CMS-287-21.R1P248f.xlsx

R1P248f.xlsx

Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)

CMS-287-21.R1P248f.xlsx

OMB: 0938-0202

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0202 can be found here:

2024-08-29 - Extension without change of a currently approved collection

Document [xlsx]

Download: xlsx | pdf

Overview

S
S-1
S-2
A
A-6
A-7
A-8
A-8-1
B Dir Cap
B-1 Dir Non-Cap
C Func Cap
C-1 FC Stats
D Func Non-Cap
D-1 FNC Stats
E Pooled
E-1 Pooled
F SumCap
F-1 SumNon-Cap
G
G-1

Sheet 1: S

MM-YY			FORM CMS-287-21								4895
											FORM APPROVED
											OMB NO. 0938-0202
											EXPIRES MM/DD/YYYY
HOME OFFICE COST STATEMENT CERTIFICATION					HOME OFFICE	PERIOD:				SCHEDULE S
					NUMBER:		FROM:		____________
					_________________		TO:	____________
					_________________		TO:	____________

PART I - COST STATEMENT STATUS - CONTRACTOR USE ONLY
1	Amended cost statement										1
2	Amendment number										2
3	Cost statement received date										3
4	First cost statement for this home office number										4
5	Last cost statement for this home office number										5
6	Cost statement status										6
7	Reopening number										7
8	NPR date										8
9	Contractor number										9
10	ECR software vendor code										10

PART II - CERTIFICATION












		SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR		CHECKBOX				ELECTRONIC SIGNATURE STATEMENT
		1		2
1											1



2	Signatory Printed Name										2
3	Signatory Title										3
4	Signature date										4































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4801 THROUGH 4801.12.)
Rev. 1											48-503

Sheet 2: S-1

4895								FORM CMS-287-21																	MM-YY
IDENTIFICATION DATA														HOME OFFICE				PERIOD:				SCHEDULE S-1
														NUMBER:					FROM:		____________
														_________________					TO:	____________
														_________________					TO:	____________

PART I - HOME OFFICE DATA
					STREET ADDRESS LINE 1					STREET ADDRESS LINE 2		P O BOX				CITY					STATE			ZIP
					1					2		3				4					5			6
1	Home Office Location																								1

											HOME OFFICE				DATE OPERATIONS		REPORTING PERIOD
			HOME OFFICE NAME								NUMBER				BEGAN				BEGINNING DATE				ENDING DATE
			1								2				3				4				5
2	Home Office Information																								2

				TYPE OF CONTROL				DESCRIPTION
				1				2
3	Home Office Control																								3

															RECONCILE TO
			PREPARED BY CPA			A / C / R			SUBMITTED		DATE AVAILABLE				COST STATEMENT
			1			2			3		4				5
4	Financial Statements																								4

				FIRST NAME			LAST NAME		TITLE		TELEPHONE NUMBER		EMAIL ADDRESS										EMPLOYER
				1			2		3		4		5										6
5	Contact Information																								5

PART II - KEY OFFICERS DATA
		POSITION / JOB TITLE					EMPLOYEE NAME
		1					2
1	President																								1
2	Vice President																								2
3	Secretary																								3
4	Treasurer																								4
5	Controller																								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



FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4801.20 THROUGH SECTION 4801.22.)
48-504																									Rev. 1

Sheet 3: S-2

MM-YY					FORM CMS-287-21											4895
LISTING OF COMPONENTS									HOME OFFICE		PERIOD:				SCHEDULE S-2
									NUMBER:			FROM:		____________
									_________________			TO:	____________
									_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS
				REPORTING PERIOD ENDING			DATE SOLD /	MEDICAID		REIMBURSE-
			OWNED OR	DURING HO FISCAL YEAR		DATE	CEASED	PARTICI-		MENT		MEDICARE			MEDICAID
	COMPONENT NAME	CCN	MANAGED	BEGINNING	ENDING	ACQUIRED	PARTICIPATION	PATION		TYPE		CONTRACTOR			CONTRACTOR
	1	2	3	4	5	6	7	8		9		10			11
1																1
2																2
3																3
4																4
5																5


