Health Facility Cash Assessment Program
Instructions for Completing Reporting Forms
Article 36 Long Term Home Health Care Provider (LTHHCP)
This form is to be used on a monthly basis to calculate the assessment liability. A separate report should be submitted even if there were no assessable cash receipts for the reporting month. The report and payment must be submitted on a timely basis to avoid incurring penalty and interest. Timely payments shall be defined as payments received (not postmarked) on or before the 15th of the month (adjusted for weekends and holidays.
When reporting, use whole dollars only.
Description. Itemize total cash receipts and list additional assessable cash receipts as detailed in the instructions.
Current Month. Report the current month´s cash receipts.
Line 1 - Cash from Patient Care Services: Enter ALL CASH RECEIPTS (and/or checks) received during the month. Cash receipts include but are not limited to payments received from Medicaid, Medicare, Blue Cross and Blue Shield, other insurance payors, Worker´s Compensation, and self-payors. Receipts are assessable in the month they are received irrespective of the service date or billing period (cash basis).
Line 2 - Other Cash Receipts: List all other cash receipts. Refer to the instructions and identify each receipt.
Line 3 - Total Other Cash Receipts: Sum of Other Cash Receipts listed under Line 2, a through j, etc.
Line 4 - Total Cash Receipts from All Sources: Line 1 plus Line 3.
Line 5 - Total Non-Assessable Cash Receipts: Enter the total of non-assessable items from Schedule L.
Line 6 - Assessable Cash Receipts: Line 4 less Line 5.
Line 7 - Assessment Rate: The applicable assessment rate for a given report period.
Line 8 - Current Month Assessment: Multiply Line 6 by Line 7.
Line 9 - Other Adjustments: Report adjustments due to errors or omissions in prior months and to report a credit for a prior month. Adjustments may be either a positive or negative. Specify the month for the adjustment, the applicable assessment rate, and the reason(s) for the adjustment. If the adjustment is for multiple months, attach a detailed schedule. Detailed records should be maintained as all data is subject to audit.
Line 10 - Amount Due: Line 8 plus Line 9. If the amount is negative (a credit amount), report on Line 11. Otherwise, remit this amount to the Assessment Fund Administrator.
Line 11 - Excess Credit for Future Remittance: Enter credit amounts from Line 10 and carry forward to Line 9 of next month´s report.
All Long Term Home Health Care Providers certified under Article 36 of the Public Health Law are assessed a percentage on monthly cash receipts from patient services and general operations.
Assessable Long Term Home Health Care Program Income
- All cash receipts from patient care services (excluding the waivered services listed in the "Non-Assessable Income" section below) less amounts applicable to patient or third-party refunds, irrespective of payment source or service date, received during the assessment period.
- Investment Income, except as otherwise referenced in this attachment.
- Cash receipts for other operating income for the time period noted above which will be assessed include:
Social Work Services Revenue
Patient Assessment and Cash Management Revenue
Housekeeping Service Revenue
Gift Shop Revenue
Revenues from Rental of Premises or Equipment
Sale of Medical Records and Abstracts
Sale of Scrap and Waste
Cash Receipts from Externally Granted Rebates and Expenses
Vending Machine Commissions
Other Operating Income Unless Specifically Referenced Below as Being Not Eligible for the Assessment
Transfers from Restricted Funds for Other Operating Expenses
Income from Interest, Penalty and Finance Charges
Sale of Medical and Surgical Supplies to Other than Patients
Sale of Drugs to Other than Patients
Non-Assessable Income - Schedule L
- Income from the following waivered services:
Social Day Care
Home Maintenance Tasks
Personal Emergency Response System
- Investment Income from Externally Restricted Plant Funds (e.g. sinking funds, funded depreciation).
- Income received from grants, charitable contributions, donations, bequests, and government deficit financing.
- Grants provided to Public Health Nursing Services as part of Local Public Health Aid financing.
- Worker Recruitment and Retention Grants
- Worker Recruitment, Training and Retention Grants
- Accessibility, Quality and Efficiency Grants
- Sales and Excise Taxes)
- Services defined as personal care services
For those agencies that provide personal care services through contracts with a local Department of Social Services, please also refer to the Personal Care Services Provider attachment.