new program. For new programs that began before
October 1, 2012 (see 42 CFR 413.79(e)(1)), enter a 1, 2, or 3, in column 3 to correspond to the
I&R academic year in the first 3 program years of the first new program’s existence that began
during the current cost reporting period, or enter a 6 to indicate this cost reporting period includes
the beginning of the program year following the 3-year new program growth period of the first
new program, or the program is beyond the new program growth period. For new programs that
began on or after October 1, 2012 (see 42 CFR 413.79(e)(1)), enter a 1, 2, 3, 4, or 5, in column 3
to correspond to the I&R academic year in the first 5 program years of the first new program’s
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existence that began during the current cost reporting period, or enter a 6 to indicate this cost
reporting period includes the beginning of the program year following the 5-year new program
growth period of the first new program, or the program is beyond the new program growth period.
If column 2 is no, make no entry in column 3.
Lines 77 through 79--Reserved for future use.
Line 80--Are you a freestanding LTCH? Enter in column 1 “Y” for yes or “N” for no. LTCHs
can only exist as independent/freestanding facilities. To be considered as independent or a
freestanding facility, a LTCH located within another hospital must meet the separateness (from
the host/co-located provider) requirements identified in 42 CFR 412.22(e).
Line 81--Are you an independent or freestanding LTCH located within another hospital, subject
to the special payment provisions of 42 CFR 412.534? Enter “Y” for yes or “N” for no. To be
considered as independent or a freestanding facility, a LTCH located within another hospital must
meet the separateness (from the host/co-located provider) requirements identified in
42 CFR 412.22.
Lines 82 through 84--Reserved for future use.
Line 85--Is this a new hospital under 42 CFR 413.40(f)(1)(i) (TEFRA)? Enter “Y” for yes or “N”
for no.
Line 86--Have you established a new “Other” subprovider (excluded unit) under
42 CFR 413.40(f)(1)(ii)? Enter “Y” for yes or “N” for no in column 1. If there is more than one
subprovider, subscript this line. Do not complete this line.
Line 87--Is this hospital a LTCH classified under section 1886(d)(1)(B)(vi) (referred to as
extended neoplastic disease care hospitals)? Enter “Y” for yes or “N” for no.
Line 88--For a cost reporting period beginning on or after October 1, 2022, is this provider
approved for a permanent adjustment to the TEFRA target amount per discharge? Enter “Y” for
yes or “N” for no in column 1. If column 1 is “Y”, in column 2, enter the number of approved
permanent adjustments, and complete line 89. See CMS Pub. 15-1, chapter 30, §3004.1 and
§3004.2, for clarification on permanent adjustments.
Line 89--If line 88, column 1, is yes, complete columns 1, 2, and 3, for the earliest (first) approved
permanent adjustment. 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. If the number on line 88, column 2, is greater than one (the hospital received multiple
approvals for permanent adjustments to the TEFRA target amount per discharge), subscript this
line consecutively as necessary to report each additional approved permanent adjustment in
chronological order. Report the earliest (first) approved permanent adjustment on line 89, and
report each subsequently approved permanent adjustment on lines 89.01, 89.02, etc. See
CMS Pub. 15-1, chapter 30, §3004.1 and §3004.2, for clarification on permanent adjustments.
Lines 90--Do you provide title V and/or XIX inpatient hospital services? Enter “Y” for yes or “N”
for no in the applicable column.
Line 91--Is this hospital reimbursed for title V and/or XIX through the cost report in full or in part?
Enter “Y” for yes or “N’ for no in the applicable column.
Line 92--If all of the nursing facility beds were certified for title XIX, and there were also
title XVIII certified beds (dual certified), were any of the title XVIII beds occupied by title XIX
patients during the cost reporting period? Enter “Y” for yes or “N” for no in the applicable column.
Complete a separate Worksheet D-1 for title XIX for each level of care.
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Line 93--Do you operate an ICF/IID facility for purposes of title XIX? Enter “Y” for yes or “N”
for no.
Line 94--Does title V and/or XIX reduce capital costs? Enter “Y” for yes or “N” for no in the
applicable column.
Line 95--For each column, if line 94 is “Y” for yes, enter the percentage by which capital costs are
reduced.
Line 96--Does title V and/or XIX reduce operating costs? Enter “Y” for yes or “N” for no in the
applicable column.
Line 97--For each column, if line 96 is “Y” for yes, enter the percentage by which operating costs
are reduced.
Line 98--Does title V or XIX follow Medicare for the interns and residents post step-down
adjustments on Worksheet B, Part I, column 25? Enter “Y” for yes or “N” for no in column 1 for
title V, and in column 2 for title XIX.
Line 98.01--Does title V or XIX follow Medicare for the reporting of charges on Worksheet C,
Part I? Enter “Y” for yes or “N” for no in column 1 for title V, and in column 2 for title XIX.
Line 98.02--Does title V or XIX follow Medicare for the calculation of observation bed costs on
Worksheet D-1, Part IV, line 89? Enter “Y” for yes or “N” for no in column 1 for title V, and in
column 2 for title XIX.
Line 98.03--Does title V or XIX follow Medicare for a CAH reimbursed 101 percent of cost for
inpatient services? Enter “Y” for yes or “N” for no in column 1 for title V, and in column 2 for
title XIX.
Line 98.04--Does title V or XIX follow Medicare for a CAH reimbursed 101 percent of cost for
outpatient services? Enter “Y” for yes or “N” for no in column 1 for title V, and in column 2 for
title XIX.
Line 98.05--Does title V or XIX follow Medicare and add back the reasonable compensation
equivalent (RCE) disallowance on Worksheet C, Part I, column 4? Enter “Y” for yes or “N” for
no in column 1 for title V, and in column 2 for title XIX.
Line 98.06--Does title V or XIX follow Medicare when cost reimbursed for Worksheet D, Parts I
through IV? Enter “Y” for yes or “N” for no in column 1 for title V, and in column 2 for title XIX.
Lines 99 through 104--Reserved for future use.
Line 105--If this hospital qualifies as a CAH, enter “Y” for yes in column 1. Otherwise, enter “N”
for no, and skip to line 108. (See 42 CFR 485.606ff.)
Line 106--If line 105 is yes, has this CAH elected the all-inclusive method of payment for
outpatient services? Enter “Y” for yes or “N” for no. If yes, an adjustment for the professional
component is still required on Worksheet A-8-2.
NOTE: If the facility elected the all-inclusive method for outpatient services, professional
component amounts are excluded from deductible and coinsurance amounts and are not
included on Worksheet E-1.

