Retroactive Per Diem Rates (Part 2)
Retroactive Per Diem Rates (Part 2)
Retroactive Per Diem Rates (Part 2)
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
---<br />
---<br />
State of Florida Office ofMedicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Orange City Nursing and Rehab Provider Number: 0263567-00<br />
2810 Enterprise Road<br />
Date: 11113/2012<br />
DeBary FL 32713<br />
Fiscal Year End: 6/30/2004<br />
---<br />
---<br />
---<br />
Audit Status: Revised Field Audit [5]<br />
Provider Type:<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 160.00 159.12 11112006<br />
Level H: AIDS 285.11 284.23 1/112006<br />
Level U: Fragile Under 21 385.49 384.61 11112006<br />
Interim x<br />
Total Interim<br />
Budget<br />
Unaudited costs<br />
-.."."..<br />
X Field audited costs<br />
Interim Component<br />
X Settlement based on costs<br />
Prior Provider Prospective data<br />
___Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
Pennanent File<br />
__For infonnation Only<br />
__No Change in Rate<br />
Home Office:<br />
---<br />
---<br />
---<br />
---<br />
X<br />
---<br />
---<br />
Southern HealthCare Management, LLC<br />
R. Mark Cronquist<br />
i:887 Glenridge Drive, Suite 150<br />
Ltlanta GA 30328<br />
Total Prospective<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
Field Audit RFA NH06-164J FYE 6/30/2004<br />
Rate Semester Change<br />
On FRV [2] as of06/261199 I<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:U2IHE Report Calculated: 11/13/2012 Report Printed: 1111312012 Book:O ID:48203263567200601012012111308525
Tuskawilla Nursing and Rehab<br />
1024 Willa Springs Drive<br />
Winter Springs FL 32708<br />
Provider Type:<br />
Nursing Home Single Level<br />
I IRate Type :1<br />
---<br />
---<br />
Interim<br />
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Level H: AIDS<br />
i Total Interim<br />
Basis:<br />
___Budget<br />
X Unaudited costs<br />
Field audited costs<br />
Level U: Fragile Under 21<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
L===--__<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
----<br />
----<br />
----<br />
----<br />
----<br />
Current<br />
Rate<br />
170.48<br />
306.76<br />
416.11<br />
X Prospective<br />
Changes:<br />
iS6mnem HeatthCare Management, LLC<br />
I<br />
IR. Mark Cronquist<br />
5887 Glenridge Drive, Suite 150<br />
Atlanta GA 30328<br />
---<br />
Provider Number:<br />
Date:<br />
Fiscal Year End:<br />
Audit Status:<br />
New<br />
Rate<br />
170.49<br />
306.77<br />
416.12<br />
X Total Prospective<br />
0263591-00<br />
111712012<br />
12/31/2006<br />
Unaudited [3J<br />
Effective<br />
Date<br />
7/112008<br />
7/1/2008<br />
7/112008<br />
Prospective Adjusted for New Costs<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVS Change<br />
X Effects ofField Audit RFA NH06-159J FYE 6/30/04<br />
____ Rate Semester Change<br />
On FRV [2] as of 11107/1994<br />
............ _-_..._---<br />
?<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:KR2LE Report Calculated: 1116/2012 Report Printed: 111712012 Book:O ID:482032635912008070120121106085021
---<br />
---<br />
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Hunter's Creek and Rehab Provider Number: 0263605-00<br />
14155 Town Loop Bovd. Date: 111112012<br />
Orlando FL 32837<br />
Fiscal Year End: 12/3112005<br />
Audit Status: Unaudited [3]<br />
Provider Type:<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 174.30 174.27 1/1/2007<br />
IRate Type: I<br />
Basis:<br />
Level H: AIDS 303.90 303.87 11112007<br />
Level U: Fragile Under 21 407.89 407.86 111/2007<br />
----<br />
Interim X Prospective<br />
Total Interim X Total Prospective<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
Prospective Adjusted for New Costs<br />
---<br />
Total Prospective with Interim Component<br />
---<br />
___Budget<br />
X Unaudited costs<br />
Field audited costs<br />
___Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Changes:<br />
[Southern HealthCare Management, LLC<br />
IR. Mark Cronquist<br />
5887 Glenridge Drive, Suite 150<br />
1I Atlanta GA 30328<br />
1..____.....__<br />
Usual and Customary Limitation<br />
--- Target Rate limitation change<br />
---<br />
---- FRVSChange<br />
X Effects of FA & RFA #NH06-1SlJ FYE 06/30/04<br />
--- Rate Semester Change<br />
--- On FRV [2] as of 05/26/1998<br />
---:J-D? Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:6XN4X Report Calculated: 1lI1/2012 Report Printed: 1111/2012 Book:O ID:554332636052007010120121l01081003<br />
l
---<br />
---<br />
---<br />
State ofFlorida Office ofMedicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Hunter's Creek Nursing and Rehab Provider Number: 0263605-00<br />
14155 Town Loop Bovd.<br />
Orlando FL 32837<br />
Provider Type:<br />
Nursing Home Single Level<br />
----<br />
----<br />
----<br />
----<br />
----<br />
Current<br />
Rate<br />
178.61<br />
---<br />
---<br />
Date:<br />
Fiscal Year End:<br />
Audit Status:<br />
New<br />
Rate<br />
178.57<br />
111l/2012<br />
1213112005<br />
Unaudited<br />
Effective<br />
Date<br />
2/1/2007<br />
Level H: AIDS 308.21 308.17 2/112007<br />
Level U: Fragile Under 21 412.20 412.16 211/2007<br />
Interim X Prospective<br />
Total Interim X Total Prospective<br />
Interim Component Prospective Adjusted for New Costs<br />
Settlement based on costs Total Prospective with Interim Component<br />
I Prior Provider Prospective data<br />
I Basis: I Changes: I<br />
___Budget<br />
Licensure Rating Change<br />
X Unaudited costs<br />
Usual and Customary Limitation<br />
Field audited costs Target Rate limitation change<br />
Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
L===-.____----'----_----'----____........,<br />
Dis tribution:<br />
Contract Management / Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
R. Mark Cronquist<br />
5887 Glenridge Drive, Suite 150<br />
Atlanta GA 30328<br />
FRYS Change<br />
X Effects of FA & RFA #NH06-151J FYE 06/30/04<br />
Rate Semester Change<br />
---- On FRY [2] as of 05/2611998<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:6XN4X Report Calculated: 111112012 Report Printed: 11/1/2012 Book:O ID:554332636052007020120121 101081010
---<br />
State ofFlorida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Hunter'S Creek Nursing and Rehab Provider Number: 0263605-00<br />
14155 Town Loop Bovd.<br />
Orlando FL 32837<br />
Provider Type:<br />
----<br />
---<br />
---<br />
Date: 111112012<br />
Fiscal Year End: 12/3112009<br />
Audit Status: Unaudited [3)<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 223.84 223.80 7/1/2010<br />
___Budget<br />
Level H: AIDS 367.18 367.14 7/112010<br />
Level U: Fragile Under 21 482.21 482.17 7/112010<br />
Total Interim<br />
X Unaudited costs<br />
Field audited costs<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
___Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
Pennanent File<br />
__For infonnation Only<br />
__No Change in Rate<br />
X Prospective<br />
----<br />
----<br />
----<br />
----<br />
----<br />
----<br />
'Southern HealthCare Management, LLC<br />
Home Office: i<br />
i R. Mark Cronquist<br />
15887 Glenridge Drive, Suite 150<br />
I GA 30328<br />
X Total Prospective<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
Effects of FA & RFA #NH06-151J FYE 06130/04<br />
Rate Semester Change<br />
On FRV [2] as of05/2611998<br />
Thomas Parker<br />
edicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:6XN4X Report Calculated: 1111/2012 Report Printed: 111112012 Book:O ID:554332636052010070120121101081132
---<br />
___Budget<br />
X<br />
---<br />
---<br />
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Boulevard Rehabilitation Center Provider Number: 0263613-00<br />
2839 South Seacrest Boulevard<br />
Boynton Beach FL 33435<br />
Provider Type:<br />
Nursing Home Single Level<br />
pe:<br />
----<br />
----<br />
----<br />
