Revised May 2023 Post-Payment Notice of Reporting Requirements

Provider Relief Fund Distributions and American Rescue Plan Rural Distribution

Post-Payment Notice of Reporting Requirements

April 7, 2023

Purpose

The purpose of this Notice is to inform the Health Resources and Services Administration (HRSA) Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural recipients of the data elements that they are required to report as part of the post-payment reporting process. This Notice supersedes the Post-Payment Notice of Reporting Requirements released on October 27, 2022. Specifically, the reporting requirements are updated to include Period 8 (i.e., payment received period from July 1, 2023, to December 31, 2023) and Period 9 (i.e., payment received period from January 1, 2024, to June 30, 2024), as well as updating the associated Periods of Availability of Funds and Reporting Time Periods for Periods 8 and 9. It also includes clarifying information regarding the use of PRF and ARP Rural payments for lost revenues after the COVID-19 Public Health Emergency ends. The COVID-19 Public Health Emergency will end on May 11, 2023.¹

Recipients who received and retained one or more General and Targeted Distributions and/or ARP Rural Distribution payments exceeding $10,000 in the aggregate during a Payment Received Period are required to report in each applicable Reporting Time Period. The reporting requirements outlined in this Notice apply to all past and future PRF and ARP Rural payments made under the legal authorities outlined in the section Overview of Legal Requirements for Reporting.

These reporting requirements apply to the following distributions:

• PRF General and Targeted Distribution payments (including the Nursing Home Infection Control (NHIC) Distribution (formally known as the Skilled Nursing Facility and Nursing Home Infection Control Distribution)², and

• ARP Rural Distribution payments.

Note: These reporting requirements do not apply to the Rural Health Clinic Coronavirus Disease 2019 (COVID-19) Testing and Mitigation Program and the Rural Health Clinic COVID-19 Testing Program³ or claims reimbursements from the HRSA COVID-19 Uninsured Program and the HRSA COVID-19 Coverage Assistance Fund.⁴

Overview of Legal Requirements for Reporting

The Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136), the Paycheck Protection Program (PPP) and Health Care Enhancement Act (P.L. 116-139), the Coronavirus Response and Relief Supplemental Appropriations (CRRSA) Act (P.L. 116-260), and the ARP Act of 2021 (P.L. 117-2) appropriated funds to reimburse eligible health care providers for health care-related expenses or lost revenues attributable to COVID-19. These funds were or will be distributed by HRSA. Recipients of these funds agreed to Terms and Conditions, which require compliance with reporting requirements as specified by the Secretary of the U.S. Department of Health and Human Services (HHS). The reporting requirements outlined in this Notice apply to all past and future PRF payments, as well as to ARP Rural payments.⁵

Period of Availability of Funds

The period of availability of funds applies to all past and future PRF and ARP Rural payments, including reconsideration payments.

PRF and ARP Rural recipients must use payments for eligible expenses, including services rendered during the period of availability, as outlined in Table 1 below. PRF and ARP Rural recipients may also use payments for lost revenues attributable to COVID-19 incurred within the period of availability, but only up to June 30, 2023, the end of the quarter in which the COVID-19 Public Health Emergency ends.

The period of availability of funds is based on the date the payment is received. The payment is received on the deposit date for automated clearing house (ACH) payments or the check cashed date. For reconsideration payments, the period of availability of funds is based on the date the reconsideration payment is received. Providers must follow their basis of accounting (e.g., cash, accrual, or modified accrual) to determine expenses.

If a provider receives both PRF and ARP Rural payments, the provider should apply their ARP Rural payment towards eligible health care expenses and lost revenues attributable to COVID-19 before using PRF payments to cover eligible health care expenses or lost revenues attributable to COVID-19. The PRF Reporting Portal system is set up to require providers to report first on the use of ARP Rural payments before PRF payments.

Table 1: Period of Availability for Eligible Expenses

Period		Payment Received Period	Period of Availability for Eligible Expenses
	1	April 10, 2020, to June 30, 2020	January 1, 2020, to June 30, 2021
	2	July 1, 2020, to December 31, 2020	January 1, 2020, to December 31, 2021
	3	January 1, 2021, to June 30, 2021	January 1, 2020, to June 30, 2022
	4	July 1, 2021, to December 31, 2021	January 1, 2020, to December 31, 2022
	5	January 1, 2022, to June 30, 2022	January 1, 2020, to June 30, 2023
	6	July 1, 2022, to December 31, 2022	January 1, 2020, to December 31, 2023
	7	January 1, 2023, to June 30, 2023	January 1, 2020, to June 30, 2024
	8	July 1, 2023, to December 31, 2023	January 1, 2020, to December 31, 2024
	9	January 1, 2024, to June 30, 2024	January 1, 2020, to June 30, 2025

PRF and ARP Rural recipients may use payments for eligible expenses incurred prior to receipt of those payments (i.e., pre-award costs) so long as they are to prevent, prepare for, and respond to COVID-19.

As mentioned above, the opportunity to apply PRF payments (excluding the NHIC Distribution) and ARP Rural payments for lost revenues will be available only from the beginning of the period of availability (e.g., January 1, 2020, for all Periods) up to June 30, 2023, the end of the quarter in which the Public Health Emergency ends.

Table 2: Period of Availability for Lost Revenues

Period	Payment Received Period	Period of Availability for Lost Revenues
1	April 10, 2020, to June 30, 2020	January 1, 2020, to June 30, 2021
2	July 1, 2020, to December 31, 2020	January 1, 2020, to December 31, 2021
3	January 1, 2021, to June 30, 2021	January 1, 2020, to June 30, 2022
4	July 1, 2021, to December 31, 2021	January 1, 2020, to December 31, 2022
5	January 1, 2022, to June 30, 2022	January 1, 2020, to June 30, 2023
6	July 1, 2022, to December 31, 2022	January 1, 2020, to June 30, 2023
7	January 1, 2023, to June 30, 2023	January 1, 2020, to June 30, 2023
8	July 1, 2023, to December 31, 2023	January 1, 2020, to June 30, 2023
9	January 1, 2024, to June 30, 2024	January 1, 2020, to June 30, 2023

Reporting Time Periods

The reporting time periods apply to all past and future PRF and ARP Rural payments.

