Supplemental to Form CMS-2552-10 Payment Adjustment for Establishing and Maintaining Access to a Buffer Stock of Essential Medicines

SUPPLEMENTAL TO FORM CMS-2552-10
PAYMENT ADJUSTMENT FOR
ESTABLISHING AND MAINTAINING ACCESS TO
A BUFFER STOCK OF ESSENTIAL MEDICINES
This supplemental form calculates the inpatient payment adjustment for the additional resource
costs of establishing and maintaining access to no less than a 6-month buffer stock of one or more
essential medicines for cost reporting periods beginning on or after October 1, 2024. The payment
adjustment is limited to 1886(d) hospitals that have 100 or fewer beds, as defined in
42 CFR 412.105(b), and are not part of a chain organization (independent). The qualifying
hospital must complete and submit this supplemental form with its Medicare Hospital and Hospital
Health Care Complex Cost Report, Form CMS-2552-10, to receive the essential medicines
payment adjustment.
Definitions.-Essential medicines--As defined in proposed 42 CFR 412.113(g).
Independent hospital--A hospital that is not part of a chain organization, defined as a group of two
or more health care facilities that are owned, leased, or through any other device, controlled by
one organization.
Part I - Essential Medicines Payment Adjustment Eligibility.--This part determines the hospital’s
eligibility to receive a payment adjustment for additional resource costs of establishing and
maintaining access to no less than a 6-month buffer stock of one or more essential medicines.
Line 1--Transfer the number of beds, as defined in 42 CFR 412.105(b), from the Medicare
Hospital and Hospital Healthcare Complex Cost Report, Form CMS 2552-10, Worksheet E,
Part A, line 4.
Line 2--Is this hospital defined as an independent hospital according to proposed 42 CFR
412.113(g)(3)? If this hospital answered “Y” for “yes” on the Medicare Hospital and Hospital
Health Care Complex Cost Report, Form CMS 2552-10, Worksheet S-2, Part I, line 140,
column 1, or completes any part of the Medicare Hospital and Hospital Health Care Complex Cost
Report, Form CMS 2552-10, Worksheet S-2, Part I, lines 141 through 143, then the response to
this line will default to an “N” for “no”, as this hospital is considered to be part of a chain
organization and not independent according to 42 CFR 412.113(g)(3). If this hospital answered
“N” for “no” on the Medicare Hospital and Hospital Health Care Complex Cost Report,
Form CMS 2552-10, Worksheet S-2, Part I, line 140, column 1, then the response to this line will
default to a “Y” for “yes”.
Line 3--Did the hospital incur cost, either directly or through a contract with an outside supplier to
establish and maintain access to no less than a 6-month buffer stock of one or more essential
medicines according to 42 CFR 412.113(g)? Enter “Y” for yes or “N” for no.
Part II - Additional Resource Cost of Essential Medicines.--This part identifies the additional
resource cost of establishing and maintaining access to no less than a 6-month buffer stock of one
or more essential medicines. Do not include the cost of the medication. Do not include cost to
establish and maintain a buffer stock for nonreimbursable cost centers.
Line 1--Enter the additional resource cost directly incurred by the hospital to establish and
maintain no less than a 6-month buffer stock of one or more essential medicines according to
42 CFR 412.113(g).

SUPPLEMENTAL TO FORM CMS-2552-10
Line 2--Enter the contractual amount paid to outside suppliers to establish and maintain no less
than a 6-month buffer stock of one or more essential medicines according to 42 CFR 412.113(g).
Line 3--Sum lines 1 and 2.
Part III - Calculation of Medicare Payment Adjustment for Essential Medicines.--This part
calculates the Medicare portion of the additional resource cost incurred by the hospital for
establishing and maintaining access to no less than a 6-month buffer stock of one or more essential
medicines. Enter the data below from the Medicare Hospital and Hospital Health Care Complex
Cost Report, Form CMS-2552-10.
Line 1--Enter the Medicare routine and ancillary cost reported from the IPPS hospital
Worksheet D-1, Part II, line 49.
Line 2--Enter the sum of Medicare acquisition cost reported from Worksheet E, Part A, line 55,
and Worksheet E, Part A, line 55.01.
Line 3--Enter the cost of physicians’ services in a teaching hospital reported from Worksheet E,
Part A, line 56.
Line 4--Sum lines 1 through 3.
Line 5--Enter the total facility cost reported from Worksheet C, Part I, line 202, column 5.
Line 6--Calculate the Medicare percentage by dividing line 4 by line 5, rounding the result to two
decimal places.
Line 7--Calculate the Medicare payment adjustment for essential medicines by multiplying line 6
by Part II, line 3. Transfer the payment adjustment to the Medicare Hospital and Hospital Health
Care Complex Cost Report, Form CMS-2552-10, Worksheet E, Part A, subscripted line 70.76,
labeled Essential Medicines Payment Adjustment.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-XXXX. The time required to complete this
information collection is estimated to be 1.00 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s), or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Please do not send applications, claims, payments, medical records, or any documents containing
sensitive information to the PRA Reports Clearance Office. Please note that any correspondence
not pertaining to the information collection burden approved under the associated OMB control
number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact 1-800-MEDICARE.