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Understanding hospital AWI's impact on Medicare reimbursement

By: Tony Daddario,

Ryan McKinnon is a Manager in BerryDunn's Healthcare practice, specializing in hospital reimbursement, with a concentration in acute prospective payment system (PPS) providers. He has over 21 years of experience working with large academic medical centers in the greater Boston area, including an in-depth understanding of medical education, organ acquisition, Medicare bad debts, and wage index.

Ryan McKinnon
10.03.25

This article is for hospital CFOs, directors of reimbursement, and reimbursement managers. 

When it comes to Medicare reimbursement, the hospital Area Wage Index (AWI) may be one of the most important and often overlooked factors influencing your bottom line. This complex formula adjusts prospective payment rates based on regional labor costs and is calculated using data you submit, meaning small reporting decisions can lead to major financial impacts. Hospitals that fully understand how the AWI works and take a proactive approach to managing their data can optimize their Medicare revenue and strengthen long-term financial stability. This article breaks down how the wage index is calculated and offers practical strategies to help you avoid common pitfalls, support audit readiness, and take full advantage of this critical reimbursement mechanism. 

What is the hospital AWI and how is it calculated? 

Developed by the Centers for Medicare & Medicaid Services (CMS), the hospital AWI is used to adjust Medicare payments to short-term, acute care hospitals under the Prospective Payment System (PPS) to account for geographic differences in hospital labor costs. It compares the average hourly wages of PPS hospitals in a specific labor market area to the national average. Essentially, the AWI enables hospitals in higher-wage areas to receive more reimbursement to reflect their higher costs, while those in lower-wage areas receive less.  

Updated annually, the AWI is calculated for each specific labor market area defined by Core-Based Statistical Areas (CBSA) as established by the US Office of Management and Budget (OMB). To calculate the AWI, CMS determines the average hourly wage from aggregated hospital data for each CBSA and compares it to the national average. For example, if a CBSA has an average hourly wage of $50 and the national average is $40, the AWI would be 1.25. This factor is applied to the labor-related portion of Medicare’s hospital payment rates to ensure more equitable reimbursement across regions with varying labor costs.   

The wage index is derived from data reported by all PPS hospitals located within each CBSA, including data from annual Medicare cost reports and occupational mix surveys completed every three years. The hospital-reported data is audited, including review of payroll records, contracts, invoices for contracted labor, and other wage documentation to validate amounts reported. As such, there is a four-year delay from the reporting of wage data in cost reports to the Federal Fiscal Year (FFY) that the wage data is used to calculate the AWI. For example, the Medicare hospital AWI used to establish prospective payments for the FFY 2026 is based on hospital data from fiscal years beginning during the FFY 2022.  

The following chart, which includes data from the Centers for Medicare & Medicaid Services Fiscal Year 2025 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule, illustrates the significant impact that the wage index factor has on hospital reimbursement. 

Strategic considerations for hospitals 


Accuracy of submitted data 
CMS scrutinizes wage index data with a high level of detail. Inaccurate or inconsistent reporting can result in reimbursement reductions or even penalties. Errors may stem from incorrect wage classifications, exclusion of eligible labor costs, or misalignment between cost report data and payroll records. Hospitals must ensure that their Medicare cost report and occupational mix survey submissions are complete, clearly documented, and compliant with CMS guidance. Regular internal reviews and cross-checks between finance and HR departments can reduce the risk of discrepancies and support a smoother audit process. 

Strategy tip: Establish a wage index review team with finance, reimbursement, and HR representation to ensure consistency and defensibility across all submissions. 

Occupational mix factor 
The occupational mix survey is required every three years and has a multiyear impact on the wage index. It adjusts for differences in staffing models among hospitals, particularly the proportion of higher-paid professionals like RNs compared to lower-paid roles such as LNAs. Even if your total wages remain constant, a change in your occupational mix can significantly alter your wage index and, by extension, your reimbursement. 

Strategy tip: If you've recently undergone staffing changes, make sure these are accurately reflected and that you’ve retained the documentation to support the reported mix.  

