Fiscal Agent - The Agency For Health Care Administration · Medicare - Prospective . Desk audited costs . Interim X Payment System Rate --- Total Interim . Average Nursing Home Rate

-------

000141800-201501

Florida Agency for Health Care Administration State of Florida Office ofMedicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive-Mail Stop 23 Tallahassee Florida 32308

Medicaid Reimbursement Per Diem Rates for Non-Institutional Providers

HCR Manor Care Services of Florida Inc Provider Number 000141800 Heartland Home Health Care and Hospice Date 011292015 8130 Baymeadows Way W Suite Fiscal Year End NIA

Jacksonville FL 32256 Audit Status NIA

IP-~---middotmiddot-middot--middot-middotmiddot----middot--middotmiddotmiddotmiddotmiddotmiddot--middotmiddotmiddot~middot___ Provider Type i Current Rate

I Rural Health Clinic

New Rate Effective Date i I

Swing-Bed Provider

Federally Qualified Health Centers I

Hospice Provider

651 Routine Home Care

652 Continuous Home Care

654 ICFIIID LC -7 Room and Board

654 ICFmD LC - 8 amp 9 Room and Board

655 Inpatient Respite Care

656 General Inpatient Care

i

I I

i

I

I

bulli

I

j

i

I

658 Room and Board ~------- shy

Basis

Budget ---Unaudited costs

Desk audited costs

---Field audited costs Medicare - Prospective Payment System Rate

--shyX Average Nursing Home Rate

Distribution Fiscal Agent Contract Management Permanent File Program Development

L_~~1_9=9~4~3~~=2=02=O=9==rL-_O_1I_0_1I_2_01_5J

X Prospective Total Prospective Prospective Adjusted for New Costs

Interim --- Total Interim

Settlement based on costs

W Rydell Samuel Administrator

Medicaid Cost Reimbursement Analysi

For information Only ( No Change in rate)

V408 Report Calculated 11292015 60655PM Report Printed 112912015

---

----

000532400-201501

Florida Agency for Health Care Administration State of Florida Office of Medicaid Cost Reimbursement Planning and Finance



Samaritan Care Hospice ofOsceola LLC Provider Number 000532400 Samaritan Care Hospice Date 011292015 1300 North Semoran Blvd Ste 210 Fiscal Year End NA

Orlando FL 32807 Audit Status NIA

i

I

I i

I

-~ - shy at1--------- -------~middot-middot~kl

Provider Type Current Rate New Rate bull Effective Date

Rural Health Clinic I Swing-Bed Provider I Federally Qualified Health Centers i

Hospice Provider


652 Contiuuous Home Care

654 ICFIIID LC - 7 Room and Board I

654 ICFIID LC - 8 amp 9 Room and Board --L shy

I 655 Inpatient Respite Care I


658 Room and Board i

20914 20995 0110112015

I

I

i

-------------~-__r----------- --~------ shyBasis


Desk audited costs


-=-shyX Average Nursing Home Rate

IRate Type I X Prospective

Total Prospective Prospective Adjusted for New Costs



Distribution Fiscal Agent

W Rydell Samuel Administrator Contract Management Permanent File Medicaid Cost Reimbursement Analysi Program Development

For information Only (No Change in rate)


---

---

000602600-201501




Vitas Healthcare Corp ofCentral Florida Provider Number 000602600 Attn Angela Santana Date 0112912015 100 S Biscayne Blvd Suite 1400 Fiscal Year End NA

Miami FL 33131 Audit Status NA

--middotmiddotT-----middotmiddotmiddot shy ---- - ---------------

Provider Type i Current Rate i New Rate Effective Date

Rural Health Clinic

Swing-Bed Provider

Federally Qualified Health Centers

Hospice Provider



654 ICFIIID LC - 7 Room and Board -- shy

654 ICFIID LC - 8 amp 9 Room and Board -- shy



658 Room and Board County

Basis Rate Type

Budget X Prospective--- shy---Unaudited costs Total Prospective Prospective Adjusted for New Costs

Field audited costs Medicare - Prospective

Desk audited costs

Interim X Payment System Rate --- Total Interim

Average Nursing Home Rate --- Settlement based on costs


w rydell samuel Administrator Contract Management Permanent File Medicaid Cost Reimbursement Analysi Program Development



-------

001572800-201501




Odyssey Health Care Miami-Dade Provider Number 001572800 Date 011292015

5755 Blue Lagoon Dr Suite 170 Fiscal Year End NIA

Miami FL 33126 Audit Status NIA --------shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



i

i i

-~ -_

Current Rate New Rate Effective Date

i

I

i

i

654 ICFmD LC - 7 Room and Board ---J I i________ ____

654 ICFIIID LC - 8 amp 9 Room and Board -~i

-------65-5-In-p-a-t-ie-n-t-R-e-s-pite-C-ar-e----------+-1 F =j 656 General Inpatient Care I

~___65_8_Room and Board _______bl==~__ _2~O~7=7=4~1=~2=1_6=2==Or 01l01l2~ Basis


Desk audited costs


--- shyX Average Nursing Home Rate

Rate Type



Settlement based on costs -___ - ---- ---------~ ___-__--- _- _--__ -__-__ _--__--_shy





