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

CHAPTER 48
HOME OFFICE COST STATEMENT
FORM CMS-287-21
Section
General ................................................................................................................................4800
Reporting Home Office Costs ....................................................................................4800.10
Determination of Allowable Costs....................................................................4800.11
Allocation of Home Office/Chain Organization Costs to Components............4800.12
Home Office/Chain Organization Costs in Providers’ Medicare Cost
Reports ........................................................................................................4800.13
Non-Concurrent Period Allocation of Home Office/Chain Organization
Costs............................................................................................................4800.14
Home Office Cost Statement Schedules ...........................................................4800.15
Electronic Reporting ..................................................................................................4800.20
Reporting Standards ..........................................................................................4800.21
Medicare Cost Statement Submission ..............................................................4800.22
Supporting Documentation ...............................................................................4800.23
Acronyms, Abbreviations and Initialisms..................................................................4800.30
Recommended Sequence of Completion ...................................................................4800.40
S Series................................................................................................................................4801
Schedule S - Home Office Cost Statement Certification ...........................................4801.10
Part I - Cost Statement Status - Contractor Use Only.......................................4801.11
Part II - Certification .........................................................................................4801.12
Schedule S-1 - Identification Data .............................................................................4801.20
Part I - Home Office Data .................................................................................4801.21
Part II - Key Officers Data ................................................................................4801.22
Schedule S-2 - Listing of Components ......................................................................4801.30
Part I - Healthcare Provider Components .........................................................4801.31
Part II - Non-Healthcare Components ..............................................................4801.32
Part III - Region/Division Components ............................................................4801.33
A Series ...............................................................................................................................4802
Schedule A - Reclassification and Adjustment of Trial Balance of Expenses ..........4802.10
Schedule A-6 - Reclassifications of Expenses ...........................................................4802.70
Schedule A-7 - Analysis of Capital Cost Centers ......................................................4802.80
Part I - Analysis of Changes in Capital Asset Balances ...................................4802.81
Part II - Reconciliation of Capital Cost Centers ...............................................4802.82
Schedule A-8 - Adjustments to Expenses ..................................................................4802.90
Schedule A-8-1 - Costs of Services from Related Organizations and/or Home
Office/Chain Organizations .................................................................................4802.100
Part I - Adjustments Required as a Result of Transactions with Related
Organizations and/or Home Office/Chain Organizations ...........................4802.101
Part II - Interrelationship of Home Office/Chain Organization to Related
Organizations ..............................................................................................4802.102

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CHAPTER 48
HOME OFFICE COST STATEMENT
FORM CMS-287-21
Section
B Series ...............................................................................................................................4803
Schedule B - Direct Allocation of Capital Related Costs ..........................................4803.10
Part I - Healthcare Provider Components .........................................................4803.11
Part II - Non-Healthcare Components ..............................................................4803.12
Part III - Region/Division Components ............................................................4803.13
Schedule B-1 - Direct Allocation of Non-Capital Related Costs ..............................4803.20
Part I - Healthcare Provider Components .........................................................4803.21
Part II - Non-Healthcare Components ..............................................................4803.22
Part III - Region/Division Components ............................................................4803.23
C Series ...............................................................................................................................4804
Schedule C - Functional Allocation of Capital Related Costs ...................................4804.10
Part I - Healthcare Provider Components .........................................................4804.11
Part II - Non-Healthcare Components ..............................................................4804.12
Part III - Region/Division Components ............................................................4804.13
Schedule C-1 - Functional Allocation of Capital Related Costs - Statistics ..............4804.20
Part I - Healthcare Provider Components .........................................................4804.21
Part II - Non-Healthcare Components ..............................................................4804.22
Part III - Region/Division Components ............................................................4804.23
D Series ...............................................................................................................................4805
Schedule D - Functional Allocation of Non-Capital Related Costs ..........................4805.10
Part I - Healthcare Provider Components .........................................................4805.11
Part II - Non-Healthcare Components ..............................................................4805.12
Part III - Region/Division Components ............................................................4805.13
Schedule D-1 - Functional Allocation of Non-Capital Related Costs Statistics ...............................................................................................................4805.20
Part I - Healthcare Provider Components .........................................................4805.21
Part II - Non-Healthcare Components ..............................................................4805.22
Part III - Region/Division Components ............................................................4805.23
E Series ...............................................................................................................................4806
Schedule E - Allocation of Pooled Costs for Double Allocation Method .................4806.10
Schedule E-1 - Allocation of Pooled Costs to Components ......................................4806.20
F Series................................................................................................................................4807
Schedule F - Summary of Capital Related Costs .......................................................4807.10
Part I - Healthcare Provider Components .........................................................4807.11
Part II - Non-Healthcare Components ..............................................................4807.12
Part III - Region/Division Components ............................................................4807.13
Schedule F-1 - Summary of Non-Capital Related Costs ...........................................4807.20
G Series ...............................................................................................................................4808
Schedule G - Balance Sheet .......................................................................................4808.10
Schedule G-1 - Statement of Revenues and Expenses...............................................4808.20
Form CMS-287-21 Schedules.............................................................................................4895

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4800.

