Provider Reimbursement Manual - Medicaid Services (CMS) Part 2, Provider Cost Reporting Forms and Instructions, Chapter 32, Form CMS-1728-94

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Provider Reimbursement Manual - Medicaid Services (CMS) Part 2, Provider Cost Reporting Forms and Instructions, Chapter 32, Form CMS-1728-94 Department of Health and Human Services (DHHS) Medicare Centers for Medicare and Provider Reimbursement Manual - Medicaid Services (CMS) Part 2, Provider Cost Reporting Forms and Instructions, Chapter 32, Form CMS-1728-94 Transmittal 19 Date: April 30, 2021 HEADER SECTION NUMBERS PAGES TO INSERT PAGES TO DELETE 3200 - 3200 (Cont.) 32-5 - 32-6 (2 pp.) 32-5 - 32-6 (2 pp.) 3206 (Cont.) - 3207 (Cont.) 32-17 - 32-20 (4 pp.) 32-17 - 32-20 (4 pp.) 3215.3 (Cont.) - 3215.4 32-34.1 - 32-34.2 (2 pp.) 32-34.1 - 32-34.2 (2 pp.) 3216.1 - 3216.1 (Cont.) 32-35 - 32-36 (2 pp.) 32-35 - 32-36 (2 pp.) 3218 - 3219 32-41 - 32-42 (2 pp.) 32-41 - 32-42 (2 pp.) 3233 - 3235.1 32-65 - 32-68 (4 pp.) 32-65 - 32-68 (4 pp.) 3290 (Cont.) - 3290 (Cont.) 32-325 - 32-326 (2 pp.) 32-325 - 32-326 (2 pp.) 32-347 - 32-348 (2 pp.) 32-347 - 32-348 (2 pp.) 32-351 - 32-354 (4 pp.) 32-351 - 32-354 (4 pp.) 3295 (Cont.) - 3295 (Cont.) 32-503 - 32-504 (2 pp.) 32-503 - 32-504 (2 pp.) 32-523 - 32-524 (2 pp.) 32-523 - 32-524 (2 pp.) 32-530.5 - 32-530.6 (2 pp.) 32-530.5 - 32-530.6 (2 pp.) 32-539 - 32-540.2 (4 pp.) 32-539 - 32-540.2 (4 pp.) NEW COST REPORTING FORMS AND INSTRUCTIONS--EFFECTIVE DATE: Cost reporting periods ending prior to December 31, 2020. This transmittal updates Chapter 32, Home Health Agency Cost Report, Form CMS-1728-94 to sunset the forms and update and clarify the instructions. Revisions include: Worksheet A • Updated instructions for Line 13 and 13.20. Worksheet C, Part III • Updated instructions for Line 16 and 16.20. Worksheet D, Part I • Updated instructions for Line 1 and 4.01. Worksheet F-1 • Added line 31.50 for the provider to report COVID-19 Public Health Emergency (PHE) funding in accordance with COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing, V. Cost Reporting, question 2; https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf. Worksheet S-4 • Updated instructions for Rural Health Clinics. Pub. 15-2-32 Worksheets O, O-3, O-4 • Unshaded line 38, columns 1 through 7, and shaded line 25, column 1. Edits • Added edit 1007S. • Revised edits 1020S, 1210S. REVISED ELECTRONIC SPECIFICATIONS EFFECTIVE DATE: Changes to the electronic reporting specifications are effective for cost reporting periods that end prior to December 31, 2020 DISCLAIMER: The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. CHAPTER 32 HOME HEALTH AGENCY COST REPORT FORM CMS 1728-94 Section General. ......................................................................................................................3200 Rounding Standards for Fractional Computations. ....................................................3201 Recommended Sequence for Completing Form CMS -1728-94. ..............................3202 Worksheet S - Home Health Agency Cost Report.....................................................3203 Part I - Certification by a Chief Financial Officer or Administrator of Provider(s). .........................................................................3203.1 Part II - Settlement Summary. .............................................................................3203.2 Worksheet S-2 - Home Health Agency Complex Identification Data. ......................3204 Worksheet S-2-1 - Home Health Agency Reimbursement Questionnaire ................3204.1 Worksheet S-3 - Home Health Agency Statistical Data. ...........................................3205 Worksheet A - Reclassification and Adjustment of Trial Balance of Expenses. .............................................................................................................3206 Worksheet A-1 - Compensation Analysis - Salaries and Wages ...............................3207 Worksheet A-2 - Compensation Analysis - Employee Benefits (Payroll Related). ...............................................................................................................3208 Worksheet A-3 - Compensation Analysis - Contracted Services/ Purchased Services… ............................................................................................................3209 Worksheet A-4 - Reclassifications.............................................................................3210 Worksheet A-5 - Adjustments to Expenses. ..............................................................3211 Worksheet A-6 - Statement of Costs of Services from Related Organizations. ......................................................................................................3212 Worksheet A-7 - Analysis of Changes in Capital Asset Balance. .............................3213 Worksheet B - Cost Allocation - General