1 Remedial Services Financial and Statistical Report Training January 20, 2009.

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Remedial Services

Financial and Statistical Report Training

January 20, 2009

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General Overview

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What is a Financial & Statistical Report?

Also called “cost report”.The purpose of the cost report is:

To define the reasonable and proper cost of each RSP service, To establish a per unit payment rate for Medicaid-payable remedial services, andTo determine a final reconciliation to actual and allowable RSP cost, also called a “settlement amount.”Report actual and allowable cost for Group Foster Care, which is used by the DHS Bureau of Purchased Services.

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Cost Report Submission

Costs should be submitted for a 12-month period consistent with the agency fiscal year.

Submitted using Form 470-4414, Financial and Statistical Report for Remedial Services.

Must be received within 3 months of the end of the agency fiscal year.

Failure to submit a complete cost report may result in a reduction of payment, eventually down to $0.

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Annual Cost Report OverviewThe cost report must be completed on the accrual basis of accounting.Information to complete the cost report may come from various sources. Personnel, payroll, provider expense records, activity logs, mileage logs, time studies or square footage studies are examples of tools that may be used to compile information to complete the cost report.RSP costs are not reimbursable under other funding sources. Cost incurred for other services shall not be reported as reimbursable for RSP.Regulations regarding the RSP cost report submission are located in Iowa Administrative Code Section 441, Ch. 79.

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What to Send and WherePer IAC 441 Chapter 79.1(23)(b)(2)

Form 470-4414 available on the IME website at http://www.ime.state.ia.us/Providers/Forms.htmlDue within 3 months of the agency fiscal year end.Email completed cost reports and documentation to: [email protected] (Preferred Method)

Mail paper copies to Provider Cost Audit & Rate Setting Unit, PO Box 36450, Des Moines, IA 50315A signed copy of the Certification Page must be mailed, with original signatures, through US Mail, FedEx, etc. Fax or email is not acceptable.

http://www.ime.state.ia.us/Providers/Forms.html

mailto:[email protected]

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Parent (Consolidated) Cost Report

Agencies that are offering RSP using more than one Medicaid provider number must prepare a “parent” cost report by consolidating all costs and units from the cost reports of each separate RSP provider number within their agency. Include the Tax ID Number on all cost reports and report “PARENT” as the report type on the Identification Page of the parent cost report.

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Submission Deadline ExtensionPer IAC 441 Chapter 79.1(23)(b)(3): “A provider may obtain a 30-day extension for submitting the cost report by sending a letter to the IME provider cost audit and rate setting unit before the cost report due date. No extensions will be granted beyond 30 days.”

Requests can be made through email or US Mail.All requests should include the following:

Provider NameFull Provider Number: NPI-Taxonomy-Zip9Applicable Medicaid ProgramReason for request

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Delinquent Cost Reports

Per IAC 441 Chapter 79.1(23)(b)(5): “If a provider fails to submit a cost report that meets the requirement of this paragraph, the department shall reduce payment to 76 percent of the current rate. The reduced payment rate shall be paid for no longer than three months, after which time no further payments will be made.”

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Supporting Financial Records

Per IAC 441 Chapter 79.1(23)(b)(1): “Financial information shall be based on the provider’s financial records. When the records are not kept on the accrual basis of accounting, the provider shall make the adjustments necessary to convert the information to an accrual basis for reporting. Failure to maintain records to support the cost report may result in termination of the provider’s Medicaid enrollment.”

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Supporting Financial RecordsPer IAC 441 Chapter 79.3: “A provider of a service that is charged to the medical assistance program shall maintain complete and legible records as required in this rule. Failure to maintain records or failure to make records available to the department or to its authorized representative timely upon request may result in claim denial or recoupment.”

Per IAC 441 Chapter 79.3(1): “A provider of service shall maintain records as necessary to:

(1)Support the determination of the provider’s reimbursement rate under the medical assistance program; and(2)Support each item of service for which a charge is made to the medical assistance program. These records include financial records and other records as may be necessary for reporting and accountability.”

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Supporting Financial Records

Per IAC 441 Chapter 79.1(23)(b)(4): “Providers of services under multiple programs shall submit a cost allocation schedule, prepared in accordance with the generally accepted accounting principles and requirements specified in OMB Circular A-87. Costs reported under remedial services shall not be reported as reimbursable costs under any other funding source. Costs incurred for other services shall not be reported as reimbursable cost under remedial services.”

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Financial and Statistical Report

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Provider Identification PageReports Provider Information:

Agency NameCityProvider Number – The full number should be used (NPI-Taxonomy-Zip9)Report Type – Actual, Projected or ParentFYE (Fiscal Year End)

Reports Unit Cost SummaryThis data is pulled from Schedule D. No input is required here.

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Iowa Department of Human Services

FINANCIAL AND STATISTICAL REPORT FOR REMEDIAL SERVICES

PROVIDER IDENTIFICATION PAGE

AGENCY NAME

CITY

PROVIDER NO.

REPORT TYPE

FYE

RATE REFLECTED - Billed Unit Cost

96152 Health and Behavior Intervention-Individual Per 15 Min $ 0.00

96153 Health and Behavior Intervention-Group Per 15 Min $ 0.00

96154 Health and Behavior Intervention-Family Per 15 Min $ 0.00

H0037 Community Psychiatric Supportive Treatment Per Day $ 0.00

H2001 Rehabilitation Program Per Half-Day $ 0.00

H2011 Crisis Intervention Service Per 15 Min $ 0.00

H2014 Skills Training and Development Per 15 Min $ 0.00

470-4414 (08/08)

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Certification Page

The purpose of the Certification Page is to report agency statistical information and record the signature of the authorized officer of the agency.

Must receive a signed Certification Page to consider the cost report complete.

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Certification PageAgency Information

Name of Person to Contact with QuestionsWe will generally try to communicate with your specified contact person; however, some circumstances may require us to direct questions to the Medicaid provider instead of a contracted preparer.

Independent AuditNot required, although beneficial.

May be requested to submit to IME, if available.

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Type of Entity: Government, Non-Profit, Proprietary

Type of Control: Individual, Partnership, Corporation, S-Corp

Accounting Basis: Accrual, Modified Cash, Cash

o This question refers to how your agency operates.o The Cost Report must be completed using the accrual basis.o Adjustments to convert to an accrual basis are required if your records

are maintained on another basis. The intent of these adjustments is to obtain information concerning the costs of providing services on a basis that is fair and comparable among providers of the service.

