09-01 FORM CMS-2552-96 3690 (Cont.) CALCULATION OF CAPITAL PAYMENT PROVIDER NO.: PERIOD: WORKSHEET L ______________ FROM __________ COMPONENT NO.: TO ____________ ______________ Check [ ] Title V [ ] Hospital [ ] Fully Prospective Method Applicable [ ] Title XVIII [ ] Subprovider [ ] Hold Harmless Method Boxes [ ] Title XIX [ ] Cost Method PART I - FULLY PROSPECTIVE METHOD 1 Capital hospital specific rate payments X 1 CAPITAL FEDERAL AMOUNT 2 Capital DRG other than outlier X 2 3 " Capital DRG outlier payments for services rendered prior to October 1, 1997" X 3 3.01 " Capital DRG outlier payments for services rendered on or after October 1, 1997" X 3.01 Indirect Medical Education Adjustment 4 Total inpatient days divided by number of days in the cost reporting period (see instructions) X 4 4.01 " Number of interns & residents (from Worksheet S-3, Part I, column 9, line 12)" X 4.01 4.02 Indirect medical education percentage (see instructions) X 4.02 4.03 Indirect medical education adjustment (sum of lines 2 & 3 times line 4.02) X 4.03 Disproportionate Share Adjustment 5 Percentage of SSI recipient patient days to Medicare Part A patient days (see instructions) X 5 5.01 " Percentage of Medicaid patient days to total days reported on Worksheet S-3, Part I (see instructions)" X 5.01 5.02 Sum of lines 5 and 5.01 X 5.02 5.03 Allowable disproportionate share percentage (see instructions) X 5.03 5.04 Disproportionate share adjustment (sum of lines 2 & 3 times line 5.03) X 5.04 6 " Total prospective capital payments (sum of lines 1-3.01, 4.03, and 5.04)" X 6 PART II - HOLD HARMLESS METHOD 1 New capital (see instructions) X 1 2 Old capital (see instructions) X 2 3 Total capital (sum of line 1 plus line 2) X 3 4 Ratio of new capital to total capital (line 1 divided by line 3) X 4 5 Total capital payments under 100% federal rate (see instructions) X 5 6 Reduction factor for hold harmless payment (see instructions) X 6 7 Reduced old capital amount (line 2 x line 6) X 7 8 Hold harmless payment for new capital (line 5 x line 4) X 8 9 Subtotal (line 7 plus line 8) X 9 10 Payment under hold harmless (greater of line 5 or line 9) X 10 PART III - PAYMENT UNDER REASONABLE COST 1 Program inpatient routine capital cost (see instructions) X 1 2 Program inpatient ancillary capital cost (see instructions) X 2 3 Total inpatient program capital cost (line 1 plus line 2) X 3 4 Capital cost payment factor (see instructions) X 4 5 Total inpatient program capital cost (line 3 x line 4) X 5 PART IV - COMPUTATION OF EXCEPTION PAYMENTS 1 Program inpatient capital costs (see instructions) X 1 2 Program inpatient capital costs for extraordinary circumstances (see instructions) X 2 3 Net program inpatient capital costs (line 1 minus line 2) X 3 4 Applicable exception percentage (see instructions) X 4 5 Capital cost for comparison to payments (line 3 x line 4) X 5 6 Percentage adjustment for extraordinary circumstances (see instructions) X 6 7 Adjustment to capital minimum payment level for extraordinary circumstances (line 2 x line 6) X 7 8 Capital minimum payment level (line 5 plus line 7) X 8 9 " Current year capital payments (from Part I, line 6 or Part II, line 10, as applicable)" X 9 10 Current year comparison of capital minimum payment level to capital payments (line 8 less line 9) X 10 11 Carryover of accumulated capital minimum payment level over capital payment 11 " (from prior year Worksheet L, Part IV, line 14)" 12 Net comparison of capital minimum payment level to capital payments (line 10 plus line 11) X 12 13 " Current year exception payment (if line 12 is positive, enter the amount on this line)" X 13 14 Carryover of accumulated capital minimum payment level over capital payment 14 " for the following period (if line 12 is negative, enter the amount on this line)" 15 Current year allowable operating and capital payment (see instructions) X 15 16 Current year operating and capital costs (see instructions) X 16 17 Current year exception offset amount X 17 "FORM CMS-2552-96 (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 3660-3660.4)" Rev. 8 36-635