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Line 107--If line 105 is yes, is this CAH eligible for 101 percent reasonable cost reimbursement
for I&R in approved training programs? Enter a “Y” for yes or an “N” for no in column 1. If
column 1 is yes, the GME elimination is not made on Worksheet B, Part I, column 25, and the
program is cost reimbursed. If yes, complete Worksheet D-2, Part II.
If column 1 is yes and line 70 and/or line 75 is yes, do I&Rs in approved medical education
programs train in the CAH’s excluded IPF and/or IRF unit? Enter a “Y” for yes or an “N” for no
in column 2. If column 2 is yes, complete Worksheet E-4, to calculate GME reimbursement for
CAH subproviders.
Line 108--Is this a rural hospital qualifying for an exception to the certified registered nurse
anesthetist (CRNA) fee schedule? (See 42 CFR 412.113(c).) Enter “Y” for yes or “N” for no, in
column 1.
Line 109--If this hospital qualifies as a CAH (response to line 105 is yes) or is a cost reimbursed
provider, are therapy services provided by outside suppliers? Enter “Y” for yes or “N” for no
under the corresponding physical, occupational, speech and/or respiratory therapy services as
applicable.
Line 110--Did this facility participate in the Rural Community Hospital Demonstration Project
(also known as the §410A Demo) for the current cost reporting period? Enter “Y” for yes or “N”
for no. If “Y”, complete Worksheet E, Part A, lines 200 through 218, and Worksheet E-2, line 200
through 215, as applicable.
Line 111--If this facility qualifies as a CAH, did it participate in the Frontier Community Health
Integration Project (FCHIP) demonstration for this cost reporting period? Enter “Y” for yes or
“N” for no in column 1. If the response in column 1 is “Y”, enter in column 2, the integration
prong of the FCHIP demonstration in which this CAH is participating. Enter all that apply: “A”
for ambulance services reimbursed at 101 percent of reasonable costs; “B” for additional beds used
only for SNF and/or NF level of care; and/or “C” for telehealth services reimbursed at 101 percent
of reasonable costs.
NOTE FOR LINE 111: If the entry in column 2 is “C”, a telemedicine cost center must exist on
Worksheet A, line 93 (Other Outpatient Service (specify)), or a subscript thereof, to report
the telehealth originating site cost and/or telehealth destination site cost of CAHs
participating in the FCHIP demonstration with a cost center code of “04050” (see §4095,
Table 5).
Line 112--Did this hospital participate in the Pennsylvania Rural Health Model (PARHM)
demonstration for any portion of the cost reporting period? In column 1, enter “Y” for yes or “N”
for no. If column 1 is “Y”, in column 2, enter the beginning date for the portion of the cost
reporting period the hospital began participation in the PARHM demonstration; and, in column 3,
enter the ending date for the portion of the cost reporting period the hospital ceased participation
in the PARHM demonstration, when applicable. If the hospital participated in the PARHM
demonstration for the entire cost reporting period enter the beginning and ending dates
accordingly. The PARHM demonstration is effective for outpatient services and inpatient
discharges ending on or after January 29, 2019.
If column 1 is “Y” and the hospital participated in the PARHM demonstration for the entire cost
reporting period, complete all hospital worksheets by selecting the “PARHM Demonstration”
indicator box at the top of each worksheet. If column 1 is “Y” and any portion of the cost reporting
period the hospital did not participate in the PARHM demonstration, complete the hospital
worksheets as “Hospital” for the period of non-participation and complete a separate set of hospital
worksheets as “PARHM Demonstration” for the period of participation.

