New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 66 - INDEPENDENT CLINIC SERVICES › Subchapter 4 - FEDERALLY QUALIFIED HEALTH CENTER (FQHC) › Appendix C

Current through Register Vol. 56, No. 14, July 15, 2024
New FQHC Medicaid Cost Reports for First and Second Years of
				  Operation
Cost Report--Instructions for FQHCs that become Medicaid
				  providers on and after November 1, 2001. These cost report instructions are for
				  the first and second calendar years that the FQHC is a Medicaid provider. The
				  FQHC's first year as a Medicaid provider may represent less than a full year of
				  operation, but is counted as a full year for cost reporting, and a cost report
				  is due to the Division for this period, ending on December 31 of the initial
				  year.
Each Federally qualified health center (FQHC) participating
				  as an independent clinic provider in the Medicaid/NJ FamilyCare program shall
				  complete a cost report, as indicated at
				  N.J.A.C.
				  10:66-1.5(d). This
				  requirement is necessary to determine the amount of reimbursement to be paid to
				  the FQHC for services provided to Medicaid/NJ FamilyCare beneficiaries.
All Worksheets, Statistical Information, and a Certification
				  Page must be completed as appropriate. Additional documentation in the form of
				  sub-worksheets etc. may be provided by a FQHC to support a particular cost or
				  reclassification, adjustment to expenses, or other item(s). Calculations
				  requiring a percentage shall be carried to five decimal places.
The completion of a cost report serves as the basis for an
				  FQHC's interim reimbursement rate and the total Medicaid or NJ FamilyCare-Plan
				  A reimbursement due to an FQHC for services provided to Medicaid and NJ
				  FamilyCare-Plan A beneficiaries.
A copy of the Medicare cost report and the FQHC's audited
				  financial statements shall be submitted with the Medicaid cost report.
Following are the cost report forms and instructions for
				  their proper completion:
FQHC-2001-07 (Certification)--(i) (ii)
COMPLETION INSTRUCTIONS
Field
Explanation
1.
Enter the Federally Qualified Health
						  Center's name and
mailing address.
2.
Enter the Medicaid Provider Number assigned
						  to the FQHC.
3.
Enter the fiscal period of the FQHC being
						  reported.
4.
Circle the category of control most
						  representative of the
FQHC.
5.
List each owner possessing an amount of
						  ownership in the
FQHC, regardless of the level.
6.
All other Federally Qualified Health
						  Centers, providers of
service, or suppliers and other entities related to the
						  center
through common ownership or control must be listed
						  here. The use
of a subschedule is permitted as necessary.
7.
All grants received by the FQHC shall be
						  listed here. The
name, number and source of the grant (for example,
						  State of New
Jersey Grant #XXXXX, Public Health Service Grant
						  #XXXXX)
duration of the grant and the total grant dollars under
						  each
grant are to be listed. If additional space is required
						  attach a
supporting subschedule listing.
Certification statement:
Enter the full name of the FQHC and the reporting period
				  covered by the report. Note: Enter the signature of the officer/owner of the
				  FQHC and his or her title and date after the completion of the cost
				  report.
FQHC-2001-07 (Reclassification and Adjustment of Trial
				  Balance of Expenses)--(Worksheet 1)--(iii)(iv)(v)
COMPLETION INSTRUCTIONS:
Worksheet 1 is used to record the trial balance of expense
				  accounts from the books and records of the center for the year being reported.
				  This worksheet provides for any adjustments or reclassifications to the FQHC's
				  cost centers that may be required.
The order of the cost centers is designed to flow to
				  subsequent worksheets, where applicable, to aid in the cost report preparation.
				  It is recognized that not all of the cost centers will apply to every FQHC. For
				  example, not every facility will offer dental services. Where a cost center is
				  listed that does not apply, leave that center blank.
Blank lines for use by the center are provided wherein a
				  unique cost center or situation may exist. If these are used, the center must
				  identify what specific cost (center/service) are included.
Columns 1 and 2--Compensation and Fringe Benefits:
The compensation and fringe benefit expenses recorded on the
				  books of the center, for the period of the cost report, are to be entered on
				  the appropriate cost center lines. These expenses come directly from the trial
				  balance of the center without adjustment. Any needed reclassification or
				  adjustment must be recorded in columns 5 and 7, as appropriate.
