Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 300 - UNIFORM REPORTING SYSTEM FOR HOSPITAL FINANCIAL DATA › Appendix 590-300-A - MHDO Standardized Accounting Template

Current through 2024-29, July 17, 2024
Line
Field Name
Definition
1
Responsible Individual
Name of individual completing the template.
2
Parent or Hospital Name
Name of parent entity or hospital.
3
Parent or Hospital Location
City/town location of parent entity or
								hospital.
4
Year
Current fiscal year end date of parent entity or
								hospital.
5
BALANCE SHEET, UNRESTRICTED
								FUNDS
Heading.
6
CURRENT ASSETS
Heading. Short-term resources (i.e., those expected
								to be converted to cash or used within one year).
7
Cash and Investment
Cash, cash equivalents (money market funds) and
								short-term investments (marketable securities) listed under current assets and
								not restricted by external (donor or grantor) or internal (board or trustee)
								designations.
8
Current Assets Whose Use Is Limited
Cash, cash equivalents (money market funds) and
								short-term investments (marketable securities) limited internally without clear
								distinction between being board-designated or trustee-held, listed under
								current assets.
9
RECEIVABLES
Heading.
10
Net Patient Accounts Receivable
Patient accounts receivable, reported net of
								provisions for bad debt/uncollectible accounts and contractual
								allowances.
11
Due from Affiliates
Current portion of receivables due from affiliated
								entities. Includes also notes receivable from/loans or advances to affiliated
								entities. Amounts greater than or equal to +/- $100,000, individually or in
								aggregate must be identified by entity name and amount.
12
Third Party Settlements Receivable
Current portion of final settlements from
								third-party payers due to the hospital.
13
Other Accounts Receivable
Includes other receivables not related to patient
								services, third party receivables or amounts due from affiliates. Includes
								amounts due from restricted funds. Does not include grants or pledges
								receivable if their purpose is restricted by external stipulations (by donors
								or grantors).
14
Inventory
Supplies used to run the organization and provide
								services.
15
Other Current Assets
All other current assets not listed above,
								including prepaid expenses and deposits.
16
Total Current Assets
Sum of all short-term resources (lines 7 through
								15).
17
NON-CURRENT ASSETS
Heading. Long-term resources (i.e., those not
								expected to be converted to cash or used within one year).
18
Line intentionally left blank
19
Trustee-held Investments
Non-current portion of assets whose use is limited
								designated as trustee held. Includes investments or assets held under a
								contractual arrangement with an outside party other than a donor/grantor; these
								include funds held by a trustee, debt service reserve funds, bond and mortgage
								sinking funds. Trustee-held investments are contractually obligated for the
								purpose specified and are not available to fulfill other obligations of the
								hospital.
20
Board-Designated and Undesignated
								Investments
Non-current portion of assets whose use is limited
								by the Board of Trustees (i.e., internally designated) and any undesignated
								long-term investments. Includes assets set aside for capital
								improvements/acquisitions, funded depreciation and assets functioning as
								endowments. These fund designations can be revoked by Board decree and used to
								meet other obligations of the parent entity or hospital if necessary (these
								funds are discretionary). Include in here "beneficial interest in net assets of
								parent" unless the amounts are clearly donor restricted.
21
Due From Affiliates
Non-current portion of receivables due from
								affiliated entities, reported as notes receivable from/loans or advances to
								affiliated entities. Amounts greater than or equal to +/- $100,000,
								individually or in aggregate must be identified by entity name and
								amount.
22
Investment in Affiliates
Amounts recorded as equity investments (i.e., less
								than 50% share). Includes amount listed as goodwill/intangible assets for the
								purchase of another entity (e.g., a physician practice). Amounts greater than
								or equal to +/-$100,000, individually or in aggregate must be identified by
								entity name and amount.
23
Other Non-current Assets
All other non-current assets not listed above,
								including amounts due from restricted funds; deposits; other non-current
								unrestricted receivables; deferred financing costs (e.g., bond issuance costs)
								and deferred charges; pension and insurance obligations or retirement programs;
								cash surrender value of life insurance; organization costs, etc.
24
Gross Property, Plant & Equipment (PP &
								E)
Gross value of land, buildings, equipment,
								construction in progress, and capitalized leases.