Service Costs and Worksheet B-1 - Cost Allocation - Statistical Basis. ....................................................................3214 Worksheet C - Apportionment of Patient Service Costs ...........................................3215 Part I - Aggregate Agency Cost Per Visit Computation ......................................3215.1 Part II - Computation of the Aggregate Medicare Cost and the Aggregate of the Medicare Limitation ...........................................................3215.2 Part III - Supplies and Drugs Cost Computation .................................................3215.3 Part IV - Comparison of the Lesser of the Aggregate Medicare Cost, the Aggregate of the Medicare Per Visit Limitation and the Aggregate Per Beneficiary Cost Limitation ....................................................................3215.4 Part V - Outpatient Therapy Reduction Computation .........................................3215.5 Worksheet D - Calculation of Reimbursement Settlement - Part A and Part B Services. ....................................................................................................3216 Part I - Computation of Lesser of Reasonable Cost or Customary Charges. .......3216.1 Part II - Computation of Reimbursement Settlement ..........................................3216.2 Worksheet D-1 - Analysis of Payments to Home Health Agencies for Services Rendered to Program Beneficiaries. ......................................................3217 Worksheets F, F-1, and F-2 - Financial Statements. ..................................................3218 Worksheet A-8-3 - Reasonable Cost Determination for Therapy Services Furnished by Outside Suppliers ...........................................................................3219 Part I - General Information. ................................................................................3219.1 Part II - Salary Equivalency Computation. ..........................................................3219.2 Part III - Travel Allowance and Travel Expense Computation - HHA Services. .........................................................................................................3219.3 Part IV - Overtime Computation..........................................................................3219.4 Part V - Computation of Therapy Limitation and Excess Cost Adjustment. ....................................................................................................3219.5 Rev. 18 32-1 CHAPTER 32 HOME HEALTH AGENCY COST REPORT FORM CMS 1728-94 Section Removed and reserved ...............................................................................................3220 Removed and reserved ...............................................................................................3221 Removed and reserved ...............................................................................................3221.1 Removed and reserved ...............................................................................................3221.2 Removed and reserved ...............................................................................................3221.3 Removed and reserved ...............................................................................................3222 Removed and reserved ...............................................................................................3222.1 Removed and reserved ...............................................................................................3222.2 Removed and reserved ...............................................................................................3222.3 Removed and reserved ...............................................................................................3223 Removed and reserved ...............................................................................................3223.1 Removed and reserved ...............................................................................................3223.2 Removed and reserved ...............................................................................................3224 Worksheet CM-1 - Allocation of General Service Costs to HHA-Based CMHC Cost Centers. ...........................................................................................3225 Part I - Allocation of General Service Costs to HHA-Based CMHC Cost Centers. ..........................................................................................................3225.1 Part II - Computation of Unit Cost Multiplier for Allocation of HHA- Based CMHC Administrative and General Costs ..........................................3225.2 Part III - Allocation of General Service Costs to HHA-Based CMHC Cost Centers - Statistical Basis ......................................................................3225.3 Worksheet CM-2 - Computation
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