Columns 1 and 2, Line 23--Pneumococcal and Influenza Vaccine
				  Services
The amounts for this line will be taken from the Medicare
				  Cost Report, Supplemental Worksheet B-1. If a FQHC is not required to complete
				  a Medicare Cost Report, Supplemental Worksheet B-1 must be completed as an
				  attachment to the Medicaid cost report. Supplemental Worksheet B-1 is the
				  mechanism for Medicaid and NJ FamilyCare reimbursement of pneumococcal and
				  influenza vaccine services.
Column 1, Line 23, Compensation--Enter the amount of
				  "Pneumococcal and Influenza Vaccine Health Care Staff Costs" From Line 3 of the
				  Medicare Cost Report, Supplemental Worksheet B-1. These amounts are excluded
				  from the totals calculations, as they are not subject to cost
				  limitations.
Column 2, Line 23, Fringe Benefits
Leave Blank, the amounts from fringe benefits are included in
				  Column 1.
Column 3--Other:
Enter the expenses of the various cost centers that are not
				  compensation or fringe benefits. These expenses come directly from the trial
				  balance of the center without adjustment. Any needed reclassification or
				  adjustment must be recorded in columns 5 and 7, as appropriate.
Column 3, Line 23, Other
Enter the amount of "Medical Supplies Cost--Pneumococcal and
				  Influenza Vaccine" from line 4 of the Medicare Cost Report, Supplemental
				  Worksheet B-1.
Column 4--Sub-Totals:
The sum of columns 1, 2 and 3, for each line is entered
				  here.
Column 5--Expense Reclassifications:
Enter any reclassification among cost centers in column 4
				  which are necessary to effect proper cost recognition and allocation.
				  Reclassifications are to be used when the expenses of a particular cost center
				  are applicable to more than one of the cost centers listed on the worksheet,
				  and are maintained in a single cost center on the books and records of the
				  center. For example, where a physician performs certain administrative duties,
				  the appropriate portion of his or her compensation and fringe would need to be
				  reclassified from the "Physician" cost center to "Administrative Costs
				  Staff--Administration" cost center. Thus, his or her administrative time (cost)
				  would be properly recognized.
Worksheet 1, Page 2-3, Line 59 Medical Records
Enter costs associated with Medical Records in Columns 1, 2
				  and 3. In Column 5, reclassify any or all amounts to appropriate Core or
				  Specialized Services categories. Appropriate schedules detailing the method of
				  allocation must be maintained for audit purposes.
Worksheet 1, Page 3-3, Line 79 Insurance--Malpractice
Enter costs associated with Insurance--Malpractice in Columns
				  1, 2 and 3. In Column 5, reclassify any or all amounts to appropriate Core or
				  Specialized Services categories. Appropriate schedules detailing the method of
				  allocation must be maintained for audit purposes.
Introduction to Column 6:
All reclassifications shall be specifically identified via
				  supporting schedules to the cost report as prepared by the center. The
				  supporting schedules must provide an appropriate explanation to each of the
				  affected cost centers. Any reduction of expense is to be shown in <
				  >angle brackets. The net total of the supporting schedule and column must
				  equal zero.
Worksheet 1, Support Schedule A is to be used for all
				  reclassifications. See instructions for specifics of this schedule.
Column 6--Reclassified Trial Balance:
This column is the total of column 4, plus or minus column 5.
				  The total of column 6, all pages, as found on Worksheet 1, line 108, Total
				  Center Costs, must equal that of column 4, line 108, Total Center Costs.
Column 7--Adjustments (Decreases/Increases):
Enter the amount of any adjustment to the center's
				  reclassified trial balance expenses. Adjustments are required to adjust
				  (increase or <decrease>) actual expenses in accordance with Medicaid and
				  NJ FamilyCare rules on allowable cost. An example of a situation in which
				  adjustment to expense would be required is where the clinic receives an
				  allocation from a central (home) office, has a practitioner assigned by the
				  National Health Service Corps, or the identification of pneumococcal vaccine
				  administration costs.
All adjustments reflected in column 7 shall be detailed on a
				  supporting schedule prepared by the clinic. The schedule shall provide an
				  explanation or rationale for the adjustment, whether the adjustment basis is
				  cost or amount received and the identification of any and all cost centers
				  affected.