Contract labor reporting 
The rise in contract and traveler staffing has introduced new complexity to wage index reporting. CMS requires hospitals to include contract labor costs that are for direct patient care services, but only when wages and hours are clearly documented and the reported costs are only related to labor (not overhead, travel, etc.). Missing or incomplete contractor data can lead to an underreported wage index, which may reduce reimbursement. Many hospitals unintentionally leave out valid contract labor costs because of poor tracking or vendor relationships that don’t provide sufficient detail. 

Strategy tip: Work with your contracted staffing vendors to ensure all contracts and invoices separate wage related rates and hours from non-wage-related cost (travel, housing, administrative fees, etc.). Develop internal controls to flag and track qualifying contract labor throughout the year, not just at cost reporting time. 

Appeal and correction opportunities 
Each year, CMS publishes a preliminary wage index in the Inpatient Prospective Payment System (IPPS) rulemaking process, followed by a correction and appeals window. Hospitals have a narrow opportunity to review, identify errors, and file appeals or correction requests, but many miss this window due to resource constraints or lack of awareness. These opportunities can help recover significant underpayments if discrepancies are discovered. 

Strategy tip: Mark your calendar for the CMS wage index correction deadlines (typically late summer or early fall) and assign someone to monitor the release of proposed rules. Establish a process for reviewing CMS-calculated wage index factors against your internal expectations to quickly identify inconsistencies. 

Geographic reclassification opportunities 
If your hospital is in a lower-wage CBSA but competes in a higher-wage labor market (or is on the border of one), you may be eligible to apply for a wage index reclassification through the Medicare Geographic Classification Review Board (MGCRB). This allows hospitals to be reclassified into a nearby CBSA with higher average wages, potentially increasing your Medicare reimbursement. 

The application must demonstrate that the hospital meets specific criteria related to proximity, commuting patterns, and wage comparability. While the process is data-intensive and must be initiated well in advance (typically by September 1 for the following federal fiscal year), a successful reclassification can yield substantial reimbursement gains. 

Strategy tip: Evaluate your geographic and wage positioning annually. Even if you haven't qualified in the past, changes in market conditions or CMS rules may make you newly eligible. BerryDunn can assist with a feasibility analysis and guide you through the MGCRB application process. 

We’re here to help 

The hospital wage index is complex and reporting wage data is more than a compliance requirement; it’s a strategic lever that can influence millions in Medicare reimbursement. At BerryDunn, our reimbursement specialists can help you: 

  • Validate and optimize your wage index data submissions 
  • Prepare for audits, respond to inquiries, and assist with disputes 
  • Complete the occupational mix survey accurately and efficiently 
  • Analyze trends and opportunities in your wage index factors 
  • Identify opportunities for reclassification  
  • Monitor CMS rule changes that impact your hospital’s reimbursement 

To learn more about how we can help your hospital make the most of the wage index, please contact our reimbursement consulting services team.  

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Read this if you are a leader in the healthcare industry.

BerryDunn recently held its first annual Healthcare Leadership Summit. Here are some highlights of the topics, presentations, and discussions of the day. 

Healthcare CFO survey results

The day began with an industry update where Connie Ouellette and Lisa Trundy-Whitten had the opportunity to present with Rob Culburt, Managing Director, Healthcare Advisory, The BDO Center for Healthcare Excellence & Innovation. Rob shared highlights from a recent survey of healthcare CFOs by The BDO Center for Healthcare Excellence & Innovation, while Connie and Lisa reflected on the similarities between study results and hospital and senior living clients.

It was no surprise the study found one of the most significant challenges CFOs are facing at both the national and local level is the sustained strain on healthcare systems amid the pandemic, and ongoing supply chain and workforce struggles. Additionally, providers are concerned about the upcoming reporting and regulation requirements. Also top of mind are the Provider Relief Fund (PRF) reporting requirements, as the requirements have been ambiguous and ever changing. There is also concern among survey respondents that a misinterpretation or reporting error could cause providers to have to pay back funding they received from PRF.

The BDO healthcare survey reported that 63% of the providers who responded to the survey are thriving, but 34% are just surviving. Out of those surveyed, 82% expect to be thriving in one year. You can view the full results of the survey here

Recruitment and retention in the current climate

Recruitment and retention of direct care providers are significant challenges within the senior living industry. Providers are facing workforce shortages that are forcing them to temporarily suspend admissions, take beds off line, and, in worst case scenarios close whole units or facilities. Sarah Olson, BerryDunn's Director of Recruiting and Bill Enck, Principal at BerryDunn discussed factors leading to the talent shortage, and shared creative short- and long-term recruitment and retention strategies to try.

