Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION (MHDO)
Chapter 300 - UNIFORM REPORTING SYSTEM FOR HOSPITAL FINANCIAL DATA
Appendix 590-300-A - MHDO Standardized Accounting Template

Line

Field Name

Definition

1

Responsible Individual

Name of individual completing the template.

2

Parent or Hospital Name

Name of parent entity or hospital.

3

Parent or Hospital Location

City/town location of parent entity or hospital.

4

Year

Current fiscal year end date of parent entity or hospital.

5

BALANCE SHEET, UNRESTRICTED FUNDS

Heading.

6

CURRENT ASSETS

Heading. Short-term resources (i.e., those expected to be converted to cash or used within one year).

7

Cash and Investment

Cash, cash equivalents (money market funds) and short-term investments (marketable securities) listed under current assets and not restricted by external (donor or grantor) or internal (board or trustee) designations.

8

Current Assets Whose Use Is Limited

Cash, cash equivalents (money market funds) and short-term investments (marketable securities) limited internally without clear distinction between being board-designated or trustee-held, listed under current assets.

9

RECEIVABLES

Heading.

10

Net Patient Accounts Receivable

Patient accounts receivable, reported net of provisions for bad debt/uncollectible accounts and contractual allowances.

11

Due from Affiliates

Current portion of receivables due from affiliated entities. Includes also notes receivable from/loans or advances to affiliated entities. Amounts greater than or equal to +/- $100,000, individually or in aggregate must be identified by entity name and amount.

12

Third Party Settlements Receivable

Current portion of final settlements from third-party payers due to the hospital.

13

Other Accounts Receivable

Includes other receivables not related to patient services, third party receivables or amounts due from affiliates. Includes amounts due from restricted funds. Does not include grants or pledges receivable if their purpose is restricted by external stipulations (by donors or grantors).

14

Inventory

Supplies used to run the organization and provide services.

15

Other Current Assets

All other current assets not listed above, including prepaid expenses and deposits.

16

Total Current Assets

Sum of all short-term resources (lines 7 through 15).

17

NON-CURRENT ASSETS

Heading. Long-term resources (i.e., those not expected to be converted to cash or used within one year).

18

Line intentionally left blank

19

Trustee-held Investments

Non-current portion of assets whose use is limited designated as trustee held. Includes investments or assets held under a contractual arrangement with an outside party other than a donor/grantor; these include funds held by a trustee, debt service reserve funds, bond and mortgage sinking funds. Trustee-held investments are contractually obligated for the purpose specified and are not available to fulfill other obligations of the hospital.

20

Board-Designated and Undesignated Investments

Non-current portion of assets whose use is limited by the Board of Trustees (i.e., internally designated) and any undesignated long-term investments. Includes assets set aside for capital improvements/acquisitions, funded depreciation and assets functioning as endowments. These fund designations can be revoked by Board decree and used to meet other obligations of the parent entity or hospital if necessary (these funds are discretionary). Include in here "beneficial interest in net assets of parent" unless the amounts are clearly donor restricted.

21

Due From Affiliates

Non-current portion of receivables due from affiliated entities, reported as notes receivable from/loans or advances to affiliated entities. Amounts greater than or equal to +/- $100,000, individually or in aggregate must be identified by entity name and amount.

22

Investment in Affiliates

Amounts recorded as equity investments (i.e., less than 50% share). Includes amount listed as goodwill/intangible assets for the purchase of another entity (e.g., a physician practice). Amounts greater than or equal to +/-$100,000, individually or in aggregate must be identified by entity name and amount.

23

Other Non-current Assets

All other non-current assets not listed above, including amounts due from restricted funds; deposits; other non-current unrestricted receivables; deferred financing costs (e.g., bond issuance costs) and deferred charges; pension and insurance obligations or retirement programs; cash surrender value of life insurance; organization costs, etc.

24

Gross Property, Plant & Equipment (PP & E)

Gross value of land, buildings, equipment, construction in progress, and capitalized leases.