Recipients who received and retained one or more payments exceeding $10,000 in the aggregate during a Payment Received Period outlined below are required to report in each applicable Reporting Time Period, as indicated in Table 3 below. Reporting must be completed and submitted to HRSA by the last date of the reporting time period. PRF and ARP Rural recipients that do not report or return funds within the respective reporting time period are out of compliance with payment Terms and Conditions and will be subject to repayment.

Table 3: Reporting Time Periods

Period	Payment Received Period	Reporting Time Period
1	April 10, 2020, to June 30, 2020	July 1, 2021, to September 30, 2021
2	July 1, 2020, to December 31, 2020	January 1, 2022, to March 31, 2022
3	January 1, 2021, to June 30, 2021	July 1, 2022, to September 30, 2022
4	July 1, 2021, to December 31, 2021	January 1, 2023, to March 31, 2023
5	January 1, 2022, to June 30, 2022	July 1, 2023, to September 30, 2023
6	July 1, 2022, to December 31, 2022	January 1, 2024, to March 31, 2024
7	January 1, 2023, to June 30, 2023	July 1, 2024, to September 30, 2024
8	July 1, 2023, to December 31, 2023	January 1, 2025, to March 31, 2025
9	January 1, 2024, to June 30, 2024	July 1, 2025, to September 30, 2025

Summary of Reporting Requirements

Table 4 summarizes how the Payment Received Periods align with the Periods of Availability for eligible expenses and lost revenues and the Reporting Time Periods.

Table 4: Summary of Reporting Requirements

Period	Payment Received Period	Period of Availability for Eligible Expenses	Period of Availability for Lost Revenues	Reporting Time Period
1	April 10, 2020, to June 30, 2020	January 1, 2020, to June 30, 2021	January 1, 2020, to June 30, 2021	July 1, 2021, to September 30, 2021
2	July 1, 2020, to December 31, 2020	January 1, 2020, to December 31, 2021	January 1, 2020, to December 31, 2021	January 1, 2022, to March 31, 2022
3	January 1, 2021, to June 30, 2021	January 1, 2020, to June 30, 2022	January 1, 2020, to June 30, 2022	July 1, 2022, to September 30, 2022
4	July 1, 2021, to December 31, 2021	January 1, 2020, to December 31, 2022	January 1, 2020, to December 31, 2022	January 1, 2023, to March 31, 2023
5	January 1, 2022, to June 30, 2022	January 1, 2020, to June 30, 2023	January 1, 2020, to June 30, 2023	July 1, 2023, to September 30, 2023
6	July 1, 2022, to December 31, 2022	January 1, 2020, to December 31, 2023	January 1, 2020, to June 30, 2023	January 1, 2024, to March 31, 2024
7	January 1, 2023, to June 30, 2023	January 1, 2020, to June 30, 2024	January 1, 2020, to June 30, 2023	July 1, 2024, to September 30, 2024
8	July 1, 2023, to December 31, 2023	January 1, 2020, to December 31, 2024	January 1, 2020, to June 30, 2023	January 1, 2025, to March 31, 2025
9	January 1, 2024, to June 30, 2024	January 1, 2020, to June 30, 2025	January 1, 2020, to June 30, 2023	July 1, 2025, to September 30, 2025

Responsibility for Reporting

Reporting entities will complete and submit required reports for PRF and ARP Rural payments in the PRF Reporting Portal. The reporting entity may differ by type of payment but generally, HRSA defines this as the entity that registers its Tax Identification Number (TIN) and reports on payments received by that TIN and/or its subsidiary TINs as indicated in Table 5.

Note: HRSA requires entities to report if the total Targeted Distribution, General Distribution, and ARP Rural payments received and retained exceed $10,000 in the aggregate in a Payment Received Period.

Table 5: Responsibility for Reporting

Type of PRF Recipient(s) 6	Required to Report Because…
General Distribution recipient that received payment in Phase 1 only	Entity that received and retained Phase 1 General Distribution payments totaling more than $10,000 in the aggregate in a Payment Received Period.
General Distribution recipient with no parent organization or subsidiaries	Entity [at the TIN level] that received and retained one or more General Distribution payments totaling more than $10,000 in the aggregate in a Payment Received Period.
General Distribution recipient with one or more subsidiaries that received payments in Funding Phases 1 to 4	Entity that meets the following three criteria: is the parent of one or more subsidiary billing TINs that received General Distribution payments in Phases 1 to 4; has associated providers that were providing diagnoses, testing, or treatment for individuals with possible or actual cases of COVID-19 on or after January 31, 2020; and can otherwise attest to the Terms and Conditions.
Targeted Distribution recipient (includes NHIC Distribution payments)	Entity (at the TIN level) that received and retained Targeted Distribution payments totaling more than $10,000 in the aggregate in a Payment Received Period.
ARP Rural Distribution recipient	Entity (at the filing TIN level) that received and retained ARP Rural Distribution payments and other PRF payments totaling more than $10,000 in the aggregate during the Payment Received Period. Regardless of whether a parent was obligated to distribute payments to its subsidiaries who qualified for ARP Rural payments, HRSA requires parent entities to report on ARP Rural payments they received from the agency. The qualifying recipient of an ARP Rural Distribution will not transfer and/or allocate the payment to another entity. (Note: This does not include the initial transfer of an ARP Rural payment from the parent TIN to the qualifying TIN.)

