Exhibit C Instructions

Transcription

1 Requirement: Frequency: Due Date: Projected Cost Center Operating and Capital Budget Contract 65E14.021(9)(a), F.A.C. Initial contract and as required Within 30 days after contract execution of upon request of the Network Manager Exhibit C For new contracts, this form is part of the required negotiation packet to be completed by the Network Service Provider (NSP) prior to the negotiation meeting. It shall be used by the NSP to represent a budget to display projected plan of operations, by cost center. The budget will then be negotiated at the negotiation meeting in accordance with the provisions in 65E14.021(9)(a), F.A.C., which is included herein by reference. Once contract negotiations are completed, the NSP shall make any necessary revisions and submit a final report to the Managing Entity no later than 30 days after contract execution. For current contracts that require a funding amendment, a revised Projected Cost Center Operating and Capital Budget reflecting the new funding, unit rates, and cost centers are required at a date the Managing Entity requires. In other cases, the form is due when specified by the Managing Entity. The Managing Entity shall provide oversight to ensure that the Projected Cost Center Operating and Capital Budget forms are completed. The role of the Network Service Provider is to complete the Agency Capacity Report using the instructions below: Agency... Date Prepared... Contract Number... Budget Period... Initial / Final... Enter name of corporation or business entity. Enter the date the preparation of this report was completed. Leave blank or obtain from the Managing Entity s Network Manager. FROM Enter July 1 of the year the contract will start. The only exception to using July 1 is if a new agency is being formed and operations will start after July 1, in which case enter the expected startup date. TO Enter contract end date. Check whether the projected budget is the initial or final submission. PART I: PROJECTED FUNDING SOURCES & REVENUES Column Headings & Letters: Funding Sources & Revenues... A A list of the specific revenue sources available to the Network Service Provider. State SAMHFunded Cost Centers B Enter as headings in columns B 1a, B 1b B 1x the names of the State Designated SAMH Cost Centers for a Program in which the Network Service Provider proposes to earn state substance abuse and mental health revenues. Do the same in columns B 2a, B 2b B 2x for a second Program, and so forth. Updated 3/1/2014 EXH C Page 1

2 Should be the same ones entered in the Personnel Detail Record. If different unit cost rates for a Cost Center are being proposed for each Program, the Cost Center information must be displayed for each Program separately. Otherwise, the information for a Cost Center may be aggregated for all applicable Programs. Total for Program... C If different unit cost rates for a Cost Center are being proposed for each Program, enter as headings in columns C 1, C 2 C 4 the names of the State SAMH Programs in which the Network Service Provider proposes to earn state substance abuse and mental health revenues. If the same unit cost rate for a Cost Center is being proposed for all Programs, enter All Programs Combined in column C 1. Represents the total amount of projected funding, by fund source, for each Program that receives state substance abuse and mental health funds. C 1 represents the sum of columns B 1a, B 1b B 1x ; C 2 represents the sum of columns B 2a, B 2b B 2x ; and so forth. Total for State SAMHFunded Cost Centers... D Represents the total amount of projected funding, by fund source, for those StateDesignated SAMH Cost Centers that receive state substance abuse and mental health funds. Represents the sum of columns C 1, C 2, C 3, and C 4. Total for NonStateFunded SAMH Cost Centers... E Represents the total amount of projected funding, by fund source, for those StateDesignated SAMH Cost Centers that receive NO state substance abuse and mental health funds. Total for All StateDesignated SAMH Cost Centers... F Represents the total amount of projected funding, by fund source, for ALL StateDesignated SAMH Cost Centers, regardless of funding sources. Represents the sum of columns D and E. NonSAMH Cost Center... G Represents the total amount of projected funding, by fund source, for the Network Service Provider s services that do NOT fall in any State Designated SAMH Cost Center. Does not apply to Section IA. Total Funding... H Represents the Network Service Provider s total amount of projected funding, by fund source. Row Sections: Represents the sum of columns F and G. Section IA Total State SAMH Funding... Obtain the total projected SAMH funding, including lines of credit, from the Network Manager of the Managing Entity funding this contract and from the Network Managers of any other Managing Entity s funding SAMH Updated 3/1/2014 EXH C Page 2