Worksheet 1, Support Schedule B is to be used to document and
				  detail the adjustments contained in column 7. See instructions for specifics of
				  this schedule.
Column 8--Adjusted Net Expenses:
This column is used to combine the reclassified trial balance
				  amounts in column 6 with the adjustment amounts found in column 7 by individual
				  cost center. The amounts resulting in column 8 will be used in later schedules
				  in the determination of reimbursement of cost for services rendered to Medicaid
				  and NJ FamilyCare beneficiaries.
FQHC-2001-07 Worksheet 1 Support Schedule
				  A--Reclassifications--(vi)
COMPLETION INSTRUCTIONS:
This supporting schedule is designed to document any
				  reclassification of cost performed on the Trial Balance of Expenses, column 4.
				  A full explanation of the reclassification must accompany each
				  reclassification. A letter code (A), (B), (C), etc., should be used to identify
				  each reclassification shown. This will enable identification of
				  reclassifications, should this be necessary. An example of a reclassification
				  would be the identification of the administration and the pharmaceutical
				  expenses for pneumococcal vaccine. Cost could be reclassified from pharmacy and
				  the physician assistant cost centers to the pneumococcal vaccine services cost
				  center.
For every cost amount reclassified, a specific cost center
				  (columns 3 or 6) and line (columns 4 and 7) must be recorded. Increases are to
				  be identified in columns 3, 4 and 5, with decreases shown in columns 6, 7 and
				  8. The totals of column 5 and column 8 must equal.
FQHC-2001-07 Worksheet 1 Support Schedule B--Adjustments to
				  Expense Detail--(vii)
COMPLETION INSTRUCTIONS:
This supporting schedule is used to provide the necessary
				  detail for all adjustments, either (decreases) or increases, affecting cost
				  centers on Worksheet 1, Pages 1, 2 and 3.
A full explanation of the adjustment is to be entered in
				  column 1. In column 2 an alpha identifier of either C (cost) or R (revenue)
				  should be entered. This designates the amount of the adjustment as either a
				  revenue (received) offset or an actual cost offset.
An example of a revenue offset would be the revenues received
				  from the operation of a vending machine in the center. The revenue received
				  should be offset against the cost of providing the service. An actual expense
				  offset would be made where the cost could actually be determined, such as when
				  an adjustment to depreciation is necessary due to an independent audit firm
				  finding.
The total of column 3 must agree to the total found on
				  Worksheet 1, line 108, column 7.
FQHC-2001-07 Worksheet 2 ENCOUNTERS--(viii)
COMPLETION INSTRUCTIONS:
General:
Worksheet 2 is used by the center to summarize the total
				  encounters actually occurring during the cost reporting period. The form is
				  divided into two primary sections, that of core services, and that of other
				  ambulatory services. Space has been provided in the other specialized service
				  area for a service that may be unique to a center and not specifically
				  identified.
It should be noted that some services are specifically
				  identified under the specialized services category, yet they would be provided
				  by a physician, such as subdermal contraceptive implants, and would be
				  considered physician services. However, for purposes of reporting and to
				  uniquely track these expenses for rate establishment, they are to be identified
				  separately and the encounter associated with these services shown under their
				  specific category. For subdermal contraceptive implant services, line 15, the
				  number of subdermal contraceptive implant insertions/removals are to be
				  recorded. The actual visit should not be included in the Physician Cost Center,
				  line 1, column 2.
While care has been taken to account for the variety of
				  services provided in a center and establish a corresponding service line, blank
				  lines have been provided for reporting of additional special service centers
				  and associated cost. Refer to
				  N.J.A.C.
				  10:66-4.1(a)  for the
				  appropriate definition of a medical encounter.
Column 1, Medicaid Fee-for-Service--Enter in the appropriate
				  service category the number of actual, valid Medicaid and NJ FamilyCare
				  fee-for-service encounters. On line 16, enter the number of Medicaid and NJ
				  FamilyCare fee-for-service pneumococcal and influenza vaccine
				  injections.
