Instructions for Completing 1% Statewide Assessment

Public Goods Pool

Gross inpatient receipts for services rendered for the Statewide Assessment are defined in legislation as all monies received for hospital inpatient services. Hospitals are required to contribute monthly to the Statewide Assessment, 1.00% of all inpatient revenues received. Payments to the Statewide Assessment are to be computed on inpatient revenues received for service(s) rendered or provided to patients discharged on or after January 1st of a calendar year.

Hospitals are to exclude such items as distributions received from the Regional and Statewide NYPHRM Pools, reimbursement for physicians´ excess malpractice insurance, SPARCS fees, telephone and television charges, HCRA surcharge payments received and any distribution from the Health Care Initiatives Pool or General Hospital Indigent Care Pool. Distributions from the Professional Education Pool (PEP) are assessable. However, please note that effective April 1, 2009, the GME Distributions made from the PEP have been repealed.

Statewide Assessment Report

Note that amounts on Lines 1 through 2e and Line 5 are extracted from the Public Goods Pool - Hospital Inpatient Services Report for the appropriate service year portion of the report filed for the same month being reported on this report.

Line 1 - Total Net Patient Services Revenue Received, including surcharges

Amount reported on Line 1 of the hospital´s Public Goods Pool - Hospital Inpatient Services Report for the corresponding service year.

Line 2 - Less Revenue Non-Assessable for the Statewide Assessment

Non-assessable net patient services revenues received during the report month according to the following categories.

Important Note: All these amounts must have been included on Line 1 - Total Net Patient Services Revenue Received, including surcharges on the Public Goods Pool - Hospital Inpatient Services Report for the corresponding service year.

Line 2(a)

Amount reported on Line 2(d) of the hospital´s Public Goods Pool - Hospital Inpatient Services Report (revenue received from a public hospital pursuant to an affiliation agreement) for the corresponding service year.

Line 2(b)

Amount reported on Line 2(e) of the hospital´s Public Goods Pool - Hospital Inpatient Services Report (revenue received for residential health care and hospice services) for the corresponding service year.

Line 2(c)

Amount reported on Line 2(f) of the hospital´s Public Goods Pool - Hospital Inpatient Services Report (physician practice or faculty practice plan revenue based on discrete billings for physician services) for the corresponding service year.

Line 2(d)

Amount reported on Line 2(g) of the hospital´s Public Goods Pool - Hospital Inpatient Services Report (payments received directly from the Public Goods Pool included in Line 1) for the corresponding service year. This would include, but not limited to, payments received directly from the Health Care Initiatives Pool and the Tobacco Control and Insurance Initiatives Pool.

Line 2(e)

Amount reported on Line 2(h) of the hospital´s Public Goods Pool - Hospital Inpatient Services Report (government deficit financing grant revenue) for the corresponding service year.

Line 2(f)

Any non-GME Pool distributions from the Public Goods Pool and any NYPHRM Pool distributions, which are not included on Lines 2(d) and 2(e). Examples include Health Care Services Pool and General Hospital Indigent Care Pool distributions. These non-assessable amounts would have been included in the amount reported on Line 2(i) (Other) of the hospital´s Public Goods Pool - Hospital Inpatient Services Report for the corresponding service year. Please note that the amount reported on Line 2(i) of the Public Goods Pool report may include items that (although not subject to the Public Goods Pool assessments) are subject to the 1% Statewide Assessment and therefore should not be included in the amount reported on this line. For example, ∗GME Pool distributions and co-payments received from patients eligible for medical assistance pursuant to Title 11 of Article 5 of the Social Services Law (Medicaid) are subject to the 1% Statewide Pool assessment.

∗ Effective April 1, 2009, the GME Distributions made from the PEP have been repealed.

Line 3 - Total Non-assessable Revenue

The sum of Lines 2(a) through 2(f).

Line 4 - Total Assessable Revenue

Line 1 minus Line 3.

Line 5 - Less Gross Surcharges Payable

Amount reported on Line 14 - Gross Surcharges Payable of the hospital´s Public Goods Pool - Hospital Inpatient Services Report for the corresponding service year.

Line 6 - Net Assessable Revenue Received

Line 4 minus Line 5.

Line 7 - Statewide Assessment

Line 6 multiplied by 1.00%.

Line 8 - Plus/Minus Overpayments/Underpayments

If your facility has overpaid/underpaid its Statewide Assessment liability, include this amount on this line. However, please note that overpayments/underpayments for non-required service years should be included on Line 8 of the first non-required service years Statewide Remittance Advice Form.

Example:If the current reporting month is January 2010, then the required service years would be 2010 and 2009. Overpayments/underpayments for service years prior to 2009 should be included on Line 8 of the 2008 Statewide Remittance Advice Form.

Line 9 - Statewide Assessment Due

Line 7 minus Line 8. This amount should agree with the check amount you are submitting to the Office of Pool Administration. Please enter your operating certificate number on the check.

The overpayment made by your facility to the Statewide Assessment should be credited against your facility´s Statewide Assessment liability for the next month.