Change management

The pandemic has forced many in healthcare to rethink how they operate their facilities. Employees have had to pivot on a moment’s notice, and in general do more with less. However, there are still initiatives that need to be undertaken and projects that must be completed in order for your facility to operate and remain financially viable. How do you manage the change associated with these projects? Can you manage the change without burning out your employees? Dan Vogt, BerryDunn Principal, and Boyd Chappell from Schoolcraft Memorial Hospital provided tips and strategies for managing change fatigue. 

Overall, the Leadership Healthcare Summit proved to be an informative and engaging event, and many new ideas and forward-looking strategies were shared to help enable providers to continue to weather current challenges and pistion themselves for success. For more in-depth information on these topics and others discussed, please visit our Healthcare Leadership Summit resources page

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Top three takeaways from BerryDunn's first annual Healthcare Leadership Summit 

Read this if you are interested in grant compliance in healthcare. 

This is a companion article to the podcast, Mitigating the compliance and revenue integrity risk of grant funded healthcare programs.

The BerryDunn Healthcare Practice Group boasts professionals who have expertise all across the spectrum of healthcare, including regulatory, revenue, integrity, general compliance, and risk management issues. This article covers the very specific arena of grant compliance affecting many of BerryDunn’s healthcare, not-for-profit, and government clients.

After starting as a newly minted MBA financial analyst with an academic medical center in Northern New England, I (Markes) worked my way into the world of grants and contracts supported by my interest in federal regulations and the non-clinical revenue streams. Fascinated to navigate through waters where it seemed no one was the expert, or really had the time or patience to figure things out, I worked to stand up a grant office in finance on the hospital side, separate from the medical school which was the usual repository for grant funding. We moved this direction because hospital leadership realized grant funding was tipping toward the clinical setting and was less focused on bench or clinical research. Put another way, less NIH and more CDC, HRSA, and CMS.

BerryDunn Senior Manager Regina Mathieson advises, “wherever there is complexity, there is compliance risk.” Whether from a federal agency like HHS, HRSA, NIH, or CDC, a state Medicaid program, foundation, or private source, grants always come with requirements, typically very specific requirements. Because the dollars are being ‘given’, those requirements for how the funds are used may be much more restrictive than loans.

Like other areas of regulatory compliance, it is reasonable to assume that grant programs often have compliance gaps that go unnoticed. For many of our clients, both in healthcare and not-for-profit, and in the government space, grant revenue has become a significant source of funding. Any kind of healthcare delivery organization, including academic medical centers, federally qualified health centers, community hospitals, behavioral health service organizations, home health providers, visiting nurse associations, and others can end up with significant portions of their income for the year being sourced by federal grants.

Grant compliance categories

We all can’t be experts in every domain of regulatory compliance, and grant compliance has a lot of breadth. Thankfully, at BerryDunn, we have a team of grant experts who work collaboratively across practice groups. When I was working on setting up the grant office and establishing a proprietary clinical FTE reporting process and system earlier in my career, I would have greatly benefited from the perspectives of other experts at the table.

When we think about grant compliance, four categories are helpful to keep in mind:

  1. Restricted funding
  2. Single audit
  3. Indirect rate
  4. Time and effort

Restricted funding

Firstly, and most universally understood and applied is that grant monies are, pretty much by definition, restricted. Aside from very specific and rare instances of monies being granted to beneficiaries who have no responsibility, all grant funding is awarded with the expectation that the funds will be expended in a specific way. 

Any funder, from the federal government to your local community organization like the Lions Club or the VFW, will likely require individuals and entities awarded a grant must promise to use the funds only for the purpose laid out in the award and proposal. Compliance with grant terms typically includes following the requested reporting requirements of that funder as well. Though this category may sound obvious, it's actually pretty far-reaching, as it usually affects sub-recipients (those entities who are partnered with the direct recipient to accomplish the grant purpose). For example, where the money goes after the initial awardee receives it, or rules about who can do the work, what type of organization, how you choose a vendor, etc.—all sorts of categories.