50																50

PART II - NON-HEALTHCARE COMPONENTS
				REPORTING PERIOD ENDING			DATE	MEDICAID		REIMBURSE-
				DURING HO FISCAL YEAR		DATE	SOLD /	PARTICI-		MENT		MEDICARE			MEDICAID
	COMPONENT NAME			BEGINNING	ENDING	ACQUIRED	CLOSED	PATION		TYPE		CONTRACTOR			CONTRACTOR
	1	2	3	4	5	6	7	8		9		10			11
1																1
2																2
3																3
4																4
5																5


50																50

PART III - REGION / DIVISION COMPONENTS
										COSTS		SEPARATE
										INCLUDED		COST			REGION /
		REGIONAL		REGION / DIVISION LOCATION						IN THIS COST		STATEMENT			DIVISION
	COMPONENT NAME	HO NUMBER		CITY				STATE		STATEMENT		FILED			CONTRACTOR
	1	2	3	4				5		6		7			8
1																1
2																2
3																3
4																4
5																5


50																50







FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4801.30 THROUGH SECTION 4801.33.)
Rev. 1																48-505

Sheet 4: A

4895				FORM CMS-287-21											MM-YY
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES								HOME OFFICE		PERIOD:				SCHEDULE A
								NUMBER:			FROM:		____________
								_________________			TO:	____________
								_________________			TO:	____________

			EXPENSES						DIRECT		FUNCTIONAL
			PER		RECLASSIFIED		NET		ALLOCATIONS		ALLOCATIONS
			HOME OFFICE	RECLASS-	TRIAL		ALLOWABLE		TO		TO			POOLED
			BOOKS	IFICATIONS	BALANCE	ADJUSTMENTS	EXPENSES		COMPONENTS		COMPONENTS			ALLOCATIONS
			1	2	3	4	5		6		7			8
		CAPITAL RELATED COST CENTERS
1	CRC-B&F														1
2	CRC-ME														2
3	Subtotal														3
		OTHER CAPITAL RELATED COST CENTERS
4	Insurance Premiums														4
5	Taxes & Licenses														5
6	Other Capital Related														6
7	Subtotal														7
		NON-CAPITAL RELATED COSTS
8	Salaries of Officers														8
9	Salaries and Wages of Others														9
10	Payroll Taxes														10
11	Employee Benefits - Payroll Related														11
12	Employee Benefits - Non-Payroll Related														12
13	Profit Sharing/Pension Plans														13
14	Legal Fees														14
15	Auditing and Accounting Fees														15
16	Utilities														16
17	Communications														17
18	Travel and Entertainment														18
19	Transportation														19
20	Cleaning, Office & Admin. Supplies														20
21	Minor Equipment														21
22	Repairs and Maintenance														22
23	Dues and Subscriptions														23
24	Contributions														24
25	Insurance Premiums - Non-Cap. Related														25
26	Taxes & Licenses - Non-Cap. Related														26
27	Interest Expense														27
28	Interest Income														28
29															29
30															30





99	Subtotal														99
100	Total														100




FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802 THROUGH SECTION 4802.10.)
48-506															Rev. 1

Sheet 5: A-6

MM-YY			FORM CMS-287-21														4895
RECLASSIFICATIONS OF EXPENSES								HOME OFFICE			PERIOD:				SCHEDULE A-6
								NUMBER:				FROM:		____________
								_________________				TO:	____________
								_________________				TO:	____________

				INCREASES					DECREASES
				SCHEDULE A COST CENTER					SCHEDULE A COST CENTER
		DESCRIPTION OF RECLASSIFICATION	CODE		DESCRIPTION	LINE #	AMOUNT			DESCRIPTION				LINE #		AMOUNT
		1	2		3	4	5			6				7		8
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
26																	26
27																	27
28																	28
29																	29
30																	30