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Iowa Department of Human Services

FINANCIAL AND STATISTICAL REPORT FOR REMEDIAL SERVICES

CERTIFICATION PAGE

AGENCY NAME 0 IRS ID#

ADDRESS PROVIDER NO. 0

CITY, STATE, ZIP CODE

PERIOD OF REPORT: From To DATE OF FISCAL YEAR END 01/00/00

ADMINISTRATOR NAME TELEPHONE NO. NAME OF PERSON TO CONTACT IF

QUESTIONS ABOUT REPORT TELEPHONE NO.

Does agency have an independent audit? Yes, for year ending No

Has a copy of the latest independent audit been submitted? Yes No

A. Type of Entity : GOVERNMENT NON-PROFIT ORGANIZATION PROPRIETARY

B. Type of Control: INDIVIDUAL PARTNERSHIP CORPORATION S CORPORATION

C. Accounting Basis : ACCRUAL MODIFIED CASH CASH

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Certification PageStatistical Data for Period of Report

#2 – If subject to licensure, number of clients licensed for:

Required for Group Foster Care services only.

#3 – No. of units of service (licensed or staffed)Required for Group Foster Care services only, optional for RSP services.

Indicate if you are reporting licensed units or staffed units (bold, underline, circle, etc.).

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#4 – Total number of units of service providedShould equal the sum of Questions 5a and 5b.Does not include units of Other Programs.Includes all units of service provided regardless of whether or not payment has been received (includes denied claims, claims not yet submitted to IME, pending claims, etc.).

#5a – DHS UnitsDHS = IME (Title XIX)

#5b – Other Client UnitsShould be fairly rare

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#6 – Percent of units provided to unit capacityRequired for Group Foster Care services .

Service ColumnsA separate column for each RSP or Group Care service.

Only complete a column for the services you have provided during the cost report period.

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D. Statistical Data For Period of Report :

1. Service Code 96152 96153 96154 H0037 H2001 H2011 H2014Child Welfare

ServiceGroup Care

Maintenance2. If subject to licensure, number of clients licensed for :3. No. of units of service (licensed or staffed)

a. Type of unit (15 Min, Daily, etc) 15 Min 15 Min 15 Min Daily Half-Day 15 Min 15 Min Daily Daily4. Total number of units of service provided5. Total number of units of service provided for :

a. DHS clientsb. Other clients

6. Percent of units provided to unit capacity(divide line 4 by line 3) #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

7.Are the rates received from non-DHS clients the same as or

more than, POS rates for the same service?yes yes yes yes yes yes yes yes yes

Indicate yes, or no, for each service. no no no no no no no no no

If no, explain.

Group Care Only

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Certification PageSignatures

Signature of Office or AdministratorCertifies that the information is true and correct. Also certifies that the cost report was prepared from the records of the facility in accordance with the instructions and that unnecessary expenses were properly excluded.

Signature of Preparer (If other than Agency)Statement that the cost report was prepared to the best of knowledge and belief, represents true and accurate data of the agency.

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Certification PageSignatures

E. Form of Certification by Officer or Administrator of Provider Agency: I CERTIFY that I have examined the accompanying schedules of revenues and expenses and the calculations of cost of service prepared for this agency and that to the best of my knowledge and belief they are true and correct. I also certify these schedules were prepared from the books and records of the facility in accordance with instructions contained in this report, and allowable cost of care excludes expenses that were not necessary to provide this care.

SIGNED (Officer or Administrator of Facility)

(Title) (Date)

F. Statement of Preparer (If Other Than Agency) I have prepared this report and to the best of my knowledge and belief, it represents true and accurate data of the agency stated above.

(Signed) (Date)

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Schedule ARevenue Report

Total RevenueThe “Total Revenue” column includes all revenues, including those from other programs

• Should reconcile to General Ledger Revenues• Is not limited to just RSP/Group Care• DHS = IME

A supporting schedule should be submitted for all “Other” Revenues, Contributions and Government Grants

o The supporting schedule should include at a minimum: Source and amount of income, description of restriction/appropriation (if applicable), purpose and period of grant & applicable program.

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Schedule ARevenue Report

Revenue for Sch D Expense DeductionIncome not directly related to the provision of service as well as contributions restricted/appropriated to an individual should offset expense, to the extent of the related expense on Schedule D.

o Revenue deductions on Schedule A should reconcile to deductions on Schedule D.

o All Revenue Deductions should be reported, regardless of program.o Examples:

Investment/Interest Income Rent Income Food/Phone reimbursement Vending

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SCHEDULE A - REVENUE REPORT

Revenue for Schedule DExpense

REVENUES : Total Revenue Deduction *

Fee for Service :

Iowa State Department of Human Services $

County Board of Supervisors

Private Clients

Department of Education (Voc Rehab)

(service fees only)

United Way (service fees only)

Social Security, SSI, SSA

Other

Service, Reimbursement of Investment Income :

Work Services Revenue $ $

Food Reimbursement (DOE)

Investment Income

Other (attach schedule)

Contributions : (schedule must be attached)

United Way : Contributions not

Restricted / Appropriated $ $

Restricted / Appropriated

Contributions **

Other : Contributions not



Contributions **

Government Grants :

TOTAL REVENUE $ 0 * $ 0

* Income which must be deducted from total service expense on Schedule D.** Agencies must have documentation or support which identifies purpose of contributions reported as restricted / appropriated.

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Schedule BGross Salaries & Staff NumbersThe purpose of Sch B is to report full-time equivalent numbers of staff and wages by job title.Wages reported on Sch B should reconcile to wages reported on Sch D, Column 1.Detail the job titles under each classification with the applicable number of staff, FTEs and Wage information.1.0 FTE is considered to be 2,080 paid hours. Detailed instructions for calculating FTEs are included in the RSP Provider Manual, page 20.

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Contracted Staff

A supporting schedule for contracted staff should be submitted.

Include:Name & Title,

Wage Rate,

Total hours worked during the period, and

Where expense is reported on Sch D

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Related Party CompensationPer CMS Publication 15-I 902.1 – The allowance of compensation for services of sole proprietors and partners is the amount determined to be the reasonable value of the services rendered regardless of whether there is any actual distribution of the profits of the business.

“Reasonable Cost” for purposes of Medicaid-payable services is defined as that amount of cost or expenses that would ordinarily be incurred by similar providers in similar markets. It is that level of cost which a prudent and cost conscious buyer of goods and services is ordinarily willing to incur in providing these kinds of services (provider manual, page 15).