Parent Reporting by Payment Type

1. General Distribution Payments: A parent entity may report on its subsidiaries’ General Distribution payments regardless of whether the subsidiary TINs received the General Distribution payments directly from HRSA or whether General Distribution payments were transferred to them by the parent entity. The parent entity may report on these General Distribution payments regardless of whether the parent or the subsidiary attested to the Terms and Conditions.

2. Targeted Distribution Payments: A parent entity may not report on its subsidiaries’ Targeted Distribution payments. The TIN that qualified for Targeted Distribution payments must report on the use of funds in accordance with the CRRSA Act. This is required regardless of whether the qualifying recipient or its parent subsequently transferred the payment. A reporting entity that is a subsidiary must indicate the payment amount of any of the Targeted Distributions it received that were transferred to/by the parent entity, if applicable.

3. ARP Rural Payments: As outlined in Table 5 above, HRSA requires parent entities to report on its subsidiaries’ use of ARP Rural payments. In accordance with the payment Terms and Conditions, the TIN that qualified for the ARP Rural Distribution payment must use the payment for eligible expenses and/or lost revenues. HRSA does not permit parent entities to use these payments. Parent entities will be required to attest that payments were allocated in accordance with the information provided in the payment letter.

Recipients who report an acquisition/divestiture/merger or entities who transfer Targeted Distribution payments are more likely to be audited, consistent with an overall risk-based audit strategy.

Steps for Reporting on Use of Funds

Reporting entities will report on their use of funds using their normal basis of accounting (e.g., cash basis, accrual basis, and modified accrual). Reporting entities will submit consolidated reports. The reporting requirements outlined in this section apply to all past and future PRF and ARP Rural payments.

Recipients will report data in the following order:

1. Interest Earned on PRF Payments (prior to Phase 4)

Reporting entities must report the dollar value of interest earned on PRF payment(s) it holds in an interest-bearing account. The total reportable use of PRF payments will include the interest earned on those PRF payments. Reporting entities will report separately interest earned on NHIC Distribution payments and interest earned on other PRF payments.

2. Interest Earned on Phase 4 and ARP Rural Payments (if applicable)

HRSA requires recipients of ARP Rural and PRF Phase 4 payments to hold those payments in an interest-bearing account. Reporting entities must report on the dollar value of interest earned on all retained ARP Rural payments separately from PRF Distributions. The total reportable amount of ARP Rural and PRF payments will include the interest earned.

3. Other Assistance Received

The reporting entity will report on other assistance received by quarter during the period of availability. Other Assistance Received is further defined within the Data Elements section below. If the reporting entity is reporting on behalf of subsidiaries, the assistance received for each category must be aggregated across each of the subsidiaries included in the report. HRSA will not use the reported Other Assistance Received in the calculation of expenses or lost revenues applied to PRF and ARP Rural payments.

4. Use of ARP Rural Distribution Payments (if applicable) for Eligible Expenses

The reporting entity will report on expenses paid for with ARP Rural payments (including any interest earned). Expense categories will include General and Administrative and/or other Health Care-Related Expenses by calendar year quarter (further defined within the Data Elements section below).

5. Use of ARP Rural Distribution Payments (if applicable) for Lost Revenues

Reporting entities may apply ARP Rural amounts not fully expended on health care-related expenses attributable to COVID-19 to patient care lost revenues incurred within the period of availability, up to June 30, 2023, the end of the quarter in which the Public Health Emergency ends, if applicable. Documentation requirements for lost revenues calculations are further defined within the Data Elements section below. Recipients may choose to apply ARP Rural payments toward lost revenues using one of three options, up to the amount:

• Option i: of the difference between actual patient care revenues.

• Option ii: of the difference between budgeted (approved prior to March 27, 2020) and actual patient care revenues.

• Option iii: calculated by any reasonable method of estimating revenues.

6. Use of NHIC Distribution Payments (if applicable)

The reporting entity will report on infection control expenses paid for with NHIC Distribution payments (including any interest earned) if the entity received funds from this Distribution. Expenses must be those that another source has not reimbursed and is not obligated to reimburse. Expense categories will include General and Administrative and/or other Health Care-Related Expenses by calendar year quarter (further defined within the Data Elements section below).

7. Use of General and Other Targeted Distribution Payments for Eligible Expenses

The reporting entity will report on expenses paid for with payments received through the General and Targeted Distribution payments (excluding NHIC Distribution payments). Expenses must be those that another source has not reimbursed and is not obligated to reimburse. Expense categories will include General and Administrative and/or other Health Care-Related Expenses by calendar year quarter (further defined within the Data Elements section below).

HRSA considers unreimbursed expenses attributable to COVID-19 first in the overall use of funds calculation.

8. Use of General and Other Targeted Distribution Payments for Lost Revenues

PRF payment amounts (excluding NHIC Distribution payments) not fully expended on health care-related expenses attributable to COVID-19 may be applied to patient care lost revenues incurred within the period of availability, up to June 30, 2023, the end of the quarter in which the Public Health Emergency ends, if applicable.⁷ Documentation requirements for lost revenues calculations are further defined within the Data Elements section below. Recipients may choose to apply PRF payments toward lost revenues using either the same option they selected for ARP Rural payment (if applicable) or one of three options, up to the amount:

• Option i: of the difference between actual patient care revenues.

• Option ii: of the difference between budgeted (approved prior to March 27, 2020) and actual patient care revenues.

• Option iii: calculated by any reasonable method of estimating revenues.

