COST REPORTING SYSTEM FOR THE WEST VIRGINIA SCHOOL BASED HEALTH SERVICES PROGRAM
Directions for completing a cost report can be found at:
TBD
General Instructions
Contents
Support
R
Admin Page
July to September - LEA Payroll Information By Position
October to December - LEA Payroll Information By Position
January to March - LEA Payroll Information By Position
April to June - LEA Payroll Information By Position
Direct Medical Services Non Payroll
Depreciation Expense for Direct Medical Service Equipment
General and Statistical Information
Contracted Direct Services Information
Transportation Payroll Information
Other Transportation Costs
Depreciation Expenses for Transportation Services Equipment
Salary and Benefit Data Summary Report
Cost Summary Report
Annual Certification
Cost Settlement
D
1.A
1.B
1.C
1.D
2
3
4
5
6
7
8
9
10
11
12
AF
T
On most of the pages in this Cost Report System are columns that are labeled "USER INPUT" which are colored in blue. These are the columns that should be filled
in with data by the user. All other columns are labeled "SYSTEM GENERATED" and are colored red. These columns are prepopulated or will generate
automatically once the user fills in data to the USER INPUT columns. Once you have filled out all the pages with USER INPUT data, the Cost Report Page will be
calculated. Once completed, please save this workbook and email it to: wvsbhs@pcgus.com.
If you need help submitting your LEA's cost report, please first use the Cost Report Instructions at:
If there are problems that cannot be address by the Cost Report Instructions, please email:
wvsbhs@pcgus.com
A support member will respond to your question within 24 hours.
TBD
Direct Service Cost Pool
Full Time
Direct Service Cost Pool
Direct Service Cost Pool
Direct Service Cost Pool
Part Time
Part Time
Part Time
Doe5
Doe6
John
John
Occupational Therapy
Occupational Therapy
Direct Service Cost Pool
Direct Service Cost Pool
Full Time
Part Time
Doe7
Doe8
Doe9
Doe10
Doe11
Doe12
John
John
John
John
John
John
Physical Therapy
Physical Therapy
Personal Care
Personal Care
Care Coordination
Care Coordination
Direct Service Cost Pool
Direct Service Cost Pool
Personal Care
Personal Care
Care Coordination
Care Coordination
Full Time
Full Time
Part Time
Part Time
Full Time
Full Time
Doe1
John
Doe2
Doe3
Doe4
District Job Title
Audiologists
Speech Language
Pathologists
Registered Nurses
Psychologist
Certified Occupational
Therapist Assistants
(COTA)
Occupational Therapists
Physical Therapist
Assistants
Physical Therapists
Aides
Aides
Care Coordinator
Care Coordinator
R
First
Name
D
Last
Name
District
Employee ID
11111
FTE Total Salaries
Total
Benefits
Compensation
Federal Sources
$10,000.00
1.00
$25,000.00
$3,900.00
22222
33333
44444
0.80
0.65
0.45
$11,000.00
$14,000.00
$18,000.00
55555
66666
1.00
0.70
77777
88888
99999
12121
23232
34343
1.00
1.00
0.40
0.50
1.00
1.00
AF
Cost Pool
John
John
John
Job Category
Audiology and Speech Language
Pathology
Audiology and Speech Language
Pathology
Nursing
Psychological Services
USER INPUT
Staff
Employment
Status
T
July to September - LEA Payroll Information By Position Page
SYSTEM GENERATED
SYSTEM GENERATED
Gross
Net
Compensation
Compensation
Expenditures
Expenditures
$28,900.00