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Lines 113 and 114--Reserved for future use.
Line 115--Is this an all-inclusive rate provider (see instructions in CMS Pub. 15-1, chapter 22,
§2208). Enter “Y” for yes or “N” for no in column 1. If yes, enter the applicable method (A, B,
or E only) in column 2. If column 2 is “E”, enter the inpatient Medicare calculation percentage in
column 3. Enter “93” for short-term hospitals where over 50 percent of all patients admitted stay
less than 30 days or “98” for long-term hospitals where over 50 percent of all patients stay 30 days
or more. (See CMS Pub. 15-1, chapter 22, §2208.1.E.)
Line 116--Are you classified as a referral center? Enter “Y” for yes or “N” for no. See
42 CFR 412.96.
Line 117--Are you legally required to carry malpractice insurance? Enter “Y” for yes or “N” for
no. Malpractice insurance, sometimes referred to as professional liability insurance, is insurance
purchased by physicians and hospitals to cover the cost of being sued for malpractice.
Line 118--Is the malpractice insurance a claims-made or occurrence policy? A claims-made
insurance policy covers claims first made (reported or filed) during the year the policy is in force
for any incidents that occur that year or during any previous period during which the insured was
covered under a "claims-made" contract. The occurrence policy covers an incident occurring while
the policy is in force regardless of when the claim arising out of that incident is filed. If the policy
is claims-made, enter 1. If the policy is occurrence, enter 2.
Line 118.01--Enter the total amount of malpractice premiums paid in column 1, enter the total
amount of paid losses in column 2, and enter the total amount of self-insurance paid in column 3.
Line 118.02--Indicate if malpractice premiums and paid losses are reported in a cost center other
than the Administrative and General (A&G) cost center. If yes, provide a supporting schedule and
list the amounts applicable to each cost center.
Malpractice insurance premiums are money paid by the provider to a commercial insurer to protect
the provider against potential negligence claims made by their patients/clients. Malpractice paid
losses is money paid by the healthcare provider to compensate a patient/client for professional
negligence. Malpractice self-insurance is money paid by the provider where the healthcare
provider acts as its own insurance company (either as a sole or part-owner) to financially protect
itself against professional negligence. Often providers will manage their own funds or purchase a
policy referred to as captive insurance, which protects providers for excess protection that may be
unavailable or cost-prohibitive at the primary level.
Line 119--This question is eliminated and this line must not be used.