Current<br />
Rate<br />
202.40<br />
---<br />
---<br />
Date: 11/2/2012<br />
Fiscal Year End: 1213112008<br />
Audit Status:<br />
New<br />
Rate<br />
202.28<br />
Unaudited [3]<br />
Effective<br />
Date<br />
7/112010<br />
Level H: AIDS 345.74 345.62 7/112010<br />
Level U: Fragile Under 21 460.77 460.65 711/2010<br />
Interim X Prospective<br />
Unaudited costs<br />
Field audited costs<br />
Total Interim X Total Prospective<br />
Interim Component Prospective Adjusted for New Costs<br />
Settlement based on costs<br />
Total Prospective with Interim COlnp()fle:nt<br />
Prior Provider Prospective data<br />
Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
r-somhenrmalthCare Management, LLC<br />
R. Mark Cronquist<br />
5887 Glenridge Drive, Suite 150<br />
Atlanta GA 30328<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
____ Target Rate limitation change<br />
---- FRVSChange<br />
X Effects of FA & RFA #NH06-154J FYE 06/30/04<br />
--- Rate Semester Change<br />
On FRV [2] as of 09/29/1988<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:0Q5ZT Report Calculated: t 11212012 Report Printed: 11/212012 Book:O ID:554332636132010070120121102104208
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
MCHS - Naples Provider Number: 0309958-00<br />
3601 Lakewood Blvd<br />
Naples FL 34112<br />
Provider Type:<br />
Interim<br />
--- ----<br />
----<br />
----<br />
----<br />
----<br />
---<br />
---<br />
Date: 10/29/2012<br />
Fiscal Year End: 5/3112005<br />
Audit Status: Revised Field Audit [5]<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 157.65 145.01 11112006<br />
Level H: AIDS 282.76 270.12 111/2006<br />
Level U: Fragile Under 21 383.14 370.50 111/2006<br />
Total Interim<br />
___Budget<br />
Unaudited costs<br />
-...".,...<br />
X Field audited costs<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
___Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1 Fiscal Agent<br />
Pennanent File<br />
__For infonnation Only<br />
__No Change in Rate<br />
Home Office:<br />
X Prospective<br />
Changes:<br />
X<br />
X Total Prospective<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVS Change<br />
Field Audit RFA NH06-196J FYE<br />
Rate Semester Change<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:EUHVR Report Calculated: 10/29/2012 Report Printed: 10/29/2012 Book:O ID:48203309958200601012012102914401
SandalWood Nursing Center<br />
1001 South Beach Street<br />
Daytona Beach FL 32114<br />
Provider Type:<br />
Nursing Home Single Level<br />
---<br />
---<br />
Interim<br />
l Basis: I<br />
___Budget<br />
State ofFlorida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Level H: AIDS<br />
Level U: Fragile Under 21<br />
Total Interim<br />
X Unaudited costs<br />
Field audited costs<br />
---<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
Field audit - interim portion<br />
Desk audited costs<br />
---D'esk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management / Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
X<br />
--<br />
Changes: I<br />
----<br />
----<br />
----<br />
Current<br />
Rate<br />
167.95<br />
306.30<br />
417.31<br />
Provider Number:<br />
__No Change in Rate<br />
iPUmam-COUIictr,m:c:----....------ ---.... - ..---,<br />
Home Office: I<br />
Date:<br />
Fiscal Year End:<br />
Audit Status:<br />
New<br />
Rate<br />
168.58<br />
306.93<br />
417.94<br />
0312045-00<br />
10/29/2012<br />
12/3112007<br />
Unaudited [3]<br />
Effective<br />
Date<br />
111/2009<br />
1/112009<br />
11112009<br />
Prospective<br />
- X Total Prospective<br />
Prospective Adjusted for New Costs<br />
--- ___ Total Prospective with Interim ClColll.ponlent<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
X Effects of FA NHll-030C FYE 12/31/06<br />
---- Rate Semester Change<br />
On FRV [2] as of 08/0111999<br />
7 z?2 Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:204WR Report Calculated: 10/29/2012 Report Printed: 10/29/2012 Book:O 10:59468312045200901012012102911195