100	Total reclassifications																100




FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.70.)
Rev. 1																	48-507

Sheet 6: A-7

4895			FORM CMS-287-21											MM-YY
ANALYSIS OF CAPITAL COST CENTERS							HOME OFFICE		PERIOD:				SCHEDULE A-7
							NUMBER:			FROM:		____________
							_________________			TO:	____________
							_________________			TO:	____________

PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES
						RETIREMENTS				FULLY
		BEGINNING	ACQUISITIONS			AND		ENDING		DEPRECIATED
		BALANCE	PURCHASES	DONATIONS	TOTAL	DISPOSALS		BALANCE		ASSETS
		1	2	3	4	5		6		7
1	Land													1
2	Land Improvements													2
3	Buildings & Fixtures													3
4	Building Improvements													4
5	Fixed Equipment													5
6	Movable Equipment													6
7	Subtotal													7
8	Reconciling Items													8
9	Total													9

PART II - RECONCILIATION OF CAPITAL COST CENTERS
		COMPUTATION OF RATIOS				ALLOCATION OF OTHER CAPITAL RELATED COSTS
		GROSS	CAPITALIZED	GROSS ASSETS		INSURANCE		TAXES &		OTHER
		ASSETS	LEASES	FOR RATIO	RATIO	PREMIUMS		LICENSES		CAPITAL REL			TOTAL
		1	2	3	4	5		6		7			8
1	CRC-B&F													1
2	CRC-ME													2
3	Total													3


			SUMMARY OF CAPITAL
			DEPRE-			INSURANCE		TAXES &		OTHER
			CIATION	LEASE	INTEREST	PREMIUMS		LICENSES		CAPITAL REL			TOTAL
			9	10	11	12		13		14			15
1	CRC-B&F													1
2	CRC-ME													2
3	Total													3

















FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4802.80 THROUGH SECTION 4802.82.)
48-508														Rev. 1

Sheet 7: A-8

MM-YY			FORM CMS-287-21											4895
ADJUSTMENTS TO EXPENSES						HOME OFFICE		PERIOD:				SCHEDULE A-8
						NUMBER:			FROM:		____________
						_________________			TO:	____________
						_________________			TO:	____________

							SCHEDULE A COST CENTER
		DESCRIPTION OF ADJUSTMENT		BASIS	AMOUNT				DESCRIPTION				LINE #
		1		2	3				4				5
1	Federal, state income tax, franchise tax, and related interest and penalties on late payments (CMS Pub. 15-1, chapter 21, §2122.2)													1
2	Stockholders servicing costs (CMS Pub. 15-1, chapter 21, §2134.9)													2
3	Acquisition expenses (CMS Pub. 15-1, chapter 21, §2134.11)													3
4	Bad debts (CMS Pub. 15-1, chapter 3, §308)													4
5	Life insurance premiums where home office is direct/indirect beneficiary (CMS Pub. 15-1, chapter 21, §2130)													5
6	Annual stockholder meeting expenses (CMS Pub. 15-1, chapter 21, §2134.9)													6
7	Non-healthcare projects (CMS Pub. 15-1, chapter 21, §2102.3)													7
8	Non-competition agreement expenses (CMS Pub. 15-1, chapter 21, §2105.1)													8
9	Fund-raising expenses (CMS Pub. 15-1, chapter 21, §2136.2)													9
10	Rebates/refunds on expenses (CMS Pub. 15-1, chapter 8, §804)													10
11	Cost of ownership of assets leased from related organization in lieu of rent (CMS Pub. 15-1, chapter 10, §1011.5)													11
12	Related organizations (CMS Pub. 15-1, chapter 10, §1000)			Sch. A-8-1										12
13	Value of services of non-paid workers (CMS Pub. 15-1, chapter 7, §700)													13
14	Interest on loans between home office and components (CMS Pub. 15-1, chapter 21, §2150.2C)													14
15	Costs of corporate acquisitions of capital stocks and acquisition & development department (CMS Pub. 15-1, chapter 21, §2150.2B)													15
16	Interest on loans paid to owners/partners (CMS Pub. 15-1, chapter 2, §218)													16
17	Abandoned construction in progress cost (CMS Pub. 15-1, chapter 21, §2155)													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