9. Net Unreimbursed Expenses Attributable to COVID-19

The reporting entity will report on unreimbursed expenses attributable to COVID-19 (net after other assistance received and PRF/ARP Rural payments are applied) by quarter for the period of availability, broken out as General and Administrative and/or other Health Care-Related Expenses. HRSA is gathering this data for informational purposes only and will have no impact on other calculations in the report. However, legislation stipulates that organizations use PRF funds for expenses that have not been reimbursed and are not obligated to reimburse by another source. As a result, HRSA expects organizations to determine if there are net unreimbursed expenses attributable to COVID-19 after applying Other Assistance Received and all PRF and ARP Rural payments.

Data Elements

The following data elements in the PRF Reporting Portal will allow HRSA to assess how recipients used PRF General and Targeted Distributions, and ARP Rural Distribution payments, consistent with the Terms and Conditions associated with payment.

1. Reporting Entity Overview

1. TIN: The nine-digit TIN associated with the eligible health care provider that is filing the report. For some recipients, this may be analogous to Social Security Number or Employer Identification Number.

2. Business Name: The business name of the reporting entity must be entered as it appears on Internal Revenue Service (IRS) Form W-9.

3. Doing Business As Name [optional]: The Doing Business As name is any registered name that a business operates under that is not its legal business name.

4. Address: The address must be entered as it appears on IRS Form W-9 and must include a street, city, state/territory, and ZIP code.

5. Contact Information: The name, email, and phone number of the person responsible for submitting the report on behalf of the reporting entity. Entering a title is optional.

6. Provider Type: The provider type must be selected from a list of provider types that best describes the reporting entity.

7. Provider Subtype: The provider subtype must be selected from a list of provider subtypes that best describes the reporting entity.

2. Subsidiary Questionnaire

This section applies to reporting entities that have subsidiaries who received General Distribution payments in Phases 1, 2, 3, or 4. Refer to the ARP Rural Distribution Payments Subsidiary Attestation section below for information on ARP Rural subsidiary reporting.

For this section the reporting entity will report the following information:

1. TINs of subsidiaries that are “eligible health care providers”⁸ and an indication whether the reporting entity is reporting on behalf of the subsidiary’s PRF General Distribution payment(s).

2. TINs of subsidiaries that are “eligible health care providers” and were acquired, divested, or merged during the period of availability.

For reporting entities that are subsidiaries:

1. TIN(s) of any parent entity reporting on behalf of the reporting entity (for PRF General Distribution payments only), if applicable.

2. Total dollar amount of PRF Targeted Distribution payment(s) transferred to/by a parent entity, if applicable.

Note: Reporting a transfer of some or all of a Targeted Distribution payment does not satisfy the requirement to report on the use of funds.

3. ARP Rural Distribution Payments Subsidiary Attestation

Parent entities that received ARP Rural Distribution payments on behalf of their subsidiaries must report and attest to the following:

1. The parent distributed ARP Rural payments in accordance with HRSA’s instructions.

2. The qualifying subsidiary used the payments.

3. The parent will provide a self-reported breakdown of each subsidiary TIN and the amount allocated to that TIN.

4. The parent will complete a consolidated report on how it used the payments.

4. Acquired/Divested/Merged Subsidiaries

Reporting entities that received General Distribution payments in Phases 1, 2, or 3 or a Targeted Distribution payment who acquired, divested of, or merged with related subsidiaries (change of ownership) must indicate the change in ownership that occurred during the period of availability.

Reporting entities that received an ARP Rural payment and/or Phase 4 General Distribution payment must indicate a change in ownership that occurred during the Payment Received Period.

HRSA requires the following data elements for each relevant TIN:

1. TIN(s) included in the acquisition/divestiture/merger

2. Effective date of acquisition/divestiture/merger

3. PRF and ARP Rural payment received for TIN acquired/divested/merged

4. Did/does the reporting entity hold a controlling interest in this entity? (Y/N)

5. Percent of ownership for acquisition/divestiture/merger

6. TIN of acquiring entity, if applicable

5. Interest Earned on PRF Payment(s) and/or ARP Rural Payment(s)

Reporting entities that held PRF payments in an interest-bearing account and PRF Phase 4 and ARP Rural recipients that are required to hold payments separately in an interest-bearing account must report the dollar value of interest earned on those payment(s).

The total reportable use of PRF and ARP Rural Distributions will include the interest earned on those payments. Reporting entities will provide:

1. Dollar amount of interest earned on NHIC Distribution, if any

2. Dollar amount of interest earned on other PRF, if any

3. Dollar amount of interest earned on ARP Rural payments.

Note: The interest earned on NHIC Distribution and ARP Rural payment(s) must be reported separately from interest earned on other PRF payments. HRSA will permit the recipient to keep the interest earned if it was used to prevent, prepare for, and respond to COVID-19.

6. Tax and Single Audit Information

1. Federal Tax Classification: Designated business type associated with the reporting entity’s primary TIN used for filing taxes. Classifications include Individual/Sole Proprietor, Limited Liability Corporation, Partnership, C Corporation, S Corporation, Trust or Estate, or other. If other, the classification must be specified.

2. Exempt Payee Code [optional]: Code as designated on IRS Form W-9.

3. Exempt from Foreign Account Tax Compliance Act Reporting Code [optional]: Code as designated on IRS Form W-9.

4. Fiscal Year-End Date: Month in which the reporting entity reports its fiscal year-end financial results.

5. Single Audit Status: Reporting entities must indicate if they are subject to Single Audit requirements during 2019 through current fiscal years, and if yes, whether PRF and ARP Rural payments are included in the Single Audit.

Note: Recipients that expend a total of $750,000 or more in federal funds (including PRF and ARP Rural payments and other federal financial assistance) during their fiscal year are subject to Single Audit requirements, as set forth in the regulations at 45 CFR § 75, Subpart F. The last day a provider can use the funds (end of the period of availability) will drive inclusion of the expenditures associated with PRF and ARP Rural payments on the Schedule of Expenditures for Federal Awards (SEFA) in a Single Audit report or equivalent schedule for a financial related audit. HRSA considers both expenses and lost revenues as expenditures for SEFA and equivalent schedule reporting purposes.