---<br />
State ofFlorida Office ofMedicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
SandalWood Nursing Center Provider Number: 0312045·00<br />
lOO 1 South Beach Street<br />
Date: 10/29/2012<br />
Daytona Beach FL 32114<br />
Fiscal Year End: 12/3112007<br />
Provider Type:<br />
Nursing Home Single Level<br />
Basis:<br />
___Budget<br />
X Unaudited costs<br />
Field audited costs<br />
----<br />
----<br />
----<br />
----<br />
Current<br />
Rate<br />
153.88<br />
---<br />
---<br />
Audit Status:<br />
New<br />
Rate<br />
154.45<br />
Unaudited [3]<br />
Effective<br />
Date<br />
3/1/2009<br />
Level H: AIDS 292.23 292.80 311/2009<br />
Level U: Fragile Under 21 403.24 403.81 311/2009<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
___Field audit· interim portion<br />
Desk audited costs<br />
---Desk audit· Interim Portion<br />
Desk Audit· Prospective portion<br />
Distribution:<br />
Contract Management / Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
16 Norcross Street<br />
/ Roswell GA 30075<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
X Effects of FA NHll-030C FYE 12/3I106<br />
Rate Semester Change<br />
---- On FRV [2] as of 08/0111999<br />
77:f? Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:204WR Report Calculated: 10/29/2012 Report Printed: 10/29/2012 Book:O 1D:594683120452009030 120 12102911200
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
MCHS - Carrollwood Provider Number: 0319350-00<br />
3030 W. Bearss Avenue<br />
Tampa FL 33618<br />
Provider Type:<br />
Date: 10/26/2012<br />
Fiscal Year End: 5/31/2005<br />
Audit Status: Revised Field Audit [5]<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 176.53 173.10 12/3112006<br />
I<br />
IRate Type: I<br />
Interim<br />
Level H: AIDS 303.66 300.23 12/3112006<br />
Level U: Fragile Under 21 405.66 402.23 12/3112006<br />
Total Interim<br />
- Interim Component<br />
- Settlement based on costs<br />
- Prior Provider Prospective data<br />
-<br />
Basis: I<br />
Budget<br />
Unaudited costs<br />
X Field audited costs<br />
Field audit - interim portion<br />
Desk audited costs<br />
Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Julie Y oxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
I<br />
X Prospective<br />
Changes: I<br />
X Total Prospective<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVS Change<br />
X FA & RFA NH06-197J prior provo 202525<br />
Rate Semester Change<br />
On FRV [2] as of 07/2011990<br />
,<br />
7-;);? Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:6HHX6 Report Calculated: 10/26/2012 Report Printed: 10/26/2012 Book:O ID:59468319350200612312012102615331
MCHS - Carrollwood<br />
3030 W. Bearss Avenue<br />
Tampa FL 33618<br />
Provider Type:<br />
Nursing Home Single Level<br />
IRate Type: I<br />
---<br />
---<br />
---<br />
Interim<br />
Budget<br />
X Unaudited costs<br />
Field audited costs<br />
State of Florida Office ofMedicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Level H: AIDS<br />
Level U: Fragile Under 21<br />
Total Interim<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
___Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk<br />
Distribution:<br />
Contract Management I Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
No Change in Rate<br />
Home Office:<br />
Julie Y oxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
X<br />
----<br />
----<br />
----<br />
----<br />
----<br />
X<br />
----<br />
----<br />
Current<br />
Rate<br />
179.34<br />
311.28<br />
417.14<br />
---<br />
---<br />
Provider Number:<br />
Date:<br />
Fiscal Year End:<br />
Audit Status:<br />
New<br />
Rate<br />
179.27<br />
311.21<br />
417.07<br />
Prospective<br />
X Total Prospective<br />
0319350-00<br />
10/26/2012<br />
513112006<br />
Unaudited<br />
Effective<br />
Date<br />
7/1/2007<br />
7/1/2007<br />
7/1/2007<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