100	Total													100





FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.90.)
Rev. 1														48-509

Sheet 8: A-8-1

4895							FORM CMS-287-21													MM-YY
COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND / OR HOME OFFICE / CHAIN ORGANIZATIONS											HOME OFFICE			PERIOD:				SCHEDULE A-8-1
											NUMBER:				FROM:		____________
											_________________				TO:	____________
											_________________				TO:	____________

PART I - ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS AND / OR HOME OFFICE / CHAIN ORGANIZATIONS
												AMOUNT			AMOUNT
	SCHEDULE A COST CENTER								PART II			ALLOWABLE			INCLUDED IN				NET
		LINE #	DESCRIPTION			EXPENSE ITEM DESCRIPTION			LINE #			IN COST			SCH. A, COL. 3				ADJUSTMENT
		1	2			3			4			5			6				7
1																				1
2																				2
3																				3
4																				4
5																				5
6																				6
7																				7
8																				8
9																				9
10																				10





100	TOTAL																			100

PART II - INTERRELATIONSHIP OF HOME OFFICE / CHAIN ORGANIZATION TO RELATED ORGANIZATIONS
	INTERRELA-
	TIONSHIP				PERCENTAGE					PERCENTAGE
	SYMBOL			NAME OF RELATED INDIVIDUAL	OWNERSHIP			RELATED ORGANIZATION NAME		OWNERSHIP			TYPE OF BUSINESS
	1			2	3			4		5			6
1																				1
2																				2
3																				3
4																				4
5																				5
6																				6
7																				7
8																				8
9																				9
10																				10




50																				50







FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.100 THROUGH SECTION 4802.102.)
48-510																				Rev. 1

Sheet 9: B Dir Cap

MM-YY					FORM CMS-287-21											4895
DIRECT ALLOCATION OF CAPITAL RELATED COSTS								HOME OFFICE		PERIOD:				SCHEDULE B
								NUMBER:			FROM:		____________
								_________________			TO:	____________
								_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS
				CAPITAL RELATED					OTHER CAPITAL RELATED
					CRC-	CRC-	INSURANCE		TAXES &		OTHER
					B&F	ME	PREMIUMS		LICENSES		CAPITAL RELATED				TOTAL
		COMPONENT NAME	CCN		1	2	4		5		6				7
1																1
2																2
3																3
4																4
5																5


50																50
51	Total															51

PART II - NON-HEALTHCARE COMPONENTS
				CAPITAL RELATED					OTHER CAPITAL RELATED
					CRC-	CRC-	INSURANCE		TAXES &		OTHER
					B&F	ME	PREMIUMS		LICENSES		CAPITAL RELATED				TOTAL
		COMPONENT NAME			1	2	4		5		6				7
1																1
2																2
3																3
4																4
5																5


50																50
51	Total															51

PART III - REGION / DIVISION COMPONENTS
				CAPITAL RELATED					OTHER CAPITAL RELATED
			REGIONAL		CRC-	CRC-	INSURANCE		TAXES &		OTHER
			HO		B&F	ME	PREMIUMS		LICENSES		CAPITAL RELATED				TOTAL
		COMPONENT NAME	NUMBER		1	2	4		5		6				7
1																1
2																2
3																3
4																4
5																5


50																50
51	Total															51
52	Grand Total															52




FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803 THROUGH SECTION 4803.13.)
Rev. 1																48-511