Column 2, Medicaid Managed Care--Enter in the appropriate
				  service category the number of actual, valid Medicaid and NJ FamilyCare Managed
				  Care encounters for which cost-based reimbursement is allowable. On line 16,
				  enter the number of allowable Medicaid and NJ FamilyCare Managed Care
				  pneumococcal and influenza vaccine injections. If data is entered into this
				  Column the FQHC is required to complete Worksheet 2, Support Schedule A.
Column 3, Medicaid Total Encounters--Total of Columns 1 and
				  2.
Column 4, Managed Care Encounters--Enter in the appropriate
				  service category the number of encounters provided to managed care
				  beneficiaries who are not eligible for cost-based reimbursement. Include in
				  these numbers any managed care encounters provided to Medicaid and NJ
				  FamilyCare beneficiaries which are not allowable for cost-based reimbursement
				  in Column 2. On line 16, enter the number of pneumococcal and influenza vaccine
				  injections.
Column 5, New Jersey Department of Health--Enter in the
				  appropriate service category the number of encounters provided under letter of
				  agreement with the New Jersey Department of Health. This amount must include
				  the base level visits assigned by the New Jersey Department of Health. On line
				  16, enter the number of pneumococcal and influenza vaccine injections provided
				  under agreement with the New Jersey Department of Health.
Column 6, Medicare--Enter in the appropriate service category
				  the number of Medicare encounters. On line 16, enter the number of Medicare
				  pneumococcal and influenza vaccine injections.
Column 7, Self-Pay--Enter in the appropriate service category
				  the number of encounters provided to individuals who are either personally
				  liable or have private insurance. On line 16, enter the number of Self-Pay
				  pneumococcal and influenza vaccine injections.
Column 8, Other--Enter in the appropriate service category
				  the number of encounters which have not been previously reported. On line 16,
				  enter the number of Other pneumococcal and influenza vaccine injections.
Line 7 All Columns:--Enter the sum of lines 1 through 6, Core
				  Services--all columns.
Line 26 All Columns:--Enter the sum of lines 10 through 25
				  for each column as appropriate.
Line 28 All Columns:--Enter the sum of lines 7 and 26. Cross
				  foot all columns to column 7.
FQHC-2001-07 Worksheet 2 Support Schedule A--Medicaid Managed
				  Care Encounter Detail--(ix)
COMPLETION INSTRUCTIONS:
Column Headings (1-9)--Enter the name of each Managed Care
				  Company with which the FQHC contracts. If the FQHC is under contract with more
				  than nine Medicaid and NJ FamilyCare HMOs, additional pages/columns must be
				  included. Enter in the appropriate service category the number of actual, valid
				  Medicaid and NJ FamilyCare Managed Care encounters provided for each Managed
				  Care Company. On Line 16, enter the number of Medicaid and NJ FamilyCare
				  Managed Care pneumococcal and influenza vaccine injections.
FQHC 2001-07--Worksheet 2--Support Schedule B-Medicaid
				  Managed Care Receipts Detail-(x)
COMPLETION INSTRUCTIONS:
Line 1--Enter the name of each Managed Care Company with
				  which the FQHC contracts in Columns A through K. If the FQHC is under contract
				  with more than ten Medicaid and NJ FamilyCare HMOs, additional pages/columns
				  must be included.
Line 2 Enter the effective date of the contract with each
				  managed care company entered on line 1.
Lines 3 through 9--Enter the receipts received to date for
				  the services provided to Medicaid and NJ FamilyCare beneficiaries for the
				  period covered by the cost report.
Line 10--Enter the total of the amounts entered in lines 3
				  through 9.
Line 11--Enter the total of the amounts entered in line 10,
				  columns F and L.
FQHC-2001-07 Worksheet 3--PRODUCTIVITY SCREENING--(xi)
COMPLETION INSTRUCTIONS:
This Worksheet is used to determine if the productivity
				  screens of the various core and other services are being met. It develops the
				  various encounters that will be used in the determination of an encounter rate
				  for each core and specialized service. Additionally, it reflects the numbers of
				  staff assigned to each of the areas. Completion of Worksheet 3 requires
				  completion of Worksheets 6, 7 and 8.
