Form CMS-1728-20 HHA Cost Report

Home Health Agency Cost Report and Supporting Regulations (CMS-1728-20)

CMS-1728-20.HHA Cost Report - 5-20-20.xlsx

Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106

OMB: 0938-0022

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0022 can be found here:

2023-07-21 - Reinstatement without change of a previously approved collection

Document [xlsx]

Download: xlsx | pdf

Overview

S, Parts I-III
S-2, Part I
S-2, Part II
S-3, Parts I-III
S-3, Part IV
S-3, Part V
S-4, Parts I-II
A
A-6
A-8
A-8-1
B, B-1
C
D
D-1
F
F-1
O
O-1
O-2
O-3
O-4
O-5
O-6I
O-6II
O-7
O-8

Sheet 1: S, Parts I-III

DRAFT				FORM CMS-1728-20				4795 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim							FORM APPROVED
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).							OMB NO. 0938-0022
							EXPIRES: (insert expiration date)
HOME HEALTH AGENCY COST REPORT					HHA CCN:	PERIOD:	WORKSHEET S
CERTIFICATION AND SETTLEMENT SUMMARY					____________________	FROM: ______________	PARTS I, II & III
					____________________	TO: _________________

PART I - COST REPORT STATUS
Provider use only		1. [ ] Electronically prepared cost report			DATE: _____________	TIME: __________
		2. [ ] Manually prepared cost report (limited to low or no utilization)
		3. [ ] If this is an amended cost report enter the number of times the provider resubmitted this cost report.
		4. [ ] Medicare Utilization. Enter "F" for full, "L" for low, or "N" for no utilization.
Contractor use only		5. [ ] Cost Report Status	6. Date Received:_________			10. NPR Date:___________
		(1) As Submitted	7. Contractor No.:________			11. Contractor Vendor Code: ____________
		(2) Settled without audit	8. [ ] Initial Report for this HHA CCN			12. [ ] If line 5, column 1 is 4: Enter the number of
		(3) Settled with audit	9. [ ] Final Report for this HHA CCN			times reopened = 0-9.
		(4) Reopened
		(5) Amended

PART II - CERTIFICATION
	MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL,
	CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN
	THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT, DIRECTLY OR INDIRECTLY, OF A KICKBACK OR WERE OTHERWISE
	ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.


	CERTIFICATION BY CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)

	I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted
	cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Number(s)}for
	the cost reporting period beginning ______________ and ending ______________ and that to the best of my knowledge and belief, this report and statement
	are true, correct, complete and prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further certify
	that I am familiar with the laws and regulations regarding the provision of health care services, and that the services identified in this cost report were provided
	in compliance with such laws and regulations.

		I have read and agree with the above certification statement. I certify that I intend my electronic signature on this certification statement to be the
		legally binding equivalent of my original signature.




				(Signed)
					Chief Financial Officer or Administrator of Provider (s)

					Title

					Date


PART III - SETTLEMENT SUMMARY
						TITLE XVIII
						1

1	HOME HEALTH AGENCY							1
The above amount represents "due to" or "due from" the Medicare program














	According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
	The valid OMB control number for this information collection is 0938-0022. The time required to complete this information collection is estimated 195 hours per
	reponse, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
	have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
	Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or
	any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information
	collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
	concerns regarding where to submit your documents, please contact 1-800-MEDICARE.
FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4704 - 4704.3)
Rev. 1								47-503

Sheet 2: S-2, Part I

4795 (Cont.)					FORM CMS-1728-20					DRAFT
IDENTIFICATION DATA							HHA CCN:	PERIOD:	WORKSHEET S-2,
							____________________	FROM: ______________	PART I
							____________________	TO: _________________

HOME HEALTH AGENCY COMPLEX ADDRESS
			STREET		P. O. BOX
			1		2
1	Address 1									1
			CITY		STATE	ZIP CODE
			1		2	3
2	Address 1									2

HOME HEALTH AGENCY COMPONENT IDENTIFICATION
		COMPONENT NAME						PROVIDER CCN	DATE CERTIFIED
		1						2	3
3	Home Health Agency									3
4	HHA-based Hospice									4
		From:	To:
		1	2
5	Cost Reporting Period:									5

6	Type of control (see instructions)									6
7	Does the HHA qualify as a nominal charge provider (see 42 CFR 409.3)?									7
8	Does the HHA contract with outside suppliers for physical therapy services?									8
9	Does the HHA contract with outside suppliers for occupational therapy services?									9
10	Does the HHA contract with outside suppliers for speech therapy services?									10
11	Are there any costs included in Worksheet A that resulted from transactions with related organizations or home office costs									11
	as defined in CMS Pub. 15-1, chapter 10? If yes, complete Worksheet A-8-1.

MALPRACTICE INSURANCE INFORMATION
12	Is this HHA legally required to carry malpractice insurance? Enter "Y" for yes or "N" for no.									12
13	If line 12 is yes, is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.									13
							PREMIUMS	PAID LOSSES	SELF-INSURANCE
							1	2	3
14	List amounts of malpractice premiums, paid losses, and self-insurance in the applicable columns.									14
15	Are malpractice premiums and paid losses reported in a cost center other than A&G? If yes, submit supporting schedule listing cost centers and amounts contained therein.									15

HOME OFFICE INFORMATION								1	2
16	Does this HHA receive an allocation of costs from more than one home office? (see instructions)									16
17	Is this HHA part of a home office or chain organization? Enter in column 1, "Y" for yes or "N" for no.									17
	If column 1 is yes, and home office costs are claimed, complete line 18.
				HOME	HOME OFFICE
				OFFICE	CONTRACTOR	STREET
		HOME OFFICE NAME		NUMBER	NUMBER	ADDRESS	CITY	STATE	ZIP CODE
		1		2	3	4	5	6	7
18	Home Office Information									18











FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4705)
47-504										Rev. 1

Sheet 3: S-2, Part II

DRAFT				FORM CMS-1728-20				4795 (Cont.)
REIMBURSEMENT DATA					HHA CCN:	PERIOD:	WORKSHEET S-2,
					____________________	FROM: _____________	PART II
					____________________	TO: _______________

PROVIDER ORGANIZATION AND OPERATION
					Y/N	Date	V/I
					1	2	3
1	Has the HHA changed ownership prior to the beginning of this cost reporting							1
	period? (see instructions) Enter "Y" for yes or "N" for no in column 1.
	If yes, enter the date of the change in column 2. (see instructions)
2	Has the HHA terminated participation in the Medicare program? Enter "Y" for							2
	yes or "N" for no in column 1. If yes, enter in column 2 the termination
	date, and enter in column 3, "V" for voluntary or "I" for involuntary.
3	Is the HHA involved in business transactions, including management contracts,							3
	with individuals or entities (e.g., chain home offices, drug or medical supply
	supply companies) that are related to the provider or its officers, medical staff,
	management personnel, or members of the board of directors through
	ownership, control, or family and other similar relationships? Enter "Y"
	for yes or "N" for no in column 1. (see instructions)

FINANCIAL DATA AND REPORTS
					Y/N	A / C / R	Date
					1	2	3
4	Column 1: Were the financial statements prepared by a certified public							4
	accountant? Enter "Y" for yes or "N" for no.
	Column 2: If yes, enter: "A" for audited, "C" for compiled, or "R" for reviewed.
	Submit complete copy of financialstatements or enter date available in column 3.
5	Are the cost report total expenses and total revenues different from those on							5
	the filed financial statements? Enter "Y" for yes or "N" for no in column 1. If
	yes, submit reconciliation.

BAD DEBT
							Y/N
6	Is the HHA or HHA-based entities seeking reimbursement for bad debts? If yes, see instructions.							6
7	If line 6 is yes, did the HHA's bad debt collection policy change during this cost reporting period? If yes, submit copy.							7
8	If line 6 is yes, were patient coinsurance amounts waived? If yes, see instructions.							8

PS&R REPORT DATA
						Y/N	Date
						1	2
9	Was the cost report prepared using the PS&R report only? Enter "Y" for yes or "N" for no in column 1.							9
	If yes, enter in column 2 the paid-through date of the PS&R report used to prepare the cost
	report. (mm/dd/yyyy) (see instructions.)
10	Was the cost report prepared using the PS&R report for totals and the provider's records for allocation?							10
	Enter "Y" for yes or "N" for no in column 1. If yes, enter in column 2 the paid-through date of the
	PS&R report. (mm/dd/yyyy) (see instructions)
11	If line 9 or 10 is yes, were adjustments made to PS&R report data for additional claims that have been							11
	billed but are not included on the PS&R report used to file the cost report? Enter "Y" for yes or
	"N" for no. If yes, see instructions.
12	If line 9 or 10 is yes, were adjustments made to PS&R report data for corrections of other PS&R report							12
	information? Enter "Y" for yes or "N" for no. If yes, see instructions.
13	If line 9 or 10 is yes, were adjustments made to PS&R Report data for Other? If yes, describe							13
	the other adjustments: ____________________________________
14	Was the cost report prepared only using the HHA's records? Enter "Y" for yes or "N" for no. If yes,							14
	see instructions.

