Low and No Medicare Utilization Cost Report

No Utilization Cost Reports

To comply with program cost reporting requirements, a provider that has not furnished any covered Medicare services during a cost reporting period must only complete the certification page of the cost report (Worksheet S) along with a waiver form certifying no Medicare utilization. Prior approval from the MAC to file a no utilization cost report is not required.

Items required to be submitted for a no Medicare utilization cost report:

- Certification Page (Worksheet S), containing a valid (ink or electronic) signature by an officer or administrator.
- Signed Low/No Utilization Cost Report Waiver form

Low Utilization Cost Reports

If a provider has been reimbursed $200,000 or less ($50,000 for FQHC/RHC, $15,000 for CMHC) during the cost report period (There is no longer an option to file a low utilization cost report based on less than 10 percent Medicare utilization. This option was only available for fiscal periods ending 12/31/2016 or earlier), they may qualify to file a low utilization cost report and waive filing of the ECR disk. Prior approval from the MAC to file a low utilization cost report is not required.

The qualifying criteria to file a low utilization cost report for a provider type other than FQHC/RHC and CMHC is:

- Net reimbursement $200,000 or less (Medicare Part A + B)

The criteria to file a low utilization cost report for an FQHC/RHC is:

- Net reimbursement $50,000 or less

The criteria to file a low utilization cost report for a CMHC is:

- Net reimbursement $15,000 or less and $0 Outlier Payments

* There is no longer an option to file a low utilization cost report based on less than 10 percent Medicare utilization. This option was only available for fiscal periods ending 12/31/2016 or earlier.

Items required to be submitted for a low utilization cost report:

- Certification Page (Worksheet S), containing a valid (ink or electronic) signature by an officer or administrator.
- Applicable S-series worksheets (see below)
- Balance sheet and income statement (these can be worksheets from the cost report, ex. F-series worksheets – see below)
- Signed Low/No Utilization Cost Report Waiver form

Cost Report Type and Form Number	S Series Worksheets	Balance Sheet/Income Statement
SNF 2540-10	Worksheet S, S-3 Pt I	G and G-3
Hospital 2552-10	Worksheet S, S-3 Pt I	G, G-2 and G-3
HHA 1728-20 – NEW*	Worksheet S, S-3 Pt I	F and F-1
Hospice 1984-14	Worksheet S, S-1 Pt II	F and F-2
RHC 222-17	Worksheet S, S-1 Pt I Lines 1-14	Balance sheet and income statement are required
FQHC 224-14	Worksheet S, S-1 Pt I Lines 1-14	F-1; balance sheet is required
ESRD 265-11	Worksheet S	F and F-1
CMHC 2088-17	Worksheet S, S-1 Pt I Lines 1-14	F; balance sheet is required

*The Home Health Agency cost report form is the CMS 1728-20. This is a new form effective for fiscal years beginning on or after 1/1/2020 and ending 12/31/2020 or later.

- By filing a no/low utilization MCR, the provider accepts interim payments as final settlement. The MAC reserves the right to require a full cost report if after review it deems it necessary to best serve the interest of the Program.
- A link to the most current form of all provider type cost reports can be found in The Provider Reimbursement Manual - Part 2
- All cost reports must be filed via mail/hand delivery or MCReF (available for cost report FYE 12/31/2017 and later). Submission via NGS Connex or email is no longer available.

Low and No Medicare Utilization Cost Report

No Utilization Cost Reports

Items required to be submitted for a no Medicare utilization cost report:

Low Utilization Cost Reports

Items required to be submitted for a low utilization cost report:

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