3 cost centers. Exhibit C In the row in Section 1A entitled From the Region funding this contract, distribute the total amount to be received under the contract among those State SAMHFunded Cost Centers (columns B 1a, B 1b B 1x ; B 2a, B 2 b B 2x ; etc.) in which the Network Service Provider proposes to earn the state substance abuse and mental health funds from the Managing Entity funding this contract. In the row entitled From Other Regions, distribute the total amount of SAMH funds received from other Managing Entities among State SAMHFunded Cost Centers (columns B 1a, B 1b B 1x ; B 2a, B 2 b B 2x ; etc.) and NonStateFunded SAMH Cost Centers (column E), based on where the Network Service Provider expects to generate or earn that particular revenue.. Then for each row in Section IA, add the individual amounts in columns B 1 a, B 1b B 1x and enter the row total in column C 1. Repeat for columns B 2a, B 2b B 2x, and C 2, and so forth. Then add the individual amounts in columns C 1, C 2 C 4 for this same row and enter the row total in column D and again in columns F and H. (Columns E and G will be blank for this row.) Section IB Other Government Funding... Section IC All Other Revenue... For each type of Other Government Funding source listed, distribute the total projected amount available among State SAMHFunded Cost Centers (columns B 1a, B 1b B 1x ; B 2a, B 2b B 2x ; etc.), NonStateFunded SAMH Cost Centers (column E), and the NonSAMH Cost Center (column G) based on where the Network Service Provider expects to generate or earn that particular revenue. For revenues which are not earned in a particular cost center or earmarked for a particular cost center by the governmental entity supplying the revenue, the Network Service Provider may assign such funds to any one or more of the StateDesignated SAMH Cost Centers, the NonStateFunded SAMH Cost Centers, and the NonSAMH Cost Center based on where they are expected to be needed to fund services. Then for each funding source row in Section IB, add the individual amounts in columns B 1a, B 1b B 1x and enter the total in column C 1. Repeat for columns B 2a, B 2b B 2x, and C 2, and so forth. Then add columns C 1, C 2 C 4 for these same rows in Section IB and enter the totals in column D. Add columns D and E for these same rows in Section IB and enter the totals in column F. Add columns F and G for these same rows in Section IB and enter the totals in column H. Add the individual rows in each column for Section IB and enter the column totals in the row entitled Total Other Government Funding. Do the same as in Section IB, except put the column totals for Section IC in the row entitled Total All Other Revenue. 1 st party payments mean fees received from clients or patients. 2 nd party payments mean fees received from any person legally Updated 3/1/2014 EXH C Page 3

4 responsible for the financial support of the client, such as a spouse, parent of a minor client, guardian, or trustee. 3 rd party payments mean funds received from commercial insurers such as workers compensation or TRIcare/VA on behalf of a specific client or patient. Medicare is a 3 rd party payment, but it should be listed separately. TOTAL PROJECTED FUNDING: Add the rows entitled Total State SAMH Funding, Total Other Government Funding, and Total All Other Revenues for each column and enter the column totals in the row entitled Total Projected Funding. PART II: PROJECTED EXPENSES Column Headings: Expense Categories... A A list of the specific categories for tracking expenditures. State SAMHFunded Cost Centers... B Enter as headings in columns B 1a, B 1b B 1x the names of the State Designated SAMH Cost Centers for a Program in which the Network Service Provider proposes to expend state substance abuse and mental health funds. Do the same in columns B 2a, B 2b B 2x for a second Program, and so forth. Should be the same ones entered in Part I, Projected Funding Sources and Revenues unless enhanced services are provided to special populations (to be negotiated between the provider and the Managing Entity and outlined in the program description). The additional costs associated with the enhanced services should be listed in a separate column appropriately titled. (e.g. Enhanced Residential Services for Cooccurring clients.) Remember, if different unit cost rates for a Cost Center are being proposed for each Program, the Cost Center information must be displayed for each Program separately. Otherwise, the information for a Cost Center may be aggregated for all applicable Programs. Updated 3/1/2014 EXH C Page 4