$18,900.00
$2,850.00
$3,125.00
$2,875.00
$13,850.00
$17,125.00
$20,875.00
$13,850.00
$17,125.00
$20,875.00
$21,000.00
$62,000.00
$2,600.00
$3,089.00
$23,600.00
$65,089.00
$23,600.00
$65,089.00
$24,500.00
$23,875.00
$12,500.00
$14,500.00
$39,000.00
$20,000.00
$3,100.00
$4,850.00
$2,859.00
$3,150.00
$2,300.00
$4,600.00
$27,600.00
$28,725.00
$15,359.00
$17,650.00
$41,300.00
$24,600.00
$27,600.00
$28,725.00
$12,859.00
$17,650.00
$41,300.00
$24,600.00
$2,500.00
Doe2
Doe3
Doe4
John
John
John
Doe5
Doe6
Doe7
Doe8
Doe9
Doe10
Doe11
Doe12
John
John
John
John
John
John
John
John
Occupational Therapy
Occupational Therapy
Physical Therapy
Physical Therapy
Personal Care
Personal Care
Care Coordination
Care Coordination
Direct Service Cost Pool
Full Time
Direct Service Cost Pool
Direct Service Cost Pool
Direct Service Cost Pool
Part Time
Part Time
Part Time
Direct Service Cost Pool
Direct Service Cost Pool
Direct Service Cost Pool
Direct Service Cost Pool
Personal Care
Personal Care
Care Coordination
Care Coordination
Full Time
Part Time
Full Time
Full Time
Part Time
Part Time
Full Time
Full Time
District Job Title
Audiologists
Speech Language
Pathologists
Registered Nurses
Psychologist
Certified Occupational
Therapist Assistants (COTA)
Occupational Therapists
Physical Therapist Assistants
Physical Therapists
LPNs
Aides
Care Coordinator
Care Coordinator
District
Employee ID
11111
FTE
Total
Salaries
Total
Benefits
1.00
$25,000.00
$3,900.00
AF
John
Cost Pool
R
Doe1
Job Category
Audiology and Speech
Language Pathology
Audiology and Speech
Language Pathology
Nursing
Psychological Services
D
First
Last Name Name
USER INPUT
Staff
Employment
Status
T
October to December - LEA Payroll Information By Position Page
SYSTEM GENERATED
SYSTEM GENERATED
Gross
Compensation
Compensation
Federal Sources
Expenditures
$10,000.00
Net
Compensation
Expenditures
$28,900.00
$18,900.00
22222
33333
44444
0.80
0.65
0.45
$11,000.00
$14,000.00
$18,000.00
$2,850.00
$3,125.00
$2,875.00
$13,850.00
$17,125.00
$20,875.00
$13,850.00
$17,125.00
$20,875.00
55555
66666
77777
88888
99999
12121
23232
34343
1.00
0.70
1.00
1.00
0.40
0.50
1.00
1.00
$21,000.00
$62,000.00
$24,500.00
$23,875.00
$12,500.00
$14,500.00
$39,000.00
$20,000.00
$2,600.00
$3,089.00
$3,100.00
$4,850.00
$2,859.00
$3,150.00
$2,300.00
$4,600.00
$23,600.00
$65,089.00
$27,600.00
$28,725.00
$15,359.00
$17,650.00
$41,300.00
$24,600.00
$23,600.00
$65,089.00
$27,600.00
$28,725.00
$12,859.00
$17,650.00
$41,300.00
$24,600.00
$2,500.00
Last
Name
First
Name
Job Category
Cost Pool
USER INPUT
Staff
Employment
Status
Direct Service Cost Pool
Full Time
Direct Service Cost Pool
Direct Service Cost Pool
Direct Service Cost Pool
Part Time
Part Time
Part Time
John
Doe2
Doe3
Doe4
John
John
John
Doe5
Doe6
John
John
Occupational Therapy
Occupational Therapy
Direct Service Cost Pool
Direct Service Cost Pool
Full Time
Part Time
Doe7
Doe8
Doe9
Doe10
Doe11
Doe12
John
John
John
John
John
John
Physical Therapy
Physical Therapy
Personal Care
Personal Care
Care Coordination
Care Coordination
Direct Service Cost Pool
Direct Service Cost Pool
Personal Care
Personal Care
Care Coordination
Care Coordination
Full Time
Full Time
Part Time
Part Time
Full Time
Full Time
District Job Title
Audiologists
Speech Language