FORM CMS-287-21

4800

GENERAL

In accordance with the Paperwork Reduction Act of 1995, CMS must inform the private sector
why information is collected and how it will use the information. This chapter presents the home
office cost statement, Form CMS-287-21, completed by a home office and/or chain organization,
hereinafter referred to as home office/chain organization (HO/CO), to support HO/CO costs
claimed in a Medicare cost report.
For Medicare and/or Medicaid purposes, CMS defines a home office as an entity that provides
centralized management and administrative services to the individual members of a chain
organization and a chain organization as an entity that consists of a group of two or more Medicarecertified providers (providers) or at least one provider and any other non-provider business or
entity owned, leased, or through any other device, under common ownership or control. The
HO/CO may also include regional offices or divisions. The home office cost statement instructions
and schedules refer collectively to the provider, non-provider, and regional office or division
members of a HO/CO as healthcare provider components, non-healthcare components, and
region/division components, respectively. When a HO/CO includes region/division components
that file separate home office cost statements, these instructions refer to the HO/CO as the parent
HO/CO.
The Form CMS-287-21, effective for a HO/CO cost statement period beginning on or after
January 1, 2021, constitutes the documentary support required for a provider to be reimbursed for
HO/CO costs claimed in the provider’s Medicare cost report (see 42 CFR 413.24(f)(5)(i)(E)(1)
and (2)). Under the authority of §§1815(a) and 1833(e) of the Social Security Act (the Act), CMS
requires that each provider of services participating in the Medicare program submit annual
information, the Medicare cost report, to determine costs for healthcare services rendered to
Medicare beneficiaries. A provider in a HO/CO may submit a Medicare cost report that includes
allowable costs allocated from the HO/CO (see §§4800.10-4800.12; CMS Pub. 15-1, chapter 10;
and CMS Pub. 15-1, chapter 21, §§2150-2153) and must provide adequate cost data based on
financial and statistical records that can be verified by qualified auditors (see 42 CFR 413.20 and
413.24).
CMS requires that the HO/CO prepare an electronic cost statement (see 4800.20). The HO/CO
may elect to electronically submit the certification statement with an electronic signature of the
home office's administrator or chief financial officer (see 4801.12).
The relationship of the HO/CO is that of a related organization to a provider (see 42 CFR 413.17).
A HO/CO usually furnishes central management and administrative services, e.g., centralized
accounting, purchasing, personnel services, management direction and control, and other services.
To the extent that the HO/CO furnishes services related to patient care to a provider, the reasonable
costs of such services are included in the provider’s cost report and are reimbursable as part of the
provider’s costs. If the HO/CO provides no services related to patient care, the costs of the HO/CO
may not be recognized in determining the allowable costs of the healthcare providers in the
HO/CO.
The HO/CO must obtain CMS approval from the Medicare Administrative Contractor (contractor),
and receive a home office number, to submit a home office cost statement.

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4800 (Cont.)

FORM CMS-287-21

DRAFT

When a parent HO/CO includes region/division components, the parent HO/CO must allocate
costs to all components, including the region/division components. Each region/division allocates
the costs allocated from the parent HO/CO, along with direct region/division costs, to the
region/division components on a separate regional home office cost statement. Like the parent
HO/CO, a region/division must obtain CMS approval through the contractor, and receive a
regional home office number, to submit a regional home office cost statement that allocates costs
to its components. The parent HO/CO must submit the home office cost statement and all regional
home office cost statements, as a combined package, to the HO/CO designated contractor(s).
The HO/CO must submit the home office cost statement to the designated contractor no later than
150 days after the end of the HO/CO accounting period. When a provider claims HO/CO costs in
its Medicare cost report and the HO/CO fails to submit an acceptable home office cost statement
that supports the HO/CO amounts claimed in the provider’s cost report, the contractor must reject
the provider’s Medicare cost report for lack of supporting documentation. If a provider claims
HO/CO costs in a cost report with a fiscal year end that is not concurrent with the accounting
period of the HO/CO, the HO/CO must submit an acceptable home office cost statement that
supports some portion of the HO/CO amounts claimed in the provider’s cost report (see §4800.14
and 42 CFR 413.24(f)(5)(i)(E)(2)).
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 0938-0202. The expiration date of this information
collection instrument is [XXXX XX, 2023]. The time required to complete this information
collection is estimated to average 466 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information
collection. Direct comments concerning the accuracy of the time estimate or suggestions for
improving this form to: Centers for Medicare and Medicaid Services, 7500 Security Boulevard,
ATTN: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Any correspondence not pertaining to the information collection burden approved under the
associated OMB control number on this form will not be reviewed, forwarded, or retained.

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4800.10

FORM CMS-287-21

4800.11.3.3

REPORTING HOME OFFICE COSTS

A HO/CO must follow the Medicare principles of reasonable cost reimbursement in the Provider
Reimbursement Manual, Part I (CMS Pub. 15-1), when completing the Medicare home office cost
statement.

4800.11

Determination of Allowable Costs

HO/CO costs directly related to services performed for a provider and related to patient care, plus
an appropriate share of indirect costs (e.g., overhead, rent for HO/CO space, administrative
salaries), are allowable to the extent the costs are reasonable. Any HO/CO costs that are not
allowable costs when incurred directly by the provider are not allowable as HO/CO costs allocated
to providers. For example, certain advertising costs, some franchise taxes and other similar taxes,
costs of non-competition agreements, certain life insurance premiums, certain membership costs,
and those costs related to non-medical enterprises, are not allowable HO/CO costs (see
CMS Pub. 15-1, chapter 21).
4800.11.1 Management Fees--Management fees charged between related organizations are not
allowable costs except as provided in CMS Pub. 15-1, chapter 10. Remove unallowable
management fees from the cost statement through the Schedule A-8-1.

4800.11.2 Owner Compensation--The compensation paid to an owner (as defined in
CMS Pub. 15-1, chapter 9) by the HO/CO is allowable only to the extent that it is related to patient
care and is reasonable.

4800.11.3 Organization, Startup, and Other Corporate Costs
4800.11.3.1 Organization Costs--The organization costs of a HO/CO, except startup costs
and costs of corporate acquisitions, are allowable costs and must be amortized in accordance
with the provisions in CMS Pub. 15-1, chapter 21, §2134ff. See CMS Pub. 15-1, chapter 21,
§2134.1B, for the description of unallowable organization costs; CMS Pub. 15-1, chapter 21,
§2134.10, for the description of unallowable reorganization costs; and CMS Pub. 15-1,
chapter 21, §2134.9, for the description of unallowable stockholder servicing costs.
4800.11.3.2 Startup Costs--Startup costs of a HO/CO are considered allowable costs and
must be amortized in accordance with the provisions of CMS Pub. 15-1, chapter 21, §2132.1.
4800.11.3.3 Costs of Corporate Acquisitions--Costs related to the acquisition of capital stock
of a facility (whether said facility participates or subsequently participates in the Medicare
program) are not allowable (see CMS Pub. 15-1, chapter 21, §2134.11). Additionally, costs
related to the transfer of assets to a HO/CO are not allowable as organization costs; these costs
must be capitalized as part of the cost of the asset (see CMS Pub. 15-1, chapter 21,
§2150.2.B.3).