Non-federal entities must have a Single Audit conducted in accordance with 45 CFR §75.514 that must be submitted electronically to the Federal Audit Clearinghouse.

Commercial organizations have two options under 45 CFR §75.216(d) and §75.501(i): (1) a financial related audit of the award or awards conducted in accordance with Generally Accepted Government Auditing Standards; or (2) an audit in conformance with the requirements of 45 CFR §75.514 - Single Audit. Commercial organizations that have received PRF funding are highly encouraged to submit their audits electronically to the Commercial Audit Reporting Portal at https://commercialaudit.hrsa.gov/s/login/. Commercial organizations not registered in the PRF Reporting Portal must submit their audits via email to HRSA’s Division of Financial Integrity at PRFaudits@hrsa.gov.

7. Other Assistance Received

The reporting entity must enter other assistance received by quarter during the period of availability. If the reporting entity is reporting on behalf of subsidiaries, the assistance received for each category must be aggregated across each of the subsidiaries included in the report.

1. Department of the Treasury and/or Small Business Administration Assistance: Total amount of COVID-19-related relief received from the Department of the Treasury and/or the Small Business Administration, including the Paycheck Protection Program, by the reporting entity during the period of availability.

2. Federal Emergency Management Agency Programs: Total amount of COVID-19- related relief received from the Federal Emergency Management Agency by the reporting entity during the period of availability.

3. HHS COVID-19 Testing: Total amount of relief received from HHS by the reporting entity for COVID-19 testing-related activities during the period of availability.

4. Local, State, and Tribal Government Assistance: Total amount of COVID-19-related relief received by the reporting entity from other local, state, or tribal government sources during the period of availability.

5. Business Insurance: Paid claims against insurance policies intended to cover losses related to various types of health care business interruption during the period of availability.

6. Other Assistance: Total amount of other federal and/or COVID-19-related assistance received by the reporting entity during the period of availability.

8. Use of ARP Rural Distribution Payments and Related Earned Interest (if applicable) on Eligible Expenses

ARP Rural payments may be used for expenses outlined in the Terms and Conditions to prevent, prepare for, and respond to COVID-19 by reimbursing the recipient for health care-related expenses or lost revenues that are attributable to COVID-19.

Expenses that reporting entities paid with ARP Rural Distribution payment(s) must be those that are unreimbursed by other sources, including PRF payments, and that other sources are not obligated to reimburse. ARP Rural payments must be fully expended on either eligible health care-related expenses and/or lost revenues attributable to COVID-19 before PRF payments can be used on eligible expenses and/or lost revenues attributable to COVID-19.

Reporting entities that received and retained between $10,001 and $499,999 in aggregated PRF and ARP Rural payments during each Payment Received Period are required to report on the use of these payments in two categories: (1) General and Administrative Expenses and (2) Health Care-Related Expenses.

HRSA requires reporting entities that received and retained $500,000 or more in aggregated PRF and ARP Rural payments during each Payment Received Period to report on the use of these payments in greater detail than the two categories of General and Administrative Expenses and Health Care-Related Expenses, according to the following sub-categories of expenses:

General and Administrative Expenses for ARP Rural Distribution Payments

1. Mortgage/Rent: Payments related to mortgage or rent for a facility.

2. Insurance: Premiums paid for property, malpractice, business insurance, or other insurance relevant to operations.

3. Personnel: Workforce-related actual expenses paid to prevent, prepare for, or respond to COVID-19 during the reporting period, such as workforce training, staffing, temporary employee or contractor payroll, overhead employees, or security personnel.

4. Fringe Benefits: Extra benefits supplementing an employee’s salary, which may include hazard pay, travel reimbursement, and employee health insurance.

5. Lease Payments: New equipment or software leases, such as fleet cars and medical equipment that is not purchased and will be returned to the owner.

6. Utilities/Operations: Lighting, cooling/ventilation, cleaning, or additional third-party vendor services not included in the “Personnel” sub-category.

7. Other General and Administrative Expenses: Expenses not captured above that are generally considered part of general and administrative expenses.

Health Care-Related Expenses for ARP Rural Distribution Payments

1. Supplies: Expenses paid for purchase of supplies (e.g., single use or reusable patient care devices, cleaning supplies, office supplies, etc.) used to prevent, prepare for, and/or respond to COVID-19 during the period of availability. Such items may include personal protective equipment (PPE), hand sanitizer, supplies for patient screening, or vaccination administration materials.

2. Equipment: Expenses paid for purchase of equipment, such as ventilators, refrigeration systems for COVID-19 vaccines, or updates to heating, ventilation, and air conditioning (HVAC) systems.

3. Information Technology (IT): Expenses paid for IT or interoperability systems to expand or preserve COVID-19 care delivery during the reporting period, such as electronic health record licensing fees, telehealth infrastructure, increased bandwidth, and teleworking to support remote workforce.

4. Facilities: Expenses such as lease or purchase of permanent or temporary structures, or to retrofit facilities to accommodate revised patient treatment practices, used to prevent, prepare for, and/or respond to COVID-19 during the reporting period.

5. Other Health Care-Related Expenses: Expenses, not previously captured above, that were paid to prevent, prepare for, and/or respond to COVID-19.

9. Use of ARP Rural Distribution Payments and Related Earned Interest (if applicable) on Lost Revenues Attributable to COVID-19

Reporting entities that expend all ARP Rural payments will not be able to select a lost revenues option. Instead, these entities will need to submit patient care revenues for the period of availability.