25

Accumulated Depreciation

Includes depreciation of plant, property & equipment and amortization of capitalized leases.

26

Net Property, Plant & Equipment

Gross plant, property & equipment minus accumulated depreciation (line 24 minus line 25).

27

Total Non-current Assets

All long-term assets (lines 19 through 23, plus line 26).

28

Total Unrestricted Assets

All current and non-current assets not restricted externally by donors or grantors (line 16 plus 27).

29

CURRENT LIABILITIES

Heading. Short-term obligations (i.e., those expected to be due within one year).

30

Current Long Term Debt (LTD)

Current portion of long-term debt/bonds payable and capital leases; does not include notes payable, lines of credit or other short-term obligations.

31

Accounts Payable + Accrued Expenses

Includes accounts payable, accrued salaries, wages, payroll taxes, interest, vacation (earned time) and other accrued liabilities.

32

Estimated Third-Party Settlements

Current portion of amounts received from third party payers which the hospital expects to be due back to third parties in the current year (i.e., amounts received from third parties in the past may be in excess of allowable amounts and may therefore be paid back to third parties or else resolved favorably and recognized as revenue in the future).

33

Due to Affiliate

Current amounts owed to related entities. Amounts greater than or equal to+/-$100,000, individually or in aggregate must be identified by entity name and amount.

34

Other Current Liabilities

All other current liabilities, including amounts due to restricted funds; notes payable (unless owed to affiliated entity); lines of credit; deferred gift annuities; construction payable; current portion of self insurance funds, pension costs and post-retirement health benefits; current portion of deferred revenue, etc.

35

Total Current Liabilities

All short-term obligations (lines 30 through 34).

36

NON-CURRENT LIABILITIES

Heading. Long-term obligations (i.e., those not due within one year).

37

Long-term debt

Non-current portion of long-term debt, capital leases and mortgage notes payable.

38

Estimated Third Party Settlements

Non-current portion of amounts received from third party payers which the hospital expects to be due back to third parties (i.e., amounts received from third parties in the past may be in excess of allowable amounts and may therefore be paid back to third parties or else resolved favorably and recognized as revenue in the future).

39

Due to Affiliate

Non-current amounts owed to related entities. Amounts greater than or equal to +/- $100,000, individually or in aggregate must be identified by entity name and amount.

40

Self-Insurance Fund

Includes self-insurance, reserve for professional liability or workers' compensation.

41

Accrued Pension & Post-Retiree Health Benefits

Non-current amounts of accrued pension and post-retirement health benefits.

42

Other Non-current Liabilities

All other non-current liabilities including amounts due to restricted funds, notes payable (unless owed to affiliated entity), deferred gift annuities, construction payable, deferred revenue, etc.

43

Total Non-current Liabilities

Sum of all long-term obligations (lines 37 through 42).

44

Fund Balance-Unrestricted

Includes all net assets that are not temporarily or permanently restricted by donor or grantor stipulations. Also includes funded depreciation.

45

Total Liabilities and Equity

Sum of all liabilities and net assets (fund balance) not restricted externally by donors or grantors (lines 35 plus 43 plus 44).

46

RESTRICTED FUNDS

Heading. Includes accounts with external (donor or grantor) stipulations.

47

Cash and Investments

Includes cash and investments restricted by donor or grantor.

48

Receivables

Pledges and grants receivable restricted by donor or grantor and amounts due from general (unrestricted) fund.

49

Other Assets

Assets other than cash, investments and receivables restricted by donor or grantor.

50

Total Restricted Assets

Sum of all restricted assets (lines 47 through 49). Check that restricted assets equal restricted liabilities and net assets (line 50 equals line 56).

51

LIABILITIES AND EQUITY

Heading.

52

Total Liabilities

Amounts due to the general fund and any liabilities whose purpose is restricted. If temporarily and permanently restricted liabilities and net assets are less than restricted assets, remove the amount necessary to balance restricted assets from unrestricted current liabilities (from other current liabilities if enough, otherwise from accrued expenses).