Columns 1 and 1a--Number of FTEs and Total Hours--Staffing is
				  to be reported by FTEs and hours worked. FTEs should be reported using the
				  method prescribed by Medicare for the Medicare FQHC Cost Report (CMS-222-92)
				  Worksheet B, Part 1. For FQHCs that file a Medicare Cost Report with Medicare,
				  FTEs should match the FTEs reported on the Medicare FQHC Cost Report
				  (CMS-222-92), Worksheet B, Part 1 for Physicians, Nurse Practitioners, Clinical
				  Psychologists and Clinical Social Workers.
Column 2--Total Encounters--The total number of encounters
				  reported in Column 2 should be taken from the corresponding line in Worksheet
				  2, Column 9.
For Pneumococcal/Influenza Vaccine Services, line 16, the
				  number of injections given are to be shown in this column.
Column 4--Minimum Encounters:--The result of multiplying
				  column 1 by column 3 for all service lines is to be entered here. The resultant
				  is the minimum encounter requirement for the appropriate center (Productivity
				  Screen).
Column 5:--Enter here the greater of column 2 or column 4 for
				  all services. This will reflect the productivity standard application where
				  applicable and the resultant will be used for development of the actual per
				  encounter rate on subsequent worksheets.
FQHC-2001-07--Worksheet 4 Encounter Rate
				  Calculation--(xii)
COMPLETION INSTRUCTIONS:
General:--This worksheet is used to determine the per visit
				  encounter rate by specific service category that is to be used in the Medicaid
				  and NJ FamilyCare reconciliation process on Worksheet 5.
Part I:--Item (A) total actual facility direct health service
				  cost is calculated from taking Worksheet 1, line 36 column 8 plus the sum of
				  Worksheet 1, lines 52 and 56, column 8.
Part I: Item (B) Allowable Administrative costs. Item (B) is
				  reported as the LOWER of:
Worksheet 1, Line 71, Column 8 plus Worksheet 1,
Line 89, Column 8
or
30 percent of Total Center Costs from Worksheet 1,
Line 108, Column 8
Part I: Item (C) Allowable Facility Overhead Cost is
				  calculated from adding Item (B) Allowable Administrative Costs, PLUS, Worksheet
				  1, Line 103, Column 8.
Part II--Specialized Services
Column 1--Direct Cost:
Transfer to the appropriate line the total cost of each
				  specialized service area as found on Worksheet 1, Page 1, column 8. Note: The
				  total expense of the dentist/dental hygienist is the sum of worksheet 1, lines
				  17 and 18 column 8.
Column 2--Ratio of Special Service Center to Total Direct
				  Health Services:
Enter here the resultant of column 1 of this section divided
				  by the total facility direct health service cost (Worksheet 4, Part I, Item
				  (A)). The percentage derived will be the percentage of each of the special
				  service centers direct cost to total cost. Remember to carry all decimal
				  figures to five places.
Column 3--Facility Overhead Applicable to the Special Service
				  Center:
Enter here the percentage shown in column 2 of this section
				  multiplied by Worksheet 4, Page 1-2, Part I, Item (C). The amount derived is
				  the percentage of allowable facility overhead attributed to the individual
				  special service cost center.
Column 4--Total Cost of Special Service Cost:
Enter the sum of column 1 and 3 of this section for each
				  special service cost center. This amount reflects the total calculated cost for
				  each of the special service cost centers.
Column 5--Productivity Screening Encounters
Enter the productivity screening encounters from Worksheet
				  3, Page 1, column 5 for each special service cost center. Amount shown as Total
				  should agree to Worksheet 3, Page 1-1, column 5, line 26. The visits for
				  subdermal contraceptive implants are the actual subdermal contraceptive implant
				  procedures done, and the
Pneumococcal/Influenza Vaccine line, will reflect the actual
				  number of injections given as shown on Worksheet 3, Page 1-1, lines 15 and 16,
				  respectively, column 2. Dental/Dental Hygienist encounters are the sum of
				  Worksheet 3, line 10 and line 11, column 5.
Column 6--Computed Encounter Rate:
Divide column 4 by column 5 and enter the answer here. This
				  is your computed encounter rate for each specialized service to include direct
				  and allowable facility overhead costs.