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Line 120--If this is an SCH (or EACH), that qualifies for the outpatient hold harmless provision in
accordance with ACA section 3121, enter “Y” for yes or “N” for no in column 1. If this is a rural
hospital with 100 or fewer beds, that qualifies for the outpatient hold harmless provision in
accordance with ACA section 3121, enter “Y” for yes or “N” for no in column 2. The ACA §3121
was amended by the Medicare and Medicaid Extenders Act (MMEA) of 2010, §108; the
Temporary Payroll Tax Cut Continuation Act of 2011, §308; and the Middle Class Tax Relief and
Job Creation Act of 2012, §3002. Note that for SCHs and EACHs, the outpatient hold harmless
provision is effective for services rendered from January 1, 2010 through February 29, 2012,
regardless of bed size, and from March 1, 2012, through December 31, 2012, for SCHs and
EACHs with 100 or fewer beds. Rural hospitals with 100 or fewer beds are also extended through
December 31, 2012. These responses impact the TOPs calculation on Worksheet E, Part B, line 8.
Line 121--Did this facility incur and report costs (direct or indirect) in the “Implantable Devices
Charged to Patients” (line 72) cost center as indicated in the 73 FR 48462 (August 19, 2008),
bearing the revenue codes established by the National Uniform Billing Committee (NUBC) for
high cost implantable devices? Enter “Y” for yes or “N” for no.
Line 122--Does the cost report contain health care related taxes as defined in §1903(w)(3) of
the Act? Enter “Y” for yes or “N” for no in column 1. If the answer in column 1 is “Y”, enter in
column 2 the Worksheet A line number where these taxes are included.
Line 123--For a cost reporting period beginning on or after October 1, 2022, did the facility and/or
its subproviders (if applicable) purchase professional services, e.g., legal, accounting, tax
preparation, bookkeeping, payroll, 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 percent 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.
Line 124--Reserved for future use.
Line 125--Is this facility a Medicare-certified transplant center? Enter “Y” for yes or “N” for no
in column 1. If yes, enter the certification date and, if applicable, the termination date on lines 126
through 132, as applicable.
Line 126--If this is a Medicare-certified kidney transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also complete Worksheet D-4.
Line 127--If this is a Medicare-certified heart transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also complete Worksheet D-4.
Line 128--If this is a Medicare-certified liver transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also complete Worksheet D-4.
Line 129--If this is a Medicare-certified lung transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also, complete Worksheet D-4.
Line 130--If Medicare pancreas transplants are performed, enter the more recent date of
July 1, 1999, (coverage of pancreas transplants) or the certification date for kidney transplants in
column 1 and, if applicable, the termination date in column 2. Also, complete Worksheet D-4.
Line 131--If this is a Medicare-certified intestinal transplant program, enter the certification date
in column 1, and, if applicable, the termination date in column 2. Also, complete Worksheet D-4.

