CMS-287-21_Crosswalk_508

FORM CMS-287-21 HOME OFFICE COST STATEMENT CROSSWALK
The Form CMS-287-21, Home Office Cost Statement, replaces the existing Form CMS-287-05. Changes to the revised cost statement, effective for
reporting periods beginning on or after January 1, 2021, include:
1. Redesignated, revised, and modified schedules to collect information in an electronic format.
2. Expanded schedules to accommodate numerous components and removed obsolete information (i.e. FOIA disclosure, old capital
policy).
The overall burden to the Home Office Cost Statement remains the same at 466 hours.

SCHEDULES
#
1.

FORM
CMS-287-05

FORM CMS-287-21
INSTRUCTIONS

SCHEDULE

PAGE #

SECTION #
4800 - 4800.40

PAGE #
48-3 - 48-18

2.

Schedule A

Schedule S,
Part I

48-503

4801.10 - 4801.12

48-19 - 48-20

3.

Schedule S-1

48-504

4801.20 - 4801.22

48-21 - 48-22

Schedule S,
Part II
Schedule S-2

48-503

4801.10 - 48101.12

48-19 - 48-20

48-505

4801.30 - 4801.33

48-23 - 48-25

6.

Schedule A,
Part I
Schedule A, Part
II
Schedule A,
Parts III, IV, V
Schedule B

Schedule A

48-506

4802.10

48-26 - 48-27

7.
8.

Schedule B-1
Schedule B-2

Schedule A-6
Schedule A-7

48-507
48-508

4802.70
4802.80 - 4802.82

48-28
48-29 - 48-31

9.

Schedule C

Schedule A-8

48-509

4802.90

48-32

10.

Schedule D

Schedule A-8-1

48-510

4802.100 - 4802.102

48-33 - 48-35

4.
5.

REASON FOR THE CHANGE /
APPLICATION OF THE
INSTRUCTIONS AND
ACCOMPANYING SCHEDULES
Updated general instructions, clarified
instructions for components with fiscal
year ends non-concurrent with the home
office reporting period, and added
instructions about electronic home office
cost statements.
Modified and moved the “Intermediary
Use Only” section to Schedule S, Part I,
and re-designated as “Contractor Use
Only.”
Moved general information and key
officers information.
Moved certification statement.
Moved component information to newly
designated Schedule S-2.
Re-designated as Schedule A and
removed obsolete references.
Re-designated as Schedule A-6.
Re-designated as Schedule A-7 and
removed obsolete references.
Re-designated as Schedule A-8 and
updated obsolete references.
Re-designated as Schedule A-8-1 and
modified interrelationship reporting.

BURDEN
EFFECT
N/A

N/A

N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A

SCHEDULES

FORM CMS-287-21
INSTRUCTIONS

#
11.

FORM
CMS-287-05
Schedule E

SCHEDULE
Schedule B

PAGE #
48-511

SECTION #
4803.10 - 4803.13

PAGE #
48-36 - 48-37

13.

Schedule E-1

Schedule B-1

48-512 - 48-514

4803.20 - 4803.23

48-38 - 48-39

13.

Schedule F,
Part I

Schedule C

48-515

4804.10 - 4804.13

48-40 - 48-42

14.

Schedule F,
Part II

Schedule C-1

48-516

4804.20 - 4804.23

48-43 - 48-44

15.

Schedule F-1,
Part I

Schedule D

48-517 - 48-519

4805.10 - 4805.13

48-45 - 48-47

16.

Schedule F-1,
Part II

Schedule D-1

48-520 - 48-522

4805.20 - 4805.23

48-48 - 48-49

17.

Schedule E

48-523

4806.10

48-51 - 48-52

Schedule E-1

48-524

4806.20 - 4806.23

48-53 - 48-55

19.

Schedule G,
Part I
Schedule G,
Part II
N/A

Schedule F

48-525

4807.10 - 4807.13

48-56 - 48-58

20.

N/A

Schedule F-1

48-526

4807-20-4807.23

48-59 - 48-61

21.
22.

Schedule J
Schedule I

Schedule G
Schedule G-1

48-527
48-528

4808.10
4808.20

48-62 - 48-65
48-66

18.

REASON FOR THE CHANGE /
APPLICATION OF THE
INSTRUCTIONS AND
ACCOMPANYING SCHEDULES
Re-designated as Schedule B and
removed obsolete references.
Re-designated as Schedule B-1 and
structured columns to correspond to
Schedule A cost centers.
Re-designated as Schedule C, removed
obsolete references, and deleted the
interest expense column.
Re-designated as Schedule C-1, removed
obsolete references, and deleted the
interest expense column.
Re-designated as Schedule D and
structured columns to correspond to
Schedule A cost centers.
Re-designated as Schedule D-1 and
structured columns to correspond to
Schedule A cost centers.
Re-designated Part I as Schedule E and
removed obsolete references.
Re-designated Part II as Schedule E-1.
New schedule added to summarize the
allocations of home office capital costs.
New schedule added to summarize the
allocations of home office non-capital
costs.
Re-designated as Schedule G.
Re-designated as Schedule G-1.

BURDEN
EFFECT
N/A
N/A

N/A

N/A

N/A

N/A
N/A

N/A
N/A