-------

__

001636100-201501




Regency Hospice ofNW Florida Inc Provider Number 001636100 Date 0112912015

4900 Bayou Blvd Ste 101 Fiscal Year End NA

Pensacola FL 32503

Provider Type

Audit Status NA

-~

~-- ~~~~-~~r----~~~-~~~--~ Current Rate New Rate Effective Date i

rmiddot Rural Health Clinic

Swing-Bed Provider I I

I

I Federally Qualified Health Centers I I

Hospice Provider i

651 Routine Home Care I 652 Continuous Home Care

654 ICFIIID LC - 7 Room and Board

i--+ =t ~ i

654 ICFIIID LC - 8 amp 9 Room and Board I-------~--------~~~---~~~-------~------~~--+--~~~--~~~ ~~~~--~



~ 20511 ~ 0110172015

Basis


Desk audited costs


-----shyX Average Nursing Home Rate

Rate Type








- ---

-------

002782200-201501




Seasons Hospice and Palliative Care of Southern FL Provider Number 002782200 Date 011292015

5200 Northeast 2nd Avenue Fiscal Year End NA

Miami FL 32405 Audit Status NA _-_ middot---_ -- __--- r--middotmiddotmiddotmiddotmiddot-middotmiddotmiddot-_middotmiddotmiddotmiddotmiddotmiddotmiddotProvider Type Current Rate i New Rate Effective Date 1

IRural Health Clinic i

Swing-Bed Provider i

I

i


Hospice Provider i

651 Routine Home Care I I652 Continuous Home CareI i

i654 ICFIID LC -7 Room and Board I shy

654 ICFIID LC - 8 amp 9 Room and Board I shy655 Inpatient Respite Care


658 Room and Board County Dade 122659 226751 010112015I I

Basis


Desk audited costs

Field audited costs ---Medicare - Prospective

IRate Type I

x Prospective Total Prospective Prospective Adjusted for New Costs

Interim ~x Payment SYstem Rate Total Interim

Average Nursing Home Rate Settlement based on costs __bull ______ bull_ bullbull____ _l_ ____ __bull_ _____________ _ _____bull__ _________





---

---

----

003694700-201501




Brevard HMA LLC Provider Number 003694700 WuesthoffBrevard Hospice amp Palliative Care Date 011292015 8060 Spyglass Rd Fiscal Year End NA

Viera FL 32940 Audit Status NIA ~- _ _ -_ ---~-- shy shy ~

bull Provider Type Current Rate New Rate Effective Date

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



654 ICFIID LC -7 Room and Board

654 ICFIID LC - 8 amp 9 Room and Board --~


656 General Inpatient Care ~

658 Room and Board County Brevard 21453 21182 010112015

Basis IRate Type I Budget

---Unaudited costs Desk audited costs

---Field audited costs Medicare - Prospective

X Payment System Rate Average Nursing Home Rate

Distribution Fiscal Agent Contract Management Permanent File



Settlement based on costs - -~~

w rydell samuel Administrator

Medicaid Cost Reimbursement Analysi Program Development



I

---

003815300middot201501




HCR Manor Care of Florida III Inc Provider Number 003815300 Heartland Hospice Services - Plantation Date 011292015 150 S Pine Island Road Suite 200 Fiscal Year End NA

Audit Status NAPlantation FL 33324 - _--shy~-~- _

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



-~-- shy


654 ICFIIID LC - 8 amp 9 Room and Board

655 Inpatieut Respite Care


Current Rate New Rate

I

I

Effective Date]

658 Room and Board 20936 21359V 0110112015

Basis IRate Type I Budget x Prospective

------Unaudited costs ---- Total Prospective Desk audited costs Prospective Adjusted for New Costs

---Field audited costs Medicare - Prospective Interim Payment System Rate --- Total Interim

---X-Average Nursing Home Rate Settlement based on costs

Distribu tion Fiscal Agent




---

004244800-201501




HCR Manor Care Services ofFL II Inc Provider Number 004244800 Heartland Hospice Services (Homestead) Date 011292015 381 N Krome Ave Suite 207 Fiscal Year End NA

Audit Status NAHomestead FL 33030 ---- - __- -- _- shy-_

I~Provider Type ~

ICurrent Rate New Rate Effective Date

Rural Health Clinic i

i

Swing-Bed Provider


Hospice Provider

651 Routine Home Care Ii 652 Continuous Home Care

654 ICFUD LC -7 Room and Board

654 ICFUD LC - 8 amp 9 Room and Board

655 Inpatient Respite Care ii

656 General Inpatient Care it 658 Room and Board 20195 20716~ 0110112015 i

Basis


Desk audited costs


---- shyX Average Nursing Home Rate




---- Total Prospective Prospective Adjusted for New Costs






-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



654 ICFIlID LC - 7 Room and Board

654 ICFIID LC - 8 amp 9 Room and Board



658 Room and Board County Polk

Curre~tRatel New Rate

19001 20385

Effective Date

0110112015

I


Compassionate Care Hospice ofMiami Dade Inc Provider Number 004579400 Compassionate Care Hospice Date 0112912015 600 Highland Drive STE 624 Fiscal Year End NA

Westampton NJ 08060 Audit Status NA shy



Basis


Desk audited costs

---Field audited costs Medicare - Prospcctive


Rate Type






---

----

087000500-201501




Hospice oflRC Provider Number 087000500 Date 01292015

1111 36th Street Fiscal Year End NIA

Vero Beach FL 32960 Audit Status NIA

Provider Type I C~rre~t~R~te New Rate Effective Date

Rural Health Clinic I

I I

Swing-Bed Provider


I

I

Hospice Provider

ou me orne651 R t H Care

I 652 Continuous Home Care

L-shy654 ICFIID LC -7 Room and Board




658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs


-~-X Average Nursing Home Rate










---

---

----

087246600-201501




Vitas Healthcare Corporation - Dade County Provider Number 087246600 Attn Angela Santana Date 011292015 100 S Biscayne Blvd Suite 1400 Fiscal Year End NA