COST REPORT PREPARER CONTACT INFORMATION
		FIRST NAME	LAST NAME			Title
		1	2			3
15	Preparer							15

16	Employer Name							16

		TELEPHONE NUMBER	EMAIL ADDRESS
		1	2
17	Contact							17











FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4706)
Rev. 1								47-505

Sheet 4: S-3, Parts I-III

4795 (Cont.)				FORM CMS-1728-20						DRAFT
STATISTICAL DATA				HHA CCN:		PERIOD:		WORKSHEET S-3
				____________________		FROM: ______________		PARTS I, II, & III
				____________________		TO: _________________

PART I - VISITS DATA

		TITLE XVIII - MEDICARE		TITLE XIX - MEDICAID		OTHER		TOTAL
			PATIENT		PATIENT		PATIENT		PATIENT
	DESCRIPTION	VISITS	CENSUS	VISITS	CENSUS	VISITS	CENSUS	VISITS	CENSUS
		1	2	3	4	5	6	7	8
1	Skilled Nursing Care - Registered Nurse									1
2	Skilled Nursing Care - Licensed Practical Nurse									2
3	Physical Therapy									3
4	Physical Therapy Assistant									4
5	Occupational Therapy									5
6	Certified Occupational Therapy Assistant									6
7	Speech-Language Pathology									7
8	Medical Social Service									8
9	Home Health Aide									9
10	All Other Services									10
11	Total Visits									11
12	Home Health Aide Hours									12
13	Unduplicated Census Count									13

PART II - EMPLOYMENT DATA (FULL TIME EQUIVALENT)
14	Number of hours in your normal work week									14
				STAFF		CONTRACT		TOTAL
				1		2		3
15	Administrator and Assistant Administrator(s)									15
16	Director and Assistant Director(s)									16
17	Other Administrative Personnel									17
18	Nursing Supervisor									18
19	Registered Nurses									19
20	Licensed Practical Nurses									20
21	Physical Therapy Supervisor									21
22	Physical Therapists									22
23	Physical Therapy Assistants									23
24	Occupational Therapy Supervisor									24
25	Occupational Therapists									25
26	Occupational Therapy Assistants									26
27	Speech-Language Pathology Supervisor									27
28	Speech-Language Pathologists									28
29	Medical Social Services Supervisor									29
30	Medical Social Services									30
31	Home Health Aide Supervisor									31
32	Home Health Aides									32
33										33

PART III - CORE BASED STATISTICAL AREA DATA
								1
34	Enter the total number of CBSAs where Medicare covered services were provided during the cost reporting period.									34
								CBSA Codes
35	List all CBSA codes for areas where Medicare covered home health services were provided. (see instructions)									35
























FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4707 - 4707.3)
47-506										Rev. 1

Sheet 5: S-3, Part IV

DRAFT		FORM CMS-1728-20					4795 (Cont.)
STATISTICAL DATA				HHA CCN:	PERIOD:	WORKSHEET S-3
				____________________	FROM: ______________	PART IV
				____________________	TO: _________________

PART IV - PPS ACTIVITY DATA
		FULL EPISODES/	FULL EPISODES/	LUPA	PEP	TOTAL
		PERIODS	PERIODS	EIPSODES/	EIPSODES/	EIPSODES/
	DESCRIPTION	WITHOUT OUTLIERS	WITH OUTLIERS	PERIODS	PERIODS	PERIODS
		1	2	3	4	5
1	Skilled Nursing Care Visits						1
2	Skilled Nursing Care Charges						2
3	Physical Therapy Visits						3
4	Physical Therapy Charges						4
5	Occupational Therapy Visits						5
6	Occupational Therapy Charges						6
7	Speech-Language Pathology Visits						7
8	Speech-Language Pathology Charges						8
9	Medical Social Service Visits						9
10	Medical Social Service Charges						10
11	Home Health Aide Visits						11
12	Home Health Aide Charges						12
13	Total Visits (sum of lines 1, 3, 5, 7, 9, and 11)						13
14	Other Charges						14
15	Total Charges (sum of lines 2, 4, 6, 8, 10, 12, and 14)						15
16	Total Number of Episodes/Periods						16
17	Total Number of Outlier Episodes/Periods						17
18	Total Non-Routine Medical Supply Charges						18






























FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4707.4)
Rev. 1							47-507

Sheet 6: S-3, Part V

4795 (Cont.)		FORM CMS-1728-20					DRAFT
STATISTICAL DATA				HHA CCN:	PERIOD:	WORKSHEET S-3
DIRECT CARE EXPENDITURES				____________________	FROM: ______________	PART V
				____________________	TO: _________________

		AMOUNT	FRINGE	ADJUSTED	PAID HOURS	AVERAGE
		REPORTED	BENEFITS	SALARIES	RELATED TO SALARY	HOURLY WAGE
	OCCUPATIONAL CATEGORY	1	2	3	4	5
Direct Salaries
	Nursing Occupations
1	Nursing Supervisor						1
2	Registered Nurses						2
3	Licensed Practical Nurses						3
4	Total Nursing (sum of lines 1 through 3)						4
5	Physical Therapy Supervisor						5
6	Physical Therapists						6
7	Physical Therapy Assistants						7
8	Occupational Therapy Supervisor						8
9	Occupational Therapists						9
10	Occupational Therapy Assistants						10
11	Speech-Language Pathology Supervisor						11
12	Speech-Language Pathologists						12
13	Other Medical Staff						13

Contract Labor
	Nursing Occupations
14	Nursing Supervisor						14
15	Registered Nurses						15
16	Licensed Practical Nurses						16
17	Total Nursing (sum of lines 14 through 16)						17
18	Physical Therapy Supervisor						18
19	Physical Therapists						19
20	Physical Therapy Assistants						20
21	Occupational Therapy Supervisor						21
22	Occupational Therapists						22
23	Occupational Therapy Assistants						23
24	Speech-Language Pathology Supervisor						24
25	Speech-Language Pathologists						25
26	Other Medical Staff						26



















FORM CMS-1728-20 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4707.5)
47-508							Rev. 1

Sheet 7: S-4, Parts I-II

DRAFT		FORM CMS-1728-20				4795 (Cont.)
HHA-BASED HOSPICE STATISTICAL DATA			HHA CCN:	PERIOD:	WORKSHEET S-4
			_________________	FROM: ___________	PARTS I & II
			HOSPICE CCN:	TO: ______________
			_________________

PART I - ENROLLMENT DAYS
		UNDUPLICATED DAYS
		TITLE XVIII	TITLE XIX
		MEDICARE	MEDICAID	OTHER	TOTAL
		1	2	3	4
1	Hospice Continuous Home Care					1
2	Hospice Routine Home Care					2
3	Hospice Inpatient Respite Care					3
4	Hospice General Inpatient Care					4
5	Total Hospice Days					5

PART II - CONTRACTED STATISTICAL DATA
		TITLE XVIII	TITLE XIX
		MEDICARE	MEDICAID	OTHER	TOTAL
		1	2	3	4
6	Hospice Inpatient Respite Care					6
7	Hospice General Inpatient Care					7























































FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4708 - 4708.2)
Rev. 1						47-509