25
Accumulated Depreciation
Includes depreciation of plant, property &
								equipment and amortization of capitalized leases.
26
Net Property, Plant & Equipment
Gross plant, property & equipment minus
								accumulated depreciation (line 24 minus line 25).
27
Total Non-current Assets
All long-term assets (lines 19 through 23, plus
								line 26).
28
Total Unrestricted Assets
All current and non-current assets not restricted
								externally by donors or grantors (line 16 plus 27).
29
CURRENT LIABILITIES
Heading. Short-term obligations (i.e., those
								expected to be due within one year).
30
Current Long Term Debt (LTD)
Current portion of long-term debt/bonds payable and
								capital leases; does not include notes payable, lines of credit or other
								short-term obligations.
31
Accounts Payable + Accrued Expenses
Includes accounts payable, accrued salaries, wages,
								payroll taxes, interest, vacation (earned time) and other accrued
								liabilities.
32
Estimated Third-Party Settlements
Current portion of amounts received from third
								party payers which the hospital expects to be due back to third parties in the
								current year (i.e., amounts received from third parties in the past may be in
								excess of allowable amounts and may therefore be paid back to third parties or
								else resolved favorably and recognized as revenue in the future).
33
Due to Affiliate
Current amounts owed to related entities. Amounts
								greater than or equal to+/-$100,000, individually or in aggregate must be
								identified by entity name and amount.
34
Other Current Liabilities
All other current liabilities, including amounts
								due to restricted funds; notes payable (unless owed to affiliated entity);
								lines of credit; deferred gift annuities; construction payable; current portion
								of self insurance funds, pension costs and post-retirement health benefits;
								current portion of deferred revenue, etc.
35
Total Current Liabilities
All short-term obligations (lines 30 through
								34).
36
NON-CURRENT LIABILITIES
Heading. Long-term obligations (i.e., those not due
								within one year).
37
Long-term debt
Non-current portion of long-term debt, capital
								leases and mortgage notes payable.
38
Estimated Third Party Settlements
Non-current portion of amounts received from third
								party payers which the hospital expects to be due back to third parties (i.e.,
								amounts received from third parties in the past may be in excess of allowable
								amounts and may therefore be paid back to third parties or else resolved
								favorably and recognized as revenue in the future).
39
Due to Affiliate
Non-current amounts owed to related entities.
								Amounts greater than or equal to +/- $100,000, individually or in aggregate
								must be identified by entity name and amount.
40
Self-Insurance Fund
Includes self-insurance, reserve for professional
								liability or workers' compensation.
41
Accrued Pension & Post-Retiree Health
								Benefits
Non-current amounts of accrued pension and
								post-retirement health benefits.
42
Other Non-current Liabilities
All other non-current liabilities including amounts
								due to restricted funds, notes payable (unless owed to affiliated entity),
								deferred gift annuities, construction payable, deferred revenue, etc.
43
Total Non-current Liabilities
Sum of all long-term obligations (lines 37 through
								42).
44
Fund Balance-Unrestricted
Includes all net assets that are not temporarily or
								permanently restricted by donor or grantor stipulations. Also includes funded
								depreciation.
45
Total Liabilities and Equity
Sum of all liabilities and net assets (fund
								balance) not restricted externally by donors or grantors (lines 35 plus 43 plus
								44).
46
RESTRICTED FUNDS
Heading. Includes accounts with external (donor or
								grantor) stipulations.
47
Cash and Investments
Includes cash and investments restricted by donor
								or grantor.
48
Receivables
Pledges and grants receivable restricted by donor
								or grantor and amounts due from general (unrestricted) fund.
49
Other Assets
Assets other than cash, investments and receivables
								restricted by donor or grantor.
50
Total Restricted Assets
Sum of all restricted assets (lines 47 through 49).
								Check that restricted assets equal restricted liabilities and net assets (line
								50 equals line 56).
51
LIABILITIES AND EQUITY
Heading.
52
Total Liabilities
Amounts due to the general fund and any liabilities
								whose purpose is restricted. If temporarily and permanently restricted
								liabilities and net assets are less than restricted assets, remove the amount
								necessary to balance restricted assets from unrestricted current liabilities
								(from other current liabilities if enough, otherwise from accrued
								expenses).