Sheet 10: B-1 Dir Non-Cap

4895

FORM CMS-287-21

MM-YY

DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE B-1,

NUMBER:

FROM:

____________

PART I

_________________

TO:

____________

PART I - HEALTHCARE PROVIDER COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

COMPONENT NAME

CCN

Total

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

CCN

Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)

48-512

Rev. 1

MM-YY

FORM CMS-287-20

4895

DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE B-1,

NUMBER:

FROM:

____________

PART II

_________________

TO:

____________

PART II - NON-HEALTHCARE COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

COMPONENT NAME

Total

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)

Rev. 1

48-513

4895

FORM CMS-287-20

MM-YY

DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE B-1,

NUMBER:

FROM:

____________

PART III

_________________

TO:

____________

PART III - REGION / DIVISION COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

REGIONAL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

COMPONENT NAME

NUMBER

Total

Grand Total

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

REGIONAL

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

NUMBER

Total

Grand Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)

48-514

Rev. 1

Sheet 11: C Func Cap

MM-YY			FORM CMS-287-21										4895
FUNCTIONAL ALLOCATION OF CAPITAL RELATED COSTS					HOME OFFICE		PERIOD:				SCHEDULE C
					NUMBER:			FROM:		____________
					_________________			TO:	____________
					_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS

						CRC-		CRC-
						B&F		ME				TOTAL
		COMPONENT NAME		CCN		1		2				3
1													1
2													2
3													3
4													4
5													5


50													50
51	Total												51

PART II - NON-HEALTHCARE COMPONENTS

						CRC-		CRC-
						B&F		ME				TOTAL
		COMPONENT NAME				1		2				3
1													1
2													2
3													3
4													4
5													5


50													50
51	Total												51

PART III - REGION / DIVISION COMPONENTS

				REGIONAL		CRC-		CRC-
				HO		B&F		ME				TOTAL
		COMPONENT NAME		NUMBER		1		2				3
1													1
2													2
3													3
4													4
5													5


50													50
51	Total												51
52	Grand Total												52























FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4804 THROUGH 4804.13.)
Rev. 1													48-515

Sheet 12: C-1 FC Stats

4895			FORM CMS-287-21									MM-YY
FUNCTIONAL ALLOCATION OF CAPITAL RELATED COSTS - STATISTICS					HOME OFFICE		PERIOD:				SCHEDULE C-1
					NUMBER:			FROM:		____________
					_________________			TO:	____________
					_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS
						CRC-		CRC-
						B&F		ME
						(ENTER		(ENTER
						BASIS)		BASIS)
		COMPONENT NAME		CCN		1		2
1												1
2												2
3												3
4												4
5												5


50												50
51	Total											51

PART II - NON-HEALTHCARE COMPONENTS
						CRC-		CRC-
						B&F		ME
						(ENTER		(ENTER
						BASIS)		BASIS)
		COMPONENT NAME				1		2
1												1
2												2
3												3
4												4
5												5


50												50
51	Total											51

PART III - REGION / DIVISION COMPONENTS
						CRC-		CRC-
						B&F		ME
				REGIONAL		(ENTER		(ENTER
				HO		BASIS)		BASIS)
		COMPONENT NAME		NUMBER		1		2
1												1
2												2
3												3
4												4
5												5


50												50
51	Total											51
52	Grand Total											52
53	Cost to be allocated											53
54	UCM											54


















FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4804.20 THROUGH SECTION 4804.23.)
48-516												Rev. 1

Sheet 13: D Func Non-Cap

MM-YY

FORM CMS-287-21

4895

FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE D,

NUMBER:

FROM:

____________

PART I

_________________

TO:

____________

PART I - HEALTHCARE PROVIDER COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

COMPONENT NAME

CCN

Total

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

CCN

Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)

Rev. 1

48-517

4895

FORM CMS-287-20

MM-YY

FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE D,

NUMBER:

FROM:

____________

PART II

_________________

TO:

____________

PART II - NON-HEALTHCARE COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

COMPONENT NAME

Total

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)

48-518

Rev. 1

MM-YY

FORM CMS-287-20

4895

FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE D,

NUMBER:

FROM:

____________

PART III

_________________

TO:

____________

PART III - REGIONAL OFFICE / DIVISION COMPONENTS

PART III - REGION / DIVISION COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

REGIONAL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

COMPONENT NAME

NUMBER

Total

Grand Total

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

REGIONAL

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

NUMBER

Total

Grand Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)

Rev. 1

48-519

Sheet 14: D-1 FNC Stats

4895

FORM CMS-287-21

MM-YY

FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS - STATISTICS

HOME OFFICE

PERIOD:

SCHEDULE D-1,

NUMBER:

FROM:

____________

PART I

_________________

TO:

____________

PART I - HEALTHCARE PROVIDER COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

(ENTER

BASIS)

COMPONENT NAME

CCN

Total

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

(ENTER

BASIS)

COMPONENT NAME

CCN

Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)

48-520

Rev. 1

MM-YY

FORM CMS-287-20

4895

FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS - STATISTICS

HOME OFFICE

PERIOD:

SCHEDULE D-1,

NUMBER:

FROM:

____________

PART II

_________________

TO:

____________

PART II - NON-HEALTHCARE COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

(ENTER

BASIS)

COMPONENT NAME

Total

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

(ENTER

BASIS)

COMPONENT NAME

Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)

Rev. 1

48-521

4895

FORM CMS-287-20

MM-YY

FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS - STATISTICS

HOME OFFICE

PERIOD:

SCHEDULE D-1,

NUMBER:

FROM:

____________

PART III

_________________

TO:

____________

PART III - REGION / DIVISION COMPONENTS

SALARIES

EMPLOYEE

PROFIT

AUDIT /

COM-

TRAVEL

& WAGES

PAYROLL

BENEFITS

SHARING/

LEGAL

ACCOUNT-

MUN-

AND

TRANS-

OFFICERS

OF OTHERS

TAXES

PAY REL

NON-PAY

PENSION

FEES

ING FEES

UTILITIES

ICATIONS

ENT

PORTATON

REGIONAL

(ENTER

BASIS)

COMPONENT NAME

NUMBER

Total

Grand Total

Cost to be allocated

UCM

CLEANING,

REPAIRS

DUES

CON-

INSUR

TAXES &

OFFICE,

MINOR

AND

TRIBU-

PREM

LICENSES

INTEREST

ADM SUP

EQUIP

MAINT

SUBSCRIP

TIONS

NON-CAP

EXPENSE

INCOME

TOTAL

REGIONAL

(ENTER

BASIS)

COMPONENT NAME

NUMBER

Total

Grand Total

Cost to be allocated

UCM

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)

48-522

Rev. 1

Sheet 15: E Pooled

MM-YY

FORM CMS-287-21

4895

ALLOCATION OF POOLED COSTS FOR DOUBLE ALLOCATION METHOD

HOME OFFICE

PERIOD:

SCHEDULE E

NUMBER:

FROM:

____________

_________________

TO:

____________

ALLOCATION

STATISTICS

CAPITAL RELATED

NON-CAPITAL RELATED

(ENTER

ALLOCATION

CRC-

SALARIES

SAL & WAGES

ALL OTHER

INTEREST

BASIS)

RATIO

B&F

OF OFFICERS

OF OTHERS

NON-CAPITAL

INCOME

Healthcare Provider Components

Non-Healthcare Components

Region / Division Components

Total

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4806 THROUGH SECTION 4806.10.)