Sheet 8: A

4795 (Cont.)						FORM CMS-1728-20							DRAFT
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES								HHA CCN:		PERIOD:		WORKSHEET A
								____________________		FROM: ______________
								____________________		TO: _________________
						CON-				RECLASSI-		EXPENSES
						TRACTED				FIED		FOR
				EMPLOYEE	TRANSPOR-	PURCHASED	OTHER		RECLASSI-	TRIAL	ADJUST-	COST
			SALARIES	BENEFITS	TATION	SERVICES	COSTS	TOTAL	FICATION	BALANCE	MENTS	ALLOCATION
			1	2	3	4	5	6	7	8	9	10
		GENERAL SERVICE COST CENTERS
1	0100	Capital Related - Buildings & Fixtures											1
2	0200	Capital Related - Movable Equipment											2
3	0300	Plant Operation & Maintenance											3
4	0400	Transportation (see instructions)											4
5	0500	Telecommunications Technology											5
6	0600	Administrative and General											6
7	0700	Nursing Administration											7
8	0800	Medical Records											8
9	0900												9
		HHA REIMBURSABLE SERVICES
16	1600	Skilled Nursing Care - Registered Nurse											16
17	1700	Skilled Nursing Care - Licensed Practical Nurse											17
18	1800	Physical Therapy											18
19	1900	Physical Therapy Assistant											19
20	2000	Occupational Therapy											20
21	2100	Certified Occupational Therapy Assistant											21
22	2200	Speech-Language Pathology											22
23	2300	Medical Social Services											23
24	2400	Home Health Aide											24
25	2500	Medical Supplies Charged to Patients											25
26	2600	Drugs											26
27	2700	Cost of Administering Vaccines											27
28	2800	Durable Medical Equipment/Oxygen											28
29	2900	Disposable Devices											29
30	3000												30
		HHA NONREIMBURSABLE SERVICES
39	3900	Home Dialysis Aide Services											39
40	4000	Respiratory Therapy											40
41	4100	Private Duty Nursing											41
42	4200	Clinic											42
43	4300	Health Promotion Activities											43
44	4400	Day Care Program											44
45	4500	Home Delivered Meals Program											45
46	4600	Homemaker Services											46
47	4700	Telehealth											47
48	4800	Advertising											48
49	4900	Fundraising											49
50	5000												50
		SPECIAL PURPOSE COST CENTERS
57	5700	Hospice											57
58	5800												58
100		Total											100






FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4709)
47-510													Rev. 1

Sheet 9: A-6

DRAFT						FORM CMS-1728-20						4795 (Cont.)
RECLASSIFICATIONS								HHA CCN:	PERIOD:		WORKSHEET A-6
								____________________	FROM: ______________
								____________________	TO: _________________

			INCREASE					DECREASE
				WS A					WS A
				LINE					LINE
		CODE1	COST CENTER	NO.	SALARY2		OTHER2	COST CENTER	NO.	SALARY2	OTHER2
	EXPLANATION OF RECLASSIFICATION(S)	1	2	3	4		5	6	7	8	9
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
19												19
20												20
21												21
22												22
23												23
24												24
25												25











100	TOTAL RECLASSIFICATIONS											100

	1 A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
	2 Transfer the amounts in columns 4, 5, 8 and 9 to Worksheet A, column 7, lines as appropriate.








FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4710)
Rev. 1												47-511

Sheet 10: A-8

4795 (Cont.)		FORM CMS-1728-20				DRAFT
ADJUSTMENTS TO EXPENSES			HHA CCN:	PERIOD:	WORKSHEET A-8
			__________________	FROM: __________
			__________________	TO: _____________

				EXPENSE CLASSIFICATION ON
				WORKSHEET A TO/FROM WHICH
		BASIS /		THE AMOUNT IS TO BE ADJUSTED
		CODE2	AMOUNT	Cost Center	Line No.
	DESCRIPTION1	1	2	3	4
1	Excess funds generated from operations, other than net income					1
2	Trade, quantity, time and other discounts on purchases (chapter 8)					2
3	Rebates and refunds of expenses (chapter 8)					3
4	Related organization transactions (chapter 10)	WKST A-8-1				4
5	Sale of medical records and abstracts					5
6	Income from imposition of interest, finance or penalty charges					6
7	Sale of medical and surgical supplies to other than patients					7
8	Sale of Drugs to other than patients					8
9	Interest expense on Medicare overpayments and borrowings					9
	to repay Medicare overpayments
10	Lobbying Activities (chapter 21)					10
11	Advertising costs (chapter 21)					11
12						12
13						13
14						14
15						15
16						16
17						17
18						18
19						19
20						20
21						21
22						22
23						23
24						24
25						25
26						26
27						27
28						28
29						29
30						30
31						31
32						32
33						33
34						34
35						35
36						36
37						37
38						38
39						39
40						40
41						41
42						42
43						43
44						44
45						45
46						46
47						47
48						48
49						49
50	TOTAL (sum of lines 1 through 49)					50

	1Description - All line references in this column pertain to the CMS Pub. 15-1
	2Basis for adjustment (see instructions)
	A. Costs - if cost, including applicable overhead, can be determined
	B. Amount Received - If cost cannot be determined












FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4711)
47-512						Rev. 1

Sheet 11: A-8-1

DRAFT				FORM CMS-1728-20						4795 (Cont.)
STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS							HHA CCN:	PERIOD:	WORKSHEET A-8-1
AND HOME OFFICE COSTS							____________________	FROM: ______________
							____________________	TO: _________________

PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR CLAIMED HOME OFFICE COSTS
						H.O.	AMOUNT OF	AMOUNT INCLUDED
	WKST A				PART II	W/S S-2,	ALLOWABLE	IN WKST. A,	NET
	LINE NO.	COST CENTER	EXPENSE ITEM		LINE NO.	PART I	COST	COL. 8	ADJUSTMENTS
	1	2	3		4	5	6	7	8*
1										1
2									0	2
3									0	3
4									0	4
5									0	5




50	TOTALS (sum of lines 1 through 49) Transfer col. 8, line 50, to Wkst. A-8, line 4, col. 2.									50

	* The amounts on lines 1 through 49 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 9, lines as appropriate.
	Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
	been posted to Worksheet A, columns 1 through 5, the amount allowable should be indicated in column 6 of this section.


PART II - INTERRELATIONSHIP TO RELATED ORGANIZATIONS AND/OR HOME OFFICE
THE SECRECTARY, BY VIRTUE OF THE AUTHORITY GRANTED UNDER SECTION 1814(b)(1) OF THE SOCIAL SECURITY ACT, REQUIRES THE HHA TO FURNISH THE INFORMATION REQUESTED ON PART II OF
THIS WORKSHEET.

THIS INFORMATION IS USED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES AND ITS CONTRACTORS IN DETERMINING THE COSTS APPLICABLE TO SERVICES, FACILITIES, AND SUPPLIES FURNISHED
BY ORGANIZATIONS RELATED TO YOU BY COMMON OWNERSHIP OR CONTROL REPRESENT REASONABLE COSTS AS DETERMINED UNDER SECTION 1861 OF THE SOCIAL SECURITY ACT. IF YOU DO NOT PROVIDE
ALL OR ANY PART OF THE REQUESTED INFORMATION, THE COST REPORT IS CONSIDERED INCOMPLETE AND NOT ACCEPTABLE FOR PURPOSES OF CLAIMING REIMBURSEMENT UNDER TITLE XVIII.

					RELATED ORGANIZATIONS AND/OR HOME OFFICE
				PERCENT OF				PERCENT OF	TYPE OF
	SYMBOL1	NAME		OWNERSHIP	NAME			OWNERSHIP	BUSINESS
	1	2		3	4			5	6
1										1
2										2
3										3
4										4
5										5



50										50

	1Use the following symbols to indicate interrelationship to related organizations:
		A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in HHA.
		B. Corporation, partnership or other organization has financial interest in HHA.
		C. HHA has financial interest in corporation, partnership or other organization.
		D. Director, officer, administrator or key person of HHA or relative of such person has financial interest in related organization.
		E. Individual is director, officer, administrator or key person of HHA and related organization.
		F. Director, officer, administrator or key person of related organization or relative of such person has financial interest in HHA.
		G. Other (financial or non-financial) specify ___________________________.


FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4712)
Rev. 1										47-513

Sheet 12: B, B-1

4795 (Cont.)					FORM CMS-1728-20					DRAFT	DRAFT				FORM CMS-1728-20					4795 (Cont.)
COST ALLOCATION							HHA CCN:	PERIOD:	WORKSHEET B		COST ALLOCATION						HHA CCN:	PERIOD:	WORKSHEET B
ALLOCATION OF GENERAL SERVICE COSTS							____________________	FROM: ______________			ALLOCATION OF GENERAL SERVICE COSTS						____________________	FROM: ______________
							____________________	TO: _________________									____________________	TO: _________________
				CAPITAL
			NET EXPENSES	RELATED COSTS		PLANT			TELE-					ADMINISTRA-	NURSING			OTHER
			FOR COST	BLDGS &	MOVABLE	OPERATION &	TRANS-		COMMUN.					TIVE	ADMINISTRA-		MEDICAL	GENERAL
			ALLOCATION	FIXTURES	EQUIPMENT	MAINTENANCE	PORTATION	SUBTOTAL	TECHNOLOGY				SUBTOTAL	& GENERAL	TION	SUBTOTAL	RECORDS	SERVICE	TOTAL
			0	1	2	3	4	4A	5				5A	6	7	7A	8	9	10
	GENERAL SERVICE COST CENTERS											GENERAL SERVICE COST CENTERS
1	Capital Related - Buildings and Fixtures			0						1	1	Capital Related - Buildings and Fixtures								1
2	Capital Related - Movable Equipment			0	0					2	2	Capital Related - Movable Equipment								2
3	Plant Operation & Maintenance			0	0	0				3	3	Plant Operation & Maintenance								3
4	Transportation (see instructions)			0	0	0				4	4	Transportation (see instructions)								4
5	Telecommunications Technology									5	5	Telecommunications Technology								5
6	Administrative and General									6	6	Administrative and General								6
7	Nursing Administration									7	7	Nursing Administration								7
8	Medical Records									8	8	Medical Records								8
9	Other General Service									9	9	Other General Service								9
	HHA REIMBURSABLE SERVICES											HHA REIMBURSABLE SERVICES
16	Skilled Nursing Care - Registered Nurse			0	0	0				16	16	Skilled Nursing Care - Registered Nurse		0						16
17	Skilled Nursing Care - Licensed Practical Nurse									17	17	Skilled Nursing Care - Licensed Practical Nurse								17
18	Physical Therapy			0	0	0				18	18	Physical Therapy		0						18
19	Physical Therapy Assistant									19	19	Physical Therapy Assistant								19
20	Occupational Therapy			0	0	0				20	20	Occupational Therapy		0						20
21	Certified Occupational Therapy Assistant									21	21	Certified Occupational Therapy Assistant								21
22	Speech-Language Pathology			0	0	0				22	22	Speech-Language Pathology		0						22
23	Medical Social Services			0	0	0				23	23	Medical Social Services		0						23
24	Home Health Aide			0	0	0				24	24	Home Health Aide		0						24
25	Medical Supplies Charged to Patients			0	0	0				25	25	Medical Supplies Charged to Patients		0						25
26	Drugs			0	0	0				26	26	Drugs		0						26
27	Cost of Administering Vaccines									27	27	Cost of Administering Vaccines								27
28	Durable Medical Equipment/Oxygen			0	0	0				28	28	Durable Medical Equipment/Oxygen		0						28
29	Disposable Devices									29	29	Disposable Devices								29
30										30	30									30
	HHA NONREIMBURSABLE SERVICES											HHA NONREIMBURSABLE SERVICES
39	Home Dialysis Aide Services									39	39	Home Dialysis Aide Services								39
40	Respiratory Therapy									40	40	Respiratory Therapy								40
41	Private Duty Nursing									41	41	Private Duty Nursing								41
42	Clinic									42	42	Clinic								42
43	Health Promotion Activities									43	43	Health Promotion Activities								43
44	Day Care Program									44	44	Day Care Program								44
45	Home Delivered Meals Program									45	45	Home Delivered Meals Program								45
46	Homemaker Services									46	46	Homemaker Services								46
47	Telehealth									47	47	Telehealth								47
48	Advertising									48	48	Advertising								48
49	Fundraising									49	49	Fundraising								49
50										50	50									50
	SPECIAL PURPOSE COST CENTER											SPECIAL PURPOSE COST CENTER
57	Hospice									57	57	Hospice								57
58										58	58									58
100	Total			0	0	0				100	100	Total		0						100





FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4713)											FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4713)
47-514										Rev. 1	Rev. 1									47-515
4795 (Cont.)					FORM CMS-1728-20					DRAFT	DRAFT				FORM CMS-1728-20					4795 (Cont.)
COST ALLOCATION							HHA CCN:	PERIOD:			COST ALLOCATION						HHA CCN:	PERIOD:	WORKSHEET B-1
STATISTICAL BASES							____________________	FROM: ______________			STATISTICAL BASES						____________________	FROM: ______________
							____________________	TO: _________________									____________________	TO: _________________
				CAPITAL
				RELATED COSTS		PLANT			TELE-					ADMINISTRA-	NURSING
				BLDGS &	MOVABLE	OPERATION &	TRANS-		COMMUN.					TIVE	ADMINISTRA-		MEDICAL	OTHER
				& FIXTURES	EQUIPMENT	MAINTENANCE	PORTATION		TECHNOLOGY					& GENERAL	TION		RECORDS	GENERAL
		COST CENTER		(SQUARE	(DOLLAR	(SQUARE		RECONCIL-	(ACCUM.				RECONCIL-	(ACCUM.	(DIRECT	RECONCIL-	(ACCUM.	SERVICE
				FEET)	VALUE)	FEET)	(MILEAGE)	IATION	COST)				IATION	COST)	NURS HRS)	IATION	COST)	(SPECIFY)	TOTAL
				1	2	3	4	5A	5				6A	6	7	8A	8	9	10
	GENERAL SERVICE COST CENTER											GENERAL SERVICE COST CENTER
1	Capital Related - Buildings and Fixtures									1	1	Capital Related - Buildings and Fixtures								1
2	Capital Related - Movable Equipment									2	2	Capital Related - Movable Equipment								2
3	Plant Operation & Maintenance									3	3	Plant Operation & Maintenance								3
4	Transportation (see instructions)									4	4	Transportation (see instructions)								4
5	Telecommunications Technology									5	5	Telecommunications Technology								5
6	Administrative and General									6	6	Administrative and General								6
7	Nursing Administration									7	7	Nursing Administration								7
8	Medical Records									8	8	Medical Records								8
9	Other General Service									9	9	Other General Service								9
	HHA REIMBURSABLE SERVICES											HHA REIMBURSABLE SERVICES
16	Skilled Nursing Care - Registered Nurse									16	16	Skilled Nursing Care - Registered Nurse								16
17	Skilled Nursing Care - Licensed Practical Nurse									17	17	Skilled Nursing Care - Licensed Practical Nurse								17
18	Physical Therapy									18	18	Physical Therapy								18
19	Physical Therapy Assistant									19	19	Physical Therapy Assistant								19
20	Occupational Therapy									20	20	Occupational Therapy								20
21	Certified Occupational Therapy Assistant									21	21	Certified Occupational Therapy Assistant								21
22	Speech-Language Pathology									22	22	Speech-Language Pathology								22
23	Medical Social Services									23	23	Medical Social Services								23
24	Home Health Aide									24	24	Home Health Aide								24
25	Medical Supplies Charged to Patients									25	25	Medical Supplies Charged to Patients								25
26	Drugs									26	26	Drugs								26
27	Cost of Administering Vaccines									27	27	Cost of Administering Vaccines								27
28	Durable Medical Equipment/Oxygen									28	28	Durable Medical Equipment/Oxygen								28
29	Disposable Devices									29	29	Disposable Devices								29
30										30	30									30
	HHA NONREIMBURSABLE SERVICES											HHA NONREIMBURSABLE SERVICES
39	Home Dialysis Aide Services									39	39	Home Dialysis Aide Services								39
40	Respiratory Therapy									40	40	Respiratory Therapy								40
41	Private Duty Nursing									41	41	Private Duty Nursing								41
42	Clinic									42	42	Clinic								42
43	Health Promotion Activities									43	43	Health Promotion Activities								43
44	Day Care Program									44	44	Day Care Program								44
45	Home Delivered Meals Program									45	45	Home Delivered Meals Program								45
46	Homemaker Services									46	46	Homemaker Services								46
47	Telehealth									47	47	Telehealth								47
48	Advertising									48	48	Advertising								48
49	Fundraising									49	49	Fundraising								49
50										50	50									50
	SPECIAL PURPOSE COST CENTER											SPECIAL PURPOSE COST CENTER
57	Hospice									57	57	Hospice								57
58										58	58									58
100	Cost To Be Allocated (per wkst B)									100	100	Cost To Be Allocated (per wkst B)								100
101	Unit Cost Multiplier									101	101	Unit Cost Multiplier								101


FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4713)											FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4713)
47-516										Rev. 1	Rev. 1									47-517

Sheet 13: C

4795 (Cont. )					FORM CMS-1728-20											DRAFT
APPORTIONMENT OF PATIENT SERVICE COSTS									HHA CCN:		PERIOD:			WORKSHEET C
									____________________		FROM: ____________			PARTS I & II
									____________________		TO: _____________