53
Temporarily Restricted Net Assets
Funds temporarily restricted by donor or grantor
								stipulations. Includes funds called specific purpose; property, plant and
								replacement; or term endowment funds.
54
Permanently Restricted Net Assets
Funds permanently restricted by donor or grantor
								stipulations, also called permanent endowment funds.
55
Total Restricted Fund Balance
Sum of temporarily and permanently restricted net
								assets (lines 53 through 54).
56
Total Restricted Liabilities and Equity
Sum of restricted liabilities and temporarily and
								permanently restricted net assets (line 52 plus 55). Restricted assets equal
								restricted liabilities and net assets (line 50 equals line 55).
57
INCOME STATEMENT
Heading.
58
Gross Inpatient Service Revenue
Total Inpatient Revenues before deductions.
59
Gross Outpatient Service Revenue
Total Outpatient Revenues before deductions.
60
Gross Patient Service Revenue (GPSR)
Total inpatient and outpatient revenues before
								deductions.
61
DEDUCTIONS
Heading.
62
Free Care (Charity Care)
Amount of charges provided for charity care.
63
Bad Debt (Provision for Bad Debts)
The estimate of Patient Accounts Receivable that
								will not be collected.
64
Contractuals
Includes discounts to third parties (Medicare,
								Medicaid, Blue Cross, commercial insurers, etc.) and employees. Record this net
								of changes in estimated settlements from prior years, which goes on the next
								line. The total of 64 plus 65 should equal total contractual
								adjustments.
65
Changes in prior year estimated/final
								settlements
If impact on Net Patient Service Revenue is
								favorable, record this as a negative number (reduction in revenue deduction);
								if unfavorable, record a positive number.
66
Net Patient Service Revenue
Gross patient service revenue minus deductions for
								free care, bad debt and contractuals (line 60 minus 62+63+64+65).
67
Other Operating Revenue
Include any other operating revenue from
								non-patient sources (e.g., garage revenue, cafeteria revenue, rental income),
								usually reported as other operating revenue and assets released from
								restriction for operations.
68
Total Operating Revenue
Sum of net patient service revenue and other
								operating revenue (line 66 plus 67).
69
OPERATING EXPENSES
Heading.
70
Depreciation and Amortization
Includes amounts listed as depreciation and
								amortization.
71
Interest
Includes all interest expense. If the hospital has
								no long-term debt, enter zero.
72
Advertising Expenses
Total advertising expenses, including allowable and
								unallowable costs using the definitions as specified in the most current
								version of the
Centers for Medicare & Medicaid Services, Provider
								Reimbursement Manual
and found at the MHDO website at
https://mhdo.maine.gov/hospital_financials.htm
(line 73 plus line 74).
73
Allowed Advertising Expenses
Allowable advertising costs using the definitions
								as specified in the most current version of the
Centers for Medicare
								& Medicaid Services, Provider Reimbursement Manual
and found at
								the MHDO website at
https://mhdo.maine.gov/hospital_financials.htm
.
74
Non-allowed Advertising Expenses
Unallowable advertising costsusing the definitions
								as specified in the most current version of the
Centers for Medicare
								& Medicaid Services, Provider Reimbursement Manual
and found at
								the MHDO website at
https://mhdo.maine.gov/hospital_financials.htm
.
75
Salaries and Benefits
Total salaries and benefits paid for personnel
								services, including full-time, part-time, local tenums, contracted, permanent,
								and temporary personnel.
76
Other Operating Expenses
Includes all operating expenses other than
								depreciation/amortization, interest, advertising, salaries & benefits, and
								bad debt.
77
Total Operating Expenses
Includes depreciation, interest, advertising,
								salaries & benefits, and all other operating expenses. (Note: Amount will
								be less than reported on income statement by amount of bad debt.)
78
Net Operating Income
Total operating revenue minus total operating
								expense (line 68 minus 77).
79
NONOPERATING REVENUE
Heading. Includes all gains/losses due to
								activities relating to the mission of the hospital.
80
Interest and Dividends
Includes dividend income; interest income from and
								realized gains/losses on sale of unrestricted investments; and unrestricted
								income on restricted assets.