Rev. 1

48-523

Sheet 16: E-1 Pooled

4895					FORM CMS-287-21											MM-YY
ALLOCATION OF POOLED COSTS TO COMPONENTS									HOME OFFICE		PERIOD:				SCHEDULE E-1
									NUMBER:			FROM:		____________
									_________________			TO:	____________
									_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS
				ALLOCATION
				STATISTICS		CAPITAL RELATED		NON-CAPITAL RELATED
				(ENTER	ALLOCATION	CRC-	CRC-	SALARIES		SAL & WAGES		ALL OTHER			INTEREST
				BASIS)	RATIO	B&F	ME	OF OFFICERS		OF OTHERS		NON-CAPITAL			INCOME
		COMPONENT NAME	CCN	1	2	3	4	5		6		7			8
1																1
2																2
3																3
4																4
5																5


50																50
51	Total															51

PART II - NON-HEALTHCARE COMPONENTS
				ALLOCATION
				STATISTICS		CAPITAL RELATED		NON-CAPITAL RELATED
				(ENTER	ALLOCATION	CRC-	CRC-	SALARIES		SAL & WAGES		ALL OTHER			INTEREST
				BASIS)	RATIO	B&F	ME	OF OFFICERS		OF OTHERS		NON-CAPITAL			INCOME
		COMPONENT NAME		1	2	3	4	5		6		7			8
1																1
2																2
3																3
4																4
5																5


50																50
51	Total															51

PART III - REGION / DIVISION COMPONENTS
				ALLOCATION
				STATISTICS		CAPITAL RELATED		NON-CAPITAL RELATED
			REGIONAL	(ENTER	ALLOCATION	CRC-	CRC-	SALARIES		SAL & WAGES		ALL OTHER			INTEREST
			HO	BASIS)	RATIO	B&F	ME	OF OFFICERS		OF OTHERS		NON-CAPITAL			INCOME
		COMPONENT NAME	NUMBER	1	2	3	4	5		6		7			8
1																1
2																2
3																3
4																4
5																5


50																50
51	Total															51
52	Grand Total															52

FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4806.20 THROUGH 4806.23.)
48-524																Rev. 1

Sheet 17: F SumCap

MM-YY			FORM CMS-287-21											4895
SUMMARY OF CAPITAL RELATED COSTS						HOME OFFICE		PERIOD:				SCHEDULE F
						NUMBER:			FROM:		____________
						_________________			TO:	____________
						_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS
													TOTAL
													CAPITAL
					DIRECT		FUNCTIONAL		POOLED				COST
		COMPONENT NAME		CCN	1		2		3				4
1														1
2														2
3														3
4														4
5														5


50														50
51	Total													51

PART II - NON-HEALTHCARE COMPONENTS
													TOTAL
													CAPITAL
					DIRECT		FUNCTIONAL		POOLED				COST
		COMPONENT NAME			1		2		3				4
1														1
2														2
3														3
4														4
5														5


50														50
51	Total													51

PART III - REGION / DIVISION COMPONENTS
													TOTAL
													CAPITAL
				REGIONAL	DIRECT		FUNCTIONAL		POOLED				COST
		COMPONENT NAME		HO NUMBER	1		2		3				4
1														1
2														2
3														3
4														4
5														5


50														50
51	Total													51
52	Grand Total													52




FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4807 THROUGH SECTION 4807.13.)
Rev. 1														48-525

Sheet 18: F-1 SumNon-Cap

4895						FORM CMS-287-21											MM-YY
SUMMARY OF NON-CAPITAL RELATED COSTS										HOME OFFICE		PERIOD:				SCHEDULE F-1
										NUMBER:			FROM:		____________
										_________________			TO:	____________
										_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS
				SALARIES				ALL OTHER NON-CAPITAL COSTS								TOTAL
							SUBTOTAL						SUBTOTAL ALL			NON-CAPITAL
				DIRECT	FUNCTIONAL	POOLED	SALARIES	DIRECT	FUNCTIONAL		POOLED		OTH NON-CAP			COST
		COMPONENT NAME	CCN	1	2	3	4	5	6		7		8			9
1																	1
2																	2
3																	3
4																	4
5																	5