53

Temporarily Restricted Net Assets

Funds temporarily restricted by donor or grantor stipulations. Includes funds called specific purpose; property, plant and replacement; or term endowment funds.

54

Permanently Restricted Net Assets

Funds permanently restricted by donor or grantor stipulations, also called permanent endowment funds.

55

Total Restricted Fund Balance

Sum of temporarily and permanently restricted net assets (lines 53 through 54).

56

Total Restricted Liabilities and Equity

Sum of restricted liabilities and temporarily and permanently restricted net assets (line 52 plus 55). Restricted assets equal restricted liabilities and net assets (line 50 equals line 55).

57

INCOME STATEMENT

Heading.

58

Gross Inpatient Service Revenue

Total Inpatient Revenues before deductions.

59

Gross Outpatient Service Revenue

Total Outpatient Revenues before deductions.

60

Gross Patient Service Revenue (GPSR)

Total inpatient and outpatient revenues before deductions.

61

DEDUCTIONS

Heading.

62

Free Care (Charity Care)

Amount of charges provided for charity care.

63

Bad Debt (Provision for Bad Debts)

The estimate of Patient Accounts Receivable that will not be collected.

64

Contractuals

Includes discounts to third parties (Medicare, Medicaid, Blue Cross, commercial insurers, etc.) and employees. Record this net of changes in estimated settlements from prior years, which goes on the next line. The total of 64 plus 65 should equal total contractual adjustments.

65

Changes in prior year estimated/final settlements

If impact on Net Patient Service Revenue is favorable, record this as a negative number (reduction in revenue deduction); if unfavorable, record a positive number.

66

Net Patient Service Revenue

Gross patient service revenue minus deductions for free care, bad debt and contractuals (line 60 minus 62+63+64+65).

67

Other Operating Revenue

Include any other operating revenue from non-patient sources (e.g., garage revenue, cafeteria revenue, rental income), usually reported as other operating revenue and assets released from restriction for operations.

68

Total Operating Revenue

Sum of net patient service revenue and other operating revenue (line 66 plus 67).

69

OPERATING EXPENSES

Heading.

70

Depreciation and Amortization

Includes amounts listed as depreciation and amortization.

71

Interest

Includes all interest expense. If the hospital has no long-term debt, enter zero.

72

Advertising Expenses

Total advertising expenses, including allowable and unallowable costs using the definitions as specified in the most current version of the Centers for Medicare & Medicaid Services, Provider Reimbursement Manual and found at the MHDO website at https://mhdo.maine.gov/hospital_financials.htm (line 73 plus line 74).

73

Allowed Advertising Expenses

Allowable advertising costs using the definitions as specified in the most current version of the Centers for Medicare & Medicaid Services, Provider Reimbursement Manual and found at the MHDO website at https://mhdo.maine.gov/hospital_financials.htm.

74

Non-allowed Advertising Expenses

Unallowable advertising costsusing the definitions as specified in the most current version of the Centers for Medicare & Medicaid Services, Provider Reimbursement Manual and found at the MHDO website at https://mhdo.maine.gov/hospital_financials.htm.

75

Salaries and Benefits

Total salaries and benefits paid for personnel services, including full-time, part-time, local tenums, contracted, permanent, and temporary personnel.

76

Other Operating Expenses

Includes all operating expenses other than depreciation/amortization, interest, advertising, salaries & benefits, and bad debt.

77

Total Operating Expenses

Includes depreciation, interest, advertising, salaries & benefits, and all other operating expenses. (Note: Amount will be less than reported on income statement by amount of bad debt.)

78

Net Operating Income

Total operating revenue minus total operating expense (line 68 minus 77).

79

NONOPERATING REVENUE

Heading. Includes all gains/losses due to activities relating to the mission of the hospital.

80

Interest and Dividends

Includes dividend income; interest income from and realized gains/losses on sale of unrestricted investments; and unrestricted income on restricted assets.