Miami FL 33131 Audit Status NA ~~~------I~-- ~- - lt lt ----_ - ---~lt-~-~lt~~- ~~~~~- lt-T~~-~~~-

laquo New Rate Effective Date Iibull Provider Type Current Rate i Rural Health Clinic I I

Swing-Bed Provider I I i Federally Qualified Health Centers II Hospice Provider I i

651 Routine Home CareI I 652 Continuous Home Care I

654 ICFIID LC - 7 Room and BoardI I 654 ICFIID LC - 8 amp 9 Room and Board I i655 Inpatient Respite Care I 656 General Inpatient Care I

658 Roomltand Board County Dade n 22675 I 0110112015 i

Basis


Desk audited costs

Field audited costs ---~ Medicare - Prospective




Rate Type







---

----

087255500-201501




St Francis Hospice Provider Number 087255500 Date 011292015

1250-B Grumman Place Fiscal Year End NA

Titusville FL 32780 Audit Status NA

I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider



654 ICFIID LC - 7 Room and Board




658 Room and Board _--_


20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs


Payment System Rate -X-Average Nursing Home Rate

Rate Type


Interim --- TotalInterim

Settlement based on costs -==------- ---- ---------- shy





---

----

087256300-201501




Hospice of the Comforter Provider Number 087256300 Date 011292015

480 West Central Pkwy Fiscal Year End NA Audit Status NAAltamonte Springs FL 32714

--- __ --- shyI --~ -~

New Rate i Effective D~Provider Type Current Rate

I i

i

Rural Health Clinic i i

Swing-Bed Provider I I Federally Qualified Health Centers

Hospice Provider

I 651 Routine Home Care I

652 Continuous Home Care i





658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs

Field audited costs ---Medicare - Prospeetive Payment System Rate

--=--- shyX Average Nursing Home Rate



Rate Type







----

087407800~201501




Community Hospice ofNortheast Provider Number 087407800 Date 0112912015

4266 Sunbeam Road Fiscal Year End NA

Jacksonville FL 32257 Audit Status NA ----_ -----shy ------ shy

Provider Type I Current Rate New Rate Effective Date bull


Swing-Bed Provider


Hospice Provider I

651 Routine Home Care I





656 General Inpatient Care i

I -shy ~

20853Y 01l01l2~15 I658 Room and Board 20446 ~---

Basis


Desk audited costs

l-- shy Field audited costs

Medicare - Prospective Payment System Rate

X ~ Average Nursing Home Rate



Rate Type







---

----

--

087514700-201501




Hospice ofMartin amp St Lucie Provider Number 087514700 Date 01292015

1201 SE Indian Street Fiscal Year End NA

Stuart FL 34997 Audit Status NA -- - -~ _- -- -- --- - ---- -------- shy

Provider Type Current Rate New Rate I Effective Date

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



654 ICFIID LC -7 Room and Board bull




658 Room--andBoard 22599 22743 VOl101l2015

Basis


Desk audited costs

Field audited costs ---Medicare - Prospective Payment System Rate

-7X-Average Nursing Home Rate

IRate Type I x Prospective








---

----

087515500-201501




Hernando-Pasco Hospice Inc Provider Number 087515500 Date 011292015

12107 Majestic Blvd Fiscal Year End NA Audit Status NAHudson FL 34667

- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider






656 General Inpatient Care -shy --__shy_

658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs


-X-Average Nursing Home Rate

IRate Type I



Settlement based on costs ~--





---

087516300-201501




Hospice of Palm Beach County Provider Number 087516300 Date 011292015

5300 East Avenue Fiscal Year End NIA

West Palm Beach FL 33407 Audit Status NIA -~-~~ ~-~-

bull Provider Type Current Rate Effective Date

Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider


652 Continuous Home Care I




I656 General Inpatient Care

658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I

x Prospective ---- Total Prospective

Prospective Adjusted for New Costs






---

----

I

087517100-201501


2727 Mahan Drive-Mail Stop 23 Tallahassee florida 32308


Covenant Hospice Inc Provider Number 087517100 Date 01292015

5041 N 12th Fiscal Year End NA

Pensacola FL 32504 Audit Status NA

Provider Type Current Rate New Rate Effective Date

Rural Health Clinic

Swing-Bed Provider


Hospice Provider




654 ICFIID LC - 8 amp 9 Room and Board --------~--------+-----------+-------~----------~



658 Room and Board 20653 20769 V01l01l2015

Basis


Desk audited costs


----shyX A verage Nursing Home Rate

Rate Type







V40amp Report Calculated 112912015 60655PM Report Printed 11292015

---

---

----

087519800-201501




North Central Florida Hospice Provider Number 087519800 Attn Revenue Accounting Manager Date 0112912015 4200 NW 90th Blvd Fiscal Year End NA