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4800.11.4

FORM CMS-287-21

DRAFT

4800.11.4 Interest on Loans between Home Office/Chain Organization and Components--When
the HO/CO loans money to, or borrows money from, one of its components, the interest paid is
generally not an allowable cost and the interest income earned from such a loan is not used to
reduce allowable interest expense. (See CMS Pub. 15-1, chapter 2, §§218 and 218.1, for the
general rule, and §§218.2 and 220 for exceptions to the general rule.) Treat interest income from
other sources, as well as the interest income received by the HO/CO if interest expense is allowed
under the exceptions of CMS Pub. 15-1, chapter 2, §§218.2 and 220, according to the provisions
of CMS Pub. 15-1, chapter 2, §§202.2 and 202.3.

4800.11.5 Interest on Loans from Unrelated Sources--Interest expense (see CMS Pub. 15-1,
chapter 2, §§200 and 202.1) is allowable to the extent that the proceeds of the related loan,
mortgage, bond issue, etc., are used either to acquire assets for use in patient care activities or to
provide funds for operations related to patient care. When proceeds of a loan, mortgage, bond
issue, etc., are used to acquire stock ownership (as opposed to assets and liabilities) of additional
facilities, the interest expense is not allowable.

4800.11.6 Home Office/Chain Organization Planning Costs - Expanding, Rebuilding, or
Relocating Existing Providers--Planning costs, as described in CMS Pub. 15-1, chapter 21,
§§2154.1 and 2154.2, incurred by the HO/CO to purchase or construct a new facility in order to
expand, rebuild, or relocate a provider that is a member of the HO/CO, are allowable if:




the costs are reasonable and prudent as defined in CMS Pub. 15-1, chapter 21, §2103;
the costs have been included in the historical cost of the completed facility; and
the facility has been certified to participate in Medicare.

Planning costs incurred to purchase land become part of the historical cost of the land and are not
included in the historical cost of the depreciable assets of the completed facility. Planning costs
for both land and a facility that cannot be specifically identified with either the land or facility
must be allocated between the land and facility based on the cost of each to the total cost.
Abandoned planning costs are treated according to the provisions of CMS Pub. 15-1, chapter 21,
§2154.4. Any allowable abandonment costs must be directly allocated to the appropriate provider.

4800.11.7 Expansion of the Chain Operation--Planning costs incurred by the HO/CO to construct
a new facility or to purchase an existing facility (excluding land) to expand a HO/CO and not to
expand an existing provider are recognized when the requirements in §4800.11.6 are met. The
costs of such plans subsequently abandoned are considered an investment loss and are not
allowable. The costs of abandoned land acquisition plans are not allowable.

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FORM CMS-287-21

4800.11.9

4800.11.8 Malpractice and Comprehensive General Liability, Unemployment and Workers’
Compensation Insurance Coupled with Second Injury Coverage--Payments by a HO/CO for its
providers or payments made individually by members of a HO/CO to an independent fiduciary for
malpractice, comprehensive general liability insurance coverage, unemployment and workers’
compensation insurance coupled with second injury coverage, are recognized if made to a fund
established in accordance with the requirements in CMS Pub. 15-1, chapter 21, §2162ff.

4800.11.9 Interest Expense and Interest Income of Home Office/Chain Organization--The
HO/CO must assign and/or allocate interest expense incurred by the HO/CO in accordance with
§4800.12. The HO/CO must identify interest expense as capital related or non-capital related cost.
Similarly, the HO/CO must identify all interest income as capital related or non-capital related.
The HO/CO must appropriately assign and/or allocate interest income in accordance with
§4800.12 and offset against allowable interest expense. The net amount of capital related interest
expense and interest income (whether positive or negative), so determined at the HO/CO level for
each provider, must be appropriately included with that provider’s costs as described in §4800.13.

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4800.12
4800.12

FORM CMS-287-21

DRAFT

Allocation of Home Office/Chain Organization Costs to Components

The home office cost statement provides the mechanism to allocate allowable HO/CO costs to the
healthcare provider components (providers), non-healthcare components, and region/division
components. All components must receive their allocable share of HO/CO capital and non-capital
costs. Starting with the HO/CO total costs (including those costs paid on behalf of providers),
remove all costs that are not allowable in accordance with program instructions. Identify the
remaining costs (total allowable costs) into two groups, capital related costs or non-capital related
costs, and allocate each group to all components that received services from the HO/CO. Allocate
HO/CO costs to the components in the following order:
Step 1: Allocate Direct Costs--Allocate allowable HO/CO costs incurred for the benefit of, or
directly attributable to, a specific component (healthcare provider, non-healthcare, or
region/division) to the component for which the costs were incurred (direct allocation of cost).
For example, directly allocate to a provider the interest expense paid by the HO/CO on a loan
related solely to the provider. Allocate HO/CO salaries to the component where the employees
worked. Directly allocate to a provider any HO/CO cost to rent space for that provider. The
HO/CO may simplify the allocation of costs to the components by transferring the costs at the
time incurred through inter-company accounts.
Step 2: Allocate Functional Costs--Allocate allowable HO/CO costs that are not directly
allocable among the components receiving a benefit from the allowable costs using a statistical
basis that reasonably relates to the cost (functional allocation of cost). Where practical, and
the amounts material, allocate the costs of HO/CO centralized services (e.g., central payroll or
central purchasing) provided to the components on a functional basis. For example, allocate
costs of a central payroll operation to the components based on the number of paychecks
issued. Allocate the costs of central purchasing based on purchases made or requisitions
handled. The HO/CO must use the same statistical basis from one accounting period to another
when allocating costs on a functional basis. If the HO/CO wishes to change an allocation basis
because it believes the change will result in a more accurate allocation, the HO/CO must submit
a written request to the contractor in accordance with PRM 15-1, chapter 21, §2150.3.D.2.

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FORM CMS-287-21

4800.12 (Cont.)