81

Realized Gains/losses on sales of securities

Includes realized gains and losses on investments which accrue to the unrestricted fund; omit realized gains and losses accruing to restricted funds (see changes in net assets).

82

Permanently impaired security write downs

Includes unrealized losses deemed other than temporary by management, and taken out of income.

83

Total investment income

Sum of lines 80 through 82.

84

Gains/losses on joint ventures/equity investments

Includes gains or losses on the sale of fixed assets and gains/losses from equity investments and joint ventures.

85

Permanently impaired write-downs of other asset

Includes write-downs of assets deemed not worth their historical cost value, other than marketable securities.

86

Other Non-Operating Revenues (gifts, bequests, etc.)

Mostly contributions, gifts, bequest, although may include the "other" category.

87

Total Non-Operating Revenue

Sum of lines 83 through 86.

88

Excess of Revenue Over Expenses

Net operating income plus non-operating revenue (line 78 plus 87).

89

Extraordinary Gains (Losses)

Generally related to extraordinary gains/losses from advance extinguishment of debt.

90

Total Surplus/Deficit

Line 88 plus line 89.

91

CHANGES OF NET ASSETS

Heading.

92

Net assets released for restrictions -capital

Includes transfers from restricted funds for capital and direct capital donations.

93

Unrealized Gains (Losses) on Investments

Use the number in the statement of changes in unrestricted net assets; avoid using a total unrealized gain/loss that would include those accruing to restricted funds.

94

Minimum Pension Liability Adjustment

Occurs when market value of pension assets drops below a minimum level relative to the value of benefits.

95

Transfers from (to) Affiliates

Generally disclosed in statement of changes in net assets; may be reported as non-operating expenses. Amounts greater than or equal to +/- $100,000, individually or in aggregate must be identified by entity name and amount.

96

Mergers

Cash impact of mergers.

97

Consolidations with Support Organizations

Value of assets held on hospitals behalf by other organizations.

98

Other Changes

Include accounting policy changes and other non-income transactions not specifically identified above, that affect unrestricted net assets.

99

Total Change in Unrestricted Net Assets

Sum of lines 90 through 98.

100

STATEMENT OF CASH FLOWS

Heading.

101

CASH GENERATED FROM OPERATING ACTIVITIES

Heading.

102

Total Surplus/Deficit

Line 90.

103

Non-cash Expenses (Revenues)

Includes non-cash items affecting the total surplus number, such as depreciation and amortization expenses, gains/losses on equity investments, gain/loss on sale of assets, realized gain on sale of investments, and gains/losses associated with extraordinary items. Do not include any adjustments for restricted accounts or for items not included in the total surplus number (e.g., unrealized gains, accounting policy changes, etc.).

104

Funds from Operations

Lines 102 plus 103.

105

Decrease/Increase Current Assets Limited Use

Prior year minus current year current portion of assets whose use is limited (Change in line 8).

106

Decrease/Increase Accounts Receivable

Prior year minus current year current portion of patient accounts and other receivables excluding 3rd party and affiliate receivables (Change in lines 10 and 13).

107

Decrease/Increase Affiliate Receivable

Prior year minus current year current portion of affiliate receivable (Change in line 11).

108

Decrease/Increase 3rd Party Receivable

Prior year minus current year current portion of 3rd party receivables (Change in line 12).

109

Decrease/Increase Inventory

Prior year minus current year current portion of inventories (Change in line 14).

110

Decrease/Increase Other Current Assets

Prior year minus current year of other current assets (Change in line 15).

111

Increase/Decrease Accounts Payable/Accrued Expenses

Current year minus prior year current portion of Accounts Payable and Accrued Expenses (Change in line 31).

112

Increase/Decrease 3rd Party Settlement

Current year minus prior year current portion of 3rd party receivables (Change in line 32).

113

Increase/Decrease Due to Affiliates

Current year minus prior year current portion of due to affiliates (Change in line 33).

114

Increase/Decrease Other Current Liabilities (except Long Term Debt)

Current year minus prior year of other current liabilities (Change in line 34).

