STATE OF NEW JERSEY - DIVISION OF TAXATION NHA-100 NURSING HOME PROVIDER ASSESSMENT RETURN (4/05) For the Quarter Ending In accordance with P.L.2003, c.105, as amended by P.L. 2004, c.41, it is requested that you complete the following form so that it can be determined the Assessment that will be due and payable within twenty (20) days after the end of the quarter. Please make any necessary corrections to the information listed below. NJ/Federal Employer Identification Number FOR DIVISION USE ONLY LICENSED NAME ADDRESS CITY ST ZIP Your Long Term Care Program Reporting Classification is: TAX CLASSIFICATION and PROGRAM NAME B Related Revenue Received or Accrued Whole Dollars (excluding cents) SA D MP O L N E O O T N FI LY LE A Number of Patient Days Line 1. Medicare Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Non-Medicare Days, including bedhold: Line 2. Private ................................ 00 Line 3. Medicaid ................................ 00 Line 4. Therapeutic leave . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Line 5. Respite ................................ 00 Line 6. Other Non-Medicare days . . . . . . . . . . . . . . . . . . . . . 00 Line 7. Assessed Days and Revenue. Add Lines 2 through 6 and enter here. . . . . . . . . . . Line 8. Classification Assessment Rate . . . . . . . . . . . . . . . . ASSESSMENT RATE 00 Line 9. Assessment Due (Line 7A x Line 8) . . . . . . . . . . . . . Line 10. Penalty and Interest Due . . . . . . . . . . . . . . . . . . . . . Line 11. Total Amount Due (add Lines 9 and Line 10) . . . . . . Make check payable to: File return with payment to: NJ Nursing Home Provider Assessment New Jersey Division of Taxation Revenue Processing Center PO Box 646 Trenton, NJ 08646-0646 Misrepresentations or falsification of any patient days or revenue data may be punishable by fine and/or imprisonment. I declare under the penalties provided by law, that this return has been examined by me and to the best of my knowledge and belief is a true, correct and complete return. If the return is prepared by a person other than the taxpayer, his declaration is based on all the information related to the matters required to be reported on the return of which he has knowledge. __________________________________________________ ______________________________________________________ _______________ Signature Title (Officer, Owner, or Administrator ONLY) Date __________________________________________________ ______________________________________________________ _______________ Preparer’s Signature Preparer’s Firm Name and Firm Federal ID Number Date (Only Required if other than Officer, Owner, or Administrator) I authorize the Division of Taxation to forward this return and/or the information contained herein to the Department of Health and Senior Services, Division of Senior Benefits and Utilization Management to facilitate the administration of the “Nursing Home Quality of Care Improvement Fund” as established pursuant to P.L. 2003, c.105, as amended by P.L. 2004, c.41. __________________________________________________ _______________________________________________ _____________________ Signature Title (Officer, Owner, or Administrator ONLY) Date RETURN INSTRUCTIONS GENERAL INFORMATION REGARDING PATIENT DAYS AND RELATED REVENUE RECEIVED OR ACCRUED (1) A Non-Medicare patient day is any day that a patient occupies a nursing bed (includes bedhold) which is paid for by any payer, public or private, other than Medicare. (2) Revenue received or accrued means the amount received or receivable, whether in cash or in kind, from patients, third party payors and others for nursing home services furnished by the nursing home provider, including retroactive adjustments under reimbursement agreements with third party payers without any deduction for expenses of any kind. Enter Related Revenue Received or Accrued as Whole Dollars, excluding cents. When rounding off to whole dollars, eliminate any amount under 50 cents and increase any amount 50 cents or more to the next highest dollar. (3) For the purpose of this assessment, Residential Days, CPCH Days and Daycare Days data are excluded and are not to be reported on this return. LINE ITEM INSTRUCTIONS Line 1 Medicare Days - Enter patient days and revenue data for Medicare patients. Non- Medicare Days: Line 2 Private - Enter patient day and revenue data paid by private insurance companies or individuals. Line 3 Medicaid - Enter patient day and revenue data paid by Medicaid (Include Medicaid Bedhold Days). Line 4 Therapeutic Leave - Enter patient day and revenue data. Line 5 Respite - Enter patient day and revenue data. Line 6 Other