5 Total for Program... C If different unit cost rates for a Cost Center are being proposed for each Program, enter as headings in columns C 1, C 2 C 4 the names of the State SAMH Programs in which the Network Service Provider proposes to expend state substance abuse and mental health funds. If the same unit cost rate for a Cost Center is being proposed for all Programs, enter All Programs Combined in column C 1. If an enhanced rate for a special population is proposed it will also be included. Represents the total amount of projected expenditures, by expense category, for each Program that receives state substance abuse and mental health funds. C 1 represents the sum of columns B 1a, B 1b B 1x ; C 2 represents the sum of columns B 2a, B 2b B 2x ; and so forth. Total for State SAMHFunded Cost Centers... D Represents the total amount of projected expenditures, by expense category, for those StateDesignated SAMH Cost Centers that receive state substance abuse and mental health funds. Represents the sum of columns C 1, C 2, C 3, and C 4. Total for NonStateFunded SAMH Cost Centers... E Represents the total amount of projected expenditures, by expense category, for those StateDesignated SAMH Cost Centers that receive NO state substance abuse and mental health funds. Total for All StateDesignated SAMH Cost Centers... F Represents the total amount of projected expenditures, by expense category, for ALL StateDesignated SAMH Cost Centers, regardless of funding sources. Represents the sum of columns D and E. NonSAMH Cost Center... G Represents the total amount of projected expenditures, by expense category, for the Network Service Provider s services that do NOT fall in any StateDesignated SAMH Cost Center. Other Support Costs (optional)... H Represents the amount of support costs that indirectly contribute to or benefit the service delivery cost centers and administration. This might entail such optional indirect cost pools as billing, transportation, data processing, and medical records. If not treated separately, these costs shall be treated as Administration and included in Column I. Administration... I Represents the amount of general administrative overhead costs that indirectly contribute to or benefit the service delivery cost centers. Total Expenses... J Represents the Network Service Provider s total amount of projected expenses, by expense category. Represents the sum of columns F, G, H, and I for Sections IIA, IIB and IIE, and the sum of columns F and G for Sections IIC and IID. Updated 3/1/2014 EXH C Page 5

6 Sections: Section IIA Personnel Expenses... Enter the Total Net Salary amounts from the Personnel Detail Record in the salaries row of columns B 1a, B 1b B 1x ; B 2a, B 2b B 2x ; etc., E, G, H, and I. For the fringe benefits row, distribute the total fringe benefit costs among columns B 1a, B 1b B 1x ; B 2a, B 2b B 2x ; etc., E, G, H, and I in relation to the corresponding position distribution. Then for each row in Section IIA, add the individual amounts in columns B 1 a, B 1b B 1x and enter the total in column C 1. Repeat for columns B 2a, B 2 b B 2x, and C 2, and so forth. Then add columns C 1, C 2 C 4 for these same rows in Section IIA and enter the totals in column D. Add columns D and E for these same rows in Section IIA and enter the totals in column F. Add columns F, G, H, and I for these same rows in Section IIA and enter the totals in column J. Add the individual rows in each column for Section IIA and enter the column totals in the row entitled Total Personnel Expenses. Section IIB Other Expenses... TOTAL PERSONNEL & OTHER EXPENSES: Section IIC Distributed Indirect Costs... For each expense category listed, distribute the total Network Service Provider s projected costs among columns B 1a, B 1b B 1x ; B 2a, B 2b B 2x ; etc., E, G, H, and I based on where these cost are expected to be incurred. Then for each expense category row in Section IIB, add the individual amounts in columns B 1a, B 1b B 1x and enter the total in column C 1. Repeat for columns B 2a, B 2b B 2x, and C 2, and so forth. Then add columns C 1, C 2 C 4 for these same rows in Section IIB and enter the totals in column D. Add columns D and E for these same rows in Section IIB and enter the totals in column F. Add columns F, G, H, and I for these same rows in Section IIB and enter the totals in column J. Add the individual rows in each column for Section IIB and enter those column totals in the row entitled Total Other Expenses. Add the row entitled Total Personnel Expenses to the row entitled Total Other Expenses in each column and enter those column totals in the row entitled Total Personnel and Other Expenses. For the Other Support Costs row in Section IIC, enter the Total Personnel and Other Expenses row amount found in column H, if any, as a negative number, and then distribute the positive amount among columns B 1a, B 1 b B 1x ; B 2a, B 2b B 2x ; etc., E, G, and I in accordance with the Network Service Provider s written plan for allocating indirect support costs to service delivery cost centers and to administration. For the Administration row in Section IIC, add the Total Personnel and Other Expenses row amount found in column I to the Other Support Cost row amount distributed to column I, if any. Enter that sum as a negative number in the Administration row, and then distribute the positive sum among columns B 1a, B 1b B 1x ; B 2a, B 2b B 2x ; etc., E and G in accordance Updated 3/1/2014 EXH C Page 6