Effects of FA & RFA NH06-197J prior provo 202525<br />
Rate Semester Change<br />
On FRV [2J as of 0712011990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.006.1.2:6HHX6 Report Calculated: 10/26/2012 Report Printed: 10/26/2012 Book:O ID:594683 193502007070120121026 I 5333
I<br />
Heartland ofJacksonville FL, LLC<br />
8495 Normandy Blvd<br />
Jacksonville FL 32221<br />
Provider Type:<br />
Nursing Home Single Level<br />
IRate Type: I<br />
---<br />
---<br />
Interim<br />
I I<br />
___Budget<br />
State of Florida Office ofMedicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Level H: AIDS<br />
Level U: Fragile Under 21<br />
Total Interim<br />
X Unaudited costs<br />
Field audited costs<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
___Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion i<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
IHeR Mahor Care<br />
•Julie Yoxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
----<br />
----<br />
----<br />
----<br />
Current<br />
Rate<br />
172.92<br />
309.20<br />
418.55<br />
X Prospective<br />
Changes: I<br />
---<br />
---<br />
Provider Number:<br />
Date:<br />
Fiscal Year End:<br />
Audit Status:<br />
New<br />
Rate<br />
172.84<br />
309.12<br />
418.47<br />
X Total Prospective<br />
0325236-00<br />
10/30/2012<br />
613012007<br />
Unaudited [3]<br />
Effective<br />
Date<br />
7/1/2008<br />
7/112008<br />
7/112008<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
X Effects of FA RFA NH06-195J for prior prov 201511<br />
Rate Semester Change<br />
---- On FRV [2] as of 01112/1990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:Q833C Report Calculated: 9/2612012 Report Printed: 10/30/2012 Book:O ID:482033252362008070 1201209261 04207<br />
I
-<br />
--<br />
I I<br />
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Heartland of Jacksonville FL, LLC Provider Number: 0325236-00<br />
8495 Normandy Blvd<br />
Date: 10/30/2012<br />
Jacksonville FL 32221<br />
Fiscal Year End: 6/30/2008<br />
Audit Status: Unaudited [3J<br />
Provider Type:<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 176.73 176.65 11112009<br />
I Type I<br />
Level H: AIDS 315.08 315.00 11112009<br />
Level U: Fragile Under 21 426.09 426.01 11112009<br />
Interim X Prospective<br />
Total Interim<br />
--Interim Component<br />
-Settlement based on costs<br />
Prior Provider Prospective data<br />
Basis: Changes: I<br />
X Total Prospective<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Budget<br />
Licensure Rating Change<br />
X Unaudited costs Usual and Customary Limitation<br />
Field audited costs<br />
Target Rate limitation change<br />
Field audit - interim portion<br />
FRVSChange<br />
Desk audited costs X Effects of FA RFA NH06-195J for prior prov 201511<br />
Desk audit - Interim Portion i Rate Semester Change<br />
Desk Audit - Prospective portion<br />
i<br />
On FRV [2J as of 0111211990<br />
Distribution:<br />
Thomas Parker<br />
Contract Management / Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
Medicaid Cost Reimbursement Planning and Finance<br />
__No Change in Rate<br />
Home Office:<br />
I 333 North Summit Street<br />
Toledo OH 43604<br />
V7.005.1.2:Q833C Report Calculated: 9/26/2012 Report Printed: 10/30/2012 Book:O ID:4820332523620090 lO 1201209261 042 t0
---<br />
State of Florida Office ofMedicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Heartland of Jacksonville FL, LLC Provider Number: 0325236-00<br />
8495 Nonnandy Blvd<br />
Date: 10/30/2012<br />
Jacksonville FL 32221<br />
Fiscal Year End: 6/3012008<br />
Provider Type:<br />
----<br />
----<br />
----<br />
----<br />
__X __<br />
----<br />
---<br />
---<br />
Audit Status: Unaudited [3]<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 161.92 161.85 3/112009<br />
Interim<br />
Level H: AIDS 300.27 300.20 3/1/2009<br />
Level U: Fragile Under 21 411.28 411.21 3/1/2009<br />
