Health Facility Cash Assessment Program

Instructions for Completing Reporting Forms

Article 28 General Hospitals

General Instructions

This form is to be used on a monthly basis to calculate the assessment liability. A separate report should be submitted even if there were no assessable cash receipts for the reporting month. The report and payment must be submitted on a timely basis to avoid incurring penalty and interest. Timely payments shall be defined as payments received (not postmarked) on or before the 15th of the month (adjusted for weekends and holidays.

When reporting, use whole dollars only.

Columnar Descriptions

Description. Itemize total cash receipts and list additional assessable cash receipts as detailed in the instructions.

Current Month. Report the current month´s cash receipts.

Linear Descriptions

Line 1 - Cash from Patient Care Services: Enter ALL CASH RECEIPTS (and/or checks) received during the month. Cash receipts include but are not limited to payments received from Medicaid, Medicare, Blue Cross and Blue Shield, other insurance payors, Worker´s Compensation, and self-payors. Receipts are assessable in the month they are received irrespective of the service date or billing period (cash basis).

Line 2 - Other Cash Receipts: List all other cash receipts. Refer to the instructions and identify each receipt.

Line 3 - Total Other Cash Receipts: Sum of Other Cash Receipts listed under Line 2, a through j, etc.

Line 4 - Total Cash Receipts from All Sources: Line 1 plus Line 3.

Line 5 - Total Non-Assessable Cash Receipts: Enter the total of non-assessable items from Schedule H.

Line 6 - Assessable Cash Receipts: Line 4 less Line 5.

Line 7 - Assessment Rate: The applicable assessment rate for a given report period.

Line 8 - Current Month Assessment: Multiply Line 6 by Line 7.

Line 9 - Other Adjustments: Report adjustments due to errors or omissions in prior months and to report a credit for a prior month. Adjustments may be either a positive or negative. Specify the month for the adjustment, the applicable assessment rate, and the reason(s) for the adjustment. If the adjustment is for multiple months, attach a detailed schedule. Detailed records should be maintained as all data is subject to audit.

Line 10 - Amount Due: Line 8 plus Line 9. If the amount is negative (a credit amount), report on Line 11. Otherwise, remit this amount to the Assessment Fund Administrator.

Line 11 - Excess Credit for Future Remittance: Enter credit amounts from Line 10 and carry forward to Line 9 of next month´s report.

Each month, hospitals licensed under Article 28 of the Public Health Law (PHL), are assessed a percentage on cash receipts from patient services and general operations.

Assessable Hospital Income

  • All cash receipts from Patient Care Services less any amounts applicable to patient or third party refunds, IRRESPECTIVE OF PAYMENT SOURCE OR SERVICE DATE, received during the assessment period.
  • All GME distributions.
  • Investment Income, except as otherwise referenced on this attachment, received during the assessment period.
  • Other Operating Income, including but not limited to:
    • Non-Patient Food Sales
    • Laundry and Linen Services Revenue
    • Social Work Services Revenue
    • Housing Revenue
    • Parking Revenue
    • Housekeeping Services Revenue
    • Telephone and Telegraph Revenue
    • Data Processing Services Revenue
    • Purchasing Services Revenue
    • Sale of Abstracts/Medical Records
    • Sale of Scrap and Waste
    • Cash Receipts from Externally Granted Rebates and Refunds
    • Vending Machine Commissions
    • Other Commissions
    • Television/Radio Rentals
    • Non-Patient Room Rentals
    • Management Services Revenue
    • Other Operating Revenue Unless Specifically Referenced Below as Being Non-Assessable
    • Transfers from Restricted Funds for Other Operating Expenses
    • Gift Shop Revenue

Non-Assessable Income - Schedule H

  • Patient Personal Fund Allowances
    • Income earned on Patient Personal Funds
  • Investment Income from Externally Restricted Plant Funds (e.g., sinking funds, operating escrow, funded depreciation, mortgage repayment escrow accounts).
  • Distributions and Special Payments received from:
    • Health Care Initiatives Pool Distributions pursuant to §PHL 2807-l including, but not limited to:
      • Commissioner´s Priority Distributions
      • Senate Priority Distributions
      • Assembly Priority Distributions
      • Payments to Poison Control Center Grants
      • Health Work Force Retraining Program
      • Primary Health Care Services
      • Rural Health Care Initiatives: Development
      • Rural Health Care Access: Access
      • Health Information & Health Care Quality Improvement
    • Tobacco Control and Insurance Initiatives Distributions pursuant to PHL 2807-v including, but not limited to:
      • Tobacco Use Prevention and Control Program
      • School Based Health Center Grants
      • Workforce Retention-Public General Hospital Grants
      • Infertility Services Program
    • Medicaid Disproportionate Share Hospital (DSH) Payments, including but not limited to:
      • Indigent Care Pool payments pursuant to §PHL 2807-k (Note: Also include non-DSH payments pursuant to §PHL 2807-k).
      • High Need Indigent Care Adjustment Pool payments pursuant to §PHL 2807-w, including rural hospital payments (Note: Also include non-DSH payments pursuant to §PHL 2807-w).
      • Public General Hospital Indigent Care Adjustment payments pursuant to §PHL 2807-c(14-f).
      • Additional DSH payments to certain public hospitals pursuant to Chapter 474 of the Laws on 1996, as subsequently amended.
      • Additional DSH payments to certain non-public hospitals pursuant to Chapter 119 of the Laws of 1997, as subsequently amended.
    • Medicaid supplemental payments as follows
      • Revenue from inpatient Specialty Hospital Adjustment payments to certain public hospitals located in a city with a population of over one million persons pursuant to section twelve of part A, and section thirteen of part B, of chapter 1 of the laws of 2002.
      • Revenue from outpatient Proportionate Share payments to certain public hospitals located in a city with a population of over one million persons pursuant to section fourteen of part A, and section fourteen of part B, of Chapter 1 of the Laws of 2002.
  • Physician practice or faculty practice plan revenue received by a general hospital based on discrete billings for private practicing physician services.
  • Revenue received by a general hospital from a public hospital pursuant to an affiliation agreement contract for the delivery of health care services to such public hospital.
  • Medical Malpractice Insurance Funds.
  • Grants.
  • Governmental deficit financing.
  • Donations, Bequests and Charitable Contributions.
  • All schools leading to licensure.
  • Sales and Excise Taxes.
  • Health Care Reform Act surcharges received.