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April 13, 2015
«Greeting» «FirstName» «LastName»
«ProviderName»
«Address»
«City», «State» 43952
RE:
Hospital Franchise Fee (HFF) 2015 Program Preliminary and Final Notice:
ASSESSMENT DUE DATES & AMOUNTS. This is the only notice you will receive
regarding this year's program.
Dear «Greeting» «LastName»:
The Ohio Department of Medicaid (ODM) has completed calculations for the 2015 HFF Program
(October 1, 2014 – September 30, 2015) assessment amounts. This letter is both your
preliminary and final assessment notice. Your hospital’s total assessment, installment amounts
and invoice numbers are shown below. Ohio Administrative Code rule 5160-2-30 will be effective
on or before April 27, 2015 and establishes an assessment rate for the HFF 2015 Program of
2.6463589%. Table 2 details the calculation of the assessment.
In order to complete all Franchise Fee related transactions during this State Fiscal Year, the time
frame for this year’s assessment is very compressed. Your assessment is to be paid in two
installments, each due on the dates shown below.
Provider #: «Prov_Num»
Your facility's total annual assessment is:
Installment Due
Invoice Number
April 30, 2015
HFF151«Prov_Num»
May 18, 2015
HFF152«Prov_Num»
«Assess»
Amount Due
«Payment1»
«Payment2»
The due date shown is the date by which the assessment must be received (not
transmitted). Please do not schedule your assessment to arrive more than 14 days
before the due date.
Your payment must be submitted via EFT. Please EFT your payments to the following bank
routing address:
EFT Routing Address and accompanying information:
Routing Number: ABA# 041001039
Key Bank – To Credit State of Ohio Regular
Account#: 014511001050
In reference field: ODM – HFF 2015 for InvoiceNumber
Email Contact: [email protected]
Special Instructions: If you desire to test this routing address, please use an amount of $0.01.
2015 Hospital Franchise Fee Assessment Letter
April 13, 2015
Page 2
New Instructions: Please format the reference field as shown above and include the invoice
number shown in the table above for each installment. If you are emailing the contact above,
with questions or updates, please include the invoice number in your email.
In accordance with Section 5168.22 of the Ohio Revised Code, a hospital may submit a written
request for reconsideration of this determination. The request for reconsideration of the
assessment amount must be accompanied by written materials setting forth the basis of the
reconsideration, and should include documentation to support the hospital's position. This
material should be sent or faxed to:
Roy Sutton
Ohio Department of Medicaid
Rate Setting and Cost Settling Unit
P.O. Box 182709
Columbus, OH 43218-2709
Fax: 614-752-2349
The hospital's request for reconsideration must be submitted to ODM at the above address no
later than 14 days after the mailing date of this letter, and must be RECEIVED BY ODM no
later than the close of business on April 27, 2015.
In accordance with Section 5168.22 (C) of the Ohio Revised Code, a hospital may appeal this
determination to the Court of Common Pleas of Franklin County. Appeals to the Court of Common
Pleas shall be governed by Chapter 2505 of the Ohio Revised Code, and must be perfected within
thirty days of your facility’s receipt of this determination. During the appeal process, any amounts
not in dispute must still be paid.
If you have questions, please contact me at 614-752-4408.
Sincerely,
Roy Sutton
Ohio Department of Medicaid
Rate Setting and Cost Settling Unit
2015 Hospital Franchise Fee Assessment Letter
April 13, 2015
Page 3
Table 2
Hospital Franchise Fee Assessment Determination for Provider «Prov_Num»
«ProviderName»
Adjusted Total Facility Costs
Medicare Cost:
Inpatient Hospital
Organ Acquisition
I/P GME
O/P GME
Routine Other Pass Through
Ancillary Other Pass Through
Outpatient Hospital 1
Outpatient Hospital 2
Outpatient Hospital 3
Outpatient Hospital 4
Less: Total Medicare Costs
Adjusted Total Facility Costs – Modified (ATFC-M)
Hospital Franchise Fee Assessment
«ATFC»
«IPHosp»
«OrganAcq»
«IPGME»
«OPGME»
«Routine»
«Ancillary»
«OPHosp1»
«OPHosp2»
«OPHosp4»
«OPHosp3»
ATFC-M * 2.6463589%
Cost Report Location of Medicare Cost Data Elements
Medicare Cost Center
Inpatient Hospital+
Organ Acquisition
I/P GME
O/P GME
Routine Other Pass Through
Ancillary Other Pass Through
Outpatient Hospital 1+
Outpatient Hospital 2+
Outpatient Hospital 3+
Outpatient Hospital 4*
+
CMS 2552-10 Location
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
Worksheet
D-1, Line 49, Column 1
D-4, Line 69, Column 1
E-4, Line 49, Column 1
E-4, Line 50, Column 1
E, Part A, Line 57, Column 1
E, Part A, Line 58, Column 1
E, Part B, Line 1, Column 1
E, Part B, Line 2, Column 1
E, Part B, Line 2, Column 1.01
E, Part B, Line 9, Column 1
When applicable, costs for the primary hospital as well as an IRF and IPF are included.
«MCareCost»
«ATFCM»
«Assess»