Total Interim<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
___Budget<br />
X Unaudited costs<br />
Field audited costs<br />
--- ___Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management I Fiscal Agent<br />
Pennanent File<br />
__For infonnation Only<br />
__No Change in Rate<br />
Home Office:<br />
Julie Yoxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
X Prospective<br />
X Total Prospective<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Changes:<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
Effects of FA RFA NH06-195J for prior prov 201511<br />
Rate Semester Change<br />
On FRV [2J as of01112/1990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:Q833C Report Calculated: 9126/2012 Report Printed: 1013012012 Book:O ID:482033252362009030120120926104214
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Heartland of Jacksonville FL, LLC Provider Number: 0325236-00<br />
8495 Normandy Blvd<br />
Jacksonville FL 32221<br />
Provider Type:<br />
Date: 10/30/2012<br />
Fiscal Year End: 6/30/2008<br />
Audit Status: Unaudited [3]<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 206.15 206.06 7/1/2009<br />
IRate Type: I<br />
Interim<br />
I Basis: I<br />
Level H: AIDS 346.50 346.41 7/1/2009<br />
Level U: Fragile Under 21 459.12 459.03 7/1/2009<br />
Total Interim<br />
- Interim Component<br />
- Settlement based on costs<br />
-<br />
-<br />
Budget<br />
X Unaudited costs<br />
Field audited costs<br />
Prior Provider Prospective data<br />
Field audit - interim portion<br />
Desk audited costs<br />
Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Julie Y oxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
X Prospective<br />
Changes: I<br />
X Total Prospective<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVS Change<br />
X Effects of FA RFA NH06-195J for prior prov 201511<br />
Rate Semester Change<br />
On FRV [2] as of01112/1990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:Q833C Report Calculated: 9/26/2012 Report Printed: 1013012012 Book:O ID:482033252362009070120120926104220
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Heartland of Jacksonville LLC Provider Number: 0325236-00<br />
8495 Normandy Blvd<br />
Jacksonville FL 32221<br />
Date:<br />
Fiscal Year End:<br />
10/3012012<br />
6/30/2008<br />
Provider Type:<br />
Audit Status: Unaudited [3]<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 208.27 208.19 1/1/2010<br />
I<br />
IRate Type: I<br />
Level H: AIDS 350.19 350.11 11112010<br />
Level U: Fragile Under 21 464.07 463.99 11112010<br />
nterrm<br />
Total Interim<br />
-- Interim Component<br />
-- Settlement based on costs<br />
-- Prior Provider Prospective data<br />
--<br />
Basis: I<br />
Budget<br />
X Unaudited costs<br />
Field audited costs<br />
Field audit - interim portion<br />
Desk audited costs<br />
Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Yoxtheimer<br />
North Summit Street<br />
Toledo OH 43604<br />
x Prospective<br />
Changes: I<br />
X Total Prospective<br />
Prospective Adjusted for New Costs<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
X Effects of FA RFA NH06-195J for prior prov 201511<br />
Rate Semester Change<br />
On FRV [2] as of01/12/1990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:Q833C Report Calculated: 9/26/2012 Report Printed: 10/30/2012 Book:O ID:482033252362010010120120926104225
---<br />
--<br />
--<br />
--<br />
I Basis: I<br />
State of Florida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Heartland ofJacksonville FL, LLC Provider Number: 0325236-00<br />
8495 Normandy Blvd<br />
Jacksonville FL 32221<br />
----<br />
Date: 10/30/2012<br />
Fiscal Year End: 6/30/2010<br />
Audit Status: Unaudited [3]<br />
Provider Type:<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 202.42 202.34 11112011<br />
IRate Type: I<br />
X<br />
Level H: AIDS 347.28 347.20 11112011<br />
Level U: Fragile Under 21 463.53 463.45 11112011<br />
Interim x Prospective<br />