Pathologists
Registered Nurses
Psychologist
Certified Occupational
Therapist Assistants
(COTA)
Occupational Therapists
Physical Therapist
Assistants
Physical Therapists
LPNs
Aides
Care Coordinator
Care Coordinator
District
Employee ID
FTE Total Salaries
R
D
Total
Benefits
11111
1.00
$25,000.00
$3,900.00
22222
33333
44444
0.80
0.65
0.45
$11,000.00
$14,000.00
$18,000.00
55555
66666
1.00
0.70
77777
88888
99999
12121
23232
34343
1.00
1.00
0.40
0.50
1.00
1.00
AF
Doe1
Audiology and Speech
Language Pathology
Audiology and Speech
Language Pathology
Nursing
Psychological Services
T
January to March - LEA Payroll Information By Position Page
SYSTEM GENERATED
SYSTEM GENERATED
Gross
Compensation
Compensation
Federal Sources
Expenditures
$10,000.00
Net
Compensation
Expenditures
$28,900.00
$18,900.00
$2,850.00
$3,125.00
$2,875.00
$13,850.00
$17,125.00
$20,875.00
$13,850.00
$17,125.00
$20,875.00
$21,000.00
$62,000.00
$2,600.00
$3,089.00
$23,600.00
$65,089.00
$23,600.00
$65,089.00
$24,500.00
$23,875.00
$12,500.00
$14,500.00
$39,000.00
$20,000.00
$3,100.00
$4,850.00
$2,859.00
$3,150.00
$2,300.00
$4,600.00
$27,600.00
$28,725.00
$15,359.00
$17,650.00
$41,300.00
$24,600.00
$27,600.00
$28,725.00
$12,859.00
$17,650.00
$41,300.00
$24,600.00
$2,500.00
Last
Name
First
Name
Job Category
Cost Pool
USER INPUT
Staff
Employment
Status
Direct Service Cost Pool
Full Time
Direct Service Cost Pool
Direct Service Cost Pool
Direct Service Cost Pool
Part Time
Part Time
Part Time
John
Doe2
Doe3
Doe4
John
John
John
Doe5
Doe6
John
John
Occupational Therapy
Occupational Therapy
Direct Service Cost Pool
Direct Service Cost Pool
Full Time
Part Time
Doe7
Doe8
Doe9
Doe10
Doe11
Doe12
John
John
John
John
John
John
Physical Therapy
Physical Therapy
Personal Care
Personal Care
Care Coordination
Care Coordination
Direct Service Cost Pool
Direct Service Cost Pool
Personal Care
Personal Care
Care Coordination
Care Coordination
Full Time
Full Time
Part Time
Part Time
Full Time
Full Time
District Job Title
Audiologists
Speech Language
Pathologists
Registered Nurses
Psychologist
Certified Occupational
Therapist Assistants
(COTA)
Occupational Therapists
Physical Therapist
Assistants
Physical Therapists
LPNs
Aides
Care Coordinator
Care Coordinator
District
Employee ID
FTE Total Salaries
R
D
Total
Benefits
11111
1.00
$25,000.00
$3,900.00
22222
33333
44444
0.80
0.65
0.45
$11,000.00
$14,000.00
$18,000.00
55555
66666
1.00
0.70
77777
88888
99999
12121
23232
34343
1.00
1.00
0.40
0.50
1.00
1.00
AF
Doe1
Audiology and Speech
Language Pathology
Audiology and Speech
Language Pathology
Nursing
Psychological Services
T
April to June - LEA Payroll Information By Position Page
SYSTEM GENERATED
SYSTEM GENERATED
Gross
Compensation
Compensation
Federal Sources
Expenditures
$10,000.00
Net
Compensation
Expenditures
$28,900.00
$18,900.00
$2,850.00
$3,125.00
$2,875.00
$13,850.00
$17,125.00
$20,875.00
$13,850.00
$17,125.00
$20,875.00
$21,000.00
$62,000.00
$2,600.00
$3,089.00
$23,600.00
$65,089.00
$23,600.00
$65,089.00
$24,500.00
$23,875.00
$12,500.00
$14,500.00
$39,000.00
$20,000.00
$3,100.00
$4,850.00
$2,859.00
$3,150.00
$2,300.00
$4,600.00
$27,600.00
$28,725.00
$15,359.00
$17,650.00
$41,300.00
$24,600.00
$27,600.00
$28,725.00
$12,859.00
$17,650.00