Step 3: Allocate Pooled Costs--Allocate the residual amount (or pool) of HO/CO costs (the
remaining costs incurred for general management or administrative services and not directly
or functionally allocated) to the components on a reasonable allocation basis:
1. If the HO/CO consists solely of comparable inpatient healthcare providers (e.g., a
HO/CO with short-term acute care hospitals and no hospital complexes), allocate the
pooled costs among the providers based on inpatient days. When the HO/CO
providers are not comparable inpatient healthcare providers (e.g., a HO/CO with
short-term acute care hospitals, hospital complexes, and skilled nursing facilities),
allocate the pooled costs among the providers based on total costs. Total costs are
costs before applying Medicare adjustments plus any direct HO/CO costs.
2. If the HO/CO consists of healthcare and non-healthcare and/or region/division
components, use the double allocation method to allocate the pooled costs among the
component groups based on total costs. Then allocate the pooled costs among the
components in each grouping (see CMS Pub. 15-1, §2150.3.D.2.).
a. For the healthcare provider components, if the providers are comparable
(e.g., short-term acute care hospitals and no hospital complexes), allocate the
pooled costs among the providers based on inpatient days; or, if the providers are
not comparable (e.g., short-term acute care hospitals, hospital complexes, and
skilled nursing facilities), allocate the pooled costs among the providers based on
total costs. Total costs are costs before applying Medicare adjustments plus any
direct HO/CO costs.
b. For the non-healthcare and region/division components, allocate the pooled costs
among the components based on total costs. Total costs are costs before applying
Medicare adjustments plus any direct HO/CO costs.
When the allocation basis permits the use of inpatient days, each provider shares in the pooled
costs in the same proportion that its total inpatient days bear to the total inpatient days of all
the providers in the HO/CO. When the allocation basis requires the use of total costs, each
component shares in the pooled costs in the same proportion that its total costs (including direct
HO/CO costs and excluding previously allocated HO/CO functional and pooled costs) bear to
the total costs of all components in the HO/CO.

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4800.13
4800.13

FORM CMS-287-21

DRAFT

Home Office/Chain Organization Costs in Providers’ Medicare Cost Reports

A provider includes HO/CO costs directly allocated to the provider in the appropriate account in
the provider’s trial balance. The provider allocates the HO/CO costs through the cost finding
process.
A provider includes HO/CO capital related costs not directly allocated to the provider, but
allocated on a functional or pooled basis, in the provider’s capital related cost centers, i.e.,
buildings and fixtures, movable equipment, or other capital (for insurance, taxes and other capital
costs).
A provider includes lease cost with depreciation, not as other capital.
A provider includes HO/CO non-capital related costs not directly allocated to the provider, but
allocated on a functional or pooled basis, in the provider’s A&G cost. The provider includes the
allocated costs as one amount, designated by an appropriately descriptive heading, e.g., "home
office costs."
Although the share of the HO/CO costs allocated to a provider may become allowable costs under
the program, the allowed costs of a provider in a HO/CO must not exceed the cost allowed for
similar institutions not so affiliated. Thus, the costs of a HO/CO provider (including any allowable
HO/CO costs) are not recognized or allowed when determined to be out of line with similar
institutions in the same area. (See CMS Pub. 15-1, chapter 21, §2102ff.)

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4800.14

FORM CMS-287-21

4800.14

Non-Concurrent Period Allocation of Home Office/Chain Organization Costs

When the HO/CO accounting period is not concurrent with a provider’s cost reporting period, the
provider reports allowable HO/CO costs for the portion of the provider’s cost reporting period that
overlaps the HO/CO accounting period, and the provider projects an amount of allowable HO/CO
costs for the portion of its cost reporting period not covered by the home office cost statement.
The projected cost must not exceed the previous year HO/CO costs as set forth in the applicable
home office cost statement. The provider allocates the total HO/CO costs (the allowable plus the
projected costs) through the cost finding process.
For example, the Home Office Z accounting period began January 1, 2017, and ended
December 31, 2017. Home Office Z allocated $120,000 to Provider A and $84,000 to Provider B.
Provider A’s cost reporting period began September 1, 2017, and ended on August 31, 2018; and
Provider B’s cost reporting period began April 1, 2017, and ended on March 31, 2018. Neither
provider’s cost reporting period was concurrent with the Home Office Z accounting period.
During its 12-month accounting period ending December 31, 2017, Home Office Z allocated
home office costs of $7,000 per month ($84,000 divided by the Home Office Z 12-month
accounting period), to Provider B. For the 9 months (April 1, 2017, through December 31, 2017)
that the Provider B cost reporting period overlaps the Home Office Z accounting period,
Provider B reports home office costs of $63,000 ($7,000 per month for 9 months). For the
remaining 3 months of the cost reporting period (January 1, 2018, through March 31, 2018),
Provider B estimates home office costs of $21,000, projected at a rate not in excess of the previous
year ($7,000 per month). Therefore, Provider B reports total home office costs for the cost
reporting period of April 1, 2017, through March 31, 2018, of $84,000 ($63,000 actual and $21,000
projected). The contractor adjusts the projected costs to actual HO/CO costs allocated to the
provider in the home office cost statement for the subsequent HO/CO accounting period.
During its 12-month accounting period ending December 31, 2017, Home Office Z allocated
home office costs of $7,000 per month ($84,000 divided by the Home Office Z 12-month
accounting period), to Provider B. For the 9 months (April 1, 2017, through December 31, 2017)
that the Provider B cost reporting period overlaps the Home Office Z accounting period,
Provider B reports home office costs of $63,000 ($7,000 per month for 9 months). For the
remaining 3 months of the cost reporting period (January 1, 2018, through March 31, 2018),
Provider B estimates home office costs of $21,000, projected at a rate not in excess of the previous
year ($7,000 per month). Therefore, Provider B reports total home office costs for the cost
reporting period of April 1, 2017, through March 31, 2018, of $84,000 ($63,000 actual and $21,000
projected). The contractor adjusts the projected costs to actual HO/CO costs allocated to the
provider in the home office cost statement for the subsequent HO/CO accounting period.

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4800.15
4800.15

FORM CMS-287-21

DRAFT

Home Office Cost Statement Schedules

The home office cost statement consists of the following:
A certification of the accuracy of the home office cost statement (Schedule S)
and information about the organization of the HO/CO (Schedules S-1 and
S-2);
A detailed analysis of allocable HO/CO costs beginning with the trial balance
of expenses (Schedule A);
Medicare reclassifications to the trial balance costs (Schedule A-6);
A reconciliation of capital costs (Schedule A-7);
Medicare adjustments to the trial balance costs (Schedule A-8);
A statement of costs from related organizations (Schedule A-8-1);
An allocation of the direct capital and non-capital HO/CO costs (Schedules B
and B-1);
A functional allocation of HO/CO capital costs (Schedules C and C-1);
A functional allocation of HO/CO non-capital costs (Schedules D and D-1);
An allocation of pooled HO/CO costs (Schedules E and E-1);
A summary allocation of HO/CO capital costs (Schedule F);
A summary allocation of HO/CO salaries and non-capital costs (Schedule F-1);
The HO/CO balance sheet (Schedule G);
The statement of revenues and expenses (Schedule G-1).