115

Other Non-cash Expenses (Revenues)

Includes non-cash items affecting the total surplus number not already identified. Completion of this field requires an explanation.

116

Cash from Working Capital

Sum of lines 105 through 115.

117

Cash from Operating Activities

Sum of funds from operations and cash from working capital (line 104 plus 116).

118

CASH FROM INVESTING ACTIVITIES

Heading. Investing activities include changes in non-current assets.

119

Decrease/Increase Board Designated Investment

Prior year minus current year balance of board designated and undesignated investments (Change in line 20).

120

Decrease/Increase Trustee Held Investment

Prior year minus current year balance in trustee-held investments (Change in line 19). All unrealized gains and losses go into line 119.

121

Decrease/Increase Due From Affiliates

Prior year minus current year non-current portion of due from affiliates (Change in line 21).

122

Decrease/Increase Affiliate Investments

Prior year minus current year non-current portion of investment in affiliates (Change in line 22). Gains/losses in equity of affiliate should be added/subtracted. Also, if amortization amount is available for any goodwill/intangible assets included in "affiliate investments," subtract amortization amount and report on line 126.

123

Decrease/Increase Other Non-Current Assets

Prior year minus current year of other non-current assets (Change in line 23). If amortization amounts available for assets included in "other non-current assets, "subtract amortization amounts and report on line 126.

124

Decrease/Increase Gross Plant Property & Equipment (PP&E)

Insert amount reported on cash flow statement, reported as purchase of additions to PP&E or capital expenditures.

125

Sale of Fixed Assets

Proceeds from the sale of fixed assets/plant, property & equipment.

126

Other Cash Provided (Used) in Investing Activities

Includes other cash or non-cash items affecting the total investing activities not already identified. Completion of this field requires an explanation.

127

Cash Provided (Used) In Investing Activities

Sum of lines 119 through 126.

128

Cash Position Before Outside Financing Activities

Sum of lines 117 and 127.

129

CASH FROM FINANCING ACTIVITIES

Heading. Includes changes in long-term debt (include current portion) and non-current liabilities and amounts transferred to/from restricted funds and other entities.

130

Issue Long Term Debt (include leases for equipment even if reported as non cash; be sure to add the amount added to PP&E)

Insert amount reported on cash flow statement, reported as proceeds from/issue of long-term debt/bonds payable and capital lease obligations. Do not insert reported proceeds from short-term obligations/notes payable/lines of credit, captured in line 114 (change in other current liabilities).

131

Repay Long Term Debt (include Current Long Term Debt)

Insert amount reported on cash flow statement, reported as payment of long-term debt/bonds payable and capital lease obligations (Amount reported should include change in current portion of long-term debt). Do not insert amounts reported for payment of financing costs/bond issuance costs, which are captured in line 123 (change in other non current assets), or any payment of short-term obligations/notes payable/line of credit, which are captured in line 114 (change in other current liabilities).

132

Increase/Decrease Third Party Settlement

Current year minus prior year non-current portion of 3rd party settlements (Change in line 38).

133

Increase/Decrease Due to Affiliates

Current year minus prior year non-current portion of due to affiliates (Change in line 39).

134

Increase/Decrease Pension, Self Insurance

Current year minus prior year non-current portion of accrued pension, self insurance reserves (Change in lines 40 and 41).

135

Increase/Decrease other Non-Current Liabilities

Current year minus prior year of other non-current liabilities (Change in line 42).

136

Transfers From (To) Restricted Funds

Transfers to/from restricted funds from/to general (unrestricted) fund for capital, as reported on line 92.

137

Transfers From (To) Other Entities

Equity transfers from/to other entities, line 95.

138

Other Cash Provided (Used ) in Financing Activities

Includes other cash or non-cash items affecting financing activities not already identified. Completion of this field requires an explanation.

139

Cash Provided (Used) Financing Activities

Sum of lines 130 through 138.

140

Net Change in Cash

Sum of lines 128 and 139.