Reporting entities using ARP Rural payments for lost revenues incurred within the period of availability will provide information used to calculate lost revenues attributable to COVID-19 from the beginning of the period of availability up to June 30, 2023, the end of the quarter in which the Public Health Emergency ends. Reporting entities electing Option i or Option ii (refer to Step 5 of Steps for Reporting on Use of Funds above) will provide the following:

Total Revenues⁹/Net Charges from Patient Care¹⁰ Related Sources:

Reporting entities will submit revenues/net charges from patient care (prior to netting with expenses) incurred within the period of availability, by payer mix (including out of pocket charges), and by quarter for each quarter during the period of availability up to June 30, 2023, the end of the quarter in which the Public Health Emergency ends. Reporting entities electing Option i will provide actuals and reporting entities electing Option ii will provide both budgeted and actuals.

1. Medicare Part A or B: Revenues/net charges received from Medicare Part A or B for patient care.

2. Medicare Part C (Medicare Advantage): revenues/net charges received from Medicare Part C for patient care.

3. Medicaid/Children’s Health Insurance Program (CHIP): Revenues/net charges received from Medicaid/CHIP for patient care.

4. Commercial Insurance: Revenues/net charges from commercial insurance payers for patient care.

5. Self-Pay (No Insurance): Revenues/net charges received from self-pay patients, including the uninsured or individuals without insurance who bear the burden of paying for health care themselves.

6. Other: Revenues/net charges from other sources received for patient care services and not included in the list above.

Additional Revenue Information

In addition to providing patient care revenues, reporting entities will need to provide documentation to substantiate the revenue information provided if Option ii or Option iii was used to calculate lost revenues attributable to COVID-19 (refer to Step 5 of Steps for Reporting on Use of Funds above).

• Option ii: Reporting entities must also submit: (1) a copy of a budget, which must have been approved before March 27, 2020; and (2) an attestation from the reporting entity’s Chief Executive Officer, Chief Financial Officer, or similar responsible individual, attesting under 18 USC § 1001 that the exact budget being submitted was established and approved prior to March 27, 2020.

• Option iii: Alternate methodology for calculating lost revenues attributable to COVID-19. Reporting entities must submit: (1) a narrative document describing methodology, an explanation of why the methodology is reasonable, and a description establishing how lost revenues were attributable to COVID-19, as opposed to a loss caused by any other source; and (2) a calculation of lost revenues attributable to COVID-19 using the methodology described in the narrative document. All recipients seeking to use an alternate methodology face an increased likelihood of an audit by HRSA. HRSA will notify a recipient if their proposed methodology is not reasonable, including if it does not demonstrate with a reasonable certainty that COVID-19 caused the claimed lost revenues. If HRSA determines that a recipient’s proposed alternate methodology is not reasonable, the recipient must resubmit its report within 30 days of notification using either Option i or Option ii to calculate lost revenues attributable to COVID-19.

10. Use of NHIC Distribution Payments (if applicable)

NHIC Distribution payments may be used for infection control expenses limited to those outlined in the Terms and Conditions as follows:

• costs associated with administering COVID-19 testing;

• reporting COVID-19 test results to local, state, or federal governments;

• hiring staff to provide patient care or administrative support;

• providing additional services to residents; or

• other expenses incurred to improve infection control.

Expenses that reporting entities paid with NHIC Distribution payments must be those that other sources do not reimburse and that other sources are not obligated to reimburse. HRSA expects providers to follow their basis of accounting when determining applicable expenses.

Reporting entities that received and retained between $10,001 and $499,999 in aggregated PRF and ARP Rural payments during each Payment Received Period are required to report on the use of these infection control payments in two categories: (1) General and Administrative Expenses and (2) Health Care-Related Expenses. Although HRSA does not require the same level of detail, providers may use the expenses categories as a basis for identifying General and Administrative and Health Care-Related expenses.

Reporting entities that received and retained $500,000 or more in aggregated PRF and ARP Rural payments during each Payment Received Period are required to report on the use of these infection control payments in greater detail than the two categories of General and Administrative Expenses and Health Care-Related Expenses, according to the following sub-categories of expenses:

General and Administrative Expenses for NHIC Distribution Payments

1. Mortgage/Rent: Payments related to mortgage or rent for a facility specifically for infection control.

2. Insurance: Premiums paid for property, malpractice, business insurance, or other insurance relevant to operations for infection control.

3. Personnel: Workforce-related expenses as outlined in the Terms and Conditions such as personnel costs associated with administering COVID-19 testing; reporting COVID-19 test results to local, state, or federal governments; hiring staff to provide patient care or administrative support; providing additional services to residents; workforce training; and mentorship programs to improve infection control; or other personnel costs incurred for infection control. Staffing, including temporary employee or contractor payroll and overhead employees, is included.

4. Fringe Benefits: Extra benefits supplementing an employee’s salary, which may include hazard pay, travel reimbursement, and employee health insurance. May only be charged in proportion to salary costs for infection control.

5. Lease Payments: New equipment or software leases, fleet cars, and medical equipment that is not purchased and will be returned to its owner, so long as it is used for infection control.

6. Utilities/Operations: Lighting, cooling/ventilation, cleaning, or additional third-party vendor services not included in the “Personnel” sub-category and whose purpose is for infection control.

7. Other General and Administrative Expenses: Expenses not captured above that are for infection control and generally considered part of general and administrative expenses.

Health Care-Related Expenses for NHIC Distribution Payments

1. Supplies: Expenses paid for purchase of supplies (e.g., single use or reusable patient care devices, cleaning supplies, office supplies, etc.) used for the purpose of infection control during the period of performance. Such items may include PPE, hand sanitizer, and supplies for patient or staff COVID-19 testing, or expenses associated with distribution of a COVID-19 vaccine licensed or authorized by the Food and Drug Administration.

