This letter transmits revisions to the JFS 02911 Title IV-E Single Cost Report form and JFS 02911-I Instructions for Completing JFS 02911 Title IV-E Single Cost Report instructions which are used pursuant to OAC 5101:2-47-26.1 “Title IV-E agencies, private child placing agencies (PCPA), private noncustodial agencies (PNA), residential care facilities, substance use disorder (SUD) facilities and a qualified residential treatment program (QRTP): Title IV-E cost report filing requirements, record retention requirements and related party disclosure requirements”. 

The revised form and instructions are to be used for the state fiscal year reporting period of July 1, 2021, through June 30, 2022 (SFY 2022). An explanation of the revisions to the cost report form and instructions appears below:

Form

• All worksheet footers updated to reflect "JFS 02911 (Rev. 9/2022)."
• Agency Info worksheet:  Operational Status and State selection fields added.  Cost Reporting Period field updated to reflect SFY 2022 period.
• Agency Summary worksheet:  Note 1 added for Medicaid providers to list all billing National Provider Identifier (NPI) assigned by Centers for Medicare & Medicaid (CMS).  Note 2 added for reported cost related to Medicaid and Other Program lines, Other Cost column, consisting of aftercare support, aftercare services, and/or other cost plus a requested explanation of types of cost involved for the reported amounts.  Reported program cost for identified items will automatically tally an aggregate amount in the highlighted cell of Other line, Other Cost column.
• IV-E Summary worksheet:  PFC (purchased foster care) service section’s Consultant column title modified.  RES (residential) service section modified to add columns for reported cost of Nurse, Clinician, Consultant-Nurse-Direct, Consultant-Nurse-Support, Consultant-Clinician-Direct, Consultant-Clinician-Support, and QRTP Transition.
• Reimbursement Ceilings worksheet:  Based upon Consumer Price Index data for SFY 2022 reporting period, inflation factor updated to 16.4%.
• PFC worksheets:  Personnel, Staff Group column added.
• RES worksheets:  Facility/Service Type selection field added.  Personnel, Staff Group column added.  Nurse, Clinician, Consultant-Nurse, Consultant-Clinician, and Consultant-Other position title lines added to Personnel.  Non-Personnel, QRTP Accreditation line added as a cost category.  Note 1 section added for provider to describe nurse and clinician duties offered.

Instructions

• Specific guidance language added regarding form revisions noted above.

An agency which seeks to establish Title IV-E reimbursement ceilings for the effective period April 1, 2023, through March 31, 2024, must complete the filing requirements outlined in OAC 5101:2-47-26.1 (cost report) and OAC 5101:2-47-26.2 (agreed-upon procedures) for SFY 2022. Please note that these effective period timeframes may change based on Tiered Foster Care statewide implementation.