	Instructions for Wage Index Pension Cost Worksheet
	"This worksheet was developed as a tool to assist providers and Medicare contractors in developing the pension costs to be reported for wage index purposes per the policy adopted in the FY 2012 IPPS final rule (CMS-1518-F; 76 FR 51586 - 51590, August 18, 2011).  

Note: Only defined benefit pension plans which meet the applicable requirements for a qualified pension plan under Section 401(a) of the Internal Revenue Code are subject to the policy adopted in the FY 2012 IPPS final rule 

The use of this worksheet is not required.
"
Line	
	STEP 1
1	Enter the Wage Index FY for which pension costs are to be determined. The upcoming year is FY 2016. This worksheet applies to Wage Index FY's starting with 2012.
2	"Enter the provider cost reporting period to be used for the Wage Index year in Line 1.  This cost period must commence in the Medicare FY (10/1-9/30) four years prior to the relevant upcoming Federal Fiscal Year. For example, the provider cost reporting period for the FY 2016 Wage Index must commence in the Medicare FY ending September 30, 2012"
3	"Enter the midpoint of  the provider cost reporting period shown in Line 2.  This should always be the first day of a calendar month.  If the midpoint occurs in the middle of a month, enter either the first day of the midpoint month or the first day of the following month. (If using the automated worksheet, enter ""+"" in the highlighted area to shift date to the first day of the following month, or ""-"" to shift date to the first day of the midpoint month.)"
4	Enter the date (1st of a month) which occurs 18 months prior to the midpoint date shown in line 3. (Note: This date will not necessarily coincide with the beginning of a cost reporting period)
5	Enter the date (last day of a month) which occurs 18 months after the midpoint date shown in line 3. (Note: This date will not necessarily coincide with the end of a cost reporting period)
	STEP 2 
	STEP 2 IS OPTIONAL.  Complete Step 2 only if all of the following apply:
	> The provider has  a new defined benefit plan that was effective during the averaging period determined in STEP 1; 
	> The provider had no other defined benefit plan in effect during the averaging period;
	> The provider did not report pension costs for the new plan in a prior period based on a 36 month averaging period which included cost reporting periods ending prior to the plan effective date;
	> The provider elects to report costs for the new pension plan based on a shortened averaging period excluding all cost reporting periods which ended prior to the plan effective date.
6	Enter the effective date of the new plan which occurs within the averaging period determined in Step 1.
7	"Enter the first day of the provider's cost reporting period in which the plan was effective. For example, if the plan was effective during the provider's cost reporting period which began on 01/01/2010, enter 01/01/2010."
8	"Enter the date from Line 7 if it is the first of a calendar month; otherwise enter the first of the month immediately preceding or following the date in Line 7.  (If using the automated worksheet, enter ""+"" in the highlighted area to shift date to the first day of the following month, or ""-"" to shift date to the first day of the current month.)"
	STEP 3
9	"Enter the beginning date of the averaging period from Line 4 or Line 8, as applicable."
10	Enter the ending date of the averaging period from Line 5.
11	"Complete the table to show the total provider contributions made (on a cash basis) during the averaging period commencing on the date shown on Line 9 and ending on the date shown on Line 10.  Contributions may be grouped to correspond with the periods shown in supporting documentation.  Contributions made under a pension plan that covers multiple providers or employers shall be allocated on a basis consistent with plan records.  If the plan does not provide for a separate accounting of the costs, contributions, and/or assets attributable to each participating provider or employer, the allocation basis must represent a reasonable approximation of the costs attributable to each employer.  Supporting documentation must show the amounts and dates of deposit for all contributions reported and the data to support the allocation of total plan contributions, if applicable.  Examples of acceptable documentation to support the total deposits include pension trust or insurance statements, or Schedule SB of IRS Form 5500.  "
12	"Enter the total number of calendar months included in the averaging period (enter ""36"" unless Step 2 was completed for a new plan)."
13	Total the contributions listed in the table under Line 11.
14	The average monthly contribution during the averaging period is Line 13 divided by Line 12.
15	Enter the number of (full or partial) months in the provider's cost reporting period shown on Line 2.
16	The average pension contributions equal Line 14 multiplied by Line 15.
	STEP 4
	"If the Wage Index FY shown on Line 1 is after 2022, enter ""0"" on Lines 17 and 18."
17	"If the provider established a prefunding balance in FY 2013, FY 2014 or FY 2015, enter the annual prefunding installment from Line 8 of the Pension Prefunding Worksheet from FY 2013, 2014 or FY 2015 (unless a provider is revising their prefunding worksheet (with supporting documentation) from FY 2013, 2014 or FY 2015 for FY 2016).  If the provider has not elected to establish a pension prefunding balance, enter ""0"".  If the Prefunding Installment has not been previously determined, use the worksheet posted on the CMS website to determine the prefunded amount for FY 2016."
18	The reportable prefunding installment is the amount shown on Line 17 multiplied by Line 15 divided by 12.
19	The reportable pension cost for the Wage Index equals Line 18 plus Line 16.