Each provider is responsible for keeping documentation to support their methodology and calculation of reasonable compensation. This should be submitted to IME with the cost report.

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Related Party CompensationPer CMS Publication 15-I 902.2 – Compensation (for Corporate Owners) may be included in allowable provider cost only to the extent that it represents reasonable remuneration for managerial, administrative, professional and other services related to the operation of the facility and rendered in connection with direct patient care. Services not related to patient care, are not recognized as an allowable cost.

Payments found to represent a return on equity capital are not compensation and are in no event allowable as an item of reimbursable cost. Nor are such payments considered as compensation for purposes of determining the reasonable level of reimbursement of the owner.

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SCHEDULE B - STAFF GROSS SALARIES AND STAFF NUMBERS

JOB CLASSIFICATIONS: NUMBER OF STAFF GROSSSALARIES

Full Part FTE's AND Time Time WAGES

ADMINISTRATIVE - NO. 2110Title:

ADMINISTRATIVE TOTAL - NO. 2110 0 0 0.00 $ 0

PROFESSIONAL - NO. 2120Title:

PROFESSIONAL TOTAL - NO. 2120 0 0 0.00 $ 0

DIRECT CLIENT CARE - NO. 2130Title:

DIRECT CLIENT CARE TOTAL - NO. 2130 0 0 0.00 $ 0

CLERICAL - NO. 2150Title:

CLERICAL TOTAL - NO. 2150 0 0 0.00 $ 0

OTHER STAFF - NO. 2190Title:

OTHER STAFF TOTAL - NO. 2190 0 0 0.00 $ 0

TOTAL SALARIES & STAFF NUMBERS 0 0 0.00 $ 0

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Schedule C Depreciation & Amortization Expense

The purpose of Schedule C is to report information related to depreciable assets.

Schedule C includes the original acquisition costs, capital improvements, and depreciation on buildings and equipment owned by the provider.

May submit an Asset Depreciation Schedule from your accounting system in lieu of Schedule C. This must include subtotals and reconcile to Schedule D.

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The total depreciation amounts reported on Sch. C must reconcile to the amounts reported on Sch. D.Any property expenses related to providing room and board are not reimbursable under rule for the RSP program and should be excluded.Depreciation expense must be calculated using the straight-line method.

If the agency does not use the straight-line method, the difference between methods should be adjusted in Column 3 of Schedule D so that only Straight-line Depreciation Expense is allocated.

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To determine the estimated useful life on new assets, the American Hospital Association guidelines should be followed.

If a depreciable asset at the time of its acquisition has an estimated useful life of at least two years and a historical cost of at least $5,000, the cost must be capitalized and depreciated over the estimated useful life.

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When items are purchased as an integrated system, all items must be considered as a single asset when applying the capitalization threshold. Items that have a stand-alone functional capability may be considered on an item-by-item basis.

For example, an integrated system of office cubicles must be considered as a single asset;

Stand-alone office furniture such as a chairs may be considered on an item-by-item basis.

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Change of OwnershipIf a change of ownership occurs, the historical cost of the assets acquired will be the historical cost less depreciation allowed to the previous owner (book value).

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SCHEDULE C - DEPRECIATION AND AMORTIZATION EXPENSE

ACCT DEPREC. RECORDEDNO. YEAR ORIGINAL RECORDED DEPREC. ANNUAL DEPREC.

(Schedule D) ACQUIRED COST PRIOR YEAR METHOD RATE EXPENSE

EQUIPMENT: BUILDING EQUIPMENT 4420

1. SL $ 02. SL $ 03. SL $ 0

SUBTOTAL EQUIPMENT

4420 $ 0To Schedule D, line 4420 $ 0


(Schedule D) ACQUIRED COST PRIOR YEAR METHOD RATE EXPENSE

MOTOR VEHICLES: 44101. SL $ 02. SL $ 03. SL $ 0

SUBTOTAL VEHICLES

4410 $ 0To Schedule D, line 4410

$ 0

TOTAL EQUIPMENT


(Schedule D) ACQUIRED COST PRIOR YEAR METHOD RATE EXPENSEBUILDINGS: BUILDINGS 4480

1. SL $ 02. SL $ 03. SL $ 04. SL $ 0TOTAL

BUILDINGS & LEASEHOLDS

4480 $ 0To Schedule D, line 4480

$ 0

TOTAL EQUIPMENT

& BUILDINGS

4400 $ 0To Schedule D, line 4400 $ 0

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Schedule C Related Party Property Cost

If property is leased from a related party, information regarding the lessor’s costs must be submitted on Schedule C.

Related party is defined as an ownership related through control, form ownership, capital investment, directorship or other means.

Related party property cost is limited to the lessor’s cost.

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RELATED PARTY PROPERTY COSTS

1. Is any property being leased from a party "related to provider" using the definitions in the contract and the Provider Handbook? Yes No

2. SCHEDULE OF LESSOR'S COSTS :

If answer to number 1 is yes, provide lessor's costs in the space below.

Depreciation on property

Property taxes

Mortgage interest on property

Insurance

Other (describe)

0.00 TOTAL $

SCHEDULE C - DEPRECIATION AND AMORTIZATION EXPENSE

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Schedule DExpense Report

The purpose of Schedule D, is to report total agency expenses and allocate those expenses to the various services provided by an agency.

The allocation of costs per service includes all costs for the agency and should be consistent with the costs included on the general ledger.

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Direct Cost includes expenses that are identifiable to a specific service. Direct cost could include, but is not limited to:

All direct personnel & immediate supervisors involved in a service (salary, benefits and payroll tax),

Mileage costs for travel necessary in the provision of service

Time spent documenting services provided,

Time spent in staff meetings related to a specific service,

Occupancy expenses related to space dedicated to a specific service.

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Indirect Cost includes expenses that are not identifiable to any specific service. This includes expenses incurred to benefit all functions of the agency.

Indirect Cost will be allocated across all programs. Therefore, all expenses included in Indirect Cost must be allowable under all programs.

Indirect Costs can include, but are not limited to:o Administrative and Clerical staff,

o Office supplies,

o Occupancy Expense related to general use areas,

o Property or liability insurance.

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Provide supporting documentation for the allocation method used in determining indirect costs and in apportioning direct costs (Provider Manual, Page 16).

In general, ensure that supporting documentation is maintained for all costs reported and numbers of staff devoted to remedial services and group foster care.