Gainesville FL 32606 Audit Status NA


Rural Health Clinic

Swing-Bed Provider


Hospice Provider iI i651 Routine Home Care

i

i i

I

Con Care I

654 ICFIID LC -7 Room and Board i


655 Inpatient Respite Care I

r 656 General Inpatient Care

658 Room and Board County Alachua ~

2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type




w rydeU samuel Administrator


V408 Report Calculated 1I292015 65443PM Report Printed 112912015

---

----

087520100-201501




Hospice of Marion County Provider Number 087520100 Date 01292015

PO Box 4860 Fiscal Year End NA

Ocala FL 34478 Audit Status NA ----c--~ ~~-- ~ ~~--~~~~~~~~--~~~~

Provider Type Current Ratemiddot New Rate Effective Date

Rural Health Clinic

Swing-Bed Provider


Hospice Provider

651 Routine Home Care i I


654 ICFIID LC - 7 Room and Board i

654 ICFIID LC - 8 amp 9 Room and Board I i655 Inpatient Respite Care

IL 656 General InpatIent Care I ~~~ L 658 Room and Board 21634 21175+- 0110112015 ~___________________________________ ~ ____~~~~~~~~~~_-L-_____~

Basis


Desk audited costs





Rate Type







00-201501

Florida Agency for Health Care Administration State ofFlorida Office of Medicaid Cost Reimbursement Planning and Finance



Hospice of Health First Provider Number 087522800 Date 011292015

1900 Dairy Road Fiscal Year End NIA Audit Status NIAWest Melbourne FL 32904

-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider







Current R~tel New Rate

bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015

il_B_asis IRate Type I

I Budget Unaudited costs

---Desk audited costs




Interim --shy Total Interim






-------

087523600-201501




Hospice of Vol usia Provider Number 087523600 Date 011292015

3800 Woodbriar Trail Fiscal Year End NA Audit Status NAPort Orange FL 32129

- -- - -_ --- ------ ------~~ ~ -~--- ~- -1-------middotshy INew Rate Effective D~I Rural Health Clinic

Provider Type ICurrent Rate I

I iSwing-Bed Provider i

i IFederally Qualified Health Centers I

Hospice Provider I I iI 651 Routine Home Care I

652 Continuous Home Care I 654 ICFIIID LC - 7 Room and Board I I

i

654 ICFIIID LC - 8 amp 9 Room and Board II 655 Inpatient Respite Care i I I

i I i656 General Inpatient Care I -~--~--~ ~

20883Vmiddot0110112015 ~j658 Room and Board 20159I

Basis


Desk audited costs

---Field audited costs Medicare - Prospective Payment System Rate --shy

X Average Nursing Home Rate

middotmiddotIRate Type I X Prospective







V408 Report Caleulated 11292015 60655PM Report Printed tl292015

-------

I

087524400-201501




Big Bend Hospice Provider Number 087524400 Date 011292015

1723 Mahan Center Blvd Fiscal Year End NA

Tallahassee FL 32308 Audit Status NA --_ shy middotmiddotmiddotmiddot-r-middotmiddot __-

I

Provider Type Current Rate New Rate Effective Date I

Rural Health Clinic

Swing-Bed Provider I Federally Qualified Health Centers

I

Hospice Provider I 651 Routine Home Care

652 C fon muous H orne Care I

i 654 ICFIIID LC - 7 Room and Board

ICFnD LC - 8 amp 9 Room and Board

I

~-



658 Room and Board ~~ -

21696 214 i

0110112015 ~

Basis


Desk audited costs

---Field audited costs Medicare - Prospective Payment System Rate -=-shyX Average Nursing Home Rate



IRate Type 1 X Prospective



Settlement based on costs --==-~-




-------

087525200-201501




Hospice of the Florida Keys Inc Provider Number 087525200 Date o1I292015

1319 William Street Fiscal Year End NA Audit Status NAKey West FL 33040

~ --~ --~-- shy --r~ --~--- --_----shyI Provider Type ICurrent Rate New Rate I Effective Date I I

I Rural Health Clinic I I

Swing-Bed Provider I J

I Federally Qualified Health Centers I Hospice Provider J---shy

II 651 Routine Home Care

I 652 Continuous Home Care I

654 ICFIID LC - 7 Room and Board 654 ICFIID LC - 8 amp 9 Room and Board

655 Inpatient Respite Care I I

656 General Inpatient Care I I I

i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501




Hospice ofLake and Sumter Provider Number 087526100 Date 01292015

12300 Lane Park Road Fiscal Year End NIA

Tavares FL 32778 Audit Status NIA

Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider



654 ICFllD LC - 7 Room and Board

654 ICFllD LC - 8 amp 9 Room and Board



-Current Rate New Rate bull Effective Date

bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501




Tidewell Hospice amp Palliative Care Provider Number 087527900 Date 011292015

5955 Rand Blvd Fiscal Year End NA Audit Status NASarasota FL 34238

~-I~--~ -~--- -1- _- - I Provider Type Current Rate I New Rate Effective Date i

I I R I H Ith crI ura ea IDIC

I Ii Swing-Bed Provider I I Federally Qualified Health Centers I I

iHospice Provider i

I



I I I 654 ICFIIID LC - 7 Room and Board I I

i654 ICFIID LC - 8 amp 9 Room and Board I Ibull655 Inpatient Respite Care i I I656 General Inpatient Care I