2. Equipment: Expenses paid for purchase of equipment used for infection control, such as updates to HVAC systems or sanitizing equipment.

3. IT: Expenses paid for IT or interoperability systems to expand or preserve infection control during the reporting period, such as telehealth infrastructure, increased bandwidth, technology that permits residents to connect with their families, and teleworking to support remote workforce.

4. Facilities: Expenses such as lease or purchase of permanent or temporary structures, or to retrofit facilities to accommodate revised patient treatment practices to support infection control during the period of performance.

5. Other Health Care-Related Expenses: Expenses not captured above that are for infection control and are health care-related expenses.

11. Use of PRF General and Other Targeted Distribution Payments on Eligible Expenses

This section explains reporting for General and Targeted Distribution PRF payments excluding NHIC Distribution payments (refer to Section 10 above). Expenses that reporting entities paid with PRF payments must be those that are unreimbursed by other sources and that other sources are not obligated to reimburse. Reporting entities that also received an ARP Rural payment must expend the ARP Rural funds on eligible expenses and/or lost revenues attributable to COVID-19 before PRF payments may be used on eligible expenses and/or lost revenues attributable to COVID-19.

Reporting entities that received and retained between $10,001 and $499,999 in aggregated PRF and ARP Rural payments during each Payment Received Period are required to report on the use of General and Other Targeted PRF payments, as well as ARP Rural payments, in two categories: (1) General and Administrative Expenses and (2) Health Care-Related Expenses.

Reporting entities that received and retained $500,000 or more in aggregated PRF and ARP Rural payments during each Payment Received Period are required to report on the use of these General and Other Targeted Distribution PRF payments, as well as ARP Rural payments, in greater detail than the two categories of General and Administrative Expenses and Health Care-Related Expenses, according to the following sub- categories of expenses:

General and Administrative Expenses Attributable to COVID-19

1. Mortgage/Rent: Payments related to mortgage or rent for a facility.

2. Insurance: Premiums paid for property, malpractice, business insurance, or other insurance relevant to operations.

3. Personnel: Workforce-related actual expenses paid to prevent, prepare for, or respond to COVID-19 during the reporting period, such as workforce training, staffing, temporary employee or contractor payroll, overhead employees, or security personnel.

4. Fringe Benefits: Extra benefits supplementing an employee’s salary, which may include hazard pay, travel reimbursement, and employee health insurance.

5. Lease Payments: New equipment or software leases, such as fleet cars and medical equipment that is not purchased and will be returned to the owner.

6. Utilities/Operations: Lighting, cooling/ventilation, cleaning, or additional third-party vendor services not included in the “Personnel” sub-category.

7. Other General and Administrative Expenses: Expenses not captured above that are generally considered part of general and administrative expenses.

Health Care-Related Expenses Attributable to COVID-19

1. Supplies: Expenses paid for purchase of supplies (e.g., single use or reusable patient care devices, cleaning supplies, office supplies, etc.) used to prevent, prepare for, and/or respond to COVID-19 during the reporting period. Such items may include PPE, hand sanitizer, supplies for patient screening, or vaccination administration materials.

2. Equipment: Expenses paid for purchase of equipment, such as ventilators, refrigeration systems for COVID-19 vaccines, or updates to HVAC systems.

3. IT: Expenses paid for IT or interoperability systems to expand or preserve COVID-19 care delivery during the reporting period, such as electronic health record licensing fees, telehealth infrastructure, increased bandwidth, and teleworking to support remote workforce.

4. Facilities: Expenses such as lease or purchase of permanent or temporary structures, or to retrofit facilities to accommodate revised patient treatment practices, used to prevent, prepare for, and/or respond to COVID-19 during the reporting period.

5. Other Health Care-Related Expenses: Expenses, not previously captured above, that were paid to prevent, prepare for, and/or respond to COVID-19.

12. Use of PRF General and Other Targeted Distribution Payments on Lost Revenues Attributable to COVID-19

Reporting entities that expend all ARP Rural and PRF payments on expenses and lost revenues attributable to COVID-19, all PRF payments on expenses, or those with only NHIC Distribution payments will not be able to select a lost revenues option. Instead, these entities will need to submit patient care revenues for the period of availability.

Reporting entities using PRF for lost revenues incurred within the period of availability will provide information used to calculate lost revenues attributable to COVID-19 from the beginning of the period of availability up to June 30, 2023, the end of the quarter in which the Public Health Emergency ends. Reporting entities that are reporting on use of ARP Rural payments for lost revenues attributable to COVID-19 must select the same option for reporting on PRF payment for lost revenues attributable to COVID-19, as applicable. Reporting entities electing Option i or Option ii (refer to Step 8 of Steps for Reporting on Use of Funds above) will provide the following:

Total Revenues¹¹/Net Charges from Patient Care¹² Related Sources:

Reporting entities will submit revenues/net charges from patient care (prior to netting with expenses) incurred within the period of availability, by payer mix (including out of pocket charges), and by quarter for each quarter during the period of availability up to June 30, 2023, the end of the quarter in which the Public Health Emergency ends. Reporting entities electing Option i will provide actuals and reporting entities electing Option ii will provide both budgeted and actuals.

1. Medicare Part A or B: Revenues/net charges received from Medicare Part A or B for patient care.

2. Medicare Part C (Medicare Advantage): Revenues/net charges received from Medicare Part C for patient care.

3. Medicaid/CHIP: Revenues/net charges received from Medicaid/CHIP for patient care.

4. Commercial Insurance: Revenues/net charges from commercial insurance payers for patient care.

5. Self-Pay (No Insurance): Revenues/net charges received from self-pay patients, including the uninsured or individuals without insurance who bear the burden of paying for health care themselves.