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Gross Total – Column 1: Report total operating costs of the agency. Any difference between the amounts shown in this column and the audited financial statements, general ledger or working trial balance must be disclosed in a supplemental schedule.

Revenue Adjustments – Column 2: Use this column to offset expense with related revenue. These adjustments come from Schedule A.

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Excluded Cost – Column 3: Use this column to remove expense that is not reimbursable under the Medicaid program. This column should not be used to report Other Program Expense. Excluded Cost may include, but is not limited to, the following:

Fundraising,Bad Debt,Fines and penalties,Lobbying (includes the portion of certain organization dues apportioned for lobbying),The difference between Straight-Line Depreciation and another method,Promotional advertising/marketing,Mileage expense in excess of the State Reimbursement Rate,Other expenses unallowable per OMB Circular A-87, Att. B.

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Excluded Cost – Mileage Limit: Mileage cost is limited to the DHS employee reimbursement rate. Any reimbursement paid to employees in excess of the limit should be excluded in Column 3.

The current mileage rate can be found at the Department of Administrative Services website: http://www.das.iowa.gov

The policy is located under the “Fleet and Mail Services” menu

o 7/1/05 – 12/31/07 $0.34

o 1/1/08 – Current $0.39

http://www.das.iowa.gov/

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Adjusted Cost – Column 4: This column shows costs that are allowable and allocable to RSP, Group Foster Care, Other Programs and Indirect Expense (Gross Cost -

Revenue Deductions - Excluded Cost = Adjusted Cost). RSP Direct Service Cost – Columns 5 to 14: Use these columns to report costs directly associated with RSP services.Group Foster Care Direct Cost – Columns 12 & 13: Use these columns to report cost directly associated with group care service and maintenance. This data is summarized from Supplemental Schedule D-1.

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Other Program Direct Cost – Column 14: Use this column to report cost directly associated with any program other than RSP or Group Care.

Other Programs may include:o Children’s Mental Health or other HCBS Waiverso LPHA Assessmentso Private Pay Therapy Serviceso Family, Safety, Risk and Permanency Serviceso Educational Programs

You must maintain documentation to support Other Program cost. These documents must be organized, in detail by program or service and in an easily audited format. The IME may conduct periodic audits of this information (Provider Manual, Page 27).

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Total Facility Indirect Cost – Column 15: This column includes costs that benefit all functions of the agency and cannot be directly related to any specific service or program.

These costs will be allocated to all programs on the last page of Schedule D.

All line items may be used to report indirect expense in Column 15.

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Total Facility Indirect Cost – Continued: Each agency is responsible for developing an acceptable method of distributing indirect cost to the various programs and supporting its rationale. The standard method is based on the total accumulated direct costs for each program before the indirect cost allocation.If an agency believes that another allocation method is more appropriate, it may be used. However, the agency must submit documentation to support and justify the alternate allocation basis used.

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Unit Cost Calculation – Last Page of Sch D:Total Direct + Total Allocated Indirect = Total Expense for each service

Revenue Deductions: If deductions were not reported in Column 2, they may be entered here to reduce Total Expense for each Service

Units: Total Expense after Deductions is divided by Total Units for each Service

o Must include all units of service provided, regardless of whether or not payment has been made

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Common Expense Issues:Calculation or Completion Errors

These errors are the most common reasons why a review is put on hold during preliminary review:Hand-written cost reports are too difficult to read,Other Program Cost is not included, All columns on Schedule D correctly total,Each line cross-foots (totals across),

Col. 1 minus Col. 2 minus Col. 3 = Column 4The sum of Column 5 through Column 15 = Column 4

Sch. A Total Revenue reconciles to Sch. E,Sch. A Revenue Deductions reconcile to Sch. D,Sch. B Total Salary Expense reconciles to Sch. D,Sch. C Total Depreciation Expense reconciles to Sch. D,Sch. D Gross Total Expense reconciles to Sch. E,Sch. D Group Care Expense reconciles to Sch. D-1,Schedules specific to Group Foster Care are included.

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Common Expense Issues:Benefits & Payroll Tax

Employee benefits and payroll taxes should be allocated across direct program expense and indirect expense using the same method as salary expense.Per the Internal Revenue Code, FICA is to be 7.65% of wages up to a specific limit (changes annually).

Sole proprietors may only claim the Employer share of FICA for reimbursement, not the Employee share.Report actual FICA expense, not the amount of estimated payments.

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Common Expense Issues:Personal Property Expense

Includes expenses such as Personal Home Office Expense or use of a Personal Vehicle

Must be able to support the proportionate amount of time, space or expense that is for business purposes versus personal purposes.This may include square footage calculations or tracking all miles driven.Out of total business expense, must be able to further determine the amount applicable as a direct or indirect expense of each program and that it is a necessary expense for patient care. These calculations must be performed annually.

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96152 96153 96154 H0037Health Health Health Community

Behavior Behavior Behavior PsychACCOUNT Gross Revenue Excluded Adjusted Intervention Intervention Intervention Support

NO. TITLE Total Adjust Costs Costs Individual Group Family Daily2110 Administrative $ 0 $ 02120 Professional Staff - Direct $ 0 $ 02130 Other - Direct $ 0 $ 02150 Clerical $ 0 $ 02190 Other Staff $ 0 $ 02100 TOTAL SALARIES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2210 Health Benefits $ 02220 Retirement Plan $ 02290 Other Benefits $ 02200 TOTAL BENEFITS $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2310 FICA Expense $ 02320 Unemployment $ 02350 Workmen's Compensation $ 02300 TOTAL PAYROLL TAXES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2450 Medical & Psych Services Purchased $ 02470 Accounting and Auditing $ 02480 Attorney's Fees $ 02490 Other Non-Medical $ 02400 TOTAL PROFESSIONAL FEES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2510 Office Supplies $ 02530 Medical Supplies $ 02540 Recreation & Craft Supplies $ 02550 Food $ 02590 Other Supplies $ 02500 TOTAL SUPPLIES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2600 TELEPHONE & INTERNET $ 0

2700 POSTAGE & SHIPPING $ 0470-4414 (08/08)

SCHEDULE D - EXPENSE REPORT

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H2001 H2011 H2014 TotalSkills Child Group Facility

Crisis Training Welfare Care IndirectRehab Intervention And Service Maint. Other Service

Program Service Development Daily Daily Programs Costs$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0

