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