Budget<br />
Unaudited costs<br />
Field audited costs<br />
Total Interim X Total Prospective<br />
Interim Component Prospective Adjusted for New Costs<br />
Settlement based on costs Total Prospective with Interim Component<br />
Prior Provider Prospective data<br />
Field audit - interim portion<br />
Desk audited costs<br />
Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Julie Y oxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
I<br />
Changes: I<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVS Change<br />
X Effects of FA RFA NH06-195J for prior prov 201511<br />
Rate Semester Change<br />
On FRV [2] as of 0111211990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:Q833C Report Calculated: 9/26/2012 Report Printed: 10/30/2012 Book:O ID:4820332523620 11010 120120926104233
---<br />
State of Florida Office ofMedicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Heartland of Jacksonville FL, LLC Provider Number: 0325236-00<br />
8495 Normandy Blvd Date: 10/30/2012<br />
Jacksonville FL 32221<br />
Fiscal Year End: 6/30/2010<br />
Provider Type:<br />
----<br />
Audit Status: Unaudited [3]<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 195.00 194.93 7/1/2011<br />
IRate Type: I<br />
Level H: AIDS 341.20 341.13 7/112011<br />
Level U: Fragile Under 21 458.53 458.46 7/112011<br />
Interim X Prospective<br />
Total Interim X Total Prospective<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
Prospective Adjusted for New Costs<br />
---Total<br />
Prospective with Interim Component<br />
---<br />
Basis: Changes: I<br />
___Budget<br />
Licensure Rating Change<br />
X Unaudited costs<br />
Field audited costs<br />
---<br />
Field audit - interim portion<br />
---<br />
Desk audited costs<br />
Usual and Customary Limitation<br />
---- Target Rate limitation change<br />
---- FRVS Change<br />
X Effects of FA RFA NH06-195J for prior prov 201511<br />
---Desk audit - Interim Portion Rate Semester Change<br />
Desk Audit - Prospective portion ---- On FRV [2] as of01l12/l990<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Julie Yoxtheimer<br />
333 North Summit Street<br />
OH43604<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:Q833C Report Calculated: 9/26/2012 Report Printed: 10/30/2012 Book:O ID:482033252362011070120120926104237<br />
•
State ofFlorida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Manor Care-Carrollwood of Tampa FL, LLC Provider Number: 0325678-00<br />
3030 W. Bearass A venue<br />
Tampa FL 33618<br />
Date: 10/2/2012<br />
Fiscal Year End: 513112007<br />
Audit Status: Unaudited [3]<br />
Provider Type:<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 181.40 181.33 7/112008<br />
I<br />
In.c",,, J..r1''' °1<br />
Interim<br />
Level H: AIDS 317.68 317.61 7/112008<br />
Level U: Fragile Under 21 427.03 426.96 7/112008<br />
Total Interim<br />
- Interim Component<br />
- Settlement based on costs<br />
- Prior Provider Prospective data<br />
-<br />
I Basis: I Changes: I<br />
X<br />
Budget<br />
Unaudited costs<br />
Field audited costs<br />
Field audit - interim portion<br />
Desk audited costs<br />
Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Julie Y oxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
X Prospective<br />
X Total Prospective<br />
Prospective Adjusted for New Costs<br />
X<br />
Total Prospective with Interim Component<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVSChange<br />
Effects of FA & RFA NH06-197J prior provo 202525<br />
Rate Semester Change<br />
On FRV [2] as of0712011990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:2716J Report Calculated: 10/2/2012 Report Printed: 101212012 Book:O ID:59468325678200807012012 1002141049
---<br />
State ofFlorida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Manor Care-Carrollwood of Tampa FL, LLC Provider Number: 0325678-00<br />
3030 W. Bearass A venue<br />
Tampa FL 33618<br />
Date:<br />
Fiscal Year End:<br />
1012/2012<br />