$ 0 $ 0

From Supplemental Sch. D-1SCHEDULE D - EXPENSE REPORT

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NO. TITLE Total Adjust Costs Costs Individual Group Family Daily2810 Rent of Space $ 02820 Building & Grounds Supplies $ 02830 Utilities $ 02840 Care of Buildings & Grounds $ 02870 Interest Expense $ 02880 Insurance & Property Taxes $ 02890 Other Occupancy Expense $ 02800 TOTAL OCCUPANCY EXPENSE $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

3100 OUTSIDE PRTG - ART WORK $ 0

3210 Mileage & Auto Rental $ 03250 Agency Vehicles Expense $ 03280 Automobile Insurance $ 03290 Other Related Transportation $ 03200 TOTAL LOCAL TRANS. $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

3310 Staff Development & Training $ 03320 Annual Meetings & Bus. Conference $ 03300 TOTAL CONF. & CONVENTIONS $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

3400 SUBSCRIPTIONS/PUBLICS. $ 0 $ 0 $ 0 $ 0 $ 0

3510 Clothing & Personal Needs $ 03520 Other $ 03500 TOTAL ASSISTANCE $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

4100 ORGANIZATION DUES $ 0

4200 AWARDS & DUES $ 0470-4414 (08/08)


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H2001 H2011 H2014 TotalSkills Child Group Facility

Crisis Training Welfare Care IndirectRehab Intervention And Service Maint. Other Service

Program Service Development Daily Daily Programs Costs$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0

$ 0 $ 0$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0

$ 0 $ 0

From Supplemental Sch. D-1SCHEDULE D - EXPENSE REPORT

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NO. TITLE Total Adjust* Costs Costs Individual Group Family Daily4310 Agency Vehicle Repair $ 04320 Other Equipment Repair or Purchase $ 04300 REPAIRS & EXPENDABLE EQ UIP. $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

4410 Agency Vehicles $ 0 $ 04420 Equipment $ 0 $ 04480 Buildings and Leaseholds $ 0 $ 04400 TOTAL DEPRECIATION $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

4910 Moving & Recruitment $ 04920 Liability Insurance $ 04930 Miscellaneous $ 04900 TOTAL MISCELLANEOUS $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

5000 HOME OFFICE & MANAGEMENT FEE $ 0

TOTAL EXPENSES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 096152 96153 96154 H0037Health Health Health Community

Behavior Behavior Behavior PsychGross Revenue Excluded Adjusted Intervention Intervention Intervention Support

DESCRIPTION Total Adjust Costs Costs Individual Group Family Daily$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

ALLOCATION OF INDIRECT PROGRAM SERVICE COSTS $ 0 $ 0 $ 0 $ 0TOTAL SERVICE OR MAINTENANCE COSTS AFTER ALLOCATION OF INDIRECT $ 0 $ 0 $ 0 $ 0* PROGRAM INCOME OR REIMBURSEMENTS* UNITED WAY CONTRIBUTIONS * OTHER CONTRIBUTIONS * GOVERNMENT GRANTSTOTAL SERVICE OR MAINTENANCE COSTS AFTER DEDUCTIONS $ 0 $ 0 $ 0 $ 0 UNITS OF SERVICE 0 0 0 0 UNIT COST ** $ 0.00 $ 0.00 $ 0.00 $ 0.00

* Deductions from Schedule A

TOTAL EXPENSES


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H2001 H2011 H2014 Total

Skills Child Group FacilityCrisis Training Welfare Care Indirect

Rehab Intervention And Service Maint. Other ServiceProgram Service Development Daily Daily Programs Costs

$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0$ 0 $ 0$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

H2001 H2011 H2014 Total

Skills Child Group FacilityCrisis Training Welfare Care Indirect

Rehab Intervention And Service Maint. Other ServiceProgram Service Development Daily Daily Programs Costs

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 0

$ 0 $ 0 $ 0 $ 0 $ 0 $ 00 0 0 0 0

$ 0.00 $ 0.00 $ 0.00

From Supplemental Sch. D-1

From Supplemental Sch. D-1


63

Supplemental Schedule D-1Group Care Expense Report

The purpose of Supplemental Schedule D-1 is to report expenses related to each level of Group Care Maintenance and Service. These expenses are summarized on Schedule D. Only agencies with multiple levels of Group Care need to complete Schedule D-1. This is optional for agencies that provide one level. After Schedule D-1 is completed, cost in Columns 9 & 10 of Schedule D-1 should equal cost in Columns 13 & 14 of Schedule D.

64

ACCOUNT Service Maintenance Service Maintenance Service Maintenance Service MaintenanceNO. TITLE D160 D190 D260 D290 D360 D390 D460 D4902110 Administrative $ 0 $ 02120 Professional Staff - Direct $ 0 $ 02130 Other - Direct $ 0 $ 02150 Clerical $ 0 $ 02190 Other Staff $ 0 $ 02100 TOTAL SALARIES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2210 Health Benefits $ 0 $ 02220 Retirement Plan $ 0 $ 02290 Other Benefits $ 0 $ 02200 TOTAL BENEFITS $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2310 FICA Expense $ 0 $ 02320 Unemployment $ 0 $ 02350 Workmen's Compensation $ 0 $ 02300 TOTAL PAYROLL TAXES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2450 Medical & Psych Services Purchased $ 0 $ 02470 Accounting and Auditing $ 0 $ 02480 Attorney's Fees $ 0 $ 02490 Other Non-Medical $ 0 $ 02400 TOTAL PROFESSIONAL FEES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2510 Office Supplies $ 0 $ 02530 Medical Supplies $ 0 $ 02540 Recreation & Craft Supplies $ 0 $ 02550 Food $ 0 $ 02590 Other Supplies $ 0 $ 02500 TOTAL SUPPLIES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

2600 TELEPHONE & INTERNET $ 0 $ 0

2700 POSTAGE & SHIPPING $ 0 $ 0

2810 Rent of Space $ 0 $ 02820 Building & Grounds Supplies $ 0 $ 02830 Utilities $ 0 $ 02840 Care of Buildings & Grounds $ 0 $ 02870 Interest Expense $ 0 $ 02880 Insurance & Property Taxes $ 0 $ 02890 Other Occupancy Expense $ 0 $ 02800 TOTAL OCCUPANCY EXPENSE $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

3100 OUTSIDE PRTG - ART WORK $ 0 $ 0

3210 Mileage & Auto Rental $ 0 $ 03250 Agency Vehicles Expense $ 0 $ 03280 Automobile Insurance $ 0 $ 03290 Other Related Transportation $ 0 $ 03200 TOTAL LOCAL TRANS. $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