It should be noted that many of these grant award requirements are not dissimilar from work we already do in the healthcare compliance space to assist our clients in avoiding anti-kickback statutes and Stark risks. This is because grant compliance is grounded in the same basic concepts—no favoritism, no bribes or shady deals, and avoiding fraud, waste, and abuse. Especially if you're spending federal monies, you need to prove that you choose the vendor based on verifiable best practices, and consideration was afforded to organizations owned by women, veterans, and minorities.

Single audit 

The second category, Single Audit, is applicable to all federal funding of $750,000 or more annually. My colleague from BerryDunn’s Not-for-Profit practice group, Katie Balukas, explains: 

"The federal Single Audit Act is a requirement for entities to undergo an independent financial and compliance audit when the entity has expended over $750,000 in federal awards. These audits are conducted following guidance issued through the Governmental Auditing Standards and the United States Office of Management and Budgets' Uniform Guidance. The main focus of the compliance audit is to assess the entity's compliance with the requirements set forth by the federal agency that administered the grant funds. That includes, but is not limited to determining if the funds were utilized for allowable costs and activities and expanded within the proper grant period and that the reporting and performance objectives were met."

It is important to note that adequate, appropriately scaled internal resources are essential for any organization receiving grants and even more so with larger grants. Though the phrase has been overused, it really does “take a village”. Grant management isn't something an organization should do on the side, assigning grant accounting to someone who already has a full-time role, but unfortunately this is common and also unfortunate because under resourcing tends to lead to compliance concerns, as well as just plain old poor funding management. 

Indirect rate

Speaking of funding, the third type of grant compliance is very focused on a component of the grant world that really has a life of its own: The indirect rate. Though there is an accounting definition of ‘indirect’, the way it is defined regarding grant funding is pretty specific, and there is an entire body of work organizations undertake to get a federally approved indirect rate.

There's an awful lot to think about with the indirect rate. On the one hand, you could say it's pretty simple. For example, a lot of foundation funders and even some federal funders will offer you a 5% or 10% indirect rate without any need to make a calculation. That's because they know that if you take time to do the math, you'll come up with a number much higher than 5% or 10%. When it comes to federal grants and healthcare services organizations, the indirect rate is dependent on how an organization measures costs. For hospitals, of course, the method of measurement is driven by the Medicare cost report, and that's where we would do the fancy math to derive the indirect rate. But the reality is far from simple or straightforward. 

Time and effort

The fourth and final area of grant compliance, time and effort, is also the one I'm actually most passionate about and is probably the most minimized, or at the very least, misapplied. 

In one way, “time & effort” is exactly what it sounds like. Much of granted dollars, especially from the federal government, get appropriately spent on program staff. The challenge is to match time and effort to those dollars, but that isn't as clear as it sounds, because the standard way of measuring staff time is usually in a payroll system of some sort, which can't prove how time was spent.

Most payroll systems can be programmed to account for FTE (full-time equivalent) allocations; however, there is often a breakdown between theory and practice. Putting allocations into payroll, usually done without employee interaction, may show how an employee “should” spend their time, but it is really no guarantee that that's actually how they're spending their time.

So how does the organization typically go about assuring that? Now, I don't want to speak for everyone, but let's just say I happen to know that there's a place for two or three (or maybe 10,000) that basically put allocations into payroll, and then, unfortunately, often well after the fact and/or more than once, send that allocation to the employee to sign off on without really any option to disagree, or even to modify. We all know that is not compliant…but in the organization's defense, there really haven't been very good alternatives to that kind of woeful and frustrating process, at least none that have been widely shared or understood.

As often is the case in the compliance world, rules are not followed because there is no perceived risk, but that is not a winning strategy.

Though many people involved in grant management do not have any experience or even knowledge of time and effort violations meeting with any consequences, organization interest and grant compliance have more implications than just preventing front page news. What I find in the conversations with organizations, both large and small, is that loose time and effort management costs the organization in two major ways. 

Firstly, it is inefficient to scramble around at the close of each federal grant to fix time and effort allocations. The extra time spent by grant staff, project coordinators, managers, and the finance team to sort things out because they didn't get them right the first time is the worst kind of inefficient—poor use of time with an equally poor outcome. 