$41,300.00
$24,600.00
$2,500.00
DIRECT MEDICAL SERVICES - NON PAYROLL INFORMATION
USER INPUT
SYSTEM GENERATED
T
SYSTEM GENERATED
Materials and Supplies
AF
Provider Category
Materials and
Supplies paid with
Federal Funds
D
R
Psychological Services
Occupational Therapy
Physical Therapy
Audiology and Speech Language Pathology
Health Needs Assessment and Treatment Planning
Nursing
Care Coordination
Personal Care
Total
$160.00
$0.00
0
$20.00
$0.00
$0.00
$0.00
$0.00
$180.00
$50.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$50.00
Total Other Direct
Costs Net of Federal
Funds
$110.00
$0.00
$0.00
$20.00
$0.00
$0.00
$0.00
$0.00
$130.00
DEPRECIATION EXPENSES FOR DIRECT MEDICAL SERVICES EQUIPMENT
Job Category*
System Generated
Asset Type*
Specific Name
Date Placed in
Service*
07/01/10
10/01/12
Purchase Price*
$
$
5,500.00
5,100.00
D
R
AF
Occupational Therapy
Technology Device (Computer Term/Printers)
Audiology and Speech Language
Audiometer
Pathology
T
USER INPUT
Federal
Funding
Amount*
Useful Life of
Asset
5
10
Accumulated
Depreciation
Current Year
Depreciation
$3,300.00
$380.05
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,100.00
$510.00
GENERAL AND STATISTICAL INFORMATION
Value
LEA Name
WV LEA 123
National Provider Identification (NPI)
xxxxxxxxx
Medicaid Provider Number
xxxxxxxxx
Description:
AF
T
SYSTEM GENERATED
Description:
Medicaid IEP Rate
150
225
66.67%
7.00%
Direct Medical Service Percentage from Time Study Results
55.00%
Care Coordination Service Percentage from Time Study Results
13.00%
Personal Care Service Percentage from Time Study Results
12.00%
Description:
SYSTEM
SYSTEM
SYSTEM
USER INPUT
USER INPUT
GENERATED
GENERATED
GENERATED
Value
R
Unrestricted Indirect Cost Rate
D
SYSTEM GENERATED
Total Medicaid Spcial Education Students with an IEP-Prescribed
Reimbursable Related Service:
Total Special Education Students with an IEP-Prescribed Reimbursable
Related Service:
Value
Total Number of One-Way Trips for Medicaid Special Education
Students with Specialized Transportation Services Documented in the
IEP
24
Total Number of One-Way Trips for Special Education Students with
Specialized Transportation Services Documented in the IEP
107
Specialized Transportation Trip Ratio
22.43%
Total Number of Vehicles Used for Special Education Transportation
Purposes
4
Total Number of Vehicles Used for Transportation Purposes
13
Specialized Transportation Vehicle Rate
30.77%
CONTRACTED DIRECT SERVICES INFORMATION PAGE
USER INPUT
T
SYSTEM GENERATED
Total Contracted
Service Cost
Provider Category
$
$
$
$
$
$
$
$
$
51,110.00
64,410.00
65,455.00
98,515.00
39,140.00
318,630.00
$
$
$
$
$
$
$
$
$
D
R
AF
Psychological Services
Occupational Therapy
Physical Therapy
Audiology and Speech Language Pathology
Health Needs Assessment and Treatment Planning
Nursing
Care Coordination
Personal Care
Totals:
Contracted Service Costs
paid with Federal Funding
10,000.00
5,000.00
15,000.00
SYSTEM GENERATED
Total Contracted Service
Costs Net of Federal
Funding
$
51,110.00
$
54,410
$
65,455.00
$
98,515.00
$
$
34,140.00
$
$
$
303,630.00
T
Transportation Payroll Information Page
First Name
Doe1
Doe2
Doe3
Doe4
John
John
John
John
Job Category
Bus Driver (General Transportation)
Bus Driver (General Transportation)