3310 Staff Development & Training $ 0 $ 03320 Annual Meetings & Bus. Conference $ 0 $ 03300 TOTAL CONF. & CONVENTIONS $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

GROUP CARE EXPENSE REPORTSUPPLEMENTAL SCHEDULE D-1

Total Child Welfare Service Daily

Total Daily Maintenance Cost

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ACCOUNT Service Maintenance Service Maintenance Service Maintenance Service MaintenanceNO. TITLE D160 D190 D260 D290 D360 D390 D460 D4903400 SUBSCRIPTIONS/PUBLICS. $ 0 $ 0

3510 Clothing & Personal Needs $ 0 $ 03520 Other $ 0 $ 03500 TOTAL ASSISTANCE $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

4100 ORGANIZATION DUES $ 0 $ 0

4200 AWARDS & DUES $ 0 $ 0

4310 Agency Vehicle Repair $ 0 $ 04320 Other Equipment Repair or Purchase $ 0 $ 04300 REPAIRS & EXPENDABLE EQ UIP. $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

4410 Agency Vehicles $ 0 $ 04420 Equipment $ 0 $ 04480 Buildings and Leaseholds $ 0 $ 04400 TOTAL DEPRECIATION $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

4910 Moving & Recruitment $ 0 $ 04920 Liability Insurance $ 0 $ 04930 Miscellaneous $ 0 $ 04900 TOTAL MISCELLANEOUS $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

5000 HOME OFFICE & MANAGEMENT FEES $ 0 $ 0

TOTAL EXPENSES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

Service Maintenance Service Maintenance Service Maintenance Service MaintenanceDESCRIPTION D160 D190 D260 D290 D360 D390 D460 D490TOTAL EXPENSES $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0ALLOCATION OF INDIRECT PROGRAM SERVICE COSTS $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0TOTAL SERVICE OR MAINTENANCE COSTS AFTER INDIRECT ALLOCATION $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0* PROGRAM INCOME OR REIMBURSEMENTS $ 0 $ 0* UNITED WAY CONTRIBUTIONS $ 0 $ 0* OTHER CONTRIBUTIONS $ 0 $ 0* GOVERNMENT GRANTS $ 0 $ 0TOTAL SERVICE OR MAINTENANCE COSTS AFTER DEDUCTIONS$ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 UNITS OF SERVICE 0 0 UNIT COST $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00





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Schedule EComparative Balance Sheet

The purpose of Schedule E is to report the balance sheet of the provider as of the end of the reporting period.

Total assets must equal the total liabilities and equity.

Under, “Reconciliation of Equity or Fund Balance,”, the “add” and “deduct” entries should be completed to calculate the current fund balance reported on the balance sheet.

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SCHEDULE E - COMPARATIVE BALANCE SHEET

ASSETS, LIABILITIES AND EQUITYBalance At End Of

Current Period Prior Period

ASSETS:Cash $

Receivable from ClientsReceivable from OthersProperty and Equipment:

LandBuildings and Equipment

Less Allowance for Depreciation

Net Property and Equipment $0.00 $0.00Investments and Other Assets

$0.00 $0.00TOTAL ASSETS $

LIABILITIES AND EQUITY:

Accounts Payable $Accrued Taxes (Payroll and Property)Other Liabilities

Notes and Mortgages

TOTAL LIABILITIES

Equity or Fund Balance

$0.00 $0.00TOTAL LIABILITIES AND EQUITY $

RECONCILIATION OF EQUITY OR FUND BALANCE

TOTAL EQUITY OR FUND BALANCE BEGINNING OF PERIOD $

Add:

TOTAL REVENUE from Schedule AOther Revenue. Explain.

Deduct:TOTAL EXPENSES from Schedule D

Other Expenses. Explain.

TOTAL EQUITY OR FUND BALANCE END OF PERIOD $ $0.00 $0.00

470-4414 (08/08)

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Schedule FCost Allocation Procedures

The purpose of Schedule F is to report other supplemental information related to agency operations and accounting procedures.Cost allocations are required for direct costs benefiting more than one service or service component and for the provider’s indirect costs.“Direct Costs” are defined as those which are directly identifiable to services or components.“Indirect Costs” are defined as those which are not readily identifiable with each service or service component.

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Schedule FCost Allocation Procedures

The schedule provides questions regarding methods used in allocating expenses which benefit more than one service or service component.

The provider should send supporting documentation for the allocation basis of these costs.

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SCHEDULE F - COST ALLOCATION PROCEDURES(To be completed by Providers which offer more than one service)

Cost are allocable to a particular service, such as a grant, project, or other activity, in accordance with the relative benefits received. A cost is allocable to a service if it is treated consistently with other costs incurred for the purpose in like circumstances, and if it (1) is incurred specifically for the service, (2) benefits the service and can be distributed in reasonable proportion to the benefits received and (3) is necessary to the overall operation of the organization, although a direct relationship to a particular service cannot be shown.

Direct Costs: YES NO1. Do you have a cost allocation plan which describes the methods you

use in distributing joint costs to services or activities?

2. What is your method for allocating joint cost? Attach supporting documentation

3. If you do not have a cost allocation plan describing the methodsfollowed, do you have accounting workpapers available to support joint direct cost allocations?

4. Is your method of allocating joint service costs consistentlyfollowed from year to year?

5. Are costs allocated to services in reasonable proportion to benefitsreceived?

6. Are service income deductions allocated in a manner which is consistentwith the costs incurred in generating the income?

7. Additional comments regarding allocation of joint service costs:

Indirect Costs:1. Are the indirect costs distributed on a basis of total direct service

or costs?

2. If indirect costs are not allocated on the basis of total direct servicecosts, what was the basis used? Attach supporting documentation.

3. Is the basis for distributing indirect cost the same as that used in the previous year?

Any cost allocable to a particular service under the above principles may not be shifted to other services to overcome funding deficiencies, or to avoid other restrictions imposed by law or terms of an award or program.

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Schedule G – Part I Supplemental Allocation Report

The purpose of Schedule G Part I is to identify those costs, as allocated to Group Foster Care, eligible for Federal IV-E funding reimbursement by the Department.

Schedule G Parts I & II are used to validate Iowa’s Title IV-E funding assumptions about the allocation of Group Foster Care costs to maintenance and service activities.

Only those cost centers for which Iowa is eligible to seek Federal IV-E reimbursement are included.Only agencies with contracts for Group Care Service and Maintenance (Dx6x; Dx9x) must complete Sch G.Sch G will include cost for Group Care only. It will not include RSP cost or Other Program Cost.

