mdhhs-5919-C, HOME FOR THE AGED (HFA) AND ADULT FOSTER CARE (AFC)

DIRECT CARE WORKER WAGE PASS THROUGH REIMBURSEMENT

(For reimbursement periods beginning October 1, 2021)

Michigan Department of Health and Human Services

(Revised 10-21a)

section 1

Input information about your nursing home and the reimbursement period [i.e., the payroll period(s)] in the table below.

Facility Name

Facility License Number	Facility SIGMA Vendor ID	Facility SIGMA Address Code

Facility Address

Facility Contact	Contact’s Email

Contact’s Phone Number	Reimbursement Period

section 2 – direct care worker hours information

Input direct care worker hours in the table below, only input time associated with direct care work. Use the arrow down key after entering each amount to update totals listed below.

Hands on Personal Care Hours
Hands on Supervised Personal Care Hours
Total Standard Hours	0.00

SECTION 3 – DIRECT CARE WORKER PAYROLL TAX EXPENSES

Input total direct care worker payroll tax expenses specifically associated with the $2.35/hour direct care worker wage established by Michigan PA 87 of 2021.

Hands on Personal Care Payroll Tax Expenses	$
Hands on Supervised Personal Care Payroll Tax Expenses	$
Total Payroll Tax Expenses	$0.00

section 4 – DIRECT CARE REIMBURSEMENT DUE facility

The table below shows the total reimbursement for direct care worker related expenses due the Facility.

Direct Care Wage Reimbursement	$0.00
Payroll Tax Reimbursement	$0.00
Total Reimbursement	$0.00

By typing the individual’s name below (physical signature is not required) and checking the certification box, the individual or officer signing this HFA/AFC Reimbursement form certifies by his or her signature that he or she is authorized to sign this form on behalf of the facility, responsible governing board, official and/or contractor(s), and agrees to abide by any specific direct care worker wage pass through reimbursement guidance provided by the Michigan Department of Health and Human Services, pass on the direct care worker wage reimbursement on to eligible employees, retain documentation to support wage expenses claimed on this form, comply with Michigan PA 87 of 2021, and agrees that payments may be subject to audit and recoupment if the terms of this form are violated.

Individual Name	Individual Title	Date

Completed forms and questions about completing the form can be sent MDHHS-HFA-COVID-PAYMENT@michigan.gov.

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.