Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

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Overview

B
B-1
B-2, Part I&II
B-2, Part III

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Sheet 1: B

3990 (Cont.)				FORM CMS 287-05						08-05
TRIAL BALANCE OF EXPENSES				Home Office:			Period		SCHEDULE
RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS							From:____________________		B
							To:______________________		page 1 of 3
		Expenses per		Reclassified		Net Allowable	Direct	Functional	Pooled
Cost Center Description		Home Office	Reclassifications	Trial Balance	Medicare	Expenses	Allocations	Allocations	Allocations
	(omit cents)	Books	(from Sch.B-1)	(col. 1minus/	Adjustments	(col.3 minus/plus	To Chain	To Chain	(col.5 minus
				plus col.2)	(from Sch.C)	col.4)	Components	Components	cols. 6,7)
		1	2	3	4	5	6	7	8
1.	Old Cap. Rel. Costs--Bldg and Fixtures									1
1.01	Int. Exp.-Old Capital Bldg and Fixtures									1.01
2.	Old Cap. Rel. Costs--Movable Equip.									2
2.01	Int. Exp.-Old Capital Movable Equip.									2.01
3.	Sub-Total (Lines 1 and 2)									3
4	New Cap. Rel. Costs--Bldg and Fixtures									4
4.01	Int. Exp.-New Capital Bldg and Fixtures									4.01
5	New Cap. Rel. Costs--Movable Equip.									5
5.01	Int. Exp.-New Capital Movable Equip.									5.01
6	Sub-Total (Lines 4 and 5)									6
	Other Capital Related Costs
	----------------------------------
7	Insurance Premiums									7
8	Taxes & Licenses (Other than Income)									8
9	Other (Specify)									9
10	Sub-Total (sum of lines 7-9)									10
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)
39-106										Rev. 1
08-05				FORM CMS 287-05						3990 (Cont.)
TRIAL BALANCE OF EXPENSES				Home Office:			Period		SCHEDULE
RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS							From:____________________		B
							To:______________________		page 2 of 3
		Expenses per		Reclassified		Net Allowable	Direct	Functional	Pooled
Cost Center Description		Home Office	Reclassifications	Trial Balance	Medicare	Expenses	Allocations	Allocations	Allocations
	(omit cents)	Books	(from Sch.B-1)	(col. 1minus/	Adjustments	(col.3 minus/plus	To Chain	To Chain	(col.5 minus
				plus col.2)	(from Sch.C)	col.4)	Components	Components	cols. 6,7)
		1	2	3	4	5	6	7	8
	Non-Capital Related Cost
11	Salaries of Officers									11
12	Salaries and Wages of Others									12
13	Payroll Taxes									13
14	Employee Benefits - Payroll Related									14
15	Employee Benefits - Non-Payroll Related									15
16	Profit Sharing/Pension Plans									16
17	Legal Fees									17
18	Auditing and Accounting Fees									18
19	Utilities									19
20	Communications									20
21	Travel and Entertainment									21
22	Transportation									22
23	Cleaning, Office and Adm. Supplies									23
24	Minor Equipment Expensed									24
25	Repairs and Maintenance									25
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)
Rev. 1										39-107
3990 (Cont.)				FORM CMS 287-05						08-05
TRIAL BALANCE OF EXPENSES				Home Office:			Period		SCHEDULE
RECLASSIFICATIONS, ADJUSTMENTS AND ALLOCATIONS							From:____________________		B
							To:______________________		page 3 of 3
		Expenses per		Reclassified		Net Allowable	Direct	Functional	Pooled
Cost Center Description		Home Office	Reclassifications	Trial Balance	Medicare	Expenses	Allocations	Allocations	Allocations
	(omit cents)	Books	(from Sch.B-1)	(col. 1minus/	Adjustments	(col.3 minus/plus	To Chain	To Chain	(col.5 minus
				plus col.2)	(from Sch.C)	col.4)	Components	Components	cols. 6,7)
		1	2	3	4	5	6	7	8
	Non Capital Related Cost (Cont.)
26	Dues and Subscriptions									26
27	Contributions									27
28	Insurance Premiums - Non-Cap. Rel.									28
29	Taxes and Licenses - Non-Cap. Rel.									29
30	Interest Expense									30
31	Interest Income									31
32	Other (Specify)									32
33	Other (Specify)									33
34	Other (Specify)									34
35	Other (Specify)									35
36	Sub-Total (sum of lines 11-35)									36
100	Total Exp. (sum of lines 3, 6, 10, 36)									100
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3908)
39-108										Rev. 1

