3690 (Cont.)				CMS FORM-2552-96					08-06			
CALCULATION OF GME AND IME PAYMENTS FOR				PROVIDER NO.:		PERIOD:		WORKSHEET E-3				
REDISTRIBUTION OF UNUSED RESIDENCY SLOTS				________________		FROM  		PART VI			7/1/2005	
				COMPONENT NO.:		TO 					 365 	
				________________								
Check			  [  ]  Title V								 92 	
Applicable			  [  ]  Title XVIII									
Box			  [  ]  Title XIX									
												
PART A - INPATIENT HOSPITAL												
												
Calculation of Reduced Direct GME Cap Under Section 422 of MMA 									 			
1 	Ratio of days occurring on or after 7/1/2005 to total days in the cost reporting period (see instructions)							 X  	1 			
2 	Reduced Direct GME FTE Cap (see instructions)							 X  	2 			
3 	"Unadjusted Direct GME FTE Cap (Wkst E-3, Part IV, sum of lines 3.01 and 3.02)"							 X  	3 			
4 	Prorated Reduced  Direct GME FTE Cap (see instructions)							 X  	4 			
Calculation of Additional Direct GME Payment Attributable to Section 422 of MMA								 X  				
5 	Additional unweighted allopathic and osteopathic direct GME FTE resident cap slots received under 42 Sec. 413.79 (c ) (4)							 X  	5 			
5.01 	Prorated additional unweighted direct GME FTE resident cap slots (cost reporting periods overlapping 7/1/2005 only)							 X  	5.01 			
6 	GME FTE Resident count over Cap (see instructions)							 X  	6 			
7 	"If the amount on line 6 is greater than -0-, but less than or equal to the count on line 5 then enter the count from line 6."								7 			
	"see instructions for cost periods overlapping July 1, 2005)"							X 				
8 	Enter the locality adjustment national average per resident amount (see instructions)							 X  	8 			
9 	Multiply line 7 time line 8							 X  	9 			
10 	"Medicare program patient load from Wkst E-3 Part IV, line 6."							 X  	10 			
11 	Direct GME payment for non-managed care days (multiply line 9 times line 10)							 X  	11 			
12 	"Direct GME payment for managed care days (multiply line 9 by Wkst E-3, Part IV[(line 6.02 +6.06)/line 5]"							 X  	12 			
Calculation of Reduced IME Cap Under Section 422 of MMA 								 X  				
13 	Reduced IME FTE Cap (see instructions)							 X  	13 			
14 	"Unadjusted IME FTE Cap (Wkst E, Part A, sum of lines 3.04 and 3.05)"							 X  	14 		TRUE	
15 	Prorated Reduced  allowable IME FTE Cap 							 X  	15 			
Calculation of Additional IME Payments Attributable to Section 422 of MMA 												
16 	Number of additional allopathic and osteopathic IME FTE resident cap slots under 42 Sec. 412.105 (f)(1)(iv)(C ).							 X  	16			
17 	IME FTE Resident Count Over Cap (see instructions)							 X  	17			
18 	"If the amount on line 17 is greater than -0-, then enter the lower of line 16 or line 17 (see instructions for "								18			
	cost reporting periods overlapping 7/1/2005)							 X  				
19 	"Resident to bed ratio (divide line 18 by line 3 of Wkst E, Part A)"							 X  	19			
20 	IME Adjustment Factor (see instructions)							 X  	20			
21 	"DRG other than outlier payments for discharges on or after July 1, 2005."							 X  	21 			
22 	"Simulated Medicare managed care payments for discharges on or after July 1, 2005"							 X  	22			
23 	Additional IME payments attributable to section 422 of MMA							 X  	23			
												
												1.42 
											TRUE	 1.02 
												1.008683625 
												0.008683625 
												0.012331 
												
												
												
												
												
												
											0.66 	
											1.005175 	
											1.002092657 	
											0.002092657 	
											0.001381 	
												
												
"FORM CMS-2552-96 (08/2006) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 3633.6)"												
												
36-599.1									Rev.  16