PART I - AGGREGATE HHA COST PER VISIT AND AGGREGATE MEDICARE COST COMPUTATION
						FROM							HHA		HHA
COST PER VISIT COMPUTATION						WKST. B,					AVERAGE		MEDICARE		MEDICARE
						COL. 10,	TOTAL				COST		PROGRAM		PROGRAM
	PATIENT SERVICES					LINE:		COST		VISITS	PER VISIT		VISITS		COSTS
						1		2		3	4		5		6
1	Skilled Nursing Care - Registered Nurse					16										1
2	Skilled Nursing Care - Licensed Practical Nurse					17										2
3	Physical Therapy					18										3
4	Physical Therapy Assistant					19										4
5	Occupational Therapy					20										5
6	Certified Occupational Therapy Assistant					21										6
7	Speech-Language Pathology					22										7
8	Medical Social Services					23										8
9	Home Health Aide Services					24										9
10	Total (sum of lines 1-9)															10

PART II - SUPPLIES, DRUGS, AND DISPOSABLE DEVICES COST COMPUTATION
								MEDICARE COVERED CHARGES					COST OF MEDICARE SERVICES
							HHA SERVICES					HHA SERVICES
		FROM				OPPS		NOT SUBJECT		SUBJECT	OPPS		NOT SUBJECT		SUBJECT
		WKST. B,	TOTAL	TOTAL		REIMBURSED		TO DED &		TO DED &	REIMBURSED		TO DED &		TO DED &
	OTHERE PATIENT SERVICES	COL. 10	COST	CHARGES	RATIO	SERVICES		COINSUR		COINSUR	SERVICES		COINSUR		COINSUR
		LINE:	1	2	3	4		5		6	7		8		9
11	Cost of Medical Supplies	25														11
12	Cost of Drugs	26														12
13	Cost of Administering Vaccines	27														13
14	Disposable Devices	29														14
























FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4714 - 4714.2)
47-518																Rev. 1

Sheet 14: D

DRAFT		FORM CMS-1728-20				4795 (Cont.)
CALCULATION OF REIMBURSEMENT SETTLEMENT			HHA CCN:	PERIOD:	WORKSHEET D
			__________________	FROM: ______________
			__________________	TO: _________________

PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES FOR VACCINES

				NOT SUBJECT	SUBJECT
				TO DEDUCTIBLES	TO DEDUCTIBLES
				& COINSURANCE	& COINSURANCE
				1	2
1	Reasonable cost of vaccines (see instructions)					1
2	Total vaccines charges					2
3	Aggregate amount actually collected from patients liable for payment for services on a					3
	charge basis (from your records)
4	Amount that would have been realized from patients liable for payment for services on					4
	a charge basis had such payment been made in accordance with 42 CFR 413.13(e)
5	Ratio of line 3 to 4 (not to exceed 1.000000)					5
6	Total customary charges (multiply line 5 by line 2 for columns 1 and 2) (see instructions)					6
7	Excess of total customary charges over total reasonable cost (complete only if					7
	line 6 exceeds line 1) (see instructions)
8	Excess of reasonable cost over customary charges (see instructions)					8
9	Subtotal of Reasonable Cost (see instructions)					9

PART - COMPUTATION OF REIMBURSEMENT SETTLEMENT	II - COMPUTATION OF REIMBURSEMENT SETTLEMENT

10	Total PPS payment - full episodes/periods without outliers					10
11	Total PPS payment - full episodes/periods with outliers					11
12	Total PPS payment - LUPA episodes/periods					12
13	Total PPS payment - PEP episodes/periods					13
14	Total PPS outlier payment - full episodes/periods with outliers					14
15	Total PPS outlier payment - PEP episodes/periods					15
16	Total other payments (specify)					16
17	Payment for services reimbursed under OPPS					17
18	DME Payment					18
19	Oxygen Payment					19
20	Prosthetics and Orthotics Payment					20
21	Primary Payer Payments					21
22	Part B deductibles billed to Medicare patients (exclude coinsurance)					22
23	Subtotal (sum of lines 9 through 20 minus lines 21 and 22)					23
24	Coinsurance billed to Medicare patients (from your records)					24
25	Allowable bad debts (see instructions)					25
26	Adjusted reimbursable bad debts (see instructions)					26
27	Allowable bad debts for dual eligible beneficiaries (see instructions)					27
28	Subtotal (line 23 minus line 24, plus line 26)					28
29						29
30	Other demonstration payment adjustment amount before sequestration					30
31	Amount due HHA prior to sequestration adjustment (line 28 plus or minus line 29, minus line 30)					31
32	Sequestration adjustment (see instructions)					32
33	Amount due HHA after sequestration adjustment (line 31 minus line 32)					33
34	Other demonstration payment adjustment amount after sequestration					34
35	Amount due HHA (line 33 minus line 34)					35
36	Total interim payments (from Worksheet D-1, line 4)					36
37	Tentative settlement (For contractor use only)					37
38	Balance due HHA/Medicare program (line 35 minus lines 36 and 37) (indicate overpayments in brackets)					38
39	Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2					39






















FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4715 - 4715.2)
Rev. 1						47-519

Sheet 15: D-1

4795 (Cont.)					FORM CMS-1728-20							DRAFT
ANALYSIS OF PAYMENTS TO HHA FOR SERVICES RENDERED TO						HHA CCN:			PERIOD:	WORKSHEET D-1
PROGRAM BENEFICIARIES						____________________			FROM: ____________
						____________________			TO: _____________

								DATE			AMOUNT
			DESRIPTION					1			2
1	Total interim payments paid to HHA											1
2	Interim pymts payable on individual bills either submitted or to											2
	be submitted to the contractor, for services rendered in the
	cost reporting period. If none, write "NONE" or enter a zero.
3	List separately each retroactive lump sum						.01					3.01
	adjustment amount based on subsequent revision					Program	.02					3.02
	of the interim rate for the cost reporting period.					to	.03					3.03
	Also show date of each payment. If none, write					Provider	.04					3.04
	"NONE" or enter a zero.1						.05					3.05
							.50					3.50
						Provider	.51					3.51
						to	.52					3.52
						Program	.53					3.53
							.54					3.54
	SUBTOTAL (sum of lines 3.01 through 3.49, minus sum of lines 3.50 through 3.98)						.99					3.99
4	TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)											4
	(transfer to Worksheet D, Part II, line 36)

		TO BE COMPLETED BY CONTRACTOR
5	List separately each tentative settlement payment					Program	.01					5.01
	after desk review. Also show date of each					to	.02					5.02
	payment. If none, write "NONE" or enter					Provider	.03					5.03
	a zero. 1					Provider	.50					5.50
						to	.51					5.51
						Program	.52					5.52
	SUBTOTAL (sum of lines 5.01 through 5.49, minus sum of lines 5.50 through 5.98)						.99					5.99
6	Determine net settlement					Program	.01					6.01
	amount (balance due) based					to
	on the cost report. 1					Provider
						Provider	.02					6.02
						to
						Program
7	TOTAL MEDICARE PROGRAM LIABILITY											7
	(see instructions)
				NAME OF CONTRACTOR					CONTRACTOR NUMBER		NPR DATE	8
8

	1On lines 3, 5 and 6, where an amount is due HHA to program, show the amount and date on which the HHA
	agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
































FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4716)
47-520												Rev. 1

Sheet 16: F

DRAFT		FORM CMS-1728-20				4795 (Cont.)
BALANCE SHEET			HHA CCN:	PERIOD:	WORKSHEET F
			____________________	FROM: ______________
			____________________	TO: _________________

	ASSETS (Omit Cents)				AMOUNT
	CURRENT ASSETS
1	Cash on hand and in banks					1
2	Temporary investments					2
3	Notes receivable					3
4	Accounts receivable					4
5	Other receivables					5
6	Less: allowances for uncollectible notes and accounts receivable					6
7	Inventory					7
8	Prepaid expenses					8
9	Other current assets					9
10	TOTAL CURRENT ASSETS (sum of lines 1 through 9)					10
	FIXED ASSETS
11	Land					11
12	Land Improvements					12
13	Less: accumulated depreciation					13
14	Buildings					14
15	Less: accumulated depreciation					15
16	Leasehold improvements					16
17	Less: accumulated depreciation					17
18	Fixed equipment					18
19	Less: accumulated depreciation					19
20	Automobiles and trucks					20
21	Less: Accumulated Depreciation					21
22	Major movable equipment					22
23	Less: accumulated depreciation					23
24	Minor equipment					24
25	Less: Accumulated depreciation					25
26	Minor equipment nondepreciable					26
27	TOTAL FIXED ASSETS (sum of lines 11 through 26)					27
	OTHER ASSETS
28	Investments					28
29	Deposits on leases					29
30	Due from owners/officers					30
31	TOTAL OTHER ASSETS (sum of lines 28 through 30)					31
32	TOTAL ASSETS (sum of lines 10, 27 and 31)					32

