Nursing Home Direct Care Worker Wage Pass Through Reimbursement (For reimbursement periods beginning March 1, 2021)
Michigan Department of Health and Human Services
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
Input direct care worker hours in the table below, only input time associated with direct care work. Click the tab key after entering each amount to update totals listed below.
Direct Care Worker Hours Information
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
Input total direct care worker payroll tax expenses specifically associated with the $2.25/hour direct care worker wage established by Michigan PA 2 of 2021.
Direct Care Worker Payroll Tax Expenses
RN Payroll Tax Expenses	$
LPN Payroll Tax Expenses	$
CENA Payroll Tax Expenses	$
Respiratory Therapist Payroll Tax Expenses	$
Administrative Staff Direct Care Work Payroll Tax Expenses	$
Total Payroll Tax Expenses	$	0.00

The table below shows the total reimbursement for direct care worker related expenses due the nursing home.
Direct Care Reimbursement Due 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 2 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, gender, identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.