FQHC-2001-07--Worksheet 4 Encounter Rate
				  Calculation--(xiii)
COMPLETION INSTRUCTIONS:
Part III--Core Services:--The function of this Part of
				  Worksheet 4 is to isolate the cost of direct core and other health service
				  costs and to allocate overhead based on the ratio of these costs to total
				  direct health care service costs. This amount is then divided by the total
				  number of Core Service encounters to arrive at an average Per Encounter Rate
				  for the facility.
Line 15:--The amount from Worksheet 4, Page 1-2, Part I, Item
				  (A) is transferred to this line.
Line 16:--The total direct cost of specialized services is
				  transferred to this line from Worksheet 4, page 1-2, Part II, line 14, column
				  1.
Line 17:--The non-reimbursable cost center's expenses, as
				  found on Worksheet 1 Trial Balance of Expense, line 56, column 8, are
				  transferred to this line.
Line 18.--Add amounts appearing on line 16 and line 17 and
				  place resulting figure here.
Line 19:--Subtract line 18 from line 15 and enter remainder
				  here.
Line 20:--Divide line 19 by line 15 to determine percentage
				  of direct core and other health service cost to total health service
				  cost.
Line 21:--Enter the allowable facility overhead from
				  Worksheet 4, Page 1-2, Part I, Item (C).
Line 22:--To determine the amount of allowable facility
				  overhead applicable to direct Core and other health services multiply line 20
				  by line 21. Enter the resultant here.
Line 23:--Enter the sum of line 19 plus line 22. This is the
				  total direct and allocated core and other health services reimbursable
				  cost.
Line 24:--Enter the total core service encounters from
				  Worksheet 3, Page 1, line 7, column 5 on this line.
Line 25:--Divide line 23 by line 24 to obtain the average
				  cost per encounter for core services.
FQHC-2001-07--Worksheet 5 Final Settlement
				  Determination--(xiv)
COMPLETION INSTRUCTIONS:
General:--This worksheet will determine the actual total
				  reimbursable cost for all Medicaid and NJ FamilyCare encounters for services
				  rendered during the cost reporting period and the final settlement amount
				  either due to or from a facility.
All Services--Lines 1 through 13:
Column 2:--For each of the line items, enter the
				  Medicaid-covered and NJ FamilyCare encounters from Worksheet 2, Page 1-1,
				  column 3, as appropriate. These amounts should agree with the facility's
				  State-produced summary report for the same period as that of the cost report.
				  The encounters produced in the State's summary report will represent the
				  maximum encounters to be reimbursed.
Line 1:--Enter the figure from Worksheet 2, Page 1-1, line 7,
				  column 3.
Lines 2-12:--Enter the figures from the appropriate line item
				  on Worksheet 2, Page 1-1, column 3.
Column 3:--Enter the computed encounter rate for each
				  applicable line item from Worksheet 4, Page 1-2, column 6, (Specialized
				  Services) or Worksheet 4, Page 2-2, line 25, (Core Services).
Column 4:--To determine the Medicaid and NJ FamilyCare
				  reimbursable cost for each type of service, multiply the amounts found in
				  column 2 by column 3. Enter the result here.
Line 13:--For columns 2 and 4, enter the sum of lines 1
				  through 12. Column 4, line 13, is the total paid Medicaid or NJ FamilyCare
				  encounters and costs for services provided by the facility for the period
				  covered by the cost report.
Line 14: requires no entry
Line 15, Rate Periods--Identify the periods for which
				  different limits apply during an FQHC's fiscal year.
Period 1:--Period 1 will be from the first day of the FQHC's
				  fiscal year through the earlier of:
(1) The day prior to the first Medicaid/NJ
				FamilyCare rate limitation change occurring during the FQHC's fiscal year.
or
(2)
				The end of the FQHC's fiscal year.
Period 2:--Period 2 will be the period from the date of the
				  first Medicaid/NJ FamilyCare rate limitation change occurring during the FQHC's
				  fiscal year through the earlier of:
(1) The day prior to the second Medicaid/NJ
				FamilyCare rate limitation change occurring during the FQHC's fiscal year.
or
(2)
				The end of the FQHC's fiscal year.
Period 3:--Period 3 will be the period from the date of the
				  second Medicaid/NJ FamilyCare rate limitation change occurring during the
				  FQHC's fiscal year through the end of the FQHC's fiscal year.