	LIABILITIES AND FUND BALANCE (Omit Cents)				AMOUNT
	CURRENT LIABILITIES
33	Accounts payable					33
34	Salaries, wages & fees payable					34
35	Payroll taxes payable					35
36	Notes and payable loans (short term)					36
37	Deferred income					37
38	Accelerated payments					38
39	Other current liabilities					39
40	TOTAL CURRENT LIABILITIES (sum of lines 33 through 39)					40
	LONG TERM LIABILITIES
41	Mortgage payable					41
42	Notes payable					42
43	Unsecured loans					43
44	Other long term liabilities					44
45	TOTAL LONG TERM LIABILITIES (sum of lines 41 through 44)					45
46	TOTAL LIABILITIES (sum of lines 40 and 45)					46
	CAPITAL ACCOUNTS
47	FUND BALANCES					47
48	TOTAL LIABILITIES AND FUND BALANCES (sum of lines 46 and 47)					48















FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4717)
Rev. 1						47-521

Sheet 17: F-1

4795 (Cont.)			FORM CMS-1728-20				DRAFT
STATEMENT OF REVENUES AND EXPENSES				HHA CCN:	PERIOD:	WORKSHEET F-1
				____________________	FROM: ______________
				____________________	TO: _________________

		TITLE XVIII		TITLE XIX
		MEDICARE		MEDICAID	OTHER	TOTAL
		1		2	3	4
1	Gross patient revenues						1
2	Less: Allowances and discounts on patients' accounts						2
3	Net patient revenues (line 1 minus line 2)						3

					1	2
4	Operating expenses (from Wkst. A, line 100, col. 6)						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	Less total operating expenses (sum of lines 4 through 16)						17
18	Net income from service to patients (line 3 minus line 17)						18
	Other income:
19	Contributions, donations, bequests, etc.						19
20	Income from investments						20
21	Purchase discounts						21
22	Rebates and refunds of expenses						22
23	Sale of Medical and Nursing Supplies to other than patients						23
24	Sale of durable medical equipment to other than patients						24
25	Sale of drugs to other than patients						25
26	Sale of medical records and abstracts						26
27	Government Appropriations						27
28							28
29							29
30							30
31							31
32	Total Other Income (sum of lines 19 through 31)						32
33	Net Income or Loss for the period (line 18 plus line 32)						33


































FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4718)
47-522							Rev. 1

Sheet 18: O

DRAFT				FORM CMS 1728-20					4795 (Cont.)
ANALYSIS OF HHA-BASED HOSPICE COSTS						HHA CCN:	PERIOD:	WORKSHEET O
						_________________	FROM: ___________
						HOSPICE CCN:	TO: ______________
						_________________


					RECLASSI-		ADJUST-
		SALARIES	OTHER	SUBTOTAL	FICATIONS	SUBTOTAL	MENTS	TOTAL
		1	2	3	4	5	6	7
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt*								1
2	Cap Rel Costs-Mvble Equip*								2
3	Employee Benefits Department*								3
4	Administrative & General *								4
5	Plant Operation & Maintenance*								5
6	Laundry & Linen Service*								6
7	Housekeeping*								7
8	Dietary*								8
9	Nursing Administration*								9
10	Routine Medical Supplies*								10
11	Medical Records*								11
12	Staff Transportation*								12
13	Volunteer Service Coordination*								13
14	Pharmacy*								14
15	Physician Administrative Services*								15
16	Other General Service*								16
17	Patient/Residential Care Services								17
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care-Contracted**								25
26	Physician Services**								26
27	Nurse Practitioner**								27
28	Registered Nurse**								28
29	LPN/LVN**								29
30	Physical Therapy**								30
31	Occupational Therapy**								31
32	Speech-Language Pathology**								32
33	Medical Social Services**								33
34	Spiritual Counseling**								34
35	Dietary Counseling**								35
36	Counseling - Other**								36
37	Hospice Aide & Homemaker Services**								37
38	Durable Medical Equipment/Oxygen**								38
39	Patient Transportation**								39

*	Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.
**	See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.










FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4719)
Rev. 1									47-523
4795 (Cont.)				FORM CMS 1728-20					DRAFT
ANALYSIS OF HHA-BASED HOSPICE COSTS						HHA CCN:	PERIOD:	WORKSHEET O
						_________________	FROM: ___________
						HOSPICE CCN:	TO: ______________
						_________________


					RECLASSI-		ADJUST-
		SALARIES	OTHER	SUBTOTAL	FICATIONS	SUBTOTAL	MENTS	TOTAL
		1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)
40	Imaging Services**								40
41	Labs & Diagnostics**								41
42	Medical Supplies-Non-routine**								42
43	Drugs Charged to Patients**								43
44	Outpatient Services**								44
45	Palliative Radiation Therapy**								45
46	Palliative Chemotherapy**								46
47	**								47
NONREIMBURSABLE COST CENTERS
60	Bereavement Program *								60
61	Volunteer Program *								61
62	Fundraising*								62
63	Hospice/Palliative Medicine Fellows*								63
64	Palliative Care Program*								64
65	Other Physician Services*								65
66	Residential Care *								66
67	Advertising*								67
68	Telehealth/Telemonitoring*								68
69	Thrift Store*								69
70	Nursing Facility Room & Board*								70
71	*								71
100	Total								100

*	Transfer the amounts in column 7 to Wkst. O-5, col. 1, line as appropriate.
**	See instructions. Do not transfer the amounts in col. 7 to Wkst. O-5.





















FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4719)
47-524									Rev. 1

Sheet 19: O-1

DRAFT			FORM CMS-1728-20						4795 (Cont.)
ANALYSIS OF HHA-BASED HOSPICE COSTS						HHA CCN:	PERIOD:	WORKSHEET O-1
CONTINUOUS HOME CARE						_________________	FROM: ___________
						HOSPICE CCN:	TO: ______________
						_________________


					RECLASSI-		ADJUST-
		SALARIES	OTHER	SUBTOTAL	FICATIONS	SUBTOTAL	MENTS	TOTAL
		1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted								25
26	Physician Services								26
27	Nurse Practitioner								27
28	Registered Nurse								28
29	LPN/LVN								29
30	Physical Therapy								30
31	Occupational Therapy								31
32	Speech-Language Pathology								32
33	Medical Social Services								33
34	Spiritual Counseling								34
35	Dietary Counseling								35
36	Counseling - Other								36
37	Hospice Aide and Homemaker Services								37
38	Durable Medical Equipment/Oxygen								38
39	Patient Transportation								39
40	Imaging Services								40
41	Labs and Diagnostics								41
42	Medical Supplies-Non-routine								42
43	Drugs Charged to Patients								43
44	Outpatient Services								44
45	Palliative Radiation Therapy								45
46	Palliative Chemotherapy								46
47									47
100	Total *								100

*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 50.




















FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4720)
Rev. 1									47-525

Sheet 20: O-2

4795 (Cont.)				FORM CMS-1728-20					DRAFT
ANALYSIS OF HHA-BASED HOSPICE COST						HHA CCN:	PERIOD:	WORKSHEET O-2
ROUTINE HOME CARE						_________________	FROM: ___________
						HOSPICE CCN:	TO: ______________
						_________________


					RECLASSI-		ADJUST-
		SALARIES	OTHER	SUBTOTAL	FICATIONS	SUBTOTAL	MENTS	TOTAL
		1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted								25
26	Physician Services								26
27	Nurse Practitioner								27
28	Registered Nurse								28
29	LPN/LVN								29
30	Physical Therapy								30
31	Occupational Therapy								31
32	Speech-Language Pathology								32
33	Medical Social Services								33
34	Spiritual Counseling								34
35	Dietary Counseling								35
36	Counseling - Other								36
37	Hospice Aide and Homemaker Services								37
38	Durable Medical Equipment/Oxygen								38
39	Patient Transportation								39
40	Imaging Services								40
41	Labs and Diagnostics								41
42	Medical Supplies-Non-routine								42
43	Drugs Charged to Patients								43
44	Outpatient Services								44
45	Palliative Radiation Therapy								45
46	Palliative Chemotherapy								46
47									47
100	Total *								100

*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 51




















FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4720)
47-526									Rev. 1

Sheet 21: O-3

DRAFT			FORM CMS 1728-20						4795 (Cont.)
ANALYSIS OF HHA-BASED HOSPICE COSTS						HHA CCN:	PERIOD:	WORKSHEET O-3
INPATIENT RESPITE CARE						_________________	FROM: ___________
						HOSPICE CCN:	TO: ______________
						_________________