Bus Driver (General Transportation)
Mechanic (General Transportation)
Part Time
Part Time
Full Time
Contractor
District Job Title
Bus Driver
Bus Driver
Bus Aide
Mechanic I
R
Last Name
USER INPUT
Staff
Employment
Status
District
Employee ID
AF
SYSTEM GENERATED
D
USER INPUT
98989
87878
76767
65656
FTE Total Salaries
0.8
0.4
1
0.5
$13,000.00
$9,000.00
$85,000.00
$16,000.00
Total
Benefits
Compensation
Federal Sources
$5,000.00
$5,000.00
$5,000.00
$5,000.00
$10,000.00
SYSTEM GENERATED
Gross
Compensation Net Compensation
Expenditures
Expenditures
$18,000.00
$14,000.00
$90,000.00
$21,000.00
$8,000.00
$14,000.00
$90,000.00
$21,000.00
OTHER TRANSPORTATION COSTS
USER INPUT
Description
SYSTEM GENERATED
Service Type
Transportation Services (General Trans)
Transportation Services (General Trans)
Transportation Services (General Trans)
Transportation Services (General Trans)
Transportation Services (General Trans)
Transportation Services (General Trans)
Transportation Services (General Trans)
Transportation Services (General Trans)
SYSTEM GENERATED
USER INPUT
Lease/Rental
Insurance
Maintenance and Repairs
Fuel and Oil
Major Purchases under $5000
Contract - Transportation Services
Contract - Transportation Equipment
Total
R
Service Type
$0.00
Transportation Services (only Specialized Trans)
Transportation Services (only Specialized Trans)
Transportation Services (only Specialized Trans)
Transportation Services (only Specialized Trans)
Transportation Services (only Specialized Trans)
Transportation Services (only Specialized Trans)
Transportation Services (only Specialized Trans)
Transportation Services (only Specialized Trans)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
SYSTEM GENERATED
Gross Costs
D
Description
Gross Costs
AF
Lease/Rental
Insurance
Maintenance and Repairs
Fuel and Oil
Major Purchases under $5000
Contract - Transportation Services
Contract - Transportation Equipment
Total
Total Other General
Total Amount of Federal Transportation Costs
Funding
Net of Federal
Funding
T
SYSTEM GENERATED
Total Other
Specialized
Total Amount of Federal
Transportation Costs
Funding
Net of Federal
Funding
$2,000.00
$2,000.00
$0.00
$0.00
$0.00
$0.00
$2,000.00
$0.00
$0.00
$0.00
$2,000.00
CIATION EXPENSES FOR TRANSPORTATION SERVICES EQUIPMENT
USER INPUT
5
07/01/11
5
SYSTEM GENERATED
Prior Period
Federal
Accumulated
Revenue
Depreciation
T
07/01/09
Cost
$50,000.00
AF
Buses
Years of Useful
Life
R
Buses
Service Type
Transportation Services (General
Trans)
Transportation Services (General
Trans)
D
Asset Type
Month/Year
Placed in
Service
$60,000.00
$500.00
Depreciation for
Reporting Period
$40,000.00
$10,000.00
$23,800.00
$11,900.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
SALARY AND BENEFITS DATA SUMMARY REPORT PAGE
Year Totals
SYSTEM GENERATED
Provider Category
FTE
Total Salaries & Benefits
Psychological Services
Occupational Therapy
Physical Therapy
Audiology and Speech Language Pathology
Health Needs Assessment and Treatment Planning
Nursing
Care Coordination
Personal Care
Totals:
0.45
1.7
2
1.8
0
0.65
2
0.9
9.5
$83,500.00
$354,756.00
$225,300.00
$171,000.00
$0.00
$68,500.00
$263,600.00
$132,036.00
$1,298,692.00
Gross Compensation Compensation Federal
Expenditures
Sources
$83,500.00
$354,756.00
