HEALTH COMMERCE SYSTEM (HCS)

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Facility Name: ____________________________________
OpCert Number: ___________________________________
Cost Center 2019/2020 Ceiling Visits Maximum
Allowable Ceiling
Adjusted
Operating Cost
Reimbursable
Operating Cost
Administration $0.00 0 $0   $0
Medical $0.00 0 $0   $0
Dental $0.00 0 $0   $0
Therapy $0.00 0 $0   $0
Patient Transportation $0.00 0 $0 $0 $0
Ancillaries $0.00 0 $0 $0 $0
TOTAL   0 $0   $0
Operating Cost per Visit (total reimbursable operating cost / total visits)   #DIV/0!
Capital Cost   $0
Capital Cost per Visit (capital cost / total visits)   #DIV/0!
Total Cost per Visit (operating + capital)   #DIV/0!

Budgeted Capital Costs  
Rent  
Mortgage interest  
Depreciation  
Property insurance  
Amortization  
Other (specify)  
Total  

New FQHC rate methodology does not require actual costs for administration, therapy and medical cost centers. Therefore these cost centers use FQHC peer group ceiling allowable costs.

Patient transportation and ancillaries should be based on projected actual costs to be held to applicable peer group ceiling.

Cost Center 2019/2020 Ceiling Visits Maximum
Allowable Ceiling
Adjusted
Operating Cost
Reimbursable
Operating Cost
Administration $26.19 13064 $342,146   $342,146
Medical $85.88 11000 $944,680   $944,680
Dental $82.47 1000 $82,470   $82,470
Therapy $118.04 1064 $125,595   $125,595
Patient Transportation $0.32 13064 $4,180 $15,000 $4,180
Ancillaries $6.81 13064 $88,966 $78,000 $78,000
TOTAL   13064 $1,588,037   $1,577,071
Operating Cost per Visit (total reimbursable operating cost / total visits)   $120.72
Capital Cost   $39,404
Capital Cost per Visit (capital cost / total visits)   $3.02
Total Cost per Visit (operating + capital)   $123.74

Budgeted Capital Costs  
Rent  
Mortgage interest  
Depreciation $47,859
Property insurance $1,300
Amortization  
Other (specify)  
Total $49,160

New FQHC rate methodology does not require actual costs for administration, therapy and medical cost centers. Therefore these cost centers use FQHC peer group ceiling allowable costs.

Patient transportation and ancillaries should be based on projected actual costs to be held to applicable peer group ceiling.