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4800.20

FORM CMS-287-21

4800.20

ELECTRONIC REPORTING

CMS requires that the HO/CO prepare and submit the Form CMS-287-21 using CMS-approved
software available from electronic cost reporting (ECR) software vendors. This chapter presents
the home office cost statement, with some schedules abbreviated, as a graphic representation of
the Form CMS-287-21 created by the ECR software. Blank lines and columns on an abbreviated
schedule represent the full range of lines and columns of the schedule. For example, Schedule S-2,
Part I, provides lines 1 through 50 to report healthcare provider components in the HO/CO;
however, the graphic representation of Schedule S-2 presents lines 1 through 5, two blank lines,
and line 50, with the two blank lines representing lines 6 through 49.
The software accommodates the HO/CO reporting components, cost centers, reclassifications,
adjustments, etc. by permitting the HO/CO to subscript (add) lines on certain schedules. For
example, the HO/CO can subscript Schedule A, line 9, salaries and wages of others, to more
accurately allocate the salaries and wages for each department in the HO/CO, and to each location,
to facilitate a functional allocation of the costs instead of a pooled allocation. The software assigns
line numbers to subscripted lines, and column numbers to subscripted columns when applicable,
by numbering the line or column sequentially after the line or column from which subscripted.
Unless otherwise specified, instructional references to a line or column include all subscripts of
that line or column. Examples include the following:


When a HO/CO subscripts Schedule A, line 35, to add three additional cost centers, the
subscripted lines begin with line 35.01 and continue with lines 35.02 and 35.03; and the
subtotal on Schedule A, line 99, which is the sum of lines 8 through 98, includes line 35
and all subscripts of line 35.



When a HO/CO subscripts Schedule A-8, line 20, to add line 20.01, the subtotal on
Schedule A-8, line 100, which is the sum of lines 1 through 99, includes line 20 and all
subscripts of line 20. Additionally, the subscripted line 20.01 follows the Schedule A-8
instructions in that the adjustment amount entered in column 3 transfers to the Schedule A
cost center as indicated in Schedule A-8, columns 4 and 5.

For accuracy and consistency of reporting, the software transfers (flows) data or labels on some
schedules from certain lines and columns, including subscripts of those lines and columns, to
subsequent schedules. The instructions in this chapter indicate such data or label transfers by using
the term “transfer” and noting the source or destination of the transferred data or label. The
software maintains consistency for presentation and analysis by transferring data or labels from
the line or column of the source schedule to the same line or column on the destination schedule,
unless the instructions specify otherwise. Examples of data and label transfers:


Rev. 1

Data transfer: For a home office reporting 54 components on Schedule S-2, Part I, by
subscripting line 8 to include subscripted lines 8.01, 8.02, and 8.03, the software adds the
subscripted lines 8.01, 8.02, and 8.03 to Schedules B, Part I; B-1, Part I; C, Part I;
C-1, Part I; D, Part I; D-1, Part I; E-1, Part I; F, Part I; and F-1, Part I, and transfers the
data from Schedule S-2, columns 1 and 2, for each line 1 through 50, including the
subscripted lines 8.01, 8.02, and 8.03, to columns 1 and 2, respectively, of each schedule.
The software maintains consistency in line numbering by transferring the data from each
line on Schedule S-2 to the same line number on each destination schedule.

48-13

4800.20 (Cont.)


FORM CMS-287-21

DRAFT

Label transfer: For a home office reporting four non-payroll related employee benefits cost
centers on Schedule A by subscripting line 12 to include subscripted lines 12.01, 12.02,
and 12.03, the software adds subscripted columns 12.01, 12.02, and 12.03, on
Schedules B-1, D, and D-1, and transfers the cost center labels (abbreviated as necessary)
from Schedule A, lines 12.01, 12.02, and 12.03, to the subscripted columns on each
destination schedule. The software maintains consistency in labeling by transferring the
label from each line on Schedule A to the same numbered column on each destination
schedule.

Schedules with lines the HO/CO may subscript include the following:
 Schedule S-1, Part II, lines 6 through 20, may be subscripted up to 9 times each.
 Schedule S-2, Parts I, II, and III, lines 1 through 50, may be subscripted up to 99 times each.
 Schedule A, lines 1, 2, 4, 5, 6, and lines 8 through 98, may be subscripted up to 99 times
each.
 Schedule A-6, lines 1 through 99, may be subscripted up to 99 times each.
 Schedule A-8, line 14, and lines 18 through 99, may be subscripted up to 99 times each.
 Schedule A-8-1, Part I, lines 1 through 99, may be subscripted up to 99 times each.
 Schedule A-8-1, Part II, lines 1 through 50, may be subscripted up to 99 times each.
 Schedule F-1, Part I, II, and III, lines 1 through 50, may be subscripted up to 99 times each.
 Schedule G, lines 5, 9, 25, 30, 39, and 44, may be subscripted up to 99 times each.
 Schedule G-1, lines 10 through 14, and lines 16 through 20, may be subscripted up to
99 times each.
Schedules with lines and/or columns subscripted by the software include the following:
 Schedule B
 Part I, lines 1 through 50, the same as Schedule S-2, Part I, lines 1 through 50
 Part II, lines 1 through 50, the same as Schedule S-2, Part II, lines 1 through 50
 Part III, lines 1 through 50, the same as Schedule S-2, Part III, lines 1 through 50
 Parts I, II, and III, columns 1 through 6, the same as Schedule A, lines 1 through 6,
respectively
 Schedules B-1, D, and D-1
 Part I, lines 1 through 50, the same as Schedule S-2, Part I, lines 1 through 50
 Part II, lines 1 through 50, the same as Schedule S-2, Part II, lines 1 through 50
 Part III, lines 1 through 50, the same as Schedule S-2, Part III, lines 1 through 50
 Parts I, II and III, columns 8 through 98, the same as Schedule A, lines 8 through 98,
respectively
 Schedules C and C-1
 Part I, lines 1 through 50, the same as Schedule S-2, Part I, lines 1 through 50
 Part II, lines 1 through 50, the same as Schedule S-2, Part II, lines 1 through 50
 Part III, lines 1 through 50, the same as Schedule S-2, Part III, lines 1 through 50
 Parts I, II, and III, columns 1 and 2, the same as Schedule A, lines 1 and 2, respectively
 Schedules E-1, F, and F-1
 Part I, lines 1 through 50, the same as Schedule S-2, Part I, lines 1 through 50
 Part II, lines 1 through 50, the same as Schedule S-2, Part II, lines 1 through 50
 Part III, lines 1 through 50, the same as Schedule S-2, Part III, lines 1 through 50