7 with the Network Service Provider s written plan for allocating indirect general administrative overhead costs to service delivery cost centers. Then for each distributed cost row in Section IIC, add the individual amounts in columns B 1a, B 1b B 1x and enter the total in column C 1. Repeat for columns B 2a, B 2b B 2x, and C 2, and so forth. Then add columns C 1, C 2 C 4 for these same rows in Section IIC and enter the totals in column D. Add columns D and E for these same rows in Section IIC and enter the totals in column F. Add columns F and G for these same rows in Section IIC and enter the totals in column J. Add the individual rows in each column for Section IIC, except columns H and I, and enter those column totals in the row entitled Total Distributed Indirect Costs. No totals are needed in columns H and I because these funds were distributed to the service delivery cost centers. TOTAL PROJECTED OPERATING EXPENSES: Section IID Unallowable Costs... Section IIE Total SAMH Lines of Credit Equivalent... Add the row entitled Total Personnel & Other Expenses to the row entitled Total Distributed Indirect Costs in each column, and enter the column totals in the row entitled Total Projected Operating Expenses. Columns H and I should be $0.00 for this row because these funds were distributed to the service delivery cost centers. For columns B 1a, B 1b B 1x ; B 2a, B 2b B 2x ; etc., E and G, identify the amount of any costs that are specified in 65E14.017(4), F.A.C., as unallowable costs for the purpose of state payment, and enter those column amounts in the row entitled Unallowable Costs. Columns H and I should be blank for this row because these funds were distributed to the service delivery cost centers. Then add the individual amounts in columns B 1a, B 1b B 1x and enter the row total in column C 1. Repeat for columns B 2a, B 2b B 2x, and C 2, and so forth. Then add columns C 1, C 2 C 4 in Section IID and enter the total in column D. Add columns D and E in Section IID and enter the total in column F. Add columns F and G in Section IID and enter the total in column J. For columns B 1a, B 1b B 1x ; B 2a, B 2b B 2x ; etc., identify the total aggregate line of credit amount provided by the Managing Entity, and enter each applicable SAMH cost center s proposed cost equivalent use of the aggregate line of credit in the row entitled Total SAMH Lines of Credit Equivalent. Columns E, G, H, and I should be blank for this row because lines of credit from SAMH must be used in SAMH contracted cost centers. Then add the individual amounts in columns B 1a, B 1b B 1x and enter the row total in column C 1. Repeat for columns B 2a, B 2b B 2x, and C 2, and so forth. Updated 3/1/2014 EXH C Page 7