Secondly, loose time and effort is costly in direct salary dollars. Most grant staff are not dedicated to one project, so we need to consider the value of their other work. Whether that is on other grants or, for example, seeing patients in the clinic as many principal investigators in healthcare do, having inaccurate or fluctuating understandings of their ability costs the organization directly in wasted salary dollars or indirectly as the opportunity cost of those providers (or other roles in other organizations). 

Digging in and fixing these issues is the work I really enjoy. It's relatively simple to build a compliant model, whether that requires very little payroll redo and is just a simple recurring attestation process in built in Excel, or more complex integrated models with triggered attestations in PDF format in a database that manages the overall FTE of principal investigators. It might even drive the available clinical provider time. It can all be done. We just need to know what the goal is. 

Working in this space so rewarding, because like so much of compliance, it's about doing something better—not just being compliant—but setting organizations up to better meet their goals and fulfill their mission.

The compliance or accounting professional might still ask, “But why aren’t payroll allocations sufficient for meeting Uniform Guidance?” The truth is, when UG came into effect and superseded the A-110, 122, 133, and others, the bar was effectively lowered. Historically, organizations abiding by the old OMB circulars had to make an attestation at least twice a year, which doesn’t really seem helpful, as who can accurately allocate their time from 5 or 6 months ago? So UG did away with the timeframe reference, relying on the idea that the payroll allocations and distributions would be all that would be needed, and in the absence of those, a monthly ‘look back’ by professional staff would be in order.

I say all this, because as a result, the interpretation of ‘payroll allocations’ then becomes the standard and we have forgotten about the other elements spoken of in the regulation. Remember, for anyone salaried (the vast majority of physicians and most of the higher level grant personnel), the ‘payroll allocation’ doesn’t pass muster. It is a static allocation that has no mooring in actual activity. This is why UG calls for monthly “current and reasonable estimates” of time and effort.

So what can organizations do in response? They need to seek a solution, a process, and a method that will both pass audit muster, as well as help the organization properly manage their resources. Almost every organization manages their productivity and finances on a regular basis: monthly! That’s why the same standard should apply to grant time and effort management. It's much more reasonable to ask you how you spent your effort this month, asking you to make a reasonable estimate of your time allocations to the different efforts you worked on.

So to summarize, the four key areas of grant compliance are (1) grants are restricted funding, (2) single audit requirement for federal funding over $750,000 annually, (3) the indirect rate and related agreement, and (4) time and effort.

Of course, I would be remiss to not point out that undergirding all this is the organization’s approach to policy. Any organization that considers grant funding a regular piece of their annual income needs to have dedicated grant management policies, covering all of the above topics, with particular focus on those arenas that are unique to the world of federal funding, and being mindful to follow or otherwise update for changes in processes and/or regulations.

Final takeaways: 

  • First, what grant focused infrastructure do you have in place? If you are subject to a single audit, there should be dedicated administrative grant staff. And I don’t mean the programmatic people actually working on the grant, but people outside the grant funding—also why you have an indirect rate. 
  • Second, how are you handling time and effort? If the process relies on any long after-the-fact attestations or payroll-generated reporting, it is unlikely to be truly following the spirit…or the letter…of Uniform Guidance. 
  • Third, review your policies regarding grants. You may not actually have policies focused on grant activities, leaving them under ‘general finance’. That isn’t sufficient to cover federal funding requirements. Many have grant policies in place, but are they actually being followed through the lifecycle of your grant programs? 
  • Lastly, the grant world is a whole ball game unto itself. BerryDunn has some great resources internally to offer assistance in all phases of grant management and administration. 
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Read this if your State Medicaid Agency is planning Medicaid Enterprise System enhancements.

Are you a system integrator (SI) or a State Medicaid Agency (SMA) implementing or enhancing a Medicaid system or specific module? Have you considered how decisions made during design and implementation could impact the federal Payment Error Rate Measurement (PERM) reviews for SMAs?

The goal of PERM is to measure and report an unbiased estimate of the true improper payment rate for Medicaid and Children’s Health Insurance Program (CHIP). Every state is reviewed once every three years using a sample that includes both fee for service (FFS) and managed care (MC) payments. A state assigned error rate is not the only consequence resulting from the PERM review; there are also financial implications.

