FQHC Rate Details
Calculation Template
Facility Name: ____________________________________
OpCert Number: ___________________________________
| Cost Center | 20XX/20XX 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 start rate methodology does not require actual costs for administration, medical, dental, and 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.
Example
| 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 start rate methodology does not require actual costs for administration, medical, dental, and 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.
