Health Facility Cash Assessment Program

Instructions for Completing Reporting Forms

Residential Health Care Facility (RHCF)

General Instructions

Health Facility Cash Receipts Assessment Report - This form is to be used on a monthly basis to calculate the assessment liability. A separate report should be submitted for each month, 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 fifteenth of the month (adjusted for weekends and holidays).

Please round off to whole dollars.

Columnar Descriptions

Description. This column itemizes total cash receipts and provides space to list additional assessable cash receipts as detailed in these instructions.

Current Month. This column is to be used for reporting the current month´s cash receipts.

Linear Descriptions

Line 1 - Cash from Patient Care Services. Enter ALL CASH RECEIPTS (and/or checks) from patient care services that were received during the month. These 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. The 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 that follow as a guide to identify all other cash receipts.

Line 3 - Total Other Cash Receipts. Enter the total of all other Cash Receipts listed on Line 2.

Line 4 - Total Cash Receipts from All Sources. Lines 1 plus Line 3.

Line 5 - Total Non-Assessable Cash Receipts. Enter the total of non-assessable items from Schedule A (Line 7); a list of non-assessable items are listed below.

Line 6 - Assessable Cash Receipts. Line 4 less Line 5.

Line 7 - Assessment Rate. The applicable assessment rate for a given period.

Line 8 - Current Month Assessment. Multiply the amount on Line 6 by the applicable assessment rate.

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. Add Lines 8 and 9. If the amount is a negative number (or a credit amount), it should be also placed on Line 11. Otherwise, this is the amount that should be remitted to the Fund Administrator.

Line 11 - Excess Credit for Future Remittance. Enter any credit amount that results on Line 10. This should be carried forward and placed on Line 9 of next month´s report.

Assessable Residential Health Care Facility Income

  • All cash receipts from patient care services less any amounts applicable to patient or third party refunds, irrespective of payment source or services date, received during the assessment period.
  • Investment income, except as otherwise referenced in this attachment, received during the assessment period.
  • Cash receipts from patient services and other operating income, which will be assessed include:
Resident Services Revenue - All Sources
Nonresident Services Revenue - All Sources
Cash Receipts Applicable to Prior Periods
Supplies and Services Sold to Others
Private Duty Nursing Fees
Cafeteria, Gift Shop and Public Restaurants
Rental Income from Real Property, Equipment and Other Telephone & Telegraph Services
Vending Machine Commissions and Other Commissions
Medical Records and Abstract Fees
Sale of Scrap and Waste
Barber and Beauty Shops
Cash Receipts for Externally Granted Rebates and Refunds
Transfers from Restricted Funds for Other Operating Expenses
Income from Unrestricted Bank Accounts
Income from Unrestricted Investments
Extraordinary Income
Other Operating Revenue unless Specifically Referenced Below As Being Not Eligible for the Assessment

Non-Assessable Income - Schedule A

Charitable Contributions
Income from Funded Depreciation Accounts
Income from Operating Escrow Account
Income from Mortgage Repayment Escrow Accounts
Patient Personal Fund Allowances
Income Earned on Patient Personal Funds
Government Deficit Financing
Sales and Excise Taxes
Reimbursable Assessment
Article 36 Long Term Home Health Agency
Receipts on or after October 1, 2002 for Patient Services Provided to Medicare Beneficiaries - report these receipts only on Line 6 of Schedule A¹.


  1. Commencing October 1, 2002, residential health care facility receipts attributable to payments received pursuant to Title XVIII of the federal Social Security Act (Medicare) shall be excluded from the assessment pursuant to PHL section 2807-d(2)(b)(vi). Receipts from payors making payments as a result of providing coverage for Medicare coinsurance and/or deductibles will also be excluded. Note that the assessment shall apply to receipts from payors making payments as a result of a person´s exhaustion of Medicare benefits, or lack of Medicare benefits for a particular service. Do not include such amounts as excludable on this line.