Crosswalk

Revisions to Form CMS-1728-94 Home Health Agency (HHA) Cost Report Application/Update Form

The last revision to the Form CMS-1728-94 was 2013. The last major revision to the Form CMS-1728-94 was in 1994. These revisions of

Form CMS-1728-94 are:

1. Revisions to the hospital-based hospice worksheets to collect data to facilitate payment reform mandated by §3132 of ACA.

2. Revisions to the forms and instructions to incorporate data previously reported on the Provider Cost Report Reimbursement Questionnaire, Form CMS-339.

3. Removal of obsolete worksheets.

The overall burden to providers is estimated to remain unchanged as the proposed worksheets supersede worksheets currently in the cost report.

Changes

Issue #	Instructions Page #	Form Page #	Section	Old Package Form CMS‑1728‑94	New Package Form CMS‑1728‑94	Reason for the Change / Application of the instructions and accompanying worksheets	Burden Effect
1.	32-12.1- 32-12.5	32-304.1	3204.1	N/A	S-2-1	This worksheet incorporates relevant questions from the Form CMS-339 and eliminates a separate filing requirement.	Increase
2.	32-73 - 32-75.1	32-306	3239 - 3239.4	S-5	S-5	Effective for cost reporting periods beginning on or after October 1, 2015, HHA-based hospices will complete Worksheet S-5, Parts III & IV.	N/A
3.	32-45 - 32‑46	32-307	3220	S-6	N/A	Removed obsolete Worksheet S-6 for HHA-based CORFs reimbursed under fee schedule and no longer required to file for cost reporting periods ending on or after June 30, 2001.	N/A
4.	32-47 - 32-52	32-327 - 32-331	3221 - 3224	J series	N/A	Removed obsolete J series worksheets for HHA‑based CORFs reimbursed under fee schedule and no longer required to file for cost reporting periods ending on or after June 30, 2001.	N/A
5.	32-59 - 32-61	32-337 - 32-339	3229 -3230.3	RH series	N/A	Removed obsolete RH series worksheets for HHA‑based RHCs.	N/A
6.	32-62 - 32-64	32-340 - 32-342	3231 - 3232.3	FQ series	N/A	Removed obsolete FQ series worksheets for HHA‑based FQHCs.	N/A
7.	32-90 - 32-105	32-349 - 32-360	3247 - 3252	K; K-1; K-2; K-3; K-4, Parts I and II; K-5, Parts I through III; K-6	O; O-1; O-2; O-3; O-4; O-5; O-6, Parts I & II; O-7; and O-8	The forms and instructions are revised in accordance with the statutory requirement for hospice payment reform in §3132 of the ACA. These forms replace the previous K forms and are effective for cost reporting periods beginning on or after October 1, 2015.	N/A

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