$225,300.00
$171,000.00
$0.00
$68,500.00
$263,600.00
$132,036.00
$1,298,692.00
Net Compensation
Expenditures
$0.00
$0.00
$0.00
$40,000.00
$0.00
$0.00
$0.00
$10,000.00
$50,000.00
$83,500.00
$354,756.00
$225,300.00
$131,000.00
$0.00
$68,500.00
$263,600.00
$122,036.00
$1,248,692.00
Gross Compensation Compensation Federal
Expenditures
Sources
Net Compensation
Expenditures
July to September
AF
T
SYSTEM GENERATED
Provider Category
FTE
Total Salaries & Benefits
Psychological Services
Occupational Therapy
Physical Therapy
Audiology and Speech Language Pathology
Health Needs Assessment and Treatment Planning
Nursing
Care Coordination
Personal Care
Totals:
0.45
1.7
2
1.8
0
0.65
2
0.9
9.5
$20,875.00
$88,689.00
$56,325.00
$42,750.00
$0.00
$17,125.00
$65,900.00
$33,009.00
$324,673.00
Provider Category
FTE
Total Salaries & Benefits
Psychological Services
Occupational Therapy
Physical Therapy
Audiology and Speech Language Pathology
Health Needs Assessment and Treatment Planning
Nursing
Care Coordination
Personal Care
Totals:
0.45
1.7
2
1.8
0
0.65
2
0.9
9.5
$20,875.00
$88,689.00
$56,325.00
$42,750.00
$0.00
$17,125.00
$65,900.00
$33,009.00
$324,673.00
FTE
Total Salaries & Benefits
0.45
1.7
2
1.8
0
0.65
2
0.9
9.5
$20,875.00
$88,689.00
$56,325.00
$42,750.00
$0.00
$17,125.00
$65,900.00
$33,009.00
$324,673.00
Provider Category
FTE
Total Salaries & Benefits
SYSTEM GENERATED
Psychological Services
Occupational Therapy
Physical Therapy
Audiology and Speech Language Pathology
Health Needs Assessment and Treatment Planning
Nursing
Care Coordination
Personal Care
Totals:
0.45
1.7
2
1.8
0
0.65
2
0.9
9.5
$20,875.00
$88,689.00
$56,325.00
$42,750.00
$0.00
$17,125.00
$65,900.00
$33,009.00
$324,673.00
October to December
D
R
SYSTEM GENERATED
$20,875.00
$88,689.00
$56,325.00
$42,750.00
$0.00
$17,125.00
$65,900.00
$33,009.00
$324,673.00
$0.00
$0.00
$0.00
$10,000.00
$0.00
$0.00
$0.00
$2,500.00
$12,500.00
$20,875.00
$88,689.00
$56,325.00
$32,750.00
$0.00
$17,125.00
$65,900.00
$30,509.00
$312,173.00
Gross Compensation Compensation Federal
Expenditures
Sources
Net Compensation
Expenditures
$20,875.00
$88,689.00
$56,325.00
$42,750.00
$0.00
$17,125.00
$65,900.00
$33,009.00
$324,673.00
$0.00
$0.00
$0.00
$10,000.00
$0.00
$0.00
$0.00
$2,500.00
$12,500.00
$20,875.00
$88,689.00
$56,325.00
$32,750.00
$0.00
$17,125.00
$65,900.00
$30,509.00
$312,173.00
Gross Compensation Compensation Federal
Expenditures
Sources
Net Compensation
Expenditures
January to March
Provider Category
SYSTEM GENERATED
Psychological Services
Occupational Therapy
Physical Therapy
Audiology and Speech Language Pathology
Health Needs Assessment and Treatment Planning
Nursing
Care Coordination
Personal Care
Totals:
$20,875.00
$88,689.00
$56,325.00
$42,750.00
$0.00
$17,125.00
$65,900.00
$33,009.00
$324,673.00
$0.00
$0.00
$0.00
$10,000.00
$0.00
$0.00
$0.00
$2,500.00
$12,500.00
$20,875.00
$88,689.00
$56,325.00
$32,750.00
$0.00
$17,125.00
$65,900.00
$30,509.00
$312,173.00
Gross Compensation Compensation Federal
Expenditures
Sources
Net Compensation
Expenditures
April to June
$20,875.00
$88,689.00
$56,325.00
$42,750.00
$0.00
$17,125.00
$65,900.00
$33,009.00
$324,673.00
$0.00
$0.00
$0.00
$10,000.00
$0.00
$0.00
$0.00
$2,500.00
$12,500.00
$20,875.00
$88,689.00