8 Then add columns C 1, C 2 C 4 in Section IIE and enter the total in columns D and J. TOTAL ALLOWABLE PROJECTED OPERATING EXPENSES, Excluding SAMH Credit Equivalent: Section IIF Capital Expenditures... Section IIG Budget Narrative... Subtract the rows entitled IID. Unallowable Costs and IIE. Total SAMH Lines of Credit Equivalent from the row entitled Total Projected Operating Expenses for each column and put the results in the row entitled Total Allowable Projected Operating Expenses, Excluding SAMH Credit Equivalent. No totals are needed in columns H and I because these costs were distributed to the service delivery cost centers. NOTE: The totals for each State SAMHFunded Cost Center, by Program, shall be transferred to row d. Total Cost on the Agency Capacity Report. Enhanced rates for special populations shall be transferred to row g. Additional Costs for Enhanced Services. Enter the total amount of fixed capital outlay expenditures projected for columns B 1a, B 1b B 1x ; B 2a, B 2b B 2x ; etc., E, G, H, and I. Then add the individual amounts in columns B 1a, B 1b B 1x and enter the row total in column C 1. Repeat for columns B 2a, B 2b B 2x, and C 2, and so forth. Then add columns C 1, C 2 C 4 in Section IIF and enter the total in column D. Add columns D and E in Section IIF and enter the total in column F. Add columns F, G, H, and I in Section IIF and enter the total in column J. Identify major changes in projected expenditures from the previous year and explain the reasons for each change. Also, explain the impact these changes are expected to have on the quantity of units and quality of the services to be provided in each State SAMHFunded Cost Center. This includes those cost centers utilizing enhanced rates. PART III: CERTIFICATION The signature and title of the person responsible for completing the projected budget, along with the date of signature, are required as certification that the projections are accurate and in agreement with the agency s records and with the terms of the agency s contract with the Managing Entity. Updated 3/1/2014 EXH C Page 8

9 LSF HEALTH SYSTEMS Exhibit C SUBSTANCE ABUSE & MENTAL HEALTH SERVICES PROJECTED COST CENTER OPERATING AND CAPITAL BUDGET AGENCY: DATE PREPARED: INITIAL: FINAL: CONTRACT #: BUDGET PERIOD: FROM: TO: PART I: PROJECTED FUNDING SOURCES & REVENUES STATEDESIGNATED SAMH COST CENTERS STATE SAMHFUNDED COST CENTERS Combined Programs Program 1 Total for Non StateFunded SAMH Cost Tot. for All State Designated SAMH Cost FUNDING SOURCES & REVENUES (CC name) (CC name) Total for Combined Programs (CC name) (CC name) Total for Program 1 Total for State SAMHFunded Cost Centers Centers Centers NonSAMH Cost Center Total Funding (B 1a + +B 1x ) (B 2a + +B 2x ) (C 1 + +C 4 ) (D+E) (F+G) A B 1a B 1b C 1 B 2a B 2b C 2 D E F G H IA. TOTAL STATE SAMH FUNDING (1) From the Region funding this contract $ $ $ $ $ $ $ $ $ $ $ (2) From Other Region/Circuit $ $ $ $ $ $ $ $ $ $ $ IB. OTHER GOVERNMENT FUNDING (1) Other State Agency Funding $ $ $ $ $ $ $ $ $ $ $ (2) Medicaid $ $ $ $ $ $ $ $ $ $ $ (3) Local Government $ $ $ $ $ $ $ $ $ $ $ (4) Federal Grants and Contracts $ $ $ $ $ $ $ $ $ $ $ (5) Inkind from local govt. only $ $ $ $ $ $ $ $ $ $ $ TOT. OTHER GOVT. FUNDING = $ $ $ $ $ $ $ $ $ $ $ IC. ALL OTHER REVENUES (1) 1st & 2nd Party Payments $ $ $ $ $ $ $ $ $ $ $ (2) 3rd Party Payments (except Medicare) $ $ $ $ $ $ $ $ $ $ $ (3) Medicare $ $ $ $ $ $ $ $ $ $ $ (4) Contributions and Donations $ $ $ $ $ $ $ $ $ $ $ (5) Other $ $ $ $ $ $ $ $ $ $ $ (6) Inkind $ $ $ $ $ $ $ $ $ $ $ TOTAL ALL OTHER REVENUES = $ $ $ $ $ $ $ $ $ $ $ TOTAL PROJECTED FUNDING = $ $ $ $ $ $ $ $ $ $ $ Updated 3/1/2014 EXH C Page 9