					RECLASSI-		ADJUST-
		SALARIES	OTHER	SUBTOTAL	FICATIONS	SUBTOTAL	MENTS	TOTAL
		1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted								25
26	Physician Services								26
27	Nurse Practitioner								27
28	Registered Nurse								28
29	LPN/LVN								29
30	Physical Therapy								30
31	Occupational Therapy								31
32	Speech-Language Pathology								32
33	Medical Social Services								33
34	Spiritual Counseling								34
35	Dietary Counseling								35
36	Counseling - Other								36
37	Hospice Aide and Homemaker Services								37
38	Durable Medical Equipment/Oxygen								38
39	Patient Transportation								39
40	Imaging Services								40
41	Labs and Diagnostics								41
42	Medical Supplies-Non-routine								42
43	Drugs Charged to Patients								43
44	Outpatient Services								44
45	Palliative Radiation Therapy								45
46	Palliative Chemotherapy								46
47									47
100	Total *								100

*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 52




















FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4720)
Rev. 1									47-527

Sheet 22: O-4

4795 (Cont.)			FORM CMS-1728-20						DRAFT
ANALYSIS OF HHA-BASED HOSPICE COSTS						HHA CCN:	PERIOD:	WORKSHEET O-4
GENERAL INPATIENT CARE						_________________	FROM: ___________
						HOSPICE CCN:	TO: ______________
						_________________


					RECLASSI-		ADJUST-
		SALARIES	OTHER	SUBTOTAL	FICATIONS	SUBTOTAL	MENTS	TOTAL
		1	2	3	4	5	6	7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted								25
26	Physician Services								26
27	Nurse Practitioner								27
28	Registered Nurse								28
29	LPN/LVN								29
30	Physical Therapy								30
31	Occupational Therapy								31
32	Speech-Language Pathology								32
33	Medical Social Services								33
34	Spiritual Counseling								34
35	Dietary Counseling								35
36	Counseling - Other								36
37	Hospice Aide and Homemaker Services								37
38	Durable Medical Equipment/Oxygen								38
39	Patient Transportation								39
40	Imaging Services								40
41	Labs and Diagnostics								41
42	Medical Supplies-Non-routine								42
43	Drugs Charged to Patients								43
44	Outpatient Services								44
45	Palliative Radiation Therapy								45
46	Palliative Chemotherapy								46
47									47
100	Total *								100

*	Transfer the amount in column 7 to Wkst. O-5, column 1, line 53




















FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4720)
47-528									Rev. 1

Sheet 23: O-5

DRAFT		FORM CMS 1728-20				4795 (Cont.)
DETERMINATION OF HHA-BASED HOSPICE TOTAL EXPENSES			HHA CCN:	PERIOD:	WORKSHEET O-5
FOR ALLOCATION			____________________	FROM: ______________
			HOSPICE CCN:	TO: _________________
			____________________

				GENERAL
			HOSPICE	SERVICE
			DIRECT	EXPENSES	TOTAL
			EXPENSES	FROM WKST B	EXPENSES
	Descriptions		1	2	3
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt					1
2	Cap Rel Costs-Mvble Equip					2
3	Employee Benefits Department					3
4	Administrative & General					4
5	Plant Operation & Maintenance					5
6	Laundry & Linen Service					6
7	Housekeeping					7
8	Dietary					8
9	Nursing Administration					9
10	Routine Medical Supplies					10
11	Medical Records					11
12	Staff Transportation					12
13	Volunteer Service Coordination					13
14	Pharmacy					14
15	Physician Administrative Services					15
16	Other General Service					16
17	Patient/Residential Care Services					17
LEVEL OF CARE
50	Hospice Continuous Home Care					50
51	Hospice Routine Home Care					51
52	Hospice Inpatient Respite Care					52
53	Hospice General Inpatient Care					53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program					60
61	Volunteer Program					61
62	Fundraising					62
63	Hospice/Palliative Medicine Fellows					63
64	Palliative Care Program					64
65	Other Physician Services					65
66	Residential Care					66
67	Advertising					67
68	Telehealth/Telemonitoring					68
69	Thrift Store					69
70	Nursing Facility Room & Board					70
71						71
99	Negative Cost Center					99
100	Total					100





























FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4721)
Rev. 1						47-529

Sheet 24: O-6I

4795 (Cont.)					FORM CMS-1728-20										DRAFT
COST ALLOCATION - HHA-BASED HOSPICE									HHA CCN:		PERIOD:		WORKSHEET O-6
ALLOCATION OF HHA-BASED HOSPICE GENERAL SERVICE COSTS									_________________		FROM: ____________		PART I
									HOSPICE CCN:		TO: _____________
									_________________

			CAP REL	CAP REL		EMPLOYEE		ADMINIS-		PLANT	LAUNDRY	HOUSE-		DIETARY
		TOTAL	BLDG	MVBLE		BENEFITS		TRATIVE &		OP &	& LINEN	KEEPING
		EXPENSES	& FIX	EQUIP		DEPARTMENT	SUBTOTAL	GENERAL		MAINT
		0	1	2		3	3A	4		5	6	7		8
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt														1
2	Cap Rel Costs-Mvble Equip														2
3	Employee Benefits Department														3
4	Administrative & General														4
5	Plant Operation & Maintenance														5
6	Laundry & Linen Service														6
7	Housekeeping														7
8	Dietary														8
9	Nursing Administration														9
10	Routine Medical Supplies														10
11	Medical Records														11
12	Staff Transportation														12
13	Volunteer Service Coordination														13
14	Pharmacy														14
15	Physician Administrative Services														15
16	Other General Service														16
17	Patient/Residential Care Services														17
LEVEL OF CARE
50	Hospice Continuous Home Care														50
51	Hospice Routine Home Care														51
52	Hospice Inpatient Respite Care														52
53	Hospice General Inpatient Care														53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program														60
61	Volunteer Program														61
62	Fundraising														62
63	Hospice/Palliative Medicine Fellows														63
64	Palliative Care Program														64
65	Other Physician Services														65
66	Residential Care														66
67	Advertising														67
68	Telehealth/Telemonitoring														68
69	Thrift Store														69
70	Nursing Facility Room & Board														70
71															71
99	Negative Cost Center														99
100	Total														100









FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4722)
47-530															Rev. 1
DRAFT					FORM CMS-1728-20										4795 (Cont.)
COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS									HHA CCN:		PERIOD:		WORKSHEET O-6
									____________________		FROM: ________________		PART I
									HOSPICE CCN:		TO: ___________________
									____________________

		NURSING	ROUTINE	MEDICAL		STAFF	VOLUNTEER	PHARMACY		PHYSICIAN	OTHER	PATIENT /		TOTAL
		ADMINIS-	MEDICAL	RECORDS		TRANS-	SVC COOR-			ADMINISTRA-	GENERAL	RESIDENTIAL
		TRATION	SUPPLIES			PORTATION	DINATION			TIVE SVCS	SERVICE	CARE SVCS
	Descriptions	9	10	11		12	13	14		15	16	17		18
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt														1
2	Cap Rel Costs-Mvble Equip														2
3	Employee Benefits Department														3
4	Administrative & General														4
5	Plant Operation & Maintenance														5
6	Laundry & Linen Service														6
7	Housekeeping														7
8	Dietary														8
9	Nursing Administration														9
10	Routine Medical Supplies														10
11	Medical Records														11
12	Staff Transportation														12
13	Volunteer Service Coordination														13
14	Pharmacy														14
15	Physician Administrative Services														15
16	Other General Service														16
17	Patient/Residential Care Services														17
LEVEL OF CARE
50	Hospice Continuous Home Care														50
51	Hospice Routine Home Care														51
52	Hospice Inpatient Respite Care														52
53	Hospice General Inpatient Care														53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program														60
61	Volunteer Program														61
62	Fundraising														62
63	Hospice/Palliative Medicine Fellows														63
64	Palliative Care Program														64
65	Other Physician Services														65
66	Residential Care														66
67	Advertising														67
68	Telehealth/Telemonitoring														68
69	Thrift Store														69
70	Nursing Facility Room & Board														70
71															71
99	Negative Cost Center														99
100	Total														100









FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4722)
Rev. 1															47-531

Sheet 25: O-6II

4795 (Cont.)					FORM CMS-1728-20										DRAFT
COST ALLOCATION - HHA-BASED HOSPICE									HHA CCN:		PERIOD:		WORKSHEET O-6
STATISTICAL BASES									____________________		FROM: _______________		PART II
									HOSPICE CCN:		TO: __________________
									____________________

