Center Name: DOH License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT ADMINISTRATION Schedule A-1 DO NOT change any preprinted wording on this schedule. Description A B C D E F Number of Employees Hours Salaries and Fringe Benefits Fees and Other Expenses Recovery and Eliminations Net Routine Expenses DETAILS OF ADMINISTRATION 1 Management Fees, Provider Schedule of Explanation 2 Home Office Costs, Not in Line 1 Above 3 Director’s Fees and Expenses 4 Related Party Compensation 5 Management Auto Leasing and Depreciation 6 7 8 9 10 11 Management Out of State Travel 12 Administrator Out of State Travel 13 Assistant Administrator Out of State Travel 14 Management Salary 15 Administrator Salary 16 Assistant Administrator Salary 17 Management General Fringe Benefits 18 Administrator General Fringe Benefits 19 Assistant Administrator General Fringe Benefits 20 Management Special Fringe Benefits 21 Administrator Special Fringe Benefits 22 Assistant Administrator Special Fringe Benefits 23 Management Dues 24 Administrator Dues 25 Assistant Administrator Dues 26 Management Other (Specify): 27 Administrator Other (Specify): 28 Assistant Administrator Other (Specify): 29 Total to Schedule A, Line 23
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT OTHER ADMINISTRATIVE Schedule A-2 DO NOT change any preprinted wording on this schedule. Description Schedule A, Line Number A B C D E F Number of Employees Hours Salaries and Fringe Benefits Fees and Other Expenses Recovery and Eliminations Net Routine Expenses 1 Office Personnel 2 Office Supplies and Expenses 3 Telephone 4 License and Dues 5 Data Processing 6 Insurance Not Related to Property or Employees 7 Business Taxes 8 Travel 9 Accounting Fees 10 Legal Fees 11 Other Administrative Fees 12 Seminars 13 Medical Records 14 Help Wanted Ads 15 Services and Supplies Sold 16 Purchase Discounts and Rebates 17 Other OADM Recoveries 18 Amortization of Start-up Costs 19 Employee Gifts and Parties 20 Other (Specify): 21 Other (Specify): 22 Other (Specify): 23 Other (Specify): 24 Other (Specify): 25 Other (Specify): 26 Other (Specify): 27 Other (Specify): 28 Other (Specify): 29 Other (Specify): 30 Other (Specify): 31 Total to Schedule A, Line 24 A, 24
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT OTHER COST DETAILS Schedule A-3 Page 1 of 2 DO NOT change any preprinted wording on this schedule. Description Schedule A, Line Number A B C D E F Number of Employees Hours Salaries and Fringe Benefits Fees and Other Expenses Recovery and Eliminations Net Routine Expenses GFRB GENERAL FRINGE BENEFITS 1 FICA - OASDI 2 FICA - Medicare 3 Workers’ Compensation 4 Unemployment Insurance 5 Disability Insurance 6 Medical Insurance 7 Life and Other Insurance 8 Uniform Allowance 9 Employee Physicians and Inoculations 10 Other (Specify): Dental 11 Other (Specify): 401(k) 12 Other (Specify): CPR 13 Other (Specify): 14 Other (Specify): 15 General Fringe Benefit Recovery 16 Total to Schedule A, Line 1 A, 1 DS DEVELOPMENTAL SERVICES 17 Other Therapy: Daily Classroom Supplies 18 Other Therapy: Crafts 19 Other Therapy: 20 Other Therapy: 21 Other Therapy: 22 Other Therapy: 23 Other Therapy: 24 Total to Schedule A, Line 10 A, 10
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT EXPENSES NOT RELATED TO THE OPERATION OF THE CENTER Schedule A-4 DO NOT change any preprinted wording on this schedule. Description A B C D E F Number of Employees Hours Salaries and Fringe Benefits Fees and Other Expenses Recovery and Eliminations Net Routine Expenses 1 Personal Expenses 2 Interest 3 Fines, Penalties and Non-Allowable Interest 4 Amortization of Organization Cost 5 Prescribed Drugs 6 7 8 Income Taxes, including N. J. Corporate Business Tax on Net Income and Subsequent Years Liability 9 10 11 Contributions 12 Collection Costs for Overdue Private Patient Accounts 13 Promotional and Directory Advertising Except for Bold Print Yellow Page Ads 14 Expenses Relating to Future Expansion, to include Architect Fees 15 Fund Raising Expenses 16 Bad Debts 17 Other (Specify): 18 Other (Specify): 19 Other (Specify): 20 Other (Specify): 21 Other (Specify): 22 Other (Specify): 23 Other (Specify): 24 Other (Specify): 25 Other (Specify): 26 Other (Specify): 27 Total to Schedule A, Line 37
NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT BASIS OF ALLOCATION SCHEDULE Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: Schedule A-5 DO NOT change any preprinted wording on this schedule. Code Basis A B C D E Applicable to PMDC Applicable to Non-PMDC Total Percent Applicable to PMDC Percent Applicable to Non-PMDC 1 DEFAULT (100% Day Care) 2 Recipient Days 3 Accumulated Costs 4 Number of Meals Served 5 Square Feet 6 Other: 7 Other: 8 Other: 9 Other: 10 Other: 11 Other: 12 Other: 13 Other: 14 Other: 15 Other: 16 Other: 17 Other: 18 Other: 19 Other: 20 Other: 21 Other: 22 Other: 23 Other: 24 Other: 25 Other: 26 Other: The following allocation bases are acceptable. Only one allocation base may be used per line. This form MUST BE completed for ALL applicable lines. Use of any other basis MUST BE accompanied by the Department’s letter approving the use of the other basis. The Department’s letter is valid for a one-year period only. Use the default (0) for all 100% Pediatric Medical Day Care Center lines. Cost Center Allocation Basis 1. General Fringe Benefits, Administration and Other Administrative Recipient Days or Accumulated Costs 2. Dietary, Food Recipient Days or Number of Meals Served 3. Housekeeping, Other General Services, ALL Property Operating and Fixed Properly Cost Centers Square Feet 4. Nursing, All Special Care Cost Centers Recipient Days or Actual Cost
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT ITEMIZED SALARY SCHEDULE Schedule A-7 Page 1 of 2 DO NOT change any preprinted wording on this schedule. Sch.A Line No. Name Position Function Code * Total Hours Per Week Clinical Hours Per Week Annual Salary Full Time Equivalent Work Schedule Days and Hours of the Day Page 1 Total *Codes: A-Administration C-Clinical Staff D–Dietary Staff S-Support Staff T-Transportation Note: Administrator and Assistant Administrator are reported under “A”, Administration.
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT ITEMIZED SALARY SCHEDULE Schedule A-7 Page 2 of 2 DO NOT change any preprinted wording on this schedule. Sch.A Line No. Name Position Function Code * Total Hours Per Week Clinical Hours Per Week Annual Salary Full Time Equivalent Work Schedule Days and Hours of the Day *Codes: A-Administration C-Clinical Staff D–Dietary Staff S-Support Staff T-Transportation Note: Administrator and Assistant Administrator are reported under “A”, Administration.
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT NUMBER OF SLOTS UTILIZATION/ GROSS REVENUE FROM ROUTINE SERVICES Schedule B DO NOT change any preprinted wording on this schedule. Number of Slots E F A B C D A + B Total Amortized C + D Total Occupied Authorized Occupied AM PM AM PM A NUMBER OF SLOTS UTILIZATION 1 Private 2 Medicaid 3 4 Other (Specify): 5 Other (Specify): 6 Other (Specify): 7 Other (Specify): 8 Other (Specify): 9 ANNUAL UTILIZATION B GROSS REVENUES FROM ROUTINE SERVICES 10 Private 11 Medicaid 12 ABC Program for Medically Fragile Children 13 14 15 16 17 18 19 20 Other (Specify): 21 Other (Specify): 22 Other (Specify): 23 Other (Specify): 24 Other (Specify): 25 TOTAL REVENUES FROM ROUTINE SERVICES
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT DATA REGARDING RELATED PARTIES AND KEY EMPLOYEES Schedule D DO NOT change any preprinted wording on this schedule. A B C D E F G Related Party Type Related Party Name Loans Equity Percent of Total Reporting Period Transactions Ending Balance Annual Interest Rate Nature of Transaction(s) Schedule A Costs 1 2 3 DATA REGARDING KEY EMPLOYEES INCLUDING RELATED PARTIES H I J K L M O Title Name of Employee Hours Worked Annual Compensation Special Fringe Benefits Auto Expense and Other Related Party? Yes/No 4 Administrator 5 Asst. Administrator 6 Nursing Director 7 RN Supervisor 8 President 9 RELATED EMPLOYEE AND/OR WORKS IN MORE THAN ONE PEDIATRIC MEDICAL DAY CARE CENTER OR NURSING FACILITY Name of Employee E. I. Number Center’s Name Position(s) Hours Worked Compensation 10 11 12 13 14
Center Name: DHS License Number: Molina Number: Cost Report F.Y.E.: NEW JERSEY DEPARTMENT OF HUMAN SERVICES PEDIATRIC MEDICAL DAY CARE CENTER COST REPORT RECONCILIATION Schedule E DO NOT change any preprinted wording on this schedule. A B C D SCHEDULE COLUMN LINE AMOUNT EXPENSES 1 Total Gross Salaries Reported 2 Total Gross Salaries per Form 941 3 Difference Line (Line 1 less Line 2) 4 Explanations of Line 3 5 6 7 8 Total Expenses Reported 9 Total Expenses Per Financial Statements 10 Difference Line (Line 8 less Line 9) 11 Explanations of Line 10 12 13 14 15 16 TOTAL REVENUES 1 Routine Revenues B 2 Incidental Revenues 3 Other Operating Revenues 4 SCHEDULE 5 Total Revenues Reported 6 Total Revenues per Financial Statements 7 Difference Line (Line 5 less Line 6) 8 Explanations of Line 7 9 10 11 12 TOTAL