DRAFT	FORM CMS-2552-10
"HOSPITAL UNCOMPENSATED AND INDIGENT CARE DATA, Worksheet S-10"	
PROVIDER NO.:	
PERIOD: From: to:	
	
"For each of the following lines, enter the value in Column 1"	
Uncompensated and indigent care cost computation	
1	"Cost to charge ratio (Worksheet C, Part I line 200 column 3 divided by line 200 column 8)"
Medicaid (see instructions for each line)	
2	Net revenue from Medicaid 
3	Did you receive DSH or supplemental payments from Medicaid?
4	" If line 3 is ""yes"", does line 2 include all DSH or supplemental payments from Medicaid?"
5	" If line 4 is ""no"", then enter DSH or supplemental payments from Medicaid"
6	Medicaid charges
7	Medicaid cost (line 1 times line 6)
8	Difference between net revenue and costs for Medicaid program (line 2 plus line 5 minus line 7)
State Children's Health Insurance Program (SCHIP) (see instructions for each line)	
9	Net revenue from stand-alone SCHIP
10	Stand-alone SCHIP charges
11	Stand-alone SCHIP cost (line 1 times line 10)
12	Difference between net revenue and costs for stand-alone SCHIP (line 9 minus line 11)
Other state or local government indigent care program (see instructions for each line)	
13	"Net revenue from state or local indigent care program (Not included on lines 2, 5 or 9)"
14	Charges for patients covered under state or local indigent care program (Not included in lines 6 or 10)
15	State or local indigent care program cost (line 1 times line 14)
16	Difference between net revenue and costs for state or local indigent care program (line 13 minus line 15)
Uncompensated care (see instructions for each line)	
17	"Private grants, donations, or endowment income restricted to funding charity care"
18	"Government grants, appropriations or transfers for support of hospital operations"
19	"Total unreimbursed cost for Medicaid , SCHIP and state and local indigent care programs (sum of lines 8, 12 and 16)"
	
"For each of the following lines, enter a value for uninsured patients (column 1), insured patients (Column 2), and total patients (Column 1 + 2)"	
20	Total initial obligation of patients approved for charity care (at full charges excluding non-reimbursable cost centers) for the entire facility
21	Cost of initial obligation of patients approved for charity care (line 1 times line 20)
22	Partial payment by patients approved for charity care
23	Cost of charity care (line 21 minus line 22)
"For each of the following lines, enter the value in Column 1"	
 24	Does the amount in line 20 column 2 include charges for patient days beyond a length of stay limit imposed on patients covered by Medicaid or other indigent care program?
25	"If line 24 is ""yes,"" charges for patient days beyond an indigent care program's length of stay limit"
26	Total bad debt expense for the entire facility (see instructions)
27	"Medicare bad debts for §1886(d) hospitals from Worksheets E, Part A and E, Part B, or CAHs from Worksheet E-3, Part V."
28	Non-Medicare and Non-Reimbursable bad debt expense (line 26 minus line 27)
29	Cost of non-Medicare bad debt expense (line 1 times line 28)
30	Cost of non-Medicare uncompensated care (line 23 column 3 plus line 29) 
31	"Total unreimbursed and uncompensated care cost (line 19 plus line 23, and 30)"