$56,325.00
$32,750.00
$0.00
$17,125.00
$65,900.00
$30,509.00
$312,173.00
COST SUMMARY REPORT
DIRECT MEDICAL SERVICES
Net Direct Costs (less
Employee Salary and Other Direct Medical Federal Funds & reductions & Federal
Benefits
Services Costs Other Reductions
Sources)
$83,500.00
$354,756.00
$225,300.00
$171,000.00
$0.00
$68,500.00
$903,056.00
$110.00
$1,100.00
$0.00
$530.00
$0.00
$0.00
$1,740.00
PERSONAL CARE SERVICES
Calculation
$132,036.00
$132,036.00
CARE COORDINATION SERVICES
Calculation
Job Category
Net Contracted
Services Costs
Indirect Costs
$45,985.50
$195,720.80
$123,915.00
$72,341.50
$0.00
$37,675.00
$475,637.80
$51,110.00
$54,410.00
$65,455.00
$98,515.00
$0.00
$34,140.00
$303,630.00
$9,430.40
$28,718.62
$20,352.85
$16,103.15
$0.00
$7,184.80
$81,789.82
Net Direct Costs (less
Other Personal Care Federal Funds & reductions & Federal
Costs Other Reductions
Sources)
Application of Direct
Medical Percentage
Net Contracted
Services Costs
Indirect Costs
Net Direct Costs
plus Indirect Costs Application of IEP Ratio
$106,525.90
$278,849.42
$209,722.85
$186,959.65
$0.00
$78,999.80
$861,057.62
Medicaid Allowable
Costs
66.67%
66.67%
66.67%
66.67%
66.67%
66.67%
66.67%
$71,017.27
$185,899.61
$139,815.23
$124,639.77
$0.00
$52,666.53
$574,038.41
Net Direct Costs
plus Indirect Costs Application of IEP Ratio
Medicaid Allowable
Costs
$0.00
$10,000.00
$122,036.00
$14,644.32
$0.00
$8,542.52
$23,186.84
66.67%
$9,762.88
$0.00
$10,000.00
$122,036.00
$14,644.32
$0.00
$8,542.52
$23,186.84
66.67%
$9,762.88
Net Direct Costs (less
Other Care Federal Funds & reductions & Federal
Coordination Costs Other Reductions
Sources)
Application of Direct
Medical Percentage
Net Contracted
Services Costs
Indirect Costs
Net Direct Costs
plus Indirect Costs Application of IEP Ratio
Medicaid Allowable
Costs
D
Personal Care
Totals
$83,610.00
$355,856.00
$225,300.00
$131,530.00
$0.00
$68,500.00
$864,796.00
R
Job Category
Employee Salary and
Benefits
$0.00
$0.00
$0.00
$40,000.00
$0.00
$0.00
$40,000.00
Application of Direct
Medical Percentage
AF
Job Category
Psychological Services
Occupational Therapy
Physical Therapy
Audiology and Speech Language Pathology
Health Needs Assessment and Treatment Planning
Nursing
Totals
T
Calculation
Employee Salary and
Benefits
Care Coordination
$263,600.00
$0.00
$0.00
$263,600.00
$34,268.00
$0.00
$18,452.00
$52,720.00
66.67%
$22,845.33
Totals
$263,600.00
$0.00
$0.00
$263,600.00
$34,268.00
$0.00
$18,452.00
$52,720.00
66.67%
$22,845.33
Net Direct Costs (less
Employee Salary &
Other Medical Federal Funds & reductions & Federal
Benefits Transportation Costs Other Reductions
Sources)
Indirect Costs
Net Direct Costs plus
Indirect Costs and
Other Costs
Application of Vehicle
Ratio
Application of Trip
Ratio
Medicaid Allowable
Costs
$140.00
$10,843.00
$2,140.00
$165,743.00
N/A
30.77%
22.43%
22.43%
Totals:
$480.00
$11,438.77
$11,918.77
MEDICAL TRANSPORTATION SERVICES
Calculation
Job Category
Total Transportation Services (Only Specialized Trans)
Total Transportation Services (General Trans)
$0.00
$143,000.00
$2,000.00
$21,900.00
$0.00
$10,000.00
$2,000.00
$154,900.00
Medicaid Allowable
Costs
GRAND TOTALS
$618,565.40
Please submit completed form with original signature to:
Public Consulting Group, Inc.
