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

CHAPTER 39

HOME OFFICE COST STATEMENT

FORM CMS-287-05

Section

Home Office Costs - Chain Operations. 3900

Determination of Allowable Costs. 3901

Allocation of Home Office Costs to Components in Chain. 3902

Home Office Cost Statement. 3903

Disclosure of Home Office Cost Statement. 3904

Recommended Sequence for Completing Form CMS-287-05. 3905

Schedule A - General Information, Certification and

Listing of Chain Components. 3906

Part I - General Information. 3906.1

Part II - Certification by Officer of Home Office. 3906.2

Part III - Listing of Chain Components. 3906.3

Part IV - List of Other (Non-Provider) Chain Components. 3906.4

Part V - Listing of Regions or Divisions. 3906.5

Home Office Costs - Schedules B through I. 3907

Schedule B - Statement of Allowable Costs. 3908

Schedule B-1 - Reclassification of Home Office Expenses. 3909

Schedule B-2 - Analysis of Changes in Capital Asset Balances. 3910

Schedule C - Medicare Adjustments to Home Office Expenses. 3911

Schedule D - Statement of Costs of Services From Related Organizations. 3912

Schedule E - Direct Allocation of Home Office

Capital Costs to Chain Components. 3913

Schedule E-1 - Direct Allocation of Home

Office Non-Capital-Related Expenses to Chain Components. 3914

Schedule F - Parts I and II - Functional

Allocation of Home Office Capital-Related Expenses to Chain

Component 3915

Schedule F-1 - Parts I and II - Functional

Allocation of Home Office Non-Capital-Related

Expenses to Chain Components. 3916

Schedule G - Allocation of Pooled Costs to Chain Components. 3917

Schedule I - Statement of Revenue and Expenses. 3918

Schedule J - Balance Sheet 3919

Exhibit 1 – Form 287-05 Worksheets 3990

Rev. 1

39-1