			CAP REL	CAP REL		EMPLOYEE		ADMINIS-		PLANT	LAUNDRY	HOUSE-		DIETARY
			BLDG	MVBLE		BENEFITS		TRATIVE &		OP &	& LINEN	KEEPING
			& FIX	EQUIP		DEPARTMENT		GENERAL		MAINT
			(SQUARE	(DOLLAR		(GROSS	RECONCIL-	(ACCUM.		(SQUARE	(IN-FACIL-	(SQUARE		(IN-FACIL-
			FEET)	VALUE)		SALARIES)	IATION	COST)		FEET)	ITY DAYS)	FEET)		ITY DAYS)
	Cost Center Descriptions		1	2		3	4A	4		5	6	7		8
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt														1
2	Cap Rel Costs-Mvble Equip														2
3	Employee Benefits Department														3
4	Administrative & General														4
5	Plant Operation & Maintenance														5
6	Laundry & Linen Service														6
7	Housekeeping														7
8	Dietary														8
9	Nursing Administration														9
10	Routine Medical Supplies														10
11	Medical Records														11
12	Staff Transportation														12
13	Volunteer Service Coordination														13
14	Pharmacy														14
15	Physician Administrative Services														15
16	Other General Service														16
17	Patient/Residential Care Services														17
LEVEL OF CARE
50	Hospice Continuous Home Care														50
51	Hospice Routine Home Care														51
52	Hospice Inpatient Respite Care														52
53	Hospice General Inpatient Care														53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program														60
61	Volunteer Program														61
62	Fundraising														62
63	Hospice/Palliative Medicine Fellows														63
64	Palliative Care Program														64
65	Other Physician Services														65
66	Residential Care														66
67	Advertising														67
68	Telehealth/Telemonitoring														68
69	Thrift Store														69
70	Nursing Facility Room & Board														70
71															71
99	Negative Cost Center														99
101	Cost to be allocated														101
102	Unit cost multiplier														102






FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4722)
47-532															Rev. 1
DRAFT				FORM CMS-1728-20											4795 (Cont.)
COST ALLOCATION - HHA-BASED HOSPICE									HHA CCN:		PERIOD:		WORKSHEET O-6
STATISTICAL BASES									_________________		FROM: ____________		PART II
									HOSPICE CCN:		TO: _____________
									_________________

		NURSING	ROUTINE	MEDICAL		STAFF	VOLUNTEER	PHARMACY		PHYSICIAN	OTHER	PATIENT /
		ADMINIS-	MEDICAL	RECORDS		TRANS-	SVC COOR-			ADMINISTRA-	GENERAL	RESIDENTIAL
		TRATION	SUPPLIES			PORTATION	DINATION			TIVE SVCS	SERVICE	CARE SVCS
		(DIRECT	(PATIENT	(PATIENT			(HOURS OF			(PATIENT	(SPECIFY	(IN-FACIL-
		NURS. HRS.)	DAYS)	DAYS)		(MILEAGE)	SERVICE)	(CHARGES)		DAYS)	BASIS)	ITY DAYS)		TOTAL
	Cost Center Descriptions	9	10	11		12	13	14		15	16	17		18
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs-Bldg & Fixt														1
2	Cap Rel Costs-Mvble Equip														2
3	Employee Benefits Department														3
4	Administrative & General														4
5	Plant Operation & Maintenance														5
6	Laundry & Linen Service														6
7	Housekeeping														7
8	Dietary														8
9	Nursing Administration														9
10	Routine Medical Supplies														10
11	Medical Records														11
12	Staff Transportation														12
13	Volunteer Service Coordination														13
14	Pharmacy														14
15	Physician Administrative Services														15
16	Other General Service														16
17	Patient/Residential Care Services														17
LEVEL OF CARE
50	Hospice Continuous Home Care														50
51	Hospice Routine Home Care														51
52	Hospice Inpatient Respite Care														52
53	Hospice General Inpatient Care														53
NONREIMBURSABLE COST CENTERS
60	Bereavement Program														60
61	Volunteer Program														61
62	Fundraising														62
63	Hospice/Palliative Medicine Fellows														63
64	Palliative Care Program														64
65	Other Physician Services														65
66	Residential Care														66
67	Advertising														67
68	Telehealth/Telemonitoring														68
69	Thrift Store														69
70	Nursing Facility Room & Board														70
71															71
99	Negative Cost Center														99
101	Cost to be allocated														101
102	Unit cost multiplier														102






FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4722)
Rev. 1															47-533

Sheet 26: O-7

4795 (Cont.)						FORM CMS-1728-20											DRAFT
APPORTIONMENT OF HHA-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE									HHA CCN:			PERIOD:			WORKSHEET O-7
									____________________			FROM: _______________
									HOSPICE CCN:			TO: __________________
									____________________

		WKST. B,	TOTAL	TOTAL	COST TO	CHARGES BY LOC					SHARED SERVICE COSTS BY LOC
		COL. 10,	HHA	HHA	CHARGE
		LINE	COSTS	CHARGES	RATIO	HCHC	HRHC	HIRC		HGIP	HCHC		HRHC	HIRC		HGIP
	Cost Center Descriptions	0	1	2	3	4	5	6		7	8		9	10		11
	ANCILLARY SERVICE COST CENTERS
1	Physical Therapy	18															1
2	Physical Therapy Assistant	19															2
3	Occupational Therapy	20															3
4	Certified Occupational Therapy Assistant	21															4
5	Speech-Language Pathology	22															5
6	Medical Social Services	23															6
7	Medical Supplies (see instructions)	25															7
8	Drugs	26															8
9	Durable Medical Equipment/Oxygen	28															9
10	Totals (sum of lines 1-9)																10




































FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4723)
47-534																	Rev. 1

Sheet 27: O-8

DRAFT		FORM CMS-1728-20			4795 (Cont.)
CALCULATION OF HHA-BASED HOSPICE PER DIEM COST		HHA CCN:	PERIOD:	WORKSHEET O-8
		__________________	FROM: _____________
		HOSPICE CCN:	TO: ________________
		__________________

		TITLE XVIII	TITLE XIX
		MEDICARE	MEDICAID	TOTAL
		1	2	3
HOSPICE CONTINUOUS HOME CARE
1	Total cost (Wkst. O-6, Part I, col. 18, line 50 plus Wkst. O-7, col. 8, line 9)				1
2	Total unduplicated days (Wkst. S-4, col. 4, line 1)				2
3	Total average cost per diem (line 1 divided by line 2)				3
4	Unduplicated program days (Wkst. S-4, col. as appropriate, line 1)				4
5	Program cost (line 3 times line 4)				5
HOSPICE ROUTINE HOME CARE
6	Total cost (Wkst. O-6, Part I, col. 18, line 51 plus Wkst. O-7, col. 9, line 9)				6
7	Total unduplicated days (Wkst. S-4, col. 4, line 2)				7
8	Total average cost per diem (line 6 divided by line 7)				8
9	Unduplicated program days (Wkst. S-4, col. as appropriate, line 2)				9
10	Program cost (line 8 times line 9)				10
HOSPICE INPATIENT RESPITE CARE
11	Total cost (Wkst. O-6, Part I, col. 18, line 52 plus Wkst. O-7, col. 10, line 9)				11
12	Total unduplicated days (Wkst. S-4, col. 4, line 3)				12
13	Total average cost per diem (line 11 divided by line 12)				13
14	Unduplicated program days (Wkst. S-4, col. as appropriate, line 3)				14
15	Program cost (line 13 times line 14)				15
HOSPICE GENERAL INPATIENT CARE
16	Total cost (Wkst. O-6, Part I, col. 18, line 53 plus Wkst. O-7, col. 11, line 9)				16
17	Total unduplicated days (Wkst. S-4, col. 4, line 4)				17
18	Total average cost per diem (line 16 divided by line 17)				18
19	Unduplicated program days (Wkst. S-4, col. as appropriate, line 4)				19
20	Program cost (line 18 times line 19)				20
TOTAL HOSPICE CARE
21	Total cost (sum of line 1 + line 6 + line 11 + line 16)				21
22	Total unduplicated days (Wkst. S-4, col. 4, line 5)				22
23	Average cost per diem (line 21 divided by line 22)				23









































FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4724)
Rev. 1					47-535
4795 (Cont.)		FORM CMS-1728-20			DRAFT





























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FORM CMS-1728-20 (draft) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4724)
47-536					Rev. 1

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File Modified	0000-00-00
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