50																	50
51	Total																51

PART II - NON-HEALTHCARE COMPONENTS
				SALARIES				ALL OTHER NON-CAPITAL COSTS								TOTAL
							SUBTOTAL						SUBTOTAL ALL			NON-CAPITAL
				DIRECT	FUNCTIONAL	POOLED	SALARIES	DIRECT	FUNCTIONAL		POOLED		OTH NON-CAP			COST
		COMPONENT NAME		1	2	3	4	5	6		7		8			9
1																	1
2																	2
3																	3
4																	4
5																	5


50																	50
51	Total																51

PART III - REGION OFFICE / DIVISION COMPONENTS
				SALARIES				ALL OTHER NON-CAPITAL COSTS								TOTAL
			REGIONAL				SUBTOTAL						SUBTOTAL ALL			NON-CAPITAL
			HO	DIRECT	FUNCTIONAL	POOLED	SALARIES	DIRECT	FUNCTIONAL		POOLED		OTH NON-CAP			COST
		COMPONENT NAME	NUMBER	1	2	3	4	5	6		7		8			9
1																	1
2																	2
3																	3
4																	4
5																	5


50																	50
51	Total																51
52	Grand Total																52




FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4807.20 THROUGH SECTION 4807.23.)
48-526																	Rev. 1

Sheet 19: G

MM-YY					FORM CMS-287-21							4895
BALANCE SHEET						HOME OFFICE	PERIOD:				SCHEDULE G
						NUMBER:		FROM:		____________
						_________________		TO:	____________
						_________________		TO:	____________

											AMOUNT
				1							2

			ASSETS
		CURRENT ASSETS
1	Cash on hand and in banks											1
2	Temporary investments											2
3	Notes receivable											3
4	Accounts receivable											4
5												5
6	Less: allowances for uncollectible notes and accounts receivable											6
7	Inventory											7
8	Prepaid expenses											8
9												9
10	Total current assets											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 non-depreciable											24
25												25
26	Total fixed assets											26
		OTHER ASSETS
27	Investments											27
28	Deposits on leases											28
29	Due from owners/officers											29
30												30
31	Total other assets											31
32	Total assets											32

			LIABILITIES
		CURRENT LIABILITIES
33	Accounts payable											33
34	Salaries, wages, and fees payable											34
35	Payroll taxes payable											35
36	Notes and short-term loans payable											36
37	Deferred income											37
38	Accelerated payments											38
39												39
40	Total current liabilities											40
		LONG TERM LIABILITIES
41	Mortgage payable											41
42	Notes payable											42
43	Unsecured loans											43
44												44
45	Total long term liabilities											45
46	Total liabilities											46
			CAPITAL
47	Retained earnings											47
48	Total liabilities and retained earnings											48








FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4808 THROUGH SECTIO 4808.10.)
Rev. 1												48-527

Sheet 20: G-1

4895			FORM CMS-287-21							MM-YY
STATEMENT OF REVENUES AND EXPENSES				HOME OFFICE	PERIOD:				SCHEDULE G-1
				NUMBER:		FROM:		____________
				_________________		TO:	____________
				_________________		TO:	____________

		DESCRIPTION							AMOUNT
		1							2
1	Total operating revenue									1
2	Less: Operating expenses									2
3	Operating profit or (loss)									3
	Other income:
4	Contributions, donations, bequests, etc.									4
5	Interest income									5
6	Purchase discounts									6
7	Rebates and refunds of expenses									7
8	Parking lot receipts									8
9	Rental income									9
10										10
11										11
12										12
13										13
14										14
15	Total other income									15
	Other expenses:
16										16
17										17
18										18
19										19
20										20
21	Total other expenses									21
22	Net income or loss for the period									22










































FORM CMS-287-20 (MM/2020) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4808.20.)
48-528										Rev. 1

File Type	application/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified	0000-00-00
File Created	0000-00-00