Section He-E 806.02 - Annual Cost Reports(a) Each NF, with the exception of state-owned and operated facilities, shall submit: (1) An annual cost report of the costs of their operations utilizing the "Medicaid Annual Cost Report" form described in (b) below;(2) Financial statements for the reporting period;(3) Any certifications, opinions, or notes that are a part of (2) above;(4) Copies of federal income tax statements pertaining to the operation of the NF only if requested by the department; and(5) Copies of all signed lease agreements for property, buildings, and equipment unless they have previously been submitted and are unchanged.(b) NF providers shall submit the following statements and schedules as part of the "Medicaid Annual Cost Report" described in (a) (1) above: (1) A signed statement certifying that the information provided on the report, both in paper and electronic format, is true, accurate, and complete and acknowledging that penalties for any false statement or misrepresentation of material fact include fine or imprisonment;(2) Resident census statistics including the numbers of residents within each level of care and revenue source for each level of care;(3) Expenses as described in He-E 806.06 through He-E 806.30 and cost center allocations such as support services, resident care, and capital costs;(4) Reclassification of expenses, as needed, from one cost center to another;(5) Adjustments to expenses due to activity such as refunds, discounts, or sale of merchandise or supplies;(6) Allocation statistics which provide information regarding square footage of the facility, meals served by the facility, pounds of laundry done, and the cost centers relevant to each;(7) Building and general information including information regarding ownership or rental of the facility;(8) Fixed assets and depreciation including a listing of land, buildings, major movable equipment, and motor vehicles owned by the provider or related parties, and the depreciation on these assets;(9) Debt and interest including a listing of NF debt, related party capital debt, and the necessary interest on these debts;(10) Rental expense detail including rental costs for buildings, fixed equipment, other equipment, and motor vehicles;(11) Owner and officer compensation including a statement of compensation and other payments to owners, officers, directors, and trustees including their ownership interest, and average hours per week of work provided to the facility;(12) A financial statement including a balance sheet listing current assets, current liabilities, total equity and changes in equity, cash flow from operating, investing, and financing activities, revenues from inpatient and other operating activities, and a statement of expense and profit or loss;(13) Funded depreciation detail including a listing of fund income and payments;(14) Resident fund including a listing of resident funds received and disbursed, interest earned, and remaining balance; and(15) Staffing pattern including a listing of facility staff, consultants and contract staff, hours worked by position, and total salaries or other compensation paid.(c) The "Medicaid Annual Cost Report" and all accompanying documents shall bear original signatures of the NF administrator or owner, and paid third party preparer. All accompanying documents and original signatures shall be mailed when the "Medicaid Annual Cost Report" is filed electronically.(d) One signed copy of the "Medicaid Annual Cost Report" form and one duplicate copy shall be submitted to: NH Department of Health and Human Services
Bureau of Improvement and Integrity
Financial Compliance Unit
Main Building
105 Pleasant Street
Concord, NH 03301-3843
(e) A complete annual cost report shall be submitted:(1) No later than 3 months after the end of the facility's fiscal year, unless an extension has been granted by the department as described in (p) below. Home office costs shall be documented by the submission to the department of HCFA Form 287-92, or its replacement "Chain Home Office Cost Statement", no later than 5 months after the end of the home office fiscal year, unless an extension has been granted by the department as described in (p) below; or(2) By the former owner of the NF within 90 calendar days of the sale of the NF when a change of ownership occurs and a new rate shall be determined by the department in accordance with He-E 806.32(d) .(f) Home office costs shall be documented by the submission to the department of HCFA Form 287-92 or its replacement, "Chain Home Office Cost Statement" and necessary schedules as requested, no later than 5 months after the end of the home office fiscal year, unless an extension has been granted by the department as described in (p) below.(g) The department shall consider an annual cost report complete unless the cost report is missing information of a material nature so as to render the document unusable for the purpose of determining a per diem rate.(h) Any facility which submits an incomplete annual cost report shall be subject to penalties described in (q) below, unless an extension has been granted as described in (o) below.