Risk reduction from PERM review

Maintaining a focus on PERM review factors when making decisions during design and implementation can protect states by reducing the risk of:

  • Submitting change requests (CR) during implementation, which can result in additional cost and time
  • Implementing changes to existing Medicaid systems during maintenance and operations
  • Findings reported during certification efforts
  • Refunding federal dollars due to improperly paid claims
  • A reduction in federal match on all claims paid

It is also important to understand the benefits of a dedicated PERM team within the state organization that includes members from the system vendor and outside PERM experts. These benefits include providing states an additional level of security to help ensure a positive outcome to the federal PERM review, helping to protect federal funding.

Having a dedicated team will help ensure all decisions made during system updates and/or implementations are made while keeping focus on PERM requirements and the further impacts of PERM reviews, saving time and remaining compliant.

Plan ahead for best results

When planning for a new module or Medicaid system request for proposal (RFPs), consider PERM-related requirements to help ensure all PERM needs are met to prevent errors and repayment of federal funds. Including PERM requirements can also help your agency ensure federal compliance and successful PERM audits. Doing so will likely reduce the amount of time system integrators spend re-working earlier development decisions and help ensure claim payments are processed, and eligibility determinations are made in accordance with federal and state regulations.

If you have questions about PERM or your specific situation, please contact our Medicaid Consulting team. We’re here to help.

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Read this if you have not yet reported for Phase 1.

Phase 1 provider relief reporting portal

HRSA opened the Provider Relief Funds (PRF) reporting portal on July 1, 2021, for Phase 1 PRF reporting. In Phase 1, providers will be reporting on the use of PRF received prior to June 30, 2020. While Phase 1 reporting was originally due September 30, 2021, HRSA has provided a 60-day grace period for the reporting period. Providers will be considered out of compliance with the reporting requirements if they do not submit reporting by November 30, 2021. Providers can submit their reporting on the Provider Relief Fund portal. Please note:

  1. Providers must register for the reporting portal, as this is not the same portal as the application and attestation portal. The portal registration must be completed in one session. Follow the link to the Portal Registration User guide
  2. Providers can only report on eligible lost revenues and expenditures related to payments received before June 30, 2020. Providers are not yet allowed to report on payments received subsequent to June 30, 2020. See the June 11, 2021 Reporting Requirements Notice for more detail on reporting requirements.
  3. The period of availability for Phase 1 lost revenues and eligible expenditures is January 1, 2020 through June 30, 2021.
  4. It is extremely helpful to complete the HRSA provider portal worksheets prior to beginning the portal data entry. 
  5. Providers should return unused funds as soon as possible after submitting their report. All unused funds must be returned no later than 30 days after the end of the grace period. (December 31, 2021)
  6. Provider Relief Funds are considered federal awards under Assistance Listing Number (ALN) 93.948. Providers, both for-profit and not-for-profit, may be subject to a Uniform Guidance Audit if they expend more than $750,000 of federal awards during the provider’s fiscal year. 
  7. Providers are able to retrieve their data submission from the portal if a copy was not retained during the submission process.

Your BerryDunn Hospital team is here to help you navigate the Provider Relief Fund reporting and compliance requirements. Please contact us if you have any questions or would like to talk about your specific situation. 

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Read this if you are not familiar with the expansion of eligibility for employee retention credits (ERC).

Are you familiar with the IRS’ recent additional, taxpayer-friendly guidance that provides some clarity in claiming the employee retention credit (ERC)? 

Employee Retention Credits in the CARES Act: Background

Congress originally enacted the ERC in the CARES Act in March of 2020 to encourage employers to hire and retain employees during the pandemic. At that time, the ERC applied to wages paid after March 12, 2020 and before January 1, 2021. However, Congress later modified and extended the ERC to apply to wages paid before July 1, 2021. Then with the American Rescue Plan Act (ARPA) signed into law on March 11, 2021, the ERC was modified to apply to wages paid through December 31, 2021. The recently passed infrastructure bill eliminates the ERC the quarter ending December 31, 2021.

The rules are complex but there may be some limited ability for your organization to benefit, based on some late changes to the rules. Originally, taxpayers who received PPP loans were not eligible, but the rules changed and now provide that employers who received PPP loans may qualify for the ERC with respect to wages that were not paid for with proceeds from a forgiven PPP loan. This change is retroactive to March 12, 2020. 