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Sheet 2: B-1

08-05				FORM CMS 287-05					3990 (Cont.)
				Home Office:		Period:		SCHEDULE
	RECLASSIFICATION OF HOME OFFICE EXPENSES					From:_______________		B-1
						To: ________________
		Code		Increase			Decrease
	Explanation of Reclassification Entry	(1)	Cost Center	Line No.	Amount(2)	Cost Center	Line No.	Amount(2)
		1	2	3	4	5	6	7
1.									1.
2.									2.
3.									3.
4.									4.
5.									5.
6.									6.
7.									7.
8.									8.
9.									9.
10.									10.
11.									11.
12.									12.
13.									13.
14.									14.
15.									15.
16.									16.
17.									17.
18.									18.
	Total Reclassifications (Sum of col.4 must
100	equal sum of col.7)								100
(1) A letter (A,B, etc) must be entered on each line to identify each reclassification entry.
(2) Transfer to Schedule B, column 2, line as appropriate.
FORM CMS 287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3909)
Rev. 1									39-109

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Sheet 3: B-2, Part I&II

3990 (Cont.)				FORM CMS 287-05					08-05
ANALYSIS OF CHANGES DURING COST STATEMENT			Home Office:		PERIOD:
PERIOD IN CAPITAL ASSET BALANCES OF CHAIN					FROM: __________			SCHEDULE B-2
HOME OFFICE WHERE THE CHAIN INCLUDES HOSPITALS					TO: __________			PARTS I & II
SUBJECT TO THE PROSPECTIVE PAYMENT SYSTEM
PART I - ANALYSIS OF CHANGES IN OLD CAPITAL ASSET BALANCES
				Acquisitions		Disposals		Fully
		Beginning				and	Ending	Depreciated
	Description	Balances	Purchases	Donation	Total	Retirements	Balance	Assets
		1	2	3	4	5	6	7
1.	Land								1.
2.	Land Improvements								2.
3.	Buildings and Fixtures								3.
4.	Building Improvements								4.
5.	Fixed Equipment								5.
6.	Movable Equipment								6.
7.	SUBTOTAL								7.
8.	Reconciling Items								8.
9.	TOTAL (Line 7 minus line 8)								9.
PART II - ANALYSIS OF CHANGES IN NEW CAPITAL ASSET BALANCES
				Acquisitions		Disposals		Fully
		Beginning				and	Ending	Depreciated
	Description	Balances	Purchases	Donation	Total	Retirements	Balance	Assets
		1	2	3	4	5	6	7
1.	Land								1.
2.	Land Improvements								2.
3.	Buildings and Fixtures								3.
4.	Building Improvements								4.
5.	Fixed Equipment								5.
6.	Movable Equipment								6.
7.	SUBTOTAL								7.
8.	Reconciling Items								8.
9.	TOTAL (Line 7 minus line 8)								9.
FORM CMS 287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3910)
39-110									Rev. 1