iI

658 Room and Board County Sarasota 22142 22538 I 0110112015 i I

------B-a-si-s-----~---~-~--IR-a-te-T-y-p-e-Ie-


Desk audited costs

Field audited costs ---Medicare - Prospective X Payment System Rate

Average Nursing Home Rate








-------

087528700-201501




Hospice of the Treasure Coast Provider Number 087528700 Date 01292015

1201 SE Indian St Fiscal Year End NA

Stuart FL 34997 Audit Status NA --~~

Provider Type Current Rate New Rate i Effective Date i


Swing-Bed Provider


Hospice Provider




654 ICFfIID LC - 8 amp 9 Room and Board


656 General Inpatient Care ~-

658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis

X Prospective ---Unaudited costs

Budget Total Prospective

Desk audited costs Prospective Adjusted for New Costs

Field audited costs ---Medicare - Prospective Interim

Payment System Rate --- Total Interim ---- shy

X Average Nursing Home Rate Settlement based on costs

------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501




Hospice by the Sea Provider Number 087529500 Date 0112920 IS

1531 W Palmetto Park Road Fiscal Year End NA

Boca Raton FL 33486 Audit Status NA shy



bull Swing-Bed Provider


bull Hospice Provider



654 ICFUD LC - 7 Room and Board

654 ICFUD LC - 8 amp 9 Room and Board I655 Inpatient Respite Care


658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501




Hospice ofthe Florida Suncoast Provider Number 087532500 Date 011292015

5771 Rosevelt Blvd Fiscal Year End NA

Clearwater FL 33760 Audit Status NA

Provider Type T

I Current Rate Effective Date I

R_u_ra_I_H_e_a_It_h_C_h_middotn_ic _-_-~~========~I-Imiddotmiddotmiddot~-middotmiddot-----II------+i II

Swing-Bed Provider I

II 651 Routine Home Care I I I


I 654 ICFIIID LC - 7 Room and Board

I ICFIIID LC - 8 amp 9 Room and Board


1

i 656 General Inpatient Care I

~~-~~~f-shy v658 Room and Board 1 21245 21435- OlOi2015 I --__--_---___ _ _L~~~ J~

---------T~-~---middot~-----T-~----------r-middot~-~middotmiddot~-~middotmiddot-middot~-~middotmiddot-~middot-~--~-~--~-~-~- Basis


Desk audited costs


-X-----Average Nursing Home Rate

IRate Type I








---

----

087535000-201501




Hope Hospice amp Palliative Care Provider Number 087535000 Date 01292015

9470 Health Park Circle Fiscal Year End NIA Audit Status NIAFt Myers FL 33908

658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~

New Rate I Effective Date Provider Type


Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider

651 Routine Home Care i


654 ICFIIID LC -7 Room and Board bull



i

I

i

656 General Inpatient Care ~~ - ~ -~ ~ ~ -

Basis


Desk audited costs



IRate Type I



Settlement based on costs ~-~~~--~- ~~---~ ~-- ~-~~~--~ ~-~~--~

Distribution Fiscal Agent w Rydell Samuel Administrator Contract Management Permanent File Medicaid Cost Reimbursement Analysi Program Development


V408 Report Calculated 1129120] 5 606SSPM Report Printed 1292015

---

----

087536800-201501




Hospice of Citrus County Provider Number 087536800 Date 011292015


Beverly Hills FL 34464 Audit Status NA

bull

I

I

-- shy -~~ -~

Provider Type Current Rate New Rate

Rural Health Clinic _

Swing-Bed Provider


Hospice Provider







658 Room and Board 20068 20255

Effective Date

0110112015

bull

I

Basis

Budget ---middotUnaudited costs

Desk audited costs


----shyX Average Nursing Home Rate


Total Prospective Prospeetive Adjusted for New Costs







---

087537600-201501




Avow Hospice Provider Number 087537600 Date 011292015

1095 Whippoorwill Lane Fiscal Year End NIA

Naples FL 34105 Audit Status NA

Provider Type

Hospice Provider I

~middot~--------------------+-I----middot-------11--------shyL ___6_5_4_ICFIIID LC - 7 Room and Board-+--__~~__~~-------i I 654 ICFIID LC - 8 amp 9 Room and Board bull I I--~~~ --~--~~---~--~~- ----I--~---~- middot-r---~~- ~----- --~ I 655 Inpatient Respite Care I

Basis


Desk audited costs

---Field audited costs Medicare - Prospeetive Payment System Rate

-shyX Average Nursing Home Rate


X Prospective--- shy Total Prospective Prospective Adjusted for New Costs

Interim -- shy Total Interim






---

---

087538400-201501




Hospice of Okeechobee Provider Number 087538400 Date 011292015

411 SE 4th Street Fiscal Year End NIA

Okeechobee FL 34974 Audit Status NIA

bull Provider Type --shy


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board County Okeechobee 24140 24578 bull 0110112015





Desk audited costs



Rate Type

X Prospective -~-- Total Prospective





-------

087569400-201501




Catholic Hospice Provider Number 087569400 Date 011292015

14875 NW 77th Ave Fiscal Year End NA

Miami Lakes FL 33014 Audit Status NA -~------ --- ----- -- ----- --- -- ----- -----shy

I Provider Type iCurrent Rate New Rate~rEff~~tie-D~tel i Rural Health Clinic i

ISwing-Bed Provider i Federally Qualified Health Centers

I I

Hospice Provider

I J II 651 Routine Home Care

i

II II 652 Continuous Home Care II I

I 654 ICFIID LC - 7 Room and Board I __--shy------------shy --------+---shyI 654 ICFIID LC - 8 amp 9 Room and Board I I I 655 Inpatient Respite Care I I 656 General Inpatient Care I1 shyI 658 Room and Board 23496 23492J 0110112015