(i) An acceptable cost report shall reflect the most recent desk audit or field audit adjustments made to the previous year's cost report, if applicable, with the exception of items still under appeal that have not been resolved.(j) The department shall notify the NF by registered mail of an incomplete annual cost report within 30 days of receipt of the report.(k) The time frame for submitting a complete cost report as described in He-E 806.03 shall not change due to an incomplete report submitted by an NF.(l) Failure to submit an annual cost report or a complete annual cost report as required shall result in penalties as stated in (q) below, unless an extension has been granted by the department as described in (o) -(p) below.(m) NFs which have separate arrangements for caring for residents with different levels of care needs shall segregate their operational costs on the same annual cost report form.(n) NF providers with facilities in more than one location shall submit separate balance sheets for each location.(o) Requests for extensions for filing the annual cost report beyond the prescribed deadline shall: (2) Be submitted to the department at least 10 working days prior to the due date of the annual cost report, unless one of the circumstances identified in (p) below occurs during the 10 working days prior to the due date, in which case the request shall be made by telephone within 10 working days of the occurrence;(3) Clearly explain the necessity for the extension; and(4) Specify the date on which the report will be submitted.(p) Approval of extensions shall be made only if it is determined that the delay is caused by circumstances beyond the NF provider's control, such as, but not limited to: (3) Strikes by employees necessary for the preparation of the cost report;(5) The death of an owner or administrator.(q) Failure to submit the annual cost report or a complete report as required shall result in the following penalties, unless an extension has been granted by the department: (1) The per diem rate currently in effect shall be reduced by 25% effective on the first day of the month following the due date for filing of the completed annual cost report, and for each successive month of delinquency in filing the completed annual cost report;(2) There shall be no retroactive restoration of penalty payments or reimbursement of related working capital interest costs upon the submission of a completed cost report;(3) No determination of a new rate for the next payment period shall be made until an acceptable cost report as described in (a) - (e) above is received; and(4) Reinstatement of the pre-existing rate or the determination of a new rate of payment shall be made subsequent to the receipt of an acceptable annual cost report, but retroactive only to the date of receipt by the department of said report.(r) The commissioner shall not impose the penalties in (q) above if it is determined that the reason for the NF provider not meeting the timeframes in (o) (2) above meets the criteria in (p) above.(s) When a complete annual cost report has been submitted by the NF provider, the department shall conduct a desk review of the report and shall conduct a field audit if the NF meets one of the conditions for a field audit as described in (t) below.(t) A field audit shall be conducted as part of the review of the annual cost report in accordance with He-E 806.30 if the NF meets one or more of the following conditions: (1) The NF has been newly constructed or has had major capital improvements in the past year;(2) There are items on the annual cost report which need further clarification or investigation as determined by the department; or(3) A field audit has not been conducted on the NF during the previous 5 state fiscal years.(u) Based on the desk review or field audit, the department shall determine allowable costs and facility compliance in accordance with the provisions of He-E 806.(v) The department shall send a notice to the NF provider of the result of the desk review or field audit including: (1) A listing of all adjustments to submitted costs on the cost report, if any, as determined by the department as described in (t) above; and(2) The provider's right to a reconsideration and an administrative appeal in accordance with He-E 806.40 and He-E 806.41.(w) The department shall reopen cost reports only as a result of field adjustments by department staff or in the case of fraud.(x) Cost reports shall be reopened at the request of the provider in the case of an error of a material nature until a rate has been set based on that submitted cost report.(y) For an out-of-state provider or an out-of-state home office, any reopening by the home state or appropriate fiscal agent shall be considered a reopening for the NH Medicaid Program.N.H. Admin. Code § He-E 806.02
#8547, eff 1-24-06 (formerly He-W 593.03); ss by #9623, eff 12-24-09
Amended by Volume XXXVIII Number 02, Filed January 11, 2018, Proposed by #12440, Effective 12/23/2017, Expires 6/21/2018.Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12566, Effective 6/29/2018, Expires 6/29/2028.