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Column C, Direct Costs: Enter the total combined direct cost for Group Care Service and Maintenance from Schedule D for each listed cost center.

Benefits and Taxes: These expenses are reported on Schedule D in total for all staff classifications. Therefore, you will need to enter the proportionate expense equal to the percentage of benefits and payroll tax expense applicable to each staff classification listed.

Example: Group Care Direct Care Salaries are 30% of Total Group Care Salaries. Therefore, 30% of Total Group Care Benefit and Payroll Tax expense will be reported as Direct Care Benefits and Payroll Tax.

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Column D, Allocation of Indirect Cost: Allocate indirect cost using the following steps:Step 1: Using Schedule D, Divide Total Group Care Indirect Cost

by Total Group Care Direct Cost. This will result in a percentage.

Step 2: Multiply amounts in Column C of Sch G Part I by the percentage calculated above.

Step 3: Determine the proportionate share of Total Facility Indirect Expense from Sch D that is applicable to Group Care.

Step 4: Determine the Group Care proportionate share of Indirect Expense for each Cost Center.

Step 5: Record the lesser amount from Step 2 and Step 4 as Indirect Cost in Column D of Sch G Part I.

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Column D, Allocation of Indirect Cost Example

See handout from the Training portion of the IME Website. The handout is an Excel document

entitled “G Part I Example”

75


Column E, Total Costs: Add Column C (Direct Cost) to Column D (Indirect Cost) and enter in Column E.Column F & G, Allocation of Total Cost to Maintenance and CW Service: Allocate Total Cost according to the Provider Manual Instructions, using one of the following methods:

As specifically indicated in the manual,Time Study,

o Time Studies should be performed at least quarterly, as specified in the provider manual,

Square Foot Usage Study,o Square Foot Usage Studies must be performed annually over at

least a two week study of the space’s use.

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Schedule G – Part I Clarification of Line 2480

Line 2480 InconsistencySchedule D: Attorney’s FeesSchedule G Part I: Formalized “Non-Family-Like” Recreation

Sch. D Instructions:Report Attorney’s Fees on Line 2480Report both “Family-Like” and “Non-Family-Like” Recreation Expense in Line 2540 – Recreation and Craft Supplies“Non-Family-Like” Recreation is not an allowable expense. This will need to be excluded in Column 3 of Sch. D.

Sch. G Part I Instructions:Report “Family-Like” Recreation Expense on Line 2540Leave Line 2480 blank. Do not report either Attorney’s Fees or “Non-Family-Like” Recreation expense.

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SCHEDULE G: SUPPLEMENTAL ALLOCATION REPORT, PART IA C D E F G

Total Basis of

Direct Costs Indirect Costs Costs Maintenance CW Service Allocation

from 2190 Food Service & Maintenance Workers Salaries 0 Definintion

% of 2200 Food Service & Maintenance Workers Benefits 0 Definintion

% of 2300 Food Service & Maintenance Workers Payroll Taxes 0 Definintion

2130 Direct Care Staff Salaries 0 Time Study

% of 2200 Direct Care Staff Benefits 0 Time Study

% of 2300 Direct Care Staff Payroll Taxes 0 Time Study

from 2120 Other Direct Staff(Pgm Supv/SW-Thpst/Nurse) 0 Time Study

% of 2200 Other Direct Staff Benefits 0 Time Study

% of 2300 Other Direct Staff Payroll Taxes 0 Time Study

% of 2110 Other Admin Staff(Clinical/Pgm Supy of Mgr) Salaries 0 Time Study

% of 2200 Clerical Supervisor Benefits 0 Time Study

% of 2300 Clerical Supervisor Payroll Taxes 0 Time Study

2450 Medical and Psychological Purchased Services 0 Definintion

2490 Other Non-Medical Services Purchased 0 Definintion

2530 Medical Supplies 0 Definintion

2540 Recreation("Family-like") & Craft Supplies 0 Definintion

2480 Formalized Non "Family-like" recreation 0 Definintion

2550 Food 0 Definintion

3510+3520 Clothing, Personal Needs, School Supplies & Other 0 Definintion

2810 Rent of Space 0 Sq. Ft. - Use

2820 Building and Ground Supplies 0 Sq. Ft. - Use

2830 Utilities 0 Sq. Ft. - Use

2840 Care of Buildings and Grounds 0 Sq. Ft. - Use

2870 Interest of Buildings and Grounds 0 Sq. Ft. - Use

2880 Insurance and Property Taxes 0 Sq. Ft. - Use

2890 Other Occupancy Expenses 0 Sq. Ft. - Use

TOTALS 0 0 0 0 0Service/Maintenance Percentages 0.00% 0.00%

Allowable Allocation of Total Costs to:Account Number

B

Account Title

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Schedule G – Part II Supplemental Allocation Report

Remainder of Program Direct Costs: Total Group Care Direct Expense from Sch D less Sch G Part I Column C Direct Expense.Remainder of Program Indirect Costs: Total Group Care indirect Expense from Sch D less Sch G Part I Column D Indirect Expense.All other amounts should calculate automatically. Detailed instructions are in the provider manual, if needed.

79

0.000.00

Part II Totals: 0.00

Maintenance:MAINTENANCE PERCENTAGE FROM SCHEDULE G PART I 0.00%

TOTAL PART 2 MAINTENANCE COST 0.00

TOTAL MAINTENANCE COST FROM PART I 0.00

GRAND TOTAL MAINTENANCE COSTS 0.00

DEDUCTIONS FROM MAINTENANCE COST FROM SCHEDULE D 0.00

GRAND TOTAL MAINTENANCE COSTS AFTER DEDUCTIONS 0.00

Child Welfare Service:CHILD WELFARE SERVICE PRECENTAGE FROM SCHEDULE G PART I 0.00%

TOTAL PART II CHILD WELFARE SERVICE COST 0.00

TOTAL CHILD WELFARE SERVICE COST FROM PART I 0.00

GRAND TOTAL CHILD WELFARE SERVICE COSTS 0.00

DEDUCTIONS FROM CHILD WELFARE SERVICE COST FROM SCHEDULE D 0.00

GRAND TOTAL CHILD WELFARE SERVICE COST AFTER DEDUCTIONS 0.00

UNIT COST DETERMINATION:

Remainder of Program Direct Costs (Total Program Schedule D Direct - Part I Direct) :Remainder of Program Indirect Costs (Total Program Schedule D Indirect - Part I Indirect) :

SCHEDULE G: SUPPLEMENTAL ALLOCATION REPORT, PART IIResidual Cost NOT included in Schedule G, Part I

80

Allocation of Staff Time Worksheet

The purpose of the Time Study Worksheet is to validate the salary expenses required for the delivery of service.