L - I-~ -~

----B-a-s-is--r----------~-- ---r-R-a-te-T-yp-e-t-middot--shy


Desk audited costs

---Field audited costs Medieare Prospective Payment System Rate

- shy





Settlement based on costs --~- _ bull- __-_- -





-------

087570800-201501




Gulfside Regional Hospice Provider Number 087570800 Date 01292015

6111 Trouble Creek Rd Fiscal Year End NIA

New Port Richey FL 34653 Audit Status NA

Provider Type I I Rural Health Clinic

ICFIIID LC -7 Room and Board

ICFIIID LC - 8 amp 9 Room and Board


L 656 General Inpatient Care

I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs


Payment System Rate -~-X Average Nursing Home Rate

IRate Type I ---------~------~~-----~







-------

150000700-201501




Hospice of Gold Coast Provider Number 150000700 Date 011292015

2101 W Commercial Blvd Suite 4500 Fiscal Year End NA

Ft Lauderdale FL 33309 Audit Status NA

middotmiddot~-middot-middot~--middot~middot-middotmiddotl

Provider Type i Current Rate New Rate Effective Date i

L____R_u_r_al_H_middot_ea_l_th_C__lin_i_c________________________~--------r_------~I-________~ I Swing-Bed Provider

I Federally Qualified Health Centers

L____H__os_p_i_ce__P_r_ov_i_d_e_r____________________________~--------~--------~__________~

651 Routine Home CareI i i I


~

654 ICFIIID LC -7 Room and Board I

I 654 ICFUD LC - 8 amp 9 Room and Board I

Inpatient Respite Care I 656 General Inpatient Care

I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501




Hospice Care of South FL Provider Number 150001500 Date 011292015

7270 NW 12th St PH6 Fiscal Year End NIA

Miami FL 33126 Audit Status NIA

Provider Type -- shy shy shy ~-~--T-~-~-I

Current Rate New Rate Effective Date I Rural Health Clinic

Swing-Bed Provider J J Federally Qualified Health Centers I I I Hospice Provider I I

_______6_5_1_R__o_ut_i_n_e_H_o_m__e_c_a_r_e____________________-r__________+_________~Ibull________~ r shy 652 Continuous Home Care -----I r- 654 ICFIID LC - 7 Room and Board I---r----_~~ I 654 ICFIID LC - 8 amp 9 Room and Board I i

I~ 655 Inpatient Respite Care I I ~- I 656 General Inpatient ~are ~ I ~~ ~ ~~ ~

658 Room and Board I 2407i~ 24487j- Ol101l2015JL ______________________L l-~~~~_ _____

Basis


Desk audited costs


-~-X A verage Nursing Home Rate









---

----

150003100-201501




Florida Hospital Hospice Care Provider Number 150003100 Date 011292015

770 W Granada Blvd Suite 319 Fiscal Year End NA

Ormond Beach FL 32174 Audit Status NIA

I~---~~--middotmiddotmiddotmiddot--Provider Type Current R~feTNew Rate Effective Date



Federally Qualified Health Centers I I

Hospice Provider

i 651 Routine Home Care


I 654 ICFllID LC - 7 Room and Board I


655 InpatIent Respite Care I


21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501




Hospice ofEmerald Coast Provider Number 150009100 Date 011292015

PO Box 2127 Fiscal Year End NA Audit Status NADothan AL 36302

1

Provider Type Current Rate New Rate Effective Date i

--__R_u_r_a_l_H_e_a_lt_h_C_li_n_ic____________---II ____----L1 ____---____-- Swing-Bed Provider I 1

Federally Qualified Health Centers I I r Hospice Provider I r 651 Routine Home Care

I652 Continuous Home Care


I 654 ICFIIID LC - 8 amp 9 Room and Board

I 655 Inpatient Respite Care I j i I j J656 General Inpatient CareI

658 Room and Board County Bay 20789 1 20779~i---_OllOI201~

Basis


Desk audited costs



L~ _~~ __ ____ _





Settlement based on costs _ - -- ---------~ ~~




V408 Report Calculated 11292015 65443PM Report Printed 12920 I 5

-----

----

150013900-201501




Vitas Healthcare Corp of Florida - Congress Ave Provider Number 150013900 Attn Angela Santana Date 0112912015 100 S Biscayne Blvd Suite 1400 Fiscal Year End NA


Provider Type Current Rate - shy

New Rate Effective Date

Rural Health Clinic I Swing-Bed Provider


Hospice Provider I



I I




656 General Inpatient Care I

658 Room and Board County Palm Beach 22124 22522 I 0110112015

Basis IRate Type I X Prospective

---middotUnaudited costs Budget

Total Prospective Desk audited costs Prospective Adjusted for New Costs

---Field audited costs Medicare - Prospective Interim

X Payment System Rate --- Total Interim Average Nursing Home Rate --- Settlement based on costs





----- ---

---

---

150021000-201501




Good Shepherd Hospice Inc Provider Number 150021000 Date 0112912015

115 South Missouri Ave Fiscal Year End NA Audit Status NALakeland FL 33815

_ shyr-

Provider Type Current Rate New Rate Effective Date 1

Rural Health Clinic i J 1

I Swing-Bed Provider

Federally Qualified Health Centers -

I i I

I Hospice Provider I I i I

651 Routme Home Care

652 Continuous Home Care I I654 ICFIID LC -7 Room and Board

--- --~--+ I - i 654 ICFIIID LC - 8 amp 9 Room and Board

655 Inpatient Respite Care +1-middot~middot-middot~middot-I--~-middot-t---middot~middot--il i shy656 General Inpatient Care

-~~658 Room and Board 20190 20718 0110112015

IRate Type I

x Prospective ---Unaudited costs ---- Total Prospective

Desk audited costs

Budget


Field audited costs ---Medicare - Prospective Interim _~_Payment System Rate --- Total Interim