10 LSF HEALTH SYSTEMS Exhibit C SUBSTANCE ABUSE & MENTAL HEALTH SERVICES PROJECTED COST CENTER OPERATING AND CAPITAL BUDGET AGENCY: DATE PREPARED: INITIAL: FINAL: CONTRACT #: BUDGET PERIOD: FROM: TO: PART II: PROJECTED EXPENSES STATEDESIGNATED SAMH COST CENTERS STATE SAMHFUNDED COST CENTERS Combined Programs Program 1 *except IIC & IID Total for Program 1 or Combined (CC name) (CC name) Total for State SAMHFunded Cost Centers Total for Non StateFunded SAMH Cost Centers Tot. for All State Designated SAMH Cost Centers Total for NonSAMH Cost Other Support EXPENSE CATEGORIES (CC name) (CC name) Program 1 Center Costs (optional) Administration Total Expenses (B 1a + +B 1x ) (B 2a + +B 2x ) (C 1 + +C 4 ) (D+E) (F+G+H*+I*) A B 1a B 1b C 1 B 2a B 2b C 2 D E F G H I J IIA. PERSONNEL EXPENSES (1) Salaries $ $ $ $ $ $ $ $ $ $ $ $ $ (2) Fringe Benefits $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL PERSONNEL EXPENSES = $ $ $ $ $ $ $ $ $ $ $ $ $ IIB. OTHER EXPENSES (1) Building Occupancy $ $ $ $ $ $ $ $ $ $ $ $ $ (2) Professional Services $ $ $ $ $ $ $ $ $ $ $ $ $ (3) Travel $ $ $ $ $ $ $ $ $ $ $ $ $ (4) Equipment $ $ $ $ $ $ $ $ $ $ $ $ $ (5) Food Services $ $ $ $ $ $ $ $ $ $ $ $ $ (6) Medical and Pharmacy $ $ $ $ $ $ $ $ $ $ $ $ $ (7) Subcontracted Services $ $ $ $ $ $ $ $ $ $ $ $ $ (8) Insurance $ $ $ $ $ $ $ $ $ $ $ $ $ (9) Interest Paid $ $ $ $ $ $ $ $ $ $ $ $ $ (10) Operating Supplies & Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ (11) Other $ $ $ $ $ $ $ $ $ $ $ $ $ (12) Donated Items $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL OTHER EXPENSES = $ $ $ $ $ $ $ $ $ $ $ $ $ TOT. PERSONNEL & OTH. EXP. = $ $ $ $ $ $ $ $ $ $ $ $ $ IIC. DISTRIBUTED INDIRECT COSTS (a) Other Support Costs (Optional) $ $ $ $ $ $ $ $ $ $ $ < > $ $ (b) Administration $ $ $ $ $ $ $ $ $ $ $ 0.00 $ < > $ TOT. DISTR'D INDIRECT COSTS = $ $ $ $ $ $ $ $ $ $ XXXXXXXXXXX XXXXXXXXX $ TOTAL PROJECTED OPER. EXPENSES = $ $ $ $ $ $ $ $ $ $ $ 0.00 $ 0.00 $ IID. UNALLOWABLE COSTS $ $ $ $ $ $ $ $ $ $ XXXXXXXXXXX XXXXXXXXX $ OTAL SAMH LINES OF CREDIT EQUIVALENT = $ $ $ $ $ $ $ $ $ $ XXXXXXXXX XXXXXXXXX $ TOT. ALLOWABLE PROJ'D OPERATING EXP., Excluding SAMH Credit Equivalent = $ $ $ $ $ $ $ $ $ $ XXXXXXXXX XXXXXXXXX $ IIF. CAPITAL EXPENDITURES $ $ $ $ $ $ $ $ $ $ $ $ $ Updated 3/1/2014 EXH C Page 10

11 LSF HEALTH SYSTEMS Exhibit C SUBSTANCE ABUSE & MENTAL HEALTH SERVICES PROJECTED COST CENTER OPERATING AND CAPITAL BUDGET AGENCY: DATE PREPARED: INITIAL: FINAL: CONTRACT #: BUDGET PERIOD: FROM: TO: IIG. BUDGET NARRATIVE (attach separate set of workpapers) PART III: CERTIFICATION I certify the above to be an accurate projection and in agreement with this agency's records and with the terms of this agency's contract with the department. Signature Title Date Updated 3/1/2014 EXH C Page 11