48-14

Rev. 1

DRAFT
4800.21

FORM CMS-287-21

4800.21

Reporting Standards

Electronic reporting requires standard reporting of certain types of data. Apply the following
standards to home office cost statement reporting:
Rounding Computations--Throughout the home office cost statement, where computations result
in the use of fractions, round computations as follows:
 Round to two decimal places:





Percentages
Averages
Full time equivalent employees
Per diems, hourly rates

 Round ratios (e.g., unit cost multipliers, allocation ratios) to six decimal places
If a computation does not specify the rounding standard, the default is two decimal places. If a
residual exists as a result of computing costs using a fraction, adjust the residual in the largest
amount resulting from the computation. For example, in cost finding, a unit cost multiplier (UCM)
is applied to the statistics in determining costs. After rounding each computation, the sum of the
allocation may be more or less than the total cost to be allocated. Adjust the largest amount
resulting from the allocation by the residual amount so that the sum of the allocated amounts equals
the amount to be allocated.
Dates--Enter dates in the mm/dd/yyyy format unless otherwise specified.
Yes/No Responses--Where a question requires either a yes or a no response, enter Y for yes or N
for no.
Shading--Where shading appears on a line or in a column, no response is permitted.

Rev. 1

48-15

4800.22
4800.22

FORM CMS-287-21

DRAFT

Medicare Cost Statement Submission

A HO/CO may submit the home office cost statement ECR to the contractor in one of two ways.
The HO/CO may deliver, by mail or by hand, a CD or flash drive containing the ECR. Alternately,
the HO/CO may transmit the ECR electronically through the Medicare Cost Report e-Filing
(MCReF) portal. Ctrl+Click the following links for more information about MCReF:
Medicare Cost Report Electronic Filing (MCReF)
Medicare Cost Report E-Filing (MCReF) MLN Matters Number MM10611

4800.23

Supporting Documentation

Where the instructions direct the HO/CO to submit supporting documentation, submit the
documentation with the cost statement unless stated otherwise. Submit the supporting
documentation in the same manner as the cost statement (if submitting the cost statement through
the MCReF portal, also submit the supporting documentation through the MCReF portal). Direct
questions about submitting supporting documentation to the HO/CO contractor.

48-16

Rev. 1

DRAFT
4800.30

FORM CMS-287-21

4800.30

ACRONYMS, ABBREVIATIONS AND INITIALISMS

Commonly used acronyms, initialisms, and abbreviations in this chapter include:
CRC-B&F
CRC-ME
CCN
CFR
CMS
CMS Pub.
COL
CPA
ECR
HFS
HO
HO/CO
PRM
UCM

Rev. 1

-

Capital Related Costs-Buildings & Fixtures
Capital Related Costs-Moveable Equipment
CMS Certification Number
Code of Federal Regulations
Centers for Medicare & Medicaid Services
CMS Publication
Column
Certified Public Accountant
Electronic Cost Report
Health Financial Systems
Home Office
Home Office/Chain Organization
Provider Reimbursement Manual
Unit cost multiplier

48-17

4800.40
4800.40

FORM CMS-287-21

DRAFT

RECOMMENDED SEQUENCE OF COMPLETION

Complete the cost statement schedules in the following sequence:
Step No.

48-18

Schedule

Completion Step

1

Schedule S-1

Complete entire schedule.

2

Schedule S-2

Complete entire schedule.

3

Schedule A

Complete column 1.

4

Schedule A-7

Complete entire schedule.

5

Schedule A-6

Complete entire schedule.

6

Schedule A

Complete columns 2 and 3.

7

Schedule A-8-1

Complete entire schedule.

8

Schedule A-8

Complete entire schedule.

9

Schedule A

Complete columns 4 and 5.

10

Schedule B

Complete entire schedule.

11

Schedule B-1

Complete entire schedule.

12

Schedule A

Complete column 6.

13

Schedule C-1 and D-1

Complete statistics on Parts I through III.

14

Schedule C and D

Complete Parts I through III.

15

Schedule A

Complete column 7.

16

Schedule E-1

Complete Parts I, II, and III, column 1.

17

Schedule E

Complete entire schedule.

18

Schedule E-1

Complete Parts I, II, and III, columns 2 through 8.

19

Schedule A

Complete column 8.

20

Schedule F

Complete entire schedule.

21

Schedule F-1

Complete entire schedule.

22

Schedule G

Complete column 1.

23

Schedule G-1

Complete entire schedule.

24

Schedule S

Complete entire schedule.
Rev. 1

DRAFT

FORM CMS-287-21

4801.

