Cms-10897 Supplemental To Form Cms-2552-10

SUPPLEMENTAL TO FORM CMS-2552-10
FORM APPROVED
OMB NO. 0938-XXXX
EXPIRES XX-XX-XXXX

THIS REPORT IS REQUIRED BY LAW (42 USC 1395g; 42 CFR 413.20(b)). FAILURE TO REPORT CAN RESULT IN ALL INTERIM
PAYMENTS MADE SINCE THE BEGINNING OF THE COST REPORTING PERIOD BEING DEEMED OVERPAYMENTS (42 USC 1395g).

PAYMENT ADJUSTMENT FOR ESTABLISHING AND MAINTAINING ACCESS TO A BUFFER STOCK OF ESSENTIAL MEDICINES

PROVIDER CCN:
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PERIOD:
FROM: ______________
TO:
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PART
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I - ESSENTIAL MEDICINES PAYMENT ADJUSTMENT ELIGIBILITY
NUMBER OF BEDS
IS THIS AN INDEPENDENT HOSPITAL?
DID THE HOSPITAL INCUR COST IN ORDER TO ESTABLISH AND MAINTAIN ACCESS TO A BUFFER SUPPLY OF ESSENTIAL MEDICINES?

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PART
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II - ADDITIONAL RESOURCE COST OF ESSENTIAL MEDICINES
COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES - DIRECTLY INCURRED
COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES - CONTRACT
TOTAL COST TO ESTABLISH AND MAINTAIN BUFFER STOCK OF ESSENTIAL MEDICINES

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PART
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III - CALCULATION OF MEDICARE PAYMENT ADJUSTMENT FOR ESSENTIAL MEDICINES
MEDICARE ROUTINE/ANCILLARY COST
MEDICARE ACQUISITION COST
COST OF PHYSICIANS' SERVICES IN A TEACHING HOSPITAL
TOTAL MEDICARE REASONABLE COST
TOTAL FACILITY COST
MEDICARE PERCENTAGE
ESSENTIAL MEDICINES PAYMENT ADJUSTMENT

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