Unreimbursed Medicaid (Part I, line 7b)

Unreimbursed Costs - Other Means-Tested Government Programs (Part I, line 7c)

DISCUSSION: Examples of other means tested programs include:
- Children's Health Insurance Program (CHIP)
- state programs for uninsured adults

NARRATIVE REQUIRED: No

Worksheet 3 (Click here for Worksheet 3 instructions)




(A) Medicaid (B) Other means-tested government programs
1.   Gross patient charges from the programs 1. ___________ ___________
Less Adjustments
2.   Ratio of patient cost to charges (from Worksheet 2, if used) 2. _________% _________%
3.   Cost (multiply line 1 by line 2, or obtain from cost accounting) 3. ___________ ___________
4.   Medicaid provider taxes 4. ___________ ___________
5.   Total community benefit expense (add lines 3 and 4; enter amount from column (A) on Part I, line 7b, column (c); and enter amount from column (B) on Part I, line 7c, column (c)) 5. ___________ ___________
Direct Offsetting Revenue
6.   Net patient service revenue 6. ___________ ___________
7.   Payments from uncompensated care pools or programs 7. ___________ ___________
8.   Other revenue 8. ___________ ___________
9.   Total direct offsetting revenue (add lines 6 through 8; enter amount from column (A) on Part I, line 7b, column (d) and enter amount from column (B) on Part I, line 7c, column (d)) 9. ___________ ___________
10.   Net community benefit expense (subtract line 9 from line 5; enter amount from column (A) on Part I, line 7b, column (e); enter amount from column (B) on Part I, line 7c, column (e)) 10. ___________ ___________
11.   Total expense (enter amount from Form 990, Part IX, line 25, Column (A) on Part I, line 7b, column (f); enter amount from column (B) on Part I, line 7c, column (f)) 11. ___________ ___________
12.   Percent of total expense (line 10 divided by 11; enter amount from column (A) on Part I, line 7b, column (f); enter amount from column (B) on Part I, line 7c, column (f)) 12. _________% _________%

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