This is an essential part of the review because salaries are the single greatest expense for any provider.

81

Allocation of Staff Time WorksheetRequired for all Group Foster Care Providers

Beginning in 2007, all childcare and professional social services staff should do 100% time reporting for four days (3 within the school year, 1 during summer). Each odd numbered year thereafter, these staff should do 100% time reporting for two days each quarter of the fiscal year.Providers may want to perform the study more often if necessary to adequately reflect how staff spend their time during the course of the year.

Recommended for ALL providersThe time study form is not required for all RSP providers; however, all providers are required to be able to support how they have allocated expenses. A time study is the best way to do this.

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Time spent on all activities should be reflected. This would include Maintenance, Child Welfare Service, Medicaid RSP, Administration, and Other Programs.

Total time should equal 100%.

The result of the time study should be used to allocate expenses on the cost report.

83

Type of Staff:

Enter Percent of Time Spent on Maintenance Activities: Line 1Enter Percent of Time Spent on Child Welfare Service Activities: Line 2Enter Percent of Time Spent on Medicaid RSP Activities: Line 3Enter Percent of Time Spent on Administrative Activities: Line 4Enter Percent of Time Spent on Activities for Other Programs: Line 5Total Line 6

Add Lines 1, 2, 3 and 5: Line 7Divide Line 1 by Line 7: Line 8Divide Line 2 by Line 7: Line 9Divide Line 3 by Line 7: Line 10Divide Line 5 by Line 7: Line 11

Multiply Line 4 by Line 8: Line 12




Add Line 1 and Line 12: Line 16




470-4414 (08/08)

(This is the percentage of administrative time allocated to Child Welfare Service)

(This is the percentage of administrative time allocated to Medicaid RSP )

(This is the total percentage of time allocated to maintenance. Use this percentage to allocate staff cost to maintenance.)


(Use Separate form for each type of staff type, i.e.- Administrative, Professional, Direct Care, Supervisors, etc.)

(This is the percentage of administrative time allocated to maintenance)

(This is the percentage of administrative time allocated to Other P rograms)

(This is the total percentage of time allocated to Other P rograms. Use this percentage to allocate staff cost to service.)

* The combined percent of time spent on Maintenance, Child Welfare Service, Medicaid Service , Administrative and Other P rogram Activities should total 100%

(This is the total percentage of time allocated to service. Use this percentage to allocate staff cost to service.)

(This is the total percentage of time allocated to RSP . Use this percentage to allocate staff cost to service.)

84

Determination of Payment RatesInterim Rates

Remedial Service Providers will be paid on an interim rate until a finalized rate is established based on an annual cost report.

First Year: The interim rate was established by the Iowa Medicaid Enterprise.

On-Going: The interim rate is equal to the previous year’s finalized payment rate.

85

Determination of Payment RatesFinalized Rates

The finalized payment rates will be established retrospectively after review of Actual and Allowable Cost per Unit from the annual cost report.

Retrospective - the finalized rate becomes effective the first day of the cost report period.Becomes your new Interim Rate.Increased by 1% for services provided on or after July 1, 2008.Subject to a Rate Maximum for FYE 2009, and after.

86

Determination of Payment RatesRate Maximum

Interim and Finalized rates for FYE 2009 and after will be limited by Rate Maximums.

Rate Maximums are based on 110% of the average allowable costs.

This average will be inflated using the US Consumer Price and applied prospectively.

The new Rate Maximums will be made available by July 31st each year.

87

Determination of Payment RatesRate Maximum

The Fiscal Years Ending 2009 Rate Maximums are as follows (See Informational Letter No. 763):

96152 - $23.8496153 - $ 6.0196154 - $27.75H0037 - $71.85H2001 - $64.41H2011 - $22.65H2014 - $19.76

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Determination of Payment RatesExample

After review of a cost report for the period of 1/1/07 – 12/31/07, the actual and allowable cost per unit for 96152 was $23.71. The FYE 2009 rate maximum for this code is $23.84. The rates would be established as follows:

1/1/07 – 12/31/07 $23.71 (finalized rate for the cost report period)

1/1/08 – 6/30/08 $23.71 (interim rate)

7/1/08 – 12/31/08 $23.95 (interim rate including the 1% increase)

1/1/09 – Open Ended $23.84 (interim rate subject to the Rate Max)

89

Determination of Cost Settlement Amount

Cost Settlement is performed by adjusting each individual paid claim.

For each claim, payments made at the interim rate are taken back and new payments are made at the finalized rate.

This is evidenced by negative amounts on your remittance advice followed by a positive amount for each claim.

90

Determination of Cost Settlement Amount

The Settlement Amount is the net of all the negative and positive claims paid for all RSP services.

Shown on the last page of the Remittance Advice.

Amounts Due Provider will be paid through the usual process.

Amounts Due IME will be recouped as new Original Claims are billed.

91

Related WebsitesIowa Medicaid

Enterprisehttp://www.ime.state.ia.us

Department of Human

Serviceshttp://www.dhs.iowa.gov

Provider Manuals

http://www.dhs.state.ia.us/policyanalysis/PolicyManualPages/MedProvider

Cost Report Template

http://www.ime.state.ia.us/Providers/Forms

Informational Letters

http://www.ime.state.ia.us/Providers/Bulletins

Iowa Administrative

Codehttp://www.dhs.iowa.gov/policyanalysis/RulesPages/RulesChap

OMB Circular A-87

http://www.whitehouse.gov/omb/circulars/a087/a087-all

CMS Publication

15-Ihttp://www.cms.hhs.gov/manuals/pBm/list

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Contact InformationIowa Medicaid Enterprise

Provider Cost Audit and Rate Setting Unit

Email: [email protected]

Iowa Medicaid EnterprisePO Box 36450

Des Moines, IA 50315

515-725-1108 (Local)866-863-8610 (Toll-Free)


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Contact Information

Department of Human Services

Bureau of Purchased Services

Jody [email protected]

515-281-8369


94

Questions?

1 Remedial Services Financial and Statistical Report Training January 20, 2009.

Documents

Transcript of 1 Remedial Services Financial and Statistical Report Training January 20, 2009.