The ERC is a refundable payroll tax credit for wages paid and health coverage provided by an employer whose operations were either fully or partially suspended due to COVID-related governmental order or that experienced a significant reduction in gross receipts.  

Regarding the reduction in gross receipts, for any quarter in 2020, a greater than 50% reduction in gross receipts is required during the calendar quarter compared to the same quarter of 2019 in order to qualify. For 2021, the eligibility threshold for employers is reduced from a greater than 50% to a greater than 20% decline in gross receipts for the same quarter of 2019 in order to qualify for the ERC for any quarter. There is an alternative quarter election for 2021 that allows employers to use prior quarter gross receipts compared to the same quarter for 2019 to determine eligibility. For example, for the first calendar quarter of 2021, an employer may elect to use its gross receipts for the fourth quarter of 2020 compared to those for the fourth calendar quarter of 2019 to determine if the decline in gross receipts test is met.

The IRS recently clarified that in determining gross receipts an employer does not need to include forgiven PPP loans, shuttered venue operator grants, or restaurant revitalization grants as gross receipts. Gross receipts for exempt organizations are calculated in the same manner as gross receipts on page 1 of Form 990 in Box G, which includes proceeds from the sales of investments as well as all contribution, program and investment revenue.

The amount of the credit can be substantial. For 2020, the credit is 50% of the first $10,000 of qualified wages per employee for the qualifying period beginning as early as March 12, 2020 and ending December 31, 2020 (thus the max credit per employee is $5,000 in 2020). For 2021, the credit is 70% of the first $10,000 of qualified wages per employee, per qualifying quarter (thus the potential max credit is $21,000 per employee in 2021).  

For 2021, employers with 500 or fewer full-time employees in 2019 may include all wages and health plan expenses as qualified wages. For 2020, employers with 100 or fewer full-time employees in 2019 may include all wages and health plan expenses as qualified wages while employers with more than 100 full-time employees in 2019 may only claim the credit for qualified wages paid to employees who did not provide services. For purposes of determining full-time employees, an employer only needs to include those that work 30 hours a week or 130 hours a month in the calculation. Part-time employees working less than this would not be considered in the employee count.

There is additional interplay between claiming the ERC and the wages used for PPP loan forgiveness that will need to be considered.  

What should you do now? 

It makes sense to determine your eligibility for the ERC. We recommend that you compile your business gross receipts by calendar quarter for 2019, 2020, and the first three quarters of 2021. Let us know if you want a template to do this. We can then help you evaluate whether you have any quarters where you might qualify for the ERC.  

Keep in mind that if your business operations were either fully or partially suspended due to a COVID-related government order then you will likely already qualify for that quarter but the eligible wages will only be for the wages paid during the shutdown period.  

Please let us know if you have any questions or need any assistance.

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Read this if you are at a rural health clinic or are considering developing one.

Section 130 of H.R. 133, the Consolidated Appropriations Act of 2021 (Covid Relief Package) has become law. The law includes the most comprehensive reforms of the Medicare RHC payment methodology since the mid-1990s. Aimed at providing a payment increase to capped RHCs (freestanding and provider-based RHCs attached to hospitals greater than 50 beds), the provisions will simultaneously narrow the payment gap between capped and non-capped RHCs.

This will not obtain full “site neutrality” in payment, a goal of CMS and the Trump administration, but the new provisions will help maintain budget neutrality with savings derived from previously uncapped RHCs funding the increase to capped providers and other Medicare payment mechanisms.

Highlights of the Section 130 provision:

  • The limit paid to freestanding RHCs and those attached to hospitals greater than 50 beds will increase to $100 beginning April 1, 2021 and escalate to $190 by 2028.
  • Any RHC, both freestanding and provider-based, will be deemed “new” if certified after 12/31/19 and subject to the new per-visit cap.
  • Grandfathering would be in place for uncapped provider-based RHCs in existence as of 12/31/19. These providers would receive their current All-Inclusive Rate (AIR) adjusted annually for MEI (Medicare Economic Index) or their actual costs for the year.

If you have any questions about your specific situation, please contact us. We’re here to help.

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Section 130 Rural Health Clinic (RHC) modernization: Highlights