148 State Street , 10th Floor
Boston, MA 02109
Certification of Public Expenditures for Annual Medicaid Cost Report
LEA Name: West Virginia LEA 123
National Provider Identification (NPI): XXXXXXXXXX
__________________________________________________________________ ___________________________________________________________
_____
____________
AF
T
LEA Address: Sample Address
Medicaid Provider Number: XXXXXXXXXX
__________________________________________________________________ ___________________________________________________________
____
___________
Claimed Expenditures
This statement is of expenditures that the undersigned certifies are allocable and allowable to the State Medicaid program under Title XIX of the Social Security
Act (the Act), and in accordance with all procedures, instruction and guidance issued by the single state agency and in effect during the state fiscal year.
HEREBY CERTIFY that for the reporting period: From: 07/01/2012
To: 06/30/2013
Total Medicaid Expenditures Submitted to DHHR/BMS for School Based
Medicaid Services
618,565.40
R
$
CERTIFICATION STATEMENT BY OFFICER OF THE PROVIDER
INTENTIONAL MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED HEREIN MAY BE PUNISHABLE BY
FINE AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW.
D
1. All expenditures presented should be allowable in accordance with federal and the Memorandum of Understanding (MOU) agreement requirements.
2. I have examined this statement, the accompanying supported exhibits, the allocation of expenses and services, and the worksheets for the above indicated reporting period and to
the best of my knowledge and belief they are true and correct statements prepared from the books and records of the Provider in accordance with applicable instructions.
3. The expenditures included in this statement are based on the actual cost recorded expenditures.
4. The required amount of state and/or local funds were available and used to pay for total computable allowable expenditures included in this statement, and such state and/or local
funds were in accordance with all applicable federal requirements for the non-federal share match of expenditures (including that the funds were not Federal funds in origin, or are
Federal funds authorized by Federal law to be used to match other Federal funds, and that the claimed expenditures were not used to meet matching requirements under other
Federally funded programs.
5. Federal matching funds are being claimed on this report in accordance with the cost report instructions provided by the West Virginia School Based Health Services Program
effective for the above indicated reporting period.
6. I am the officer authorized by the referenced government agency to submit this form and I have made a good faith effort to assure that all information reported is true and accurate.
7. I understand that this information will be used as a basis for claims for Federal funds, and possibly State funds, and that a falsification and concealment of a material fact may be
prosecuted under Federal or State civil or criminal law.
________________________________
________________________________
________________________________
Signature of Signer
(CEO, CFO, or Superintendant)
Title of Signer
Date
________________________________
________________________________
Printed/Typed Name of Signer
Address of Signer
(street or P.O. Box, city, state, 5digit zip)
________________________________
________________________________
________________________________
Contact Phone Number
Fax Number
Email Address
AF
LEA NAME: WEST VIRGINIA LEA 123
NPI: XXXXXXXXXXXXXX
Medicaid Provider Number: XXXXXXXXXXXXX
Cost Reporting Period: 7/1/2012 to 6/30/2013
T
WV SBHS Cost Settlement
FEDERAL FINANCIAL PARTICIPATION RATE (FFP)
$
$
$
$
$
574,038.41
9,762.88
22,845.33
11,918.77
618,565.40
72.04%
$
445,614.51
LESS MEDICAID INTERIM PAYMENTS FOR SCHOOL BASED HEALTH SERVICES - NET FFP
*From MMIS
$
324,102.00
DIFFERENCE BETWEEN TOTAL COMPUTABLE AND MEDICAID INTERIM PAYMENTS:
$
121,512.51
COST SETTLEMENT AMOUNT - FEDERAL SHARE:
$
121,512.51
D
TOTAL MEDICAID COST - NET FFP
R
TOTAL COMPUTABLE DIRECT MEDICAL SERVICE MEDICAID COST:
TOTAL COMPUTABLE PERSONAL CARE SERVICE MEDICAID COST:
TOTAL COMPUTABLE CARE COORDINATION SERVICE MEDICAID COST:
TOTAL COMPUTABLE TRANSPORTATION MEDICAID COST:
TOTAL MEDICAID COST - GROSS