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Line 132--If this is a Medicare-certified islet transplant program, enter the certification date in
column 1, and, if applicable, the termination date in column 2. Also, complete Worksheet D-4.
Line 133--Removed and reserved.
Line 134--If this hospital operates a hospital-based organ procurement organization (OPO), enter
the OPO CCN in column 1, and termination date, if applicable, in column 2.
Lines 135 through 139--Reserved for future use.
Line 140--Are there any related organization or home office costs claimed as defined in
CMS Pub. 15-1, chapter 10? Enter “Y” for yes or “N” for no in column 1. If yes, complete
Worksheet A-8-1. If this facility is part of a chain and you are claiming home office costs, enter
in column 2, the home office chain number and complete lines 141 through 143. See
CMS Pub. 15-1, chapter 21, §2150, for a definition of a chain organization.
Line 141--Enter the name of the chain home office in column 1, the home office contractor name
in column 2, and the home office contractor number in column 3.
Line 142--Enter the street address and P. O. Box (if applicable) of the home office.
Line 143--Enter the city, State, and ZIP code, of the home office.
Line 144--Are provider-based physicians' costs included in Worksheet A? Enter “Y” for yes or
“N” for no. If yes, complete Worksheet A-8-2.
Line 145--If costs for renal dialysis services are claimed on Worksheet A, line 74, are the costs for
inpatient services only? Enter “Y” for yes or “N” for no in column 1. If column 1 is no, does the
dialysis facility include Medicare utilization for this cost reporting period? Enter “Y” for yes or
“N” for no in column 2. No response is required in column 1 or column 2 unless Worksheet A,
column 7, line 74, is greater than zero. If column 1 is yes, or column 2 is no, do not complete
Worksheet S-5 or the Worksheet I series for renal dialysis services.
Line 146--Have you changed your cost allocation methodology from the previously filed cost
report? Enter “Y” for yes or “N” for no. If yes, enter the approval date in column 2.
Line 147--Was there a change in the statistical basis? Enter “Y” for yes or “N” for no.
Line 148--Was there a change in the order of allocation? Enter “Y” for yes or “N” for no.
Line 149--Was there a change to the simplified cost finding method? Enter “Y” for yes or “N” for
no.
Lines 150 through 154--Reserved for future use.
Lines 155 through 161--If you are a hospital (public or non-public) that qualifies for an exemption
from the application of the lower of cost or charges principle as provided in 42 CFR 413.13,
indicate the component and/or services for titles V, XVIII and XIX that qualify for the exemption
by entering in the corresponding box a “Y” for yes, if you qualify for the exemption, or an “N” for
no, if you do not qualify for the exemption. Subscript as needed for additional components. For
title XVIII providers, a response of “Y” does not subject the provider to the LCC principle.
Lines 162 through 164--Reserved for future use.
Line 165--Is the hospital part of a multi-campus hospital that has one or more campuses in different
CBSAs? Enter “Y” for yes or “N” for no. (For purposes of this question, only answer yes if the
main campus and the off-site campus(es) are classified as section 1886(d) hospitals, or they are
located in Puerto Rico).
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Line 166--If you responded “Y” for yes to question 165, enter information for each campus
(including the main campus) as follows: name in column 0, county in column 1, State in column 2,
ZIP code in column 3, geographic CBSA in column 4, and the FTE count for this campus in
column 5. If additional campuses exist, subscript this line as necessary. Enter the information in
columns 0 through 5 for the main campus first, and then enter the information in each column for
the subordinate campuses, in any order. For example, for the main campus, enter on line 166 the
name, county, state, ZIP code, geographic CBSA, and FTEs per campus. For the first subordinate
campus, enter on line 166.01 the name, county, state, ZIP code, geographic CBSA, and FTEs per
campus. Report only FTE information associated with IPPS areas and not the FTE information
for excluded areas (i.e., hospital-based IPF and hospital-based IRF).
Line 167--Is this hospital/campus a meaningful user of electronic health record (EHR) technology
in accordance §1886(n) of the Social Security Act as amended by the section 4102 of the American
Recovery and Reinvestment Act (ARRA) of 2009 or the CAA of 2016, Division O, Title VI,
§602? Enter “Y” for yes or “N” for no. A CAH that is not a meaningful user beginning in
FFY 2015 is subject to a payment adjustment as defined in 42 CFR 413.70(a)(6)(i). A CAH may,
on a case-by-case basis, be granted an exception from this adjustment if CMS or its Medicare
contractor determines, on an annual basis, that a significant hardship exists, such as in the case of
a CAH in a rural area without sufficient internet access. However, in no case may a CAH be
granted an exception for more than 5 years.
Line 168--If this provider is a CAH (line 105 is “Y” for yes) and is also a meaningful EHR
technology user (line 167 is “Y” for yes), enter, if applicable, the reasonable acquisition cost
incurred for EHR assets either purchased or initially rented under a virtual purchase lease (see
42 CFR 413.130(b)(5) and (8), and CMS Pub. 15-1, chapter 1, §110.B.1.b) in the current cost
reporting period. If applicable, also enter the un-depreciated cost ( i.e., net book value) as of the
beginning of the current cost reporting period, for assets purchased or initially rented under a
virtual purchase lease in prior cost reporting period(s) which were used for EHR purposes in the
current cost reporting period. Do not enter on this line any cost for EHR assets which was already
claimed for the same assets in previous cost reporting period(s). The reasonable acquisition cost
incurred is for depreciable assets such as computers and associated hardware and software
necessary to administer certified EHR technology. (See 75 FR 44461 (July 28, 2010) and
42 CFR 495.106(a) and (c)(2).)
Additionally, if the amount on this line is greater than zero, submit a listing of the EHR assets
showing the following information for each asset: (1) nature of each asset and acquisition
cost; (2) an annotation whether the asset was purchased or leased under a virtual purchase lease
(42 CFR 413.130(b)(8)); (3) date of purchase or date the virtual purchase lease was
initiated; (4) name(s) of original purchaser (e.g., CAH, CAH’s home office, group of unrelated
providers); (5) information regarding the asset’s use (i.e., indication whether the asset (hardware
of software)) will be shared with CAH’s non-EHR systems; and, (6) tag number and location
(department unit). For cost reporting periods beginning on or after October 1, 2016, do not
complete this line.
Line 168.01--If this provider is a CAH (line 105 is “Y”) and is not a meaningful user (line 167 is
“N”), does this provider qualify for a hardship exception under 42 CFR 413.70(a)(6)(ii)? Enter
“Y” for yes or “N” for no. If no, the CAH is subject to a payment adjustment. The CAH’s
reasonable costs in providing inpatient services are adjusted as defined in 42 CFR 413.70(a)(6)(i)
for cost reporting periods that begin in or after FFY 2015. Specifically, sections 1814(l)(4)(A)
and (B) of the Act provide that, if a CAH does not demonstrate meaningful use of certified EHR
technology for an applicable EHR reporting period, then for a cost reporting period beginning in
FFY 2015, the CAHs reasonable costs shall be adjusted from 101 percent to 100.66 percent. For
a cost reporting period beginning in FFY 2016, the CAH’s reasonable costs shall be adjusted to
100.33 percent. For a cost reporting period beginning in FFY 2017 and each subsequent FFY, the
CAH’s reasonable costs shall be adjusted to 100 percent.

