NHA-100 NURSING HOME PROVIDER ASSESSMENT RETURN For the Quarter Ending

STATE OF NEW JERSEY - DIVISION OF TAXATION
NHA-100
NURSING HOME PROVIDER ASSESSMENT RETURN
(4/05)
For the Quarter Ending
In accordance with P.L.2003, c.105, as amended by P.L. 2004, c.41, it is requested that you complete the following form so that it can
be determined the Assessment that will be due and payable within twenty (20) days after the end of the quarter.
Please make any necessary corrections to the information listed below.
NJ/Federal Employer Identification Number
FOR DIVISION USE ONLY
LICENSED NAME
ADDRESS
CITY ST
ZIP
Your Long Term Care Program Reporting Classification is:
TAX CLASSIFICATION and PROGRAM NAME
B
Related Revenue Received
or Accrued
Whole Dollars (excluding cents)
SA
D MP
O L
N E
O O
T N
FI LY
LE
A
Number of Patient Days
Line 1. Medicare Days . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
Non-Medicare Days, including bedhold:
Line 2. Private
................................
00
Line 3. Medicaid
................................
00
Line 4. Therapeutic leave . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
Line 5. Respite
................................
00
Line 6. Other Non-Medicare days . . . . . . . . . . . . . . . . . . . . .
00
Line 7. Assessed Days and Revenue.
Add Lines 2 through 6 and enter here. . . . . . . . . . .
Line 8. Classification Assessment Rate . . . . . . . . . . . . . . . .
ASSESSMENT RATE
00
Line 9. Assessment Due (Line 7A x Line 8) . . . . . . . . . . . . .
Line 10. Penalty and Interest Due . . . . . . . . . . . . . . . . . . . . .
Line 11. Total Amount Due (add Lines 9 and Line 10) . . . . . .
Make check payable to:
File return with payment to:
NJ Nursing Home Provider Assessment
New Jersey Division of Taxation
Revenue Processing Center
PO Box 646
Trenton, NJ 08646-0646
Misrepresentations or falsification of any patient days or revenue data may be punishable by fine and/or imprisonment.
I declare under the penalties provided by law, that this return has been examined by me and to the best of my knowledge and belief is a true, correct
and complete return. If the return is prepared by a person other than the taxpayer, his declaration is based on all the information related to the matters
required to be reported on the return of which he has knowledge.
__________________________________________________ ______________________________________________________ _______________
Signature
Title (Officer, Owner, or Administrator ONLY)
Date
__________________________________________________ ______________________________________________________ _______________
Preparer’s Signature
Preparer’s Firm Name and Firm Federal ID Number
Date
(Only Required if other than Officer, Owner, or Administrator)
I authorize the Division of Taxation to forward this return and/or the information contained herein to the Department of Health and Senior Services,
Division of Senior Benefits and Utilization Management to facilitate the administration of the “Nursing Home Quality of Care Improvement Fund” as
established pursuant to P.L. 2003, c.105, as amended by P.L. 2004, c.41.
__________________________________________________ _______________________________________________ _____________________
Signature
Title (Officer, Owner, or Administrator ONLY)
Date
RETURN INSTRUCTIONS
GENERAL INFORMATION REGARDING PATIENT DAYS AND
RELATED REVENUE RECEIVED OR ACCRUED
(1) A Non-Medicare patient day is any day that a patient occupies
a nursing bed (includes bedhold) which is paid for by any
payer, public or private, other than Medicare.
(2) Revenue received or accrued means the amount received or
receivable, whether in cash or in kind, from patients, third party
payors and others for nursing home services furnished by the
nursing home provider, including retroactive adjustments
under reimbursement agreements with third party payers
without any deduction for expenses of any kind. Enter Related
Revenue Received or Accrued as Whole Dollars, excluding
cents. When rounding off to whole dollars, eliminate any
amount under 50 cents and increase any amount 50 cents or
more to the next highest dollar.
(3) For the purpose of this assessment, Residential Days, CPCH
Days and Daycare Days data are excluded and are not to be
reported on this return.
LINE ITEM INSTRUCTIONS
Line 1
Medicare Days - Enter patient days and revenue data for
Medicare patients.
Non- Medicare Days:
Line 2 Private - Enter patient day and revenue data paid by
private insurance companies or individuals.
Line 3 Medicaid - Enter patient day and revenue data paid by
Medicaid (Include Medicaid Bedhold Days).
Line 4 Therapeutic Leave - Enter patient day and revenue
data.
Line 5 Respite - Enter patient day and revenue data.