6. Other: Revenues/net charges from other sources received for patient care services and not included in the list above.

Additional Revenue Information

In addition to providing patient care revenues, reporting entities will need to provide documentation to substantiate the revenue information provided if Option ii or Option iii was used to calculate lost revenues attributable to COVID-19 (refer to Step 8 of Steps for Reporting on Use of Funds above).

• Option ii: Reporting entities must also submit: (1) a copy of a budget, which must have been approved before March 27, 2020; and (2) an attestation from the reporting entity’s Chief Executive Officer, Chief Financial Officer, or similar responsible individual, attesting under 18 USC § 1001 that the exact budget being submitted was established and approved prior to March 27, 2020.

• Option iii: Alternate methodology for calculating lost revenues attributable to COVID-19. Reporting entities must submit: (1) a narrative document describing methodology, an explanation of why the methodology is reasonable, and a description establishing how lost revenues were attributable to COVID-19, as opposed to a loss caused by any other source; and (2) a calculation of lost revenues attributable to COVID-19 using the methodology described in the narrative document. All recipients seeking to use an alternate methodology face an increased likelihood of an audit by HRSA. HRSA will notify a recipient if their proposed methodology is not reasonable, including if it does not demonstrate with a reasonable certainty that claimed lost revenues were caused by COVID-19. If HRSA determines that a recipient’s proposed alternate methodology is not reasonable, the recipient must resubmit its report within 30 days of notification using either Option i or Option ii to calculate lost revenues attributable to COVID-19.

13. Net Unreimbursed Expenses Attributable to COVID-19

The unreimbursed health care expenses attributable to COVID-19, net of other reimbursed sources in two categories: (1) General and Administrative expenses and (2) Health Care-Related Expenses.

14. Personnel, Patient, and Facility Metrics

Reporting entities will report on the following personnel, patient, and facility metrics by quarter for calendar year 2019 through the current period of availability:

1. Personnel Metrics: Total number of clinical and non-clinical personnel by labor category (full time, part time, contract, furloughed, separated, hired).

2. Patient Metrics: Total number of inpatient admissions, outpatient visits (in-person and virtual), emergency department visits, and facility stays (for long-term and short-term residential facilities).

3. Facility Metrics: Total number of staffed beds for medical/surgical, critical care, and other.

15. Survey

Reporting entities will answer questions regarding the impact of payments during the period of availability in the following categories:

1. Overall operations

2. Maintenance of solvency and prevention of bankruptcy

3. Retention of staff and prevention of furlough

4. Re-hire or re-activation of staff from furlough

5. Facilitation of changes needed to operate during the pandemic

6. Ability to care for and/or treat patients with COVID-19 (for applicable treatment facilities)

7. Impact on business or patient services (narrative statement) [optional]

1 More information on the end of the COVID-19 Public Health Emergency is available at: https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html#.

2 The NHIC Distribution is a Targeted Distribution payment. The distribution includes payments made in August 2020 and Nursing Home Quality Incentive Payment Program (QIP) payments.

3 More information on reporting for the Rural Health Clinic COVID-19 Testing and Mitigation Program and the Rural Health Clinic COVID-19 Testing Program is available at: https://www.rhccovidreporting.com.

4 More information on the COVID-19 Uninsured Program and Coverage Assistance Fund is available at: https://www.hrsa.gov/provider-relief/about/covid-uninsured-claim.

5 Post-Payment Notices of Reporting Requirements that were issued prior to October 27, 2022, did not include information regarding the ARP Rural Distribution payment(s). ARP Rural payments are funded separately from the PRF General and Target Distribution payments.

6 The PRF website, available at https://www.hrsa.gov/provider-relief/past-payments, contains summaries of General Distribution and Targeted Distribution funding.

7 PRF recipients that received only NHIC Distribution payments will not report on lost revenues. Per the Terms and Conditions, NHIC Distribution payments may not be used to reimburse lost revenues.

8 PRF defines “eligible health care providers” as public entities, Medicare- or Medicaid-enrolled suppliers and providers, and such for-profit entities and not-for-profit entities as the Secretary may specify, within the United States (including territories), that provide diagnoses, testing, or care for individuals with possible or actual cases of COVID-19. ARP Rural defines “eligible health care providers” as a rural health clinic as defined in section 1861(aa)(2) of the Social Security Act; a provider treated as located in a rural area pursuant to section 1886(d)(8)(E), such as critical access hospitals; or a provider or supplier that has directly billed for health care-related services between January 1, 2019, and September 30, 2020, (1) Medicare fee-for-service (Parts A and/or B); (2) Medicare Advantage (Part C); (3) their state/territory Medicaid program (fee-for service or managed care); or (4) their state/territory Children’s Health Insurance Program; and operates in or serves patients living in a rural area as defined by the HHS Federal Office of Rural Health Policy.

9 Net of uncollectible patient service revenues recognized as bad debts.

10 “Patient care” means health care, services, and supports, as provided in a medical setting, at home/telehealth, or in the community. It should not include non-patient care revenue such as insurance, retail, or real estate revenues (exception for nursing and assisted living facilities’ real estate revenues where resident fees are allowable); prescription sales revenues (except when derived through the 340B program); grants or tuition; contractual adjustments from all third-party payers; charity care adjustments; bad debt; and any gains and/or losses on investments.

11 Net of uncollectible patient service revenues recognized as bad debts.

12 “Patient care” means health care, services, and supports, as provided in a medical setting, at home/telehealth, or in the community. It should not include non-patient care revenue such as insurance, retail, or real estate revenues (exception for nursing and assisted living facilities’ real estate revenues where resident fees are allowable); prescription sales revenues (except when derived through the 340B program); grants or tuition; contractual adjustments from all third-party payers; charity care adjustments; bad debt; and any gains and/or losses on investments.

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