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NC Department of Health and Human Services
NC Division of
Medical Assistance

Nursing Facilities (Hospital Based) Cost Reports

Hospital-Based Nursing Facility providing Long Term (INC) and/or (SNC) Level of Care

Contact Information:

Michael D'Alessio or Bob Young
Email: or

All providers will use applicable CMS 2540 / CMS 2552 cost reporting forms plus NC Medicaid Supplemental Schedules as described below.

You will need to download the “SNF 2015 Instructions Version 5" document as it contains specific DMA requirements that must be followed when preparing the “NC NF Supplemental Cost Report 2015 – Version 5” Excel cost reporting forms.

The free Adobe Acrobat Reader is required to view and print PDF files.

Hospital-Based Nursing Facility with FYE 2015 through December 31, 2015

For questions directly related to the new NC NF Medicaid Supplemental Cost Report Schedules, you may download the (pdf) file using the following link - NC NF Medicaid Supplemental Cost Report FAQS (PDF, 19KB)

Frequently Asked Questions

  1. Will DMA grant an extension for filing a cost report beyond the due date? DMA does not plan to grant extensions except in the case of natural disasters, i.e. fire, floods etc.  Otherwise, cost reports must be filed by the due date. See the Cost Report Extension (21 KB) memo for further explanation.
  2. If I need to amend a cost report after it has been filed, what are the steps to do this? DMA does not normally permit amended cost reports except under certain circumstances.
  3. When is the Medicaid cost report for Hospital-based Nursing facilities due to be filed?
    Hospital-based Nursing facility cost reports must be filed no later than five months (150 days) after the facility FYE or concurrently with the Medicare cost report.
  4. If my Hospital-based nursing facility has low Medicaid utilization, will we automatically be exempted from filing a Medicaid cost report?
    No, a yearly written waiver request must be sent to the DMA Audit Section (attn: Michael D'Alessio, Audit Manager). You may e-mail to or send a fax using FAX number 919-814-0031.
  5. What are the established cost limitations for the Hospital-based NF having a fiscal year ending on or after September 30, 2003?
    The cost limitations are as follows:
    Director's Fees: $2,400 annually or $200 per meeting
    Owner or Administrator Salary:
    $57,097 (1-50 beds)
    $69,336 (51-99 beds)
    $73,414 (100-149 beds)
    $79,006 (150-199 beds)
    $89,724 (200-249 beds)
    Do not make adjustments for these limitations. The Audit Section will review and apply limitations.
  6. (FY2011 and Earlier) On the Hospital-based nursing facility cost report, are the compensation amounts reported on Schedule A-3 based on DMA limitation amounts?
    No, compensation reported on the Hospital-based cost report, Schedule A-3, should not be based on DMA limitation amounts. Report compensation after any applicable adjustments on Schedule A-2 for non-allowable amounts.The Audit Section will review compensation and apply limitations. Do NOT make adjustments to the Hospital-based nursing facility filed cost report for the DMA limitations.
  7. (FY2011 and Earlier)If the hospital CEO functions as the nursing facility administrator, is a portion of the CEO’s salary allocated to the nursing facility?
    No, the salary for the CEO functioning as the nursing facility administrator is reported in the Administrative and General Cost Center. Administrative and General Cost Center expenses are indirect expenses allocated on Schedule B to the appropriate cost center line. Ready NC Connect NC