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Line 169--If this is a §1886(d) provider that responded “N” for no to question 105 and “Y” for yes
to question 167, enter the transition factor to be used in the calculation of your EHR incentive
payment. For cost reporting periods where the transition factor is zero, enter “9.99” for software
programming purposes. For hospitals that qualify for the EHR incentive payment under
ARRA 2009, §4120, this question is not applicable for cost reporting periods beginning on or after
October 1, 2016. For Puerto Rico hospitals that qualify for the EHR incentive payment under
CAA 2016, §602, this question is not applicable for cost reporting periods beginning on or after
October 1, 2021.
See 75 FR 44458-44460 (July 28, 2010) and CAA 2016, §602. The transition factor equals:
If a subsection (d) hospital first becomes a meaningful EHR user in fiscal year 2011,
2012 or 2013; or if a subsection (d) Puerto Rico hospital first becomes a meaningful
EHR user in fiscal year 2016, 2017, or 2018:
• The first year transition factor is 1.00
• The second year transition factor is 0.75
• The third year transition factor is 0.50
• The fourth year transition factor is 0.25
• Any succeeding transition year is 0
If a subsection (d) hospital first becomes a meaningful EHR user in fiscal year 2014;
or if a subsection (d) Puerto Rico hospital first becomes a meaningful EHR user in
fiscal year 2019:
• The first year transition factor is 0.75
• The second year transition factor is 0.50
• The third year transition factor is 0.25
• Any succeeding transition year is 0
If a subsection (d) hospital first becomes a meaningful EHR user in fiscal year 2015;
or if a subsection (d) Puerto Rico hospital first becomes a meaningful EHR user in
fiscal year 2020:
• The first year transition factor is 0.50
• The second year transition factor is 0.25
• Any succeeding transition year is 0
Line 170--If line 167 is “Y”, enter the EHR reporting period. Enter in column 1, the reporting
period beginning date and, in column 2, the ending date in accordance with 42 CFR 495.4. The
EHR reporting period may be a full federal fiscal year or, if this is the first payment year, any
continuous 90-day period within a federal fiscal year. If the EHR reporting period ending date is
on or after April 1, 2013, the EHR incentive payment will be subject to the 2 percent sequestration
adjustment. The response to this question impacts the sequestration calculation on Worksheet E-1,
Part II, line 9. For cost reporting periods beginning on or after October 1, 2016, do not complete
this line except for Puerto Rico hospitals.
Line 171--If this provider is a meaningful EHR technology user (line 167 is “Y”), the days
associated with individuals enrolled in section 1876 Medicare cost plans must be included in the
calculation of the incentive payment. Indicate if you have section 1876 days included in the days
reported on Worksheet S-3, Part I, line 2, column 6, by entering “Y” for yes or “N” for no in
column 1. If column 1 is yes, enter the number of section 1876 Medicare days in column 2.