4801.11

S SERIES

On the S series of schedules, the HO/CO reports identifying information and data about the
HO/CO. The series consists of the following schedules:
Schedule S - Home Office Cost Statement Certification
Schedule S-1 - Identification Data
Schedule S-2 - Listing of Components

4801.10

SCHEDULE S - HOME OFFICE COST STATEMENT CERTIFICATION

On Schedule S, the contractor identifies the status of the cost statement and a HO/CO administrator
or chief financial officer certifies the cost statement. The schedule consists of the following parts:
Part I - Cost Statement Status - Contractor Use Only
Part II - Certification

4801.11

Part I - Cost Statement Status - Contractor Use Only

The contractor reports the type of cost statement and the status of the cost statement.
LINE DESCRIPTIONS
Line 1.--Enter Y if this cost statement is an amended cost statement (a cost statement revising the
original cost statement for the reporting period); otherwise, enter N. If Y, complete line 2.
Line 2.--If line 1 is Y, enter the number of times the cost statement has been amended. Enter 1 if
this is the first revision of a previously submitted cost statement for the same reporting period;
enter 2 if the second revision; etc. This line must be blank if line 1 is N.
Line 3.--Enter the date the contractor received an acceptable cost statement.
Line 4.--Enter Y if this cost statement is the initial (very first) for the home office number;
otherwise, enter N.
Line 5.--Enter Y if this is the final (terminating) cost statement for the home office number;
otherwise, enter N.
Line 6.--Enter the status code of the cost statement from the following list:
1
2
3
4
5

Rev. 1

=
=
=
=
=

As submitted
Settled without audit
Settled with audit
Reopened
Amended

48-19

4801.12

FORM CMS-287-21

DRAFT

Line 7.--If the status code on line 6 is 4, enter the reopening number for this cost statement.
Number each reopened cost statement sequentially, beginning with number 1 for the first cost
statement reopening, number 2 for the second cost statement reopening, etc.
Line 8.--If the status code on line 6 is 2, 3, or 4, enter the Notice of Program Reimbursement (NPR)
date.
Line 9.--Enter the five-digit contractor number.
Line 10.--Enter the ECR software vendor code for the software used by the contractor to process
the electronic cost statement. Codes for currently approved ECR software vendors are:
3 - HFS CompuMax
4 - HFS MCRIF 32

4801.12

Part II - Certification

An administrator or the Chief Financial Officer completes this certification section to comply with
the regulations set forth in 42 CFR 413.24(f)(4)(iv)(A) and (B).
LINE DESCRIPTIONS
Line 1.--The signatory (administrator or Chief Financial Officer) must:
 sign in column 1 as stated in 42 CFR 413.24(f)(4)(iv)(C)(1), and enter Y in column 2 to
check the electronic signature checkbox, to transmit the home office cost statement
electronically (see 4800.22) with an electronic signature; or
 sign in column 1 as provided in 42 CFR 413.24(f)(4)(iv)(C)(1), and enter Y in column 2
to check the electronic signature checkbox, to submit the home office cost statement
(see 4800.22) with an electronic signature; or
 sign in column 1 as provided in 42 CFR 413.24(f)(4)(iv)(C)(2), and make no entry in
column 2, to submit the home office cost statement (see 4800.22) with an original
signature.
Lines 2, 3, and 4.--Enter the signatory name, the signatory title, and the date signed, respectively.

48-20

Rev. 1

DRAFT
4801.20

FORM CMS-287-21

4801.21

SCHEDULE S-1 - IDENTIFICATION DATA

On Schedule S-1, the HO/CO reports identifying information about the HO/CO and identifying
key officers. The schedule consists of the following parts:
Part I - Home Office Data
Part II - Key Officers Data

4801.21

Part I - Home Office Data

Report identifying information about the HO/CO and the cost statement.
LINE DESCRIPTIONS
Line 1.--Enter the HO/CO street address, post office box (if applicable), city, state, and ZIP code,
in columns 1 through 6, respectively. Column 2 is not required, but is available if additional space
is needed for the street address.
Line 2.--Enter the HO/CO name, CMS-assigned home office number, the date that the HO/CO
began operations, and the cost statement period beginning and ending dates, in columns 1
through 5, respectively. If the HO/CO name changed during the cost statement period, enter the
current name followed by the former name in parentheses in column 1.
Line 3.--In column 1, enter the number from the following list that corresponds to the type of
control under which the HO/CO operated. If the entry in column 1 is 5, 9, or 14, enter a description
of the type of control in column 2.
Voluntary Non-Profit
1 = Church affiliated
2 = Community
3 = Private
4 = Charitable
5 = Other

Proprietary
6 = Individual
7 = Corporation
8 = Partnership
9 = Other

Government
10 = Federal
11 = State
12 = County
13 = City
14 = Other

A voluntary non-profit institution is a community facility that receives federal, state, and local tax
exemptions in exchange for providing a community benefit, such as services to Medicaid patients
and those unable to pay.
A proprietary institution is a for-profit health care facility owned by non-governmental interests.
A government institution is a public health care facility that receives most of its funding from
local, state, or federal sources.

Rev. 1

48-21

4801.22

FORM CMS-287-21

DRAFT

Line 4.--Enter Y in column 1 if a certified public accountant (CPA) prepared the HO/CO financial
statements; otherwise, enter N.
In column 2, if column 1 is Y, enter A if the CPA prepared audited financial statements,
C if the CPA prepared compiled financial statements, or R if the CPA prepared reviewed
financial statements. If column 1 is N, leave column 2 blank.
In column 3, enter Y or N to indicate whether the cost statement submission includes a
copy of the financial statements. Enter N if the submission does not include a copy of the
financial statements, and complete column 4. Enter Y to confirm submission of a copy of
the financial statements (whether prepared by a CPA or by the HO/CO) with the cost
statement. If column 3 is Y and column 1 is Y, submit a complete copy of the CPA-prepared financial statements (i.e., the independent CPA’s opinion, the statements, and
the footnotes) with the cost statement. If column 3 is Y and column 1 is N, submit the
cost statement with:



a copy of the internally prepared financial statements, and
a written statement of significant accounting policy and procedure changes
affecting Medicare reimbursement that occurred during the cost statement
period. The changed accounting or administrative procedures manual may be
submitted in lieu of a written statement.

In column 4, if column 3 is N (financial statements not submitted with the cost statement),
enter the date the financial statements will be available. If column 3 is Y, leave column 4
blank.
In column 5, enter Y if the total expenses and total revenues reported on the cost statement
differ from those on the financial statements, and submit a reconciliation with the cost
statement. If total expenses and total revenues are the same on the cost statement and the
financial statements (no reconciliation required), enter N.
Line 5.--Enter information for the person to be contacted with questions about the preparation of
the cost statement. Enter the name, title, telephone number, email address, and employer name for
the contact person in columns 1 through 6, respectively.