Line 16, Medicaid Limit:--Enter the amount of the Medicaid/NJ
				  FamilyCare fee-for-service limit in place during each period entered on line
				  15. The Medicaid/NJ FamilyCare limit is scheduled to be phased in over a
				  three-year period as follows:
July 1, 1996
120 percent of Medicare limit
July 1, 1997
115 percent of Medicare limit
July 1, 1998 and thereafter
110 percent of Medicare limit
The Medicare limit changes annually on January 1st.
				  Therefore, the Medicare limit established on January 1, 1996 will be inflated
				  by 20 percent to establish the initial Medicaid/NJ FamilyCare limit effective
				  July 1, 1996.
FQHCs with a fiscal year beginning prior to July 1, 1996 will
				  report that portion of the fiscal year on the previous cost reporting document.
				  All FQHCs will be required to complete the revised cost report for all or the
				  remaining portion of the fiscal year beginning July 1, 1996.
A 20 percent per annum factor will be used by Medicaid/NJ
				  FamilyCare to determine the Medicaid/NJ FamilyCare limit. The Medicaid/NJ
				  FamilyCare limit should not impact an FQHC's encounter rate more than 20
				  percent of the prior year's finalized encounter rate. (Finalized is defined as
				  the issuance of a Notification of Final Settlement by the Division of Medical
				  Assistance and Health Services, and acceptance by the FQHC.)
Line 17, Medicaid/NJ FamilyCare Encounters Per Period:--Enter
				  the Medicaid/NJ FamilyCare encounters rendered during each period reported on
				  line 15. The sum of all Medicaid/NJ FamilyCare encounters entered on line 17
				  should equal the total Medicaid or NJ FamilyCare encounters on line 13, column
				  2.
Line 18, Maximum Allowable Medicaid Costs--Line 18 is the
				  product of line 16 multiplied by line 17.
Line 19, Reimbursable Costs--Line 19 determines reimbursable
				  costs from the lower of line 13 or 18.
Line 20, Outstationed Eligibility Worker--Enter on line 20
				  the amounts charged during the cost reporting period for outstationed
				  eligibility workers.
Line 21, Pneumococcal/Influenza Vaccine Services:--Transfer
				  the number of Medicaid or NJ FamilyCare injections from Worksheet 2, Page 1-1,
				  Line 16, Column 3. Enter the rate from Worksheet 4, Page 1-2, Line 6, Column 6.
				  In Column 4 multiply the rate by the Medicaid or NJ FamilyCare injections to
				  determine reimbursable pneumococcal/influenza costs.
Line 22: Total Reimbursable Costs--Medicaid--Enter the total
				  of lines 19, 20 and 21.
Line 23, Less: Payments Received for Medicaid
				  Services:--Enter the total amount of interim payments received by the facility
				  for Medicaid and NJ FamilyCare services it rendered during the period of the
				  cost report. Please note that this figure is arrived at using the accrual
				  method of accounting and not a cash or modified cash, etc., basis. This amount
				  must agree to the summary report issued by the State for the respective period
				  of the cost report. The figure should include all payments regardless of
				  payment methodology including fee-for-service, capitation, and all payments
				  received from managed care funds as well as per encounter interim
				  payments.
Line 24, Net Due to or (From) Center:--Subtract line 23 from
				  line 22 and enter the amount here. If line 24 is positive, the resulting figure
				  is the amount owed to the facility based on the costs contained in the cost
				  report. If the amount on line 24 is negative the resultant figure is the amount
				  the facility has been overpaid during the period of the cost report for
				  Medicaid or NJ FamilyCare services rendered. This amount <negative>
				  should be placed in angle brackets. If the figure on line 24 reflects an
				  overpayment, amounts will be recouped in accordance with
				  N.J.A.C.
				  10:66-1.5(d)6  ii.
Line 25, Adjustment of Interim Payment Rate:--Enter the
				  amount from line 24 divided by total Medicaid or NJ FamilyCare encounters Line
				  13, Column 2. This amount must be further adjusted to reflect the phase-in of
				  the Medicaid/NJ FamilyCare limit.
FQHC-2001-07--Worksheet 6 Physician Detail--(xv)
Enter the required data for all physicians employed by the
				  FQHC.
Column 1--Enter the date which the physician entered
				  employment with the FQHC.