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Sheet 4: B-2, Part III

08-05				FORM CMS 287-05						3990 (Cont.)
RECONCILIATION OF CAPITAL COSTS CENTERS				Home Office:		PERIOD:																																																																																																																		STATEMENT OF REVENUE AND EXPENSES									SCHEDULE
						FROM:		SCHEDULE B-2																																																																																																																									I
						TO:		Part III
																																																																																																																													Period
PART III																																																																																																																								Home Office:		Harrod Corporation			From: 10-1-91			To: 9-30-92
			COMPUTATION OF RATIOS				ALLOCATION OF OTHER CAPITAL
				Gross Assets					Total (1)
			Capitalized	for Ratio	Ratio			Other Capital-	(Sum of																																																																																																															l. Total operating revenue							$		9,856,982
	Description	Gross Assets	Leases	(Col. 1 - Col. 2)	(See Instructions)	Insurance	Taxes	Related Costs	Columns 5-7)
*		1	2	3	4	5	6	7	8
1	Old Cap. Rel Costs-Bldgs and Fixtures									1																																																																																																														2. Less: Operating expenses
2	Old Cap. Rel. Costs-Movable Equipment									2																																																																																																														(Schedule B, column 1, line 60)							$		(8,598,750)
3	New Cap. Rel Costs-Bldgs and Fixtures									3
4	New Cap. Rel. Costs-Movable Equipment									4
5	Total (Sum of Lines 1-4)									5
																																																																																																																								a. contributions, donations					$	18,450
																																																																																																																								b. income from investments					$	1,125,400
					SUMMARY OF OLD AND NEW CAPITAL																																																																																																																			c. interest income					$	75,600
								Other Capital-	Total (2)																																																																																																															d. purchase discounts					$	25,000
						Insurance	Taxes	Related Costs	(Sum of																																																																																																															e. rebates and refunds of expenses					$	32,600
	Description		Depreciation	Lease	Interest	(From Col. 5)	(From Col. 6)	(From Col. 7)	Columns 9-14)																																																																																																															f. parking lot receipts					$	8,560
*			9	10	11	12	13	14	15																																																																																																															g. rental income					$	1,256,901
1	Old Cap. Rel Costs-Bldgs and Fixtures									1
2	Old Cap. Rel. Costs-Movable Equipment									2
3	New Cap. Rel Costs-Bldgs and Fixtures									3
4	New Cap. Rel. Costs-Movable Equipment									4
5	Total (Sum of Lines 1-4)									5
*	All lines numbers except line 5 are to be consistent with Schedule B line numbers for capital cost centers																																																																																																																							5. Total other income
(1) The sum of the amounts on lines 1 thru 4 must equal the amount on Schedule B, column 2, lines 7-9, net of other capital-related costs directly allocated to components of the chain.
(2) The amounts on lines 1 thru 4 must equal the corresponding amounts on Schedule B, Column 3, lines 1,2,4,5 and 7-9.																																																																																																																								6. Other expenses (specify)					$
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3910)																																																																																																																													$
Rev. 1										39-111
																																																																																																																								8. Net income (loss) for the period (sum of lines 3, 5, 7)							$		#VALUE!
																																																																																																																								FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
																																																																																																																									PUB. 15-II, SECTION 3126)
																																	Chain Components	Base: Sq. Ft.	Sq. Ft.	Sq. Ft.	Sq. Ft.
																																		Building		Building
																																		and	Movable	and	Movable
																																	Health Care Facilities:	Fixtures	Equipment	Fixtures	Equipment
																																	-	1	2	3	4
																																1.	Lisaville Mount Hospital	1,300	1,300	2,000	2,000
																																2.	Canyon Hospital	900	900	1,250	1,250
																																3.	Valley Memorial Hospital	830	830	800	800
																																4.	Sunrise Health Center	750	750	900	900
																																5.	Knollwood Medical Center	925	925	1,630	1,630
																																6.	Oceanside Hospital	850	850	1,450	1,450
																																7.	River Cross Hospital	850	850	960	960
																																8.	Swansonside Hospital	775	775	880	880
																																9.	Distmont Medical Center	935	935	759	759
																																10.	Harvey Lake Hospital	800	800	650	650
																																11.	Irvine City Hospital	900	900	910	910
																																12.	Brownston Nursing Home	850	850	756	756
																																13.	Hunter Valley Home Health	900	900	689	689
																																14.
																																15.
																																16.
																																17.	Total (sum of lines 1-16)	11,565	11,565	13,634	13,634
																																FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3134)
																																FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL		Home Office:	Harrod Corporation	Period	SUPPLEMENTAL
																																COSTS TO CHAIN COMPONENTS---STATISTICS				From: 10-1-91	SCHEDULE F
																																				To: 9-30-92	Part II (Cont'd)
																																			Old Capital		New Capital
																																	Chain Components	Base:	Sq. Ft.		Sq. Ft.
																																		Building		Building
																																		and	Movable	and	Movable
																																	Other Components:	Fixtures	Equipment	Fixtures	Equipment
																																	-	1	2	3	4
																																18.	Harrod Hotel	8,000	500		12,000
																																19.
																																20.
																																21.
																																22.
																																23.
																																24.
																																25.
																																26.	Managed Facilities	8,000	440	2,000	550
																																27.	Total (sum of lines 18-26)	16,000	940	2,000	12,550
FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,																																	Regional Offices:
	SECTION 3121)																																-
																																28.	East Region	3,200	400	750	600
																																29.	West Region	1,600	330	761	700
																																30.
																																31.
																																32.	Total (sum of lines 28-31)	4,800	730	1,511	1,300
																																33.	Total statistics (sum of lines 17, 27 and 32)(A)	32,365	13,235	17,145	27,484		0
																																34.	Cost to be Allocated (B)	Err:520	Err:520	Err:520	Err:520
																																35.	Unit Cost Multiplier (B/A)	Err:520	Err:520	Err:520	Err:520
																																FORM CMS-287-92 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3134)