Form Act-1 - West Virginia Acute Care Hospital Tax Page 2
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Information and Instructions
In addition to the Healthcare Provider Tax imposed on providers of inpatient and outpatient hospital
services, the Acute Care Hospital Tax is imposed on certain eligible acute care hospitals at the rate
of .45% on the gross receipts received or receivable by the eligible acute care hospital that provides
inpatient or outpatient hospital services in the State of West Virginia through a Medicaid upper payment
limit program.
Use this payment schedule to determine the due date of this return:
P
e
d
d
e r i o d
n d e d
u e
a t e
September 30, 2013
October 15, 2013
December 31, 2013
January 15, 2014
March 31, 2014
April 15, 2014
June 30, 2014
July 15, 2014
Enter the total dollar amount of gross receipts for inpatient hospital services. Multiply this amount
Line 1
by the tax rate in the Tax Rate column and enter the tax due in the Tax Due column. Gross receipts
means the amount received or receivable, whether in cash or in kind, from patients, third-party
payors and others for inpatient hospital services furnished by the provider, including retroactive
adjustments under reimbursement agreements with third-party payors, without any deduction
for any expenses of any kind: Provided, That accrual basis providers shall be allowed to reduce
gross receipts by their contractual allowances, to the extent such allowances are included therein,
and by bad debts, to the extent the amount of such bad debts was previously included in gross
receipts upon which the tax imposed by this section was paid.
Enter the total dollar amount of gross receipts for outpatient hospital services. Multiply this amount
Line 2
by the tax rate in the Tax Rate column and enter the tax due in the Tax Due column.
Line 3
Add lines 1 and 2 of the Tax Due column. This is the total Acute Care Hospital Tax owed to the
State.
Line 4
Enter the total amount remitted with the return.
Be sure to sign and date your return with the appropriate information.
Mail completed return along with payment to:
West Virginia State Tax Department
Tax Account Administration Division
PO Box 773
Charleston, WV 25323-0773
Form ACT-1
Page 2
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