81
Realized Gains/losses on sales of securities
Includes realized gains and losses on investments
								which accrue to the unrestricted fund; omit realized gains and losses accruing
								to restricted funds (see changes in net assets).
82
Permanently impaired security write downs
Includes unrealized losses deemed other than
								temporary by management, and taken out of income.
83
Total investment income
Sum of lines 80 through 82.
84
Gains/losses on joint ventures/equity
								investments
Includes gains or losses on the sale of fixed
								assets and gains/losses from equity investments and joint ventures.
85
Permanently impaired write-downs of other
								asset
Includes write-downs of assets deemed not worth
								their historical cost value, other than marketable securities.
86
Other Non-Operating Revenues (gifts, bequests,
								etc.)
Mostly contributions, gifts, bequest, although may
								include the "other" category.
87
Total Non-Operating Revenue
Sum of lines 83 through 86.
88
Excess of Revenue Over Expenses
Net operating income plus non-operating revenue
								(line 78 plus 87).
89
Extraordinary Gains (Losses)
Generally related to extraordinary gains/losses
								from advance extinguishment of debt.
90
Total Surplus/Deficit
Line 88 plus line 89.
91
CHANGES OF NET ASSETS
Heading.
92
Net assets released for restrictions
								-capital
Includes transfers from restricted funds for
								capital and direct capital donations.
93
Unrealized Gains (Losses) on Investments
Use the number in the statement of changes in
								unrestricted net assets; avoid using a total unrealized gain/loss that would
								include those accruing to restricted funds.
94
Minimum Pension Liability Adjustment
Occurs when market value of pension assets drops
								below a minimum level relative to the value of benefits.
95
Transfers from (to) Affiliates
Generally disclosed in statement of changes in net
								assets; may be reported as non-operating expenses. Amounts greater than or
								equal to +/- $100,000, individually or in aggregate must be identified by
								entity name and amount.
96
Mergers
Cash impact of mergers.
97
Consolidations with Support Organizations
Value of assets held on hospitals behalf by other
								organizations.
98
Other Changes
Include accounting policy changes and other
								non-income transactions not specifically identified above, that affect
								unrestricted net assets.
99
Total Change in Unrestricted Net Assets
Sum of lines 90 through 98.
100
STATEMENT OF CASH FLOWS
Heading.
101
CASH GENERATED FROM OPERATING ACTIVITIES
Heading.
102
Total Surplus/Deficit
Line 90.
103
Non-cash Expenses (Revenues)
Includes non-cash items affecting the total surplus
								number, such as depreciation and amortization expenses, gains/losses on equity
								investments, gain/loss on sale of assets, realized gain on sale of investments,
								and gains/losses associated with extraordinary items. Do not include any
								adjustments for restricted accounts or for items not included in the total
								surplus number (e.g., unrealized gains, accounting policy changes,
								etc.).
104
Funds from Operations
Lines 102 plus 103.
105
Decrease/Increase Current Assets Limited Use
Prior year minus current year current portion of
								assets whose use is limited (Change in line 8).
106
Decrease/Increase Accounts Receivable
Prior year minus current year current portion of
								patient accounts and other receivables excluding 3rd party and affiliate
								receivables (Change in lines 10 and 13).
107
Decrease/Increase Affiliate Receivable
Prior year minus current year current portion of
								affiliate receivable (Change in line 11).
108
Decrease/Increase 3rd Party Receivable
Prior year minus current year current portion of
								3rd party receivables (Change in line 12).
109
Decrease/Increase Inventory
Prior year minus current year current portion of
								inventories (Change in line 14).
110
Decrease/Increase Other Current Assets
Prior year minus current year of other current
								assets (Change in line 15).
111
Increase/Decrease Accounts Payable/Accrued
								Expenses
Current year minus prior year current portion of
								Accounts Payable and Accrued Expenses (Change in line 31).
112
Increase/Decrease 3rd Party Settlement
Current year minus prior year current portion of
								3rd party receivables (Change in line 32).
113
Increase/Decrease Due to Affiliates
Current year minus prior year current portion of
								due to affiliates (Change in line 33).
114
Increase/Decrease Other Current Liabilities (except
								Long Term Debt)
Current year minus prior year of other current
								liabilities (Change in line 34).