Line 6 Other Non-Medicare days - Enter patient day and
revenue data.
Line 7 Assessed Days & Revenue - Total Patient Days and
Revenue from Line 2 through Line 6 and enter in the
appropriate columns A and B, respectively.
Line 8 Classification Assessment Rate - Rate per Day.
Line 9 Assessment Due - Multiply Line 7A, Assessed days, by
Line 8, Rate, and enter result.
Line 10 Penalty and Interest Due - Report any penalty and
interest to be included in payment.
Line 11 Total Amount Due - Add Line 9 and Line 10 and enter
result. Pay this amount.
FILING INSTRUCTIONS
A. FILING OF RETURNS AND PAYMENT OF TAX - In
accordance with P.L. 2003, c.105, as amended by P.L. 2004,
c.41, Nursing Home Providers in New Jersey are to complete
the Nursing Home Provider Assessment Return, NHA-100, on
a quarterly basis within 20 days after the end of a calendar
quarter.
B. REMITTANCE - Make check payable to: NJ Nursing Home
Provider Assessment. Do not send cash.
C. WHERE TO FILE - The NHA-100 must be filed with both the
Division of Taxation and the Department of Health and Senior
Services. However, if the confidentiality waiver on the NHA100 is signed providing the Division of Taxation the authority to
forward the information to the Department of Health and
Senior Services, the NHA-100 may be filed solely with the
Division of Taxation. Mail the Nursing Home Provider
Assessment Return, NHA-100, together with remittance for the
full amount due to the New Jersey Division of Taxation,
Revenue Processing Center, PO Box 646, Trenton, NJ 08646-
0646. Mail a copy of this return to the Department of Health
and Senior Services, Office of Rate Setting and
Reimbursement, PO Box 715, Trenton, NJ 08625-0715, (only
necessary if the waiver detailed above is not signed)
Mail Original to: NJ Division of Taxation
Revenue Processing Center
PO Box 646
Trenton, NJ 08646-0646
Mail Copy to:
Department of Health and Senior Services
Office of Rate Setting
PO Box 715
Trenton, NJ 08625-0715
D. PENALTIES AND INTEREST - If the return is not filed,
penalties for late filing and payment will be applied and interest
will be charged from the original due date to date of filing and
payment.
LATE FILING PENALTY - 5% per month of fraction thereof of
the balance of assessment due at original return due date not
to exceed 25% of such assessment liability. In accordance
with N.J.S.A. 54:49-4, a delinquency penalty of $100 per
month, or fraction thereof, may be imposed for each month
each return is filed after the original due date.
If a Medicaid facility does not properly, and in a timely manner,
submit the correct, complete information and payment of the
provider assessment, the New Jersey Division of Taxation
may also deduct an estimated assessment from their UNISYS
Medicaid payments and the Medicaid facility may be subject
to a non-reimbursable two percent (eight percent annual rate)
assessment for penalty and interest.
If an exempt facility does not report the required statistics or if
the statistics are not reported in a timely manner, the exempt
facility may also be subject to a two percent assessment of
estimated gross revenue.
LATE PAYMENT PENALTY - 5% of the balance of the
assessment due paid late may be imposed.
INTEREST - The annual interest is 3% above the average
predominant prime rate. Interest is imposed each month or
fraction thereof on the unpaid balance of assessment from the
original due date to the date of payment. At the end of each
calendar year any assessment, penalties and interest
remaining due will become a part of the balance on which
interest will be charged.
Please note: In accordance with N.J.S.A. 54:49-12.3, a
Referral Cost Recovery Fee of 10% of the assessment,
penalty and interest due will be added to your liability, if this
matter is assigned to an outside collection agency. For
delinquent periods, if that period is assigned to an outside
collection agency, a Referral Cost Recovery Fee will be
assessed prior to the filing of a Certificate of Debt.
E. FURTHER INFORMATION - All general filing and forms
inquiries regarding the Nursing Facility Provider Assessment
may be directed to the NJ Division of Taxation Customer
Service Center by telephone at 609.292.6400 or by writing to
the: NJ Division of Taxation, Information and Publications
Branch, PO Box 281, Trenton, NJ
08695-0281 or
taxation@tax.state.nj.us.
Specific questions regarding data to be submitted should be
directed to: NJ Department of Health and Senior Services,
Division of Senior Benefits and Utilization Management, Office
of Nursing Facility Rate Setting and Reimbursement, PO Box
715, Trenton, NJ 08625-0715, Telephone 609.588.2691 or
William.Dawidowski @doh.state.nj.us for email inquiries.