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Exhibit 3A -- Listing of Medicaid Eligible Days for a DSH Eligible Hospital
If 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 a separate Exhibit 3A listing for each CCN. If a
SCH is eligible to receive a DSH payment adjustment but Worksheet E, Part A, line 48, is greater
than line 47, do not complete an Exhibit 3A listing; however, if Worksheet E, Part A, line 47, is
greater than line 48, the SCH must submit an Exhibit 3A listing. Enter dates in the
MM/DD/YYYY format.
Enter the provider name, CCN, CRP beginning and ending dates, the line number of
Worksheet S-2, Part I, that the listing supports, the sum of the days for columns 10 and 12, and the
sum of the days for column 11.
Columns 1 through 5--From the Medicaid patient’s claim, enter the patient name, dates of service,
and patient account or unique identification number, that correlate to the Medicaid eligible days
reported in columns 10 and 11, in columns 1 through 5, respectively.
Column 6--Enter the Medicaid recipient identification number that correlates to the Medicaid
eligible days reported in columns 10 and 11. For a newborn baby born to a Medicaid eligible
mother, enter the mother’s Medicaid identification number that correlates to the Medicaid eligible
days reported in columns 10 and 12.
Column 7--Enter the applicable State plan eligibility code number, if available. To report more
than one code, report the additional State plan eligibility codes in column 18.
Column 8--Enter a unique patient population code to identify a restricted or unrestricted Medicaid
eligible day. For restricted eligibility, use code R1 for pregnancy/labor and delivery services; use
code R2 for emergency services; or use a code R3 through R9 for user-defined restricted Medicaid
eligibility and provide the definition for the code in column 18. For unrestricted Medicaid
eligibility, use code U1 for general or use a code U2 through U9 for user-defined unrestricted
Medicaid eligibility and provide the definition for the code in column 18.
Column 9--For each entry in columns 10 and 12, or column 11, enter the Worksheet S-2, Part I,
column number where the days were reported.
Column 10--Enter the number of Medicaid eligible days during the dates of service entered in
columns 3 and 4, including the number of days for a newborn baby remaining in the hospital after
the Medicaid eligible mother’s date of discharge (see column 12 instructions for reporting newborn
baby days prior to the Medicaid eligible mother’s date of discharge). (See §4004.1 “Note for
lines 24 and 25” for definitions of the eligible Medicaid days.) The sum of the days in this column
must equal the sum of the days reported on Worksheet S-2, Part I, line 24 or 25, as applicable,
columns 1 through 5. In addition, the sum of the days summarized by each column reported in
column 9 must equal the days reported in the respective column on Worksheet S-2, Part I, line 24
or 25, as applicable. For example, if the listing supports days for Worksheet S-2, Part I, line 24,
then the sum of the days reported in column 10 of the exhibit must equal the days reported on
Worksheet S-2, Part I, line 24, sum of columns 1 through 5; and, if the days reported on
Worksheet S-2, Part I, line 24, column 3, equals 25, then the sum of the days entered in column 10
where column 9 is 3, must equal 25.
Column 11--Enter the number of labor and delivery days, defined as days during which a maternity
patient is in the labor/delivery room ancillary area at midnight at the time of census taking; the
maternity patient is not included in the census count of the inpatient routine care area because the
patient has not occupied an inpatient routine bed at some time before admission (see
CMS Pub. 15-1, chapter 22, §2205.2). The days reported in this column must equal the number
of days reported on Worksheet S-2, Part I, line 24, column 6.