Column 2--If the physician's employment terminated during the
				  cost report period, enter the date.
Column 3--Enter the physician's Social Security
				  Number.
Column 4--Enter the physician's Medicaid Provider
				  Number.
Column 5--Enter the number of encounters performed by the
				  physician. The total amounts reported must reconcile to the figure reported on
				  Worksheet 2, Page 1-1, Line 1, Column 9.
Column 6--Enter the amount of gross salary paid to the
				  physician. The total amounts reported must reconcile to the amount reported on
				  Worksheet 1, Page 1-3, Line 2, Column 1.
Column 7--Enter the number of hours for which the physician
				  was compensated. Employment contracts and time records must be maintained for
				  audit purposes.
Column 8--Enter the number of physician hours for screening
				  purposes. Each hour a physician is compensated represents one hour to be
				  reported for productivity screening in column 8. The only adjustment allowed is
				  for the medical director, for which reported hours are the greater of
				  either:
1.--Fifty percent of compensated hours, or
2.--Actual hours providing direct care.
The total hours reported in column 8 must reconcile to the
				  hours reported on Worksheet 3, Page 1-1, Line 1, Column 1a.
FQHC-2001-07--Worksheet 7 Clinical Nurse
				  Practitioner/Certified Nurse Mid-Wife Detail--(xvi)
Enter the required data for all Clinical Nurse Practitioners
				  (CNP) and Certified Nurse Mid-Wives (CNM) employed by the FQHC.
Column 1--Enter the date which the CNP/CNM entered employment
				  with the FQHC.
Column 2--If the CNP/CNM's employment terminated during the
				  cost report period, enter the date.
Column 3--Enter the CNP/CNM's social security number.
Column --Enter the CNP/CNM's License and/or
				  Qualification.
Column 5--Enter the number of encounters performed by the
				  CNP/CNM. The total amounts reported must reconcile to the figure reported on
				  Worksheet 2, Page 1-1, Lines 2 and 3, respectively, Column 9.
Column 6--Enter the amount of gross salary paid to the
				  CNP/CNM. The total amounts reported must reconcile to the amounts reported on
				  Worksheet 1, Page 1-3, Line 3 or 4, respectively, Column 1.
Column 7--Enter the number of hours for which the CNP/CNM was
				  compensated. Employment contracts and time records must be maintained for audit
				  purposes.
Column 8--Enter the number of CNP/CNM hours for screening
				  purposes. Each hour a NP/NMW is compensated represents one hour to be reported
				  for productivity screening in column 8. The total hours reported in column 8
				  must reconcile to the hours reported on Worksheet 3, Page 1-1, Line 2 or 3,
				  respectively, Column 1a.
FQHC-2001-07--Worksheet 8 Dentist/Dental Hygienist
				  Detail--(xvii)
Enter the required data for all Dentists and Dental
				  Hygienists employed by the FQHC.
Column 1--Enter the date which the Dentist/Dental Hygienist
				  entered employment with FQHC.
Column 2--If the Dentist/Dental Hygienist employment
				  terminated during the cost report period, enter the date.
Column 3--Enter the Dentist/Dental Hygienist social security
				  number.
Column 4 Enter the Dentist/Dental Hygienist License and/or
				  Qualification.
Column 5 Enter the number of encounters performed by the
				  Dentist/Dental Hygienist. The total amounts reported must reconcile to the
				  figure reported on Worksheet 2, Page 1-1, Lines 10 and 11, respectively, Column
				  9.
Column 6--Enter the amount of gross salary paid to the
				  Dentist/Dental Hygienist. The total amounts reported must reconcile to the
				  amounts reported on Worksheet 1, Page 1-3, Line 17 or 18, respectively, Column
				  1.
Column 7--Enter the number of hours for which the
				  Dentist/Dental Hygienist was compensated. Employment contracts and time records
				  must be maintained for audit purposes.
Column 8--Enter the number of Dentist/Dental Hygienist hours
				  for screening purposes. Each hour a Dentist/Dental Hygienist is compensated
				  represents one hour to be reported for productivity screening in column 8. The
				  total hours reported in column 8 must reconcile to the hours reported on
				  Worksheet 3, Page 1-1, Line 10 or 11, respectively, Column 1a.
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