-------

150022800-201501


2727 Mahan Drivemiddot Mail Stop 23 Tallahassee Florida 32308

Medicaid Reimbursement Per Diem Rates for NonmiddotlnstitutionaJ Providers

LifePath Hospice Inc Provider Number 150022800 Date 011292015

3010 W Azeele Street Fiscal Year End NA

Tampa FL 33609 Audit Status NA

655 Inpatient Res ite Care p I

I I

i

I

Provider Type Curren1 Rate New Rate middot1

Effective Date I

Rural Health Clinic j I Swing-Bed Provider

I II


Ii Hospice Provider I I I

J

651 Routine Home Care I I

652 Continuous Home Care i I

I654 ICFIIID LC - 7 Room and Board t----~

I _ J

654 ICFIIID LC - 8 amp 9 Room and Board I


658 Room and Board 20826 21460 vel101l2015 ------------------- I

-~-~

I Basis J Budget



_~_Payment System Rate

IRate Type I



X Average Nursing Home Rate Settlement based on costs i





---

----

000532400-201501




Samaritan Care Hospice ofOsceola LLC Provider Number 000532400 Samaritan Care Hospice Date 011292015 1300 North Semoran Blvd Ste 210 Fiscal Year End NA

Orlando FL 32807 Audit Status NIA

i

I

I i

I

-~ - shy at1--------- -------~middot-middot~kl


Rural Health Clinic I Swing-Bed Provider I Federally Qualified Health Centers i

Hospice Provider


652 Contiuuous Home Care

654 ICFIIID LC - 7 Room and Board I

654 ICFIID LC - 8 amp 9 Room and Board --L shy

I 655 Inpatient Respite Care I


658 Room and Board i

20914 20995 0110112015

I

I

i

-------------~-__r----------- --~------ shyBasis


Desk audited costs











---

---

000602600-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis Rate Type



Desk audited costs







-------

001572800-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



i

i i

-~ -_


i

I

i

i






Desk audited costs



Rate Type








-------

__

001636100-201501






Pensacola FL 32503

Provider Type

Audit Status NA

-~




I


Hospice Provider i



i--+ =t ~ i




~ 20511 ~ 0110172015

Basis


Desk audited costs



Rate Type








- ---

-------

002782200-201501









I

i


Hospice Provider i






Basis


Desk audited costs


IRate Type I








---

---

----

003694700-201501







Rural Health Clinic

Swing-Bed Provider


Hospice Provider




















I

---

003815300middot201501






Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



-~-- shy






I

I

Effective Date]

658 Room and Board 20936 21359V 0110112015









---

004244800-201501






I~Provider Type ~



i

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs












-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

---

000602600-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis Rate Type



Desk audited costs







-------

001572800-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



i

i i

-~ -_


i

I

i

i






Desk audited costs



Rate Type








-------

__

001636100-201501






Pensacola FL 32503

Provider Type

Audit Status NA

-~




I


Hospice Provider i



i--+ =t ~ i




~ 20511 ~ 0110172015

Basis


Desk audited costs



Rate Type








- ---

-------

002782200-201501









I

i


Hospice Provider i






Basis


Desk audited costs


IRate Type I








---

---

----

003694700-201501







Rural Health Clinic

Swing-Bed Provider


Hospice Provider




















I

---

003815300middot201501






Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



-~-- shy






I

I

Effective Date]

658 Room and Board 20936 21359V 0110112015









---

004244800-201501






I~Provider Type ~



i

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs












-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

001572800-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



i

i i

-~ -_


i

I

i

i






Desk audited costs



Rate Type








-------

__

001636100-201501






Pensacola FL 32503

Provider Type

Audit Status NA

-~




I


Hospice Provider i



i--+ =t ~ i




~ 20511 ~ 0110172015

Basis


Desk audited costs



Rate Type








- ---

-------

002782200-201501









I

i


Hospice Provider i






Basis


Desk audited costs


IRate Type I








---

---

----

003694700-201501







Rural Health Clinic

Swing-Bed Provider


Hospice Provider




















I

---

003815300middot201501






Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



-~-- shy






I

I

Effective Date]

658 Room and Board 20936 21359V 0110112015









---

004244800-201501






I~Provider Type ~



i

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs












-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

__

001636100-201501






Pensacola FL 32503

Provider Type

Audit Status NA

-~




I


Hospice Provider i



i--+ =t ~ i




~ 20511 ~ 0110172015

Basis


Desk audited costs



Rate Type








- ---

-------

002782200-201501









I

i


Hospice Provider i






Basis


Desk audited costs


IRate Type I








---

---

----

003694700-201501







Rural Health Clinic

Swing-Bed Provider


Hospice Provider




















I

---

003815300middot201501






Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



-~-- shy






I

I

Effective Date]

658 Room and Board 20936 21359V 0110112015









---

004244800-201501






I~Provider Type ~



i

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs












-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








- ---

-------

002782200-201501









I

i


Hospice Provider i






Basis


Desk audited costs


IRate Type I








---

---

----

003694700-201501







Rural Health Clinic

Swing-Bed Provider


Hospice Provider




















I

---

003815300middot201501






Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



-~-- shy






I

I

Effective Date]

658 Room and Board 20936 21359V 0110112015









---

004244800-201501






I~Provider Type ~



i

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs












-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

---

----

003694700-201501







Rural Health Clinic

Swing-Bed Provider


Hospice Provider




















I

---

003815300middot201501






Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



-~-- shy






I

I

Effective Date]

658 Room and Board 20936 21359V 0110112015









---

004244800-201501






I~Provider Type ~



i

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs












-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

003815300middot201501






Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider



-~-- shy






I

I

Effective Date]