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Column 12--Enter the number of newborn baby days occurring prior to the Medicaid eligible
mother’s date of discharge for a baby born to a Medicaid eligible mother. These newborn baby
days are in addition to the mother’s days reported in column 10. If the Medicaid eligible mother
was discharged and the newborn baby remained in the hospital, do not report the newborn baby
days occurring after the date of the mother’s discharge in this column; report the days on a separate
line in column 10.
Columns 13 and 14--Enter in column 13 the name of the insurance company or other payer with
primary responsibility for paying the claim. If applicable, enter in column 14 the name of the
insurer or other payer with secondary responsibility.
Column 15--Enter either “A” or “B” to indicate the patient’s Medicare eligibility during the dates
of service in columns 3 and 4; otherwise, if the patient was eligible for neither Part A nor Part B,
leave the column blank. If the patient was eligible for Medicare, enter “A” or “B” as follows:
•
•
•

if eligible for only Medicare Part A, enter “A”
if eligible for both Part A and Part B, enter “A”
if eligible for only Medicare Part B, enter “B”

Columns 16 and 17--If the entry in column 15 is either “A” or “B”, enter the date that the patient’s
Medicare eligibility started in column 16 and, if applicable, enter the date that the patient’s
Medicare eligibility ended in column 17.
Column 18--Enter optional comments and/or additional information as needed. To decrease
patients’ vulnerability to identity theft, do not report a patient’s date of birth or social security
number.

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EXHIBIT 3A
TITLE

MEDICAID ELIGIBLE DAYS FOR A DSH ELIGIBLE HOSPITAL

PROVIDER NAME
CCN
CRP BEGINNING DATE
CRP ENDING DATE
WS S-2, PT. I, LINE #
PREPARED BY
DATE PREPARED
TOTAL COLUMNS 10 &12
TOTAL COLUMN 11

PATIENT
LAST
NAME
1

WKST S-2,
PART I
COLUMN
NUMBER
9

40-38.4

PATIENT CLAIM INFORMATION
PATIENT
DATE OF
DATE OF
FIRST
SERVICE SERVICE NAME
FROM
TO
2
3
4

PATIENT
ACCOUNT
NUMBER
5

MEDICAID
NUMBER
6

STATE
ELIGIBILITY
CODE
7

MEDICAID DAYS
ELIGIBLE
DAYS
10

LABOR &
DELIVERY
ROOM DAYS
11

NEWBORN
BABY DAYS
12

INSURANCE OR
OTHER PAYER NAME
PRIMARY
SECONDARY
13

14

PATIENT
POPULATION
CODE
8

MEDICARE ELIGIBILITY
A/B
INDICATOR
15

START
DATE
16

END DATE
17

COMMENTS
18

Rev. 18