513112008<br />
Audit Status: Unaudited [3]<br />
Provider Type:<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 171.25 171.20 3/1/2009<br />
IRate Type: I<br />
Level H: AIDS 309.60 309.55 311/2009<br />
Level U: Fragile Under 21 420.61 420.56 311/2009<br />
----<br />
Interim X Prospective<br />
Total Interim X Total Prospective<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
Prospective Adjusted for New Costs<br />
---Total<br />
Prospective with Interim Component<br />
---<br />
___Budget<br />
X Unaudited costs<br />
Field audited costs ---<br />
Field audit - interim portion ---Desk audited costs<br />
---Desk audit - Interim Portion<br />
Desk Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
__No Change in Rate<br />
Home Office:<br />
Julie Y oxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
Changes:<br />
----<br />
----<br />
----<br />
X<br />
----<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVS Change<br />
Effects of FA & RFA NH06·197J prior prov.202525<br />
Rate Semester Change<br />
On FRV [2] as of 07/20/1990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:27161 Report Calculated: 10/2/2012 Report Printed: 101212012 Book:O 1D:594683256782009030 120 121002141104
---<br />
---<br />
---<br />
State ofFlorida Office ofMedicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Manor Care-Carrollwood of Tampa FL, LLC Provider Number: 0325678-00<br />
3030 W. Bearass Avenue<br />
Tampa FL 33618<br />
Date:<br />
Fiscal Year End:<br />
10/2/2012<br />
5/31/2009<br />
Audit Status: Unaudited [3]<br />
Provider Type:<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 210.99 210.92 1/1/2010<br />
Level H: AIDS 352.91 352.84 111/2010<br />
Level U: Fragile Under 21 466.79 466.72 111/2010<br />
----<br />
Interim X Prospective<br />
Total Interim X Total Prospective<br />
Interim Component ___ Prospective Adjusted for New<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
Total Prospective with Interim ,",VI.1JP'Ju
State ofFlorida Office of Medicaid Cost Reimbursement Planning and Finance<br />
2727 Mahan Drive-Mail Stop 23<br />
Tallahassee, Florida 32308<br />
Medicaid Reimbursement <strong>Per</strong> <strong>Diem</strong> <strong>Rates</strong><br />
Manor Care-Carrollwood of Tampa FL, LLC Provider Number: 0325678-00<br />
3030 W. Bearass Avenue<br />
Tampa FL 33618<br />
Date:<br />
Fiscal Year End:<br />
1012/2012<br />
5131/2011<br />
Audit Status: Unaudited [3J<br />
Provider Type:<br />
Current New Effective<br />
Rate Rate Date<br />
Nursing Home Single Level 205.38 205.32 11112012<br />
IRate Type: 1<br />
I --<br />
I<br />
Interim<br />
·1 Basis: ... 1<br />
Level H: AIDS 352.99 352.93 111/2012<br />
Level U: Fragile Under 21 471.45 471.39 11112012<br />
Total Interim<br />
Interim Component<br />
Settlement based on costs<br />
Prior Provider Prospective data<br />
___Budget<br />
X Unaudited costs<br />
Field audited costs<br />
---<br />
___Field audit - interim portion<br />
Desk audited costs<br />
---Desk audit - Interim Portion<br />
Audit - Prospective portion<br />
Distribution:<br />
Contract Management 1Fiscal Agent<br />
<strong>Per</strong>manent File<br />
__For information Only<br />
No Change in Rate<br />
Home Office:<br />
Julie Yoxtheimer<br />
333 North Summit Street<br />
Toledo OH 43604<br />
X Prospective --- X Total Prospective<br />
Prospective Adjusted for New Costs<br />
-- Total Prospective with Interim Component<br />
'Changes: 1<br />
----<br />
---<br />
---<br />
--<br />
Licensure Rating Change<br />
Usual and Customary Limitation<br />
Target Rate limitation change<br />
FRVS Change<br />
__X__ Effects of FA & RFA NH06-197J prior provo 202525<br />
Rate Semester Change<br />
-- On FRV [2] as of07/20/1990<br />
Thomas Parker<br />
Medicaid Cost Reimbursement Planning and Finance<br />
V7.005.1.2:2716J Report Calculated: 10/212012 Report Printed: 10/2/2012 Book:O ID:5946832567820 12010120121002141159
Change language