658 Room and Board 20936 21359V 0110112015









---

004244800-201501






I~Provider Type ~



i

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs












-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

004244800-201501






I~Provider Type ~



i

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs












-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

---

004579400-201501



Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider









19001 20385

Effective Date

0110112015

I






Basis


Desk audited costs



Rate Type






---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

087000500-201501









I I

Swing-Bed Provider


I

I

Hospice Provider







658 Room and Board 20350 20479 ~ 0110112015

Basis


Desk audited costs












---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

---

----

087246600-201501











Basis


Desk audited costs





Rate Type







---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

087255500-201501







I Provider Type

Rural Health Clinic

Swing-Bed Provider

~ ~~~~~~~-


Hospice Provider









20758 20833

Effective Date bull

V 0110112015

Basis


Desk audited costs



Rate Type








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

087256300-201501






--- __ --- shyI --~ -~


I i

i



Hospice Provider







658 Room and Board 21168 I 21591 V 0110112015

Basis


Desk audited costs





Rate Type







----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








----

087407800~201501









Swing-Bed Provider


Hospice Provider I







I -shy ~


Basis


Desk audited costs






Rate Type







---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

--

087514700-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs











---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

087515500-201501






- --- --- --- --- ----------- ------ - ---- ------- --------- - ---- -------------- - --- ---shy~ ~

Provider Type ~~


Rural Health Clinic

Swing-Bed Provider


Hospice Provider







658 Room and Board 20364 20641 ~~ 0110112015

I Basis I Budget

---Unaudited costs

Desk audited costs



IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

087516300-201501








Rural Health Clinic

New Rate

bull

Swing-Bed Provider


Hospice Provider







658 Room and Board 21938 22277 V 0110112015

Basis


Desk audited costs





IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

I

087517100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider








Basis


Desk audited costs



Rate Type








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

---

----

087519800-201501







Rural Health Clinic

Swing-Bed Provider



i

i i

I

Con Care I






2~637120220~ 0110112015

Basis


Desk audited costs





Rate Type







---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

087520100-201501








Rural Health Clinic

Swing-Bed Provider


Hospice Provider






Basis


Desk audited costs





Rate Type







00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








00-201501






-----shy

Provider Type

Rural Health Clinic

Swing-Bed Provider


Hospice Provider








bull

I

Effective Date

658 Room and Board 21128 21974 Y 0110112015













-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

087523600-201501












i




Basis


Desk audited costs











-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

I

087524400-201501







I


Rural Health Clinic


I





I

~-




21696 214 i

0110112015 ~

Basis


Desk audited costs











-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

087525200-201501















i

658 Room md Board 22476 I 22762 V 0110112015

- 1 Basis I-


Desk audited costs





1Rate Type 1







-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

087526100-201501







Provider Type

Rural Health Clinic

Swing-Bed Provider

~


Hospice Provider








bull

I

bull

i

658 Room and Board 20751 21103 -J 0110112015

I

Basis


Desk audited costs



Rate Type








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

---

----

087527900-201501









iHospice Provider i

I





iI




Desk audited costs










-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

087528700-201501









Swing-Bed Provider


Hospice Provider







658 Room and Board 21972 21790~ 0110112015I

Rate TypeBasis







------~ ----~--~~~~~~~-~-~~lt





-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

087529500-201501

















658 Room and Board 22061 22178 t 0110112015 i

bull

Basis


Desk audited costs



IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








___ ____

-------

I

087532500-201501







Provider Type T









1





Desk audited costs



IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

087535000-201501






658 Room and Board

i

I i

I

--~~ --~ ~-----~------ ~~~~--~~~ ~~



Current Rate

Rural Health Clinic

Swing-Bed Provider

I Hospice Provider






i

I

i


Basis


Desk audited costs



IRate Type I







---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

087536800-201501







bull

I

I

-- shy -~~ -~



Swing-Bed Provider


Hospice Provider








Effective Date

0110112015

bull

I

Basis


Desk audited costs











---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

087537600-201501







Provider Type

Hospice Provider I


Basis


Desk audited costs











---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

---

087538400-201501









Rural Health Clinic

Swing-Bed Provider


Hospice Provider












Desk audited costs



Rate Type






-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

087569400-201501









I I

Hospice Provider


i



L - I-~ -~



Desk audited costs


- shy










-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

087570800-201501












I ~-~8 Room and Board_-=____ 20363-1 20693 01012015

Basis


Desk audited costs



IRate Type I ---------~------~~-----~







-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

150000700-201501














~




I658 Room and Board 20852 21797 0110112015

i I

Basis


Desk audited costs












-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

150001500-201501













Basis


Desk audited costs











---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

----

150003100-201501











Hospice Provider







21572

I

I

Lshy_______________~________~~~~~=~=~ ==L_~

Basis


Desk audited costs


- shy











---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








---

---

----

150009100-201501






1









Basis


Desk audited costs



L~ _~~ __ ____ _










-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-----

----

150013900-201501










Hospice Provider I



I I















----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








----- ---

---

---

150021000-201501






_ shyr-





I i I






-~~658 Room and Board 20190 20718 0110112015

IRate Type I


Desk audited costs

Budget








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








-------

150022800-201501








I I

i

I


Effective Date I


I II



J




I _ J




-~-~

I Basis J Budget




IRate Type I








Documents

Fiscal Agent - The Agency For Health Care Administration · Medicare - Prospective . Desk audited costs . Interim X Payment System Rate --- Total Interim . Average Nursing Home Rate