Worksheet S-3 Part IV
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FORM CMS-2552-10
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV 1
ST MARYS HEALTH CARE SYSTEM INC - ATHENS, GA
Cost report status - As Submitted
[Record Code 708218 - 2010]
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| HOSPITAL WAGE RELATED COSTS | Provider CCN: 110006 | PERIOD: FROM 07/01/2019 TO 06/30/2020 |
WORKSHEET S-3, PART IV | |||
| Part IV - Wage Related Cost | ||||||
| Part A - Core List | ||||||
| Amount Reported | ||||||
| RETIREMENT COST | ||||||
| 1 | 401k Employer Contributions | 1 | ||||
| 2 | Tax Sheltered Annuity (TSA) Employer Contribution | ### | 2 | |||
| 3 | Nonqualified Defined Benefit Plan Cost (see instructions) | 3 | ||||
| 4 | Qualified Defined Benefit Plan Cost (see instructions) | ### | 4 | |||
| PLAN ADMINISTRATIVE COSTS (Paid to External Organization): | ||||||
| 5 | 401k/TSA Plan Administration fees | 5 | ||||
| 6 | Legal/Accounting/Management Fees-Pension Plan | 6 | ||||
| 7 | Employee Managed Care Program Administration Fees | 7 | ||||
| HEALTH AND INSURANCE COST | ||||||
| 8 | Health Insurance (Purchased or Self Funded) | 8 | ||||
| 8.01 | Health Insurance (Self Funded without a Third Party Administrator) | 8.01 | ||||
| 8.02 | Health Insurance (Self Funded with a Third Party Administrator) | ### | 8.02 | |||
| 8.03 | Health Insurance (Purchased) | 8.03 | ||||
| 9 | Prescription Drug Plan | 9 | ||||
| 10 | Dental, Hearing and Vision Plan | ### | 10 | |||
| 11 | Life Insurance (If employee is owner or beneficiary) | ### | 11 | |||
| 12 | Accident Insurance (If employee is owner or beneficiary) | 12 | ||||
| 13 | Disability Insurance (If employee is owner or beneficiary) | ### | 13 | |||
| 14 | Long-Term Care Insurance (If employee is owner or beneficiary) | 14 | ||||
| 15 | Workers' Compensation Insurance | ### | 15 | |||
| 16 | Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106. Non cumulative portion) | 16 | ||||
| TAXES | ||||||
| 17 | FICA-Employers Portion Only | ### | 17 | |||
| 18 | Medicare Taxes - Employers Portion Only | 18 | ||||
| 19 | Unemployment Insurance | 19 | ||||
| 20 | State or Federal Unemployment Taxes | ### | 20 | |||
| OTHER | ||||||
| 21 | Executive Deferred Compensation (Other Than Retirement Cost Reported on lines 1 through 4 above)(see instructions) | 21 | ||||
| 22 | Day Care Cost and Allowances | 22 | ||||
| 23 | Tuition Reimbursement | ### | 23 | |||
| 24 | Total Wage Related cost (Sum of lines 1 through 23) | ### | 24 | |||
| Part B - Other than Core Related Cost | ||||||
| 25 | Other Wage Related Costs (specify)__ | 25 | ||||
| FORM CMS-2552-10 (11/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.4) | ||||||
| 11-16 | Rev. 10 | |||||