115
Other Non-cash Expenses (Revenues)
Includes non-cash items affecting the total surplus
								number not already identified. Completion of this field requires an
								explanation.
116
Cash from Working Capital
Sum of lines 105 through 115.
117
Cash from Operating Activities
Sum of funds from operations and cash from working
								capital (line 104 plus 116).
118
CASH FROM INVESTING ACTIVITIES
Heading. Investing activities include changes in
								non-current assets.
119
Decrease/Increase Board Designated
								Investment
Prior year minus current year balance of board
								designated and undesignated investments (Change in line 20).
120
Decrease/Increase Trustee Held Investment
Prior year minus current year balance in
								trustee-held investments (Change in line 19). All unrealized gains and losses
								go into line 119.
121
Decrease/Increase Due From Affiliates
Prior year minus current year non-current portion
								of due from affiliates (Change in line 21).
122
Decrease/Increase Affiliate Investments
Prior year minus current year non-current portion
								of investment in affiliates (Change in line 22). Gains/losses in equity of
								affiliate should be added/subtracted. Also, if amortization amount is available
								for any goodwill/intangible assets included in "affiliate investments,"
								subtract amortization amount and report on line 126.
123
Decrease/Increase Other Non-Current Assets
Prior year minus current year of other non-current
								assets (Change in line 23). If amortization amounts available for assets
								included in "other non-current assets, "subtract amortization amounts and
								report on line 126.
124
Decrease/Increase Gross Plant Property &
								Equipment (PP&E)
Insert amount reported on cash flow statement,
								reported as purchase of additions to PP&E or capital expenditures.
125
Sale of Fixed Assets
Proceeds from the sale of fixed assets/plant,
								property & equipment.
126
Other Cash Provided (Used) in Investing
								Activities
Includes other cash or non-cash items affecting the
								total investing activities not already identified. Completion of this field
								requires an explanation.
127
Cash Provided (Used) In Investing Activities
Sum of lines 119 through 126.
128
Cash Position Before Outside Financing
								Activities
Sum of lines 117 and 127.
129
CASH FROM FINANCING ACTIVITIES
Heading. Includes changes in long-term debt
								(include current portion) and non-current liabilities and amounts transferred
								to/from restricted funds and other entities.
130
Issue Long Term Debt (include leases for equipment
								even if reported as non cash; be sure to add the amount added to
								PP&E)
Insert amount reported on cash flow statement,
								reported as proceeds from/issue of long-term debt/bonds payable and capital
								lease obligations. Do not insert reported proceeds from short-term
								obligations/notes payable/lines of credit, captured in line 114 (change in
								other current liabilities).
131
Repay Long Term Debt (include Current Long Term
								Debt)
Insert amount reported on cash flow statement,
								reported as payment of long-term debt/bonds payable and capital lease
								obligations (Amount reported should include change in current portion of
								long-term debt). Do not insert amounts reported for payment of financing
								costs/bond issuance costs, which are captured in line 123 (change in other non
								current assets), or any payment of short-term obligations/notes payable/line of
								credit, which are captured in line 114 (change in other current
								liabilities).
132
Increase/Decrease Third Party Settlement
Current year minus prior year non-current portion
								of 3rd party settlements (Change in line 38).
133
Increase/Decrease Due to Affiliates
Current year minus prior year non-current portion
								of due to affiliates (Change in line 39).
134
Increase/Decrease Pension, Self Insurance
Current year minus prior year non-current portion
								of accrued pension, self insurance reserves (Change in lines 40 and 41).
135
Increase/Decrease other Non-Current
								Liabilities
Current year minus prior year of other non-current
								liabilities (Change in line 42).
136
Transfers From (To) Restricted Funds
Transfers to/from restricted funds from/to general
								(unrestricted) fund for capital, as reported on line 92.
137
Transfers From (To) Other Entities
Equity transfers from/to other entities, line
								95.
138
Other Cash Provided (Used ) in Financing
								Activities
Includes other cash or non-cash items affecting
								financing activities not already identified. Completion of this field requires
								an explanation.
139
Cash Provided (Used) Financing Activities
Sum of lines 130 through 138.
140
Net Change in Cash
Sum of lines 128 and 139.