Non-Medicare days - Enter patient day and revenue data. Line 7 Assessed Days & Revenue - Total Patient Days and Revenue from Line 2 through Line 6 and enter in the appropriate columns A and B, respectively. Line 8 Classification Assessment Rate - Rate per Day. Line 9 Assessment Due - Multiply Line 7A, Assessed days, by Line 8, Rate, and enter result. Line 10 Penalty and Interest Due - Report any penalty and interest to be included in payment. Line 11 Total Amount Due - Add Line 9 and Line 10 and enter result. Pay this amount. FILING INSTRUCTIONS A. FILING OF RETURNS AND PAYMENT OF TAX - In accordance with P.L. 2003, c.105, as amended by P.L. 2004, c.41, Nursing Home Providers in New Jersey are to complete the Nursing Home Provider Assessment Return, NHA-100, on a quarterly basis within 20 days after the end of a calendar quarter. B. REMITTANCE - Make check payable to: NJ Nursing Home Provider Assessment. Do not send cash. C. WHERE TO FILE - The NHA-100 must be filed with both the Division of Taxation and the Department of Health and Senior Services. However, if the confidentiality waiver on the NHA100 is signed providing the Division of Taxation the authority to forward the information to the Department of Health and Senior Services, the NHA-100 may be filed solely with the Division of Taxation. Mail the Nursing Home Provider Assessment Return, NHA-100, together with remittance for the full amount due to the New Jersey Division of Taxation, Revenue Processing Center, PO Box 646, Trenton, NJ 08646- 0646. Mail a copy of this return to the Department of Health and Senior Services, Office of Rate Setting and Reimbursement, PO Box 715, Trenton, NJ 08625-0715, (only necessary if the waiver detailed above is not signed) Mail Original to: NJ Division of Taxation Revenue Processing Center PO Box 646 Trenton, NJ 08646-0646 Mail Copy to: Department of Health and Senior Services Office of Rate Setting PO Box 715 Trenton, NJ 08625-0715 D. PENALTIES AND INTEREST - If the return is not filed, penalties for late filing and payment will be applied and interest will be charged from the original due date to date of filing and payment. LATE FILING PENALTY - 5% per month of fraction thereof of the balance of assessment due at original return due date not to exceed 25% of such assessment liability. In accordance with N.J.S.A. 54:49-4, a delinquency penalty of $100 per month, or fraction thereof, may be imposed for each month each return is filed after the original due date. If a Medicaid facility does not properly, and in a timely manner, submit the correct, complete information and payment of the provider assessment, the New Jersey Division of Taxation may also deduct an estimated assessment from their UNISYS Medicaid payments and the Medicaid facility may be subject to a non-reimbursable two percent (eight percent annual rate) assessment for penalty and interest. If an exempt facility does not report the required statistics or if the statistics are not reported in a timely manner, the exempt facility may also be subject to a two percent assessment of estimated gross revenue. LATE PAYMENT PENALTY - 5% of the balance of the assessment due paid late may be imposed. INTEREST - The annual interest is 3% above the average predominant prime rate. Interest is imposed each month or fraction thereof on the unpaid balance of assessment from the original due date to the date of payment. At the end of each calendar year any assessment, penalties and interest remaining due will become a part of the balance on which interest will be charged. Please note: In accordance with N.J.S.A. 54:49-12.3, a Referral Cost Recovery Fee of 10% of the assessment, penalty and interest due will be added to your liability, if this matter is assigned to an outside collection agency. For delinquent periods, if that period is assigned to an outside collection agency, a Referral Cost Recovery Fee will be assessed prior to the filing of a Certificate of Debt. E. FURTHER INFORMATION - All general filing and forms inquiries regarding the Nursing Facility Provider Assessment may be directed to the NJ Division of Taxation Customer Service Center by telephone at 609.292.6400 or by writing to the: NJ Division of Taxation, Information and Publications Branch, PO Box 281, Trenton, NJ 08695-0281 or [email protected]. Specific questions regarding data to be submitted should be directed to: NJ Department of Health and Senior Services, Division of Senior Benefits and Utilization Management, Office of Nursing Facility Rate Setting and Reimbursement, PO Box 715, Trenton, NJ 08625-0715, Telephone 609.588.2691 or William.Dawidowski @doh.state.nj.us for email inquiries.