mdhhs-5919-A, nursing home 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 NPI	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.

Registered Nurse (RN) Hours
RN Overtime Hours
Licensed Practical Nurse (LPN) Hours
LPN Overtime Hours
Competency Evaluated Nursing Assistant (CENA) Hours
CENA Overtime Hours
Respiratory Therapist Hours
Respiratory Therapist Overtime Hours
Administrative Staff Direct Care Worker Hours
Administrative Staff Direct Care Worker Overtime Hours
Total Standard Hours	0.00
Total Overtime 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.

RN Payroll Tax Expenses	$
LPN Payroll Tax Expenses	$
CENA Payroll Tax Expenses	$
Respiratory Therapist Payroll Tax Expenses	$
Administrative Staff Direct Care Worker Payroll Tax Expenses	$
Total Payroll Tax Expenses	$0.00

section 4 – DIRECT CARE REIMBURSEMENT DUE NURSING HOME

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

Direct Care Wage Reimbursement	$0.00
Direct Care Overtime 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 Nursing Home Direct Care Worker Wage Pass Through Reimbursement Form certifies by his or her signature that he or she is authorized to sign this form on behalf of the nursing home, 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-SNF-TESTING-FINANCIAL@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.