4801.22

Part II - Key Officers Data

Report identifying information about the HO/CO key officers.
LINE DESCRIPTIONS
Lines 1 through 5.--Enter in column 2 the first and last name of the key officer for each
position/job title in column 1.
Lines 6 through 20.--For HO/CO key officers not listed on lines 1 through 5, enter the position or
job title in column 1, and enter the first and last name of the key officer in column 2.

48-22

Rev. 1

DRAFT
4801.30

FORM CMS-287-21

4801.31

SCHEDULE S-2 - LISTING OF COMPONENTS

On Schedule S-2, the HO/CO lists all components in the HO/CO. When the HO/CO provides
services to components under management contracts, the HO/CO must identify those components
for cost allocation. The schedule consists of the following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components

4801.31

Part I - Healthcare Provider Components

Enter the information for each healthcare provider component in the HO/CO.
COLUMN DESCRIPTIONS
Column 1.--Enter the name of each healthcare provider component owned or managed by the
HO/CO. Transfer each provider name to the Component Name column of Schedules B, Part I;
B-1, Part I; C, Part I; C-1, Part I; D, Part I; D-1, Part I; E-1, Part I; F, Part I; and F-1, Part I; listing
each provider on the same line on each schedule.
Column 2.--Enter the CMS certification number (CCN) for each provider listed in column 1.
Transfer each provider CCN to the CCN column of Schedules B, Part I; B-1, Part I; C, Part I;
C-1, Part I; D, Part I; D-1, Part I; E-1, Part I; F, Part I; and F-1, Part I; listing each provider on the
same line on each schedule.
Column 3.--Enter O if the HO/CO owned or M if the HO/CO managed the provider component.
Columns 4 and 5.--Enter the beginning and ending dates (in columns 4 and 5, respectively) for
each provider’s cost reporting period that ended during this cost statement period.
Column 6.--Enter the date the HO/CO acquired the provider if the acquisition occurred during this
cost statement period; otherwise, leave blank.
Column 7.--Enter the date the HO/CO sold, closed, or otherwise ceased provider operations if the
sale, closing, cessation, or termination occurred during this cost statement period; otherwise leave
blank.
Column 8.--Enter Y if the provider participated in State Medicaid program(s); otherwise, enter N.

Rev. 1

48-23

4801.32

FORM CMS-287-21

DRAFT

Column 9.--Enter the provider’s type of reimbursement:
P - prospective payment system (general acute care hospitals, skilled nursing
facilities, home health agencies, end stage renal dialysis facilities, inpatient
psychiatric facilities, inpatient rehabilitation facilities, long term care
hospitals, hospice facilities, community mental health centers and federally
qualified health centers)
O - other/cost (critical access hospitals and rural health clinics)
T - TEFRA (cancer, children’s, neoplastic disease care hospitals, religious
nonmedical health care institutions, and hospitals located in the U.S. Virgin
Islands, Guam, the Northern Mariana Island, and American Samoa)
Columns 10 and 11.--Enter the provider’s Medicare contractor number in column 10 and, if
applicable, the Medicaid contractor number in column 11.

4801.32

Part II - Non-Healthcare Components

Enter the information for each non-healthcare component in the HO/CO.
COLUMN DESCRIPTIONS
Column 1.--Enter the name of each non-healthcare component in the HO/CO. Transfer each
component name to the Component Name column of Schedules B, Part II; B-1, Part II; C, Part II;
C-1, Part II; D, Part II; D-1, Part II; E-1, Part II; F, Part II; and F-1, Part II; listing each component
on the same line on each schedule.
Columns 2 and 3.--Reserved.
Columns 4 and 5.--Enter the beginning (in column 4) and ending (in column 5) dates of the
component’s accounting period that ended during the cost statement period.
Column 6.--Enter the date the HO/CO acquired the component if the acquisition occurred during
the cost statement period; otherwise, leave blank.
Column 7.--Enter the date the HO/CO sold, closed, or otherwise ceased component operations if
the sale, closing, or cessation occurred during the cost statement period; otherwise, leave blank.

48-24

Rev. 1

DRAFT
4801.33

FORM CMS-287-21

4801.33

Part III - Region/Division Components

Enter the information for each region/division component in the HO/CO.
COLUMN DESCRIPTIONS
Column 1.--Enter the name of each region/division component in the HO/CO. Transfer each
component name to the Component Name column of Schedules B, Part III; B-1, Part III;
C, Part III; C-1, Part III; D, Part III; D-1, Part III; E-1, Part III; F, Part III; and F-1, Part III; listing
each region/division on the same line on each schedule.
Column 2.--Enter the regional home office number for the component. Transfer each regional
home office number to the regional home office number column of Schedules B, Part III;
B-1, Part III; C, Part III; C-1, Part III; D, Part III; D-1, Part III; E-1, Part III; F, Part III; and
F-1, Part III; listing each component on the same line on each schedule.
Column 3.--Reserved.
Column 4.--Enter the city location of the component.
Column 5.--Enter the two-letter abbreviation for the State location of the component.
Column 6.--Enter the costs included in this cost statement.
Column 7.--Enter Y if the region/division component filed a separate cost statement; otherwise,
enter N.
Column 8.--Enter the name of the designated contractor responsible for the audit and settlement
of the component cost statement.

Rev. 1

48-25

4802

FORM CMS-287-21

4802.

DRAFT

A SERIES

On the A series of schedules, the HO/CO reports the HO/CO trial balance of expenses and the
adjustments required to accurately determine allowable HO/CO costs. The series consists of the
following schedules:
Schedule A - Reclassification and Adjustment of Trial Balance of Expenses
Schedule A-6 - Reclassifications
Schedule A-7 - Analysis of Capital Cost Centers
Schedule A-8 - Adjustments to Expenses
Schedule A-8-1 - Costs of Services from Related Organizations and/or Home
Office/Chain Organizations

4802.10

SCHEDULE A - RECLASSIFICATION
BALANCE OF EXPENSES

AND

ADJUSTMENT

OF

TRIAL

On Schedule A, the HO/CO reports the HO/CO trial balance of expenses. The HO/CO reports
direct HO/CO costs in column 1. A regional HO/CO reports allocations from the parent HO/CO
on Schedule A-8-1. If additional lines are needed, see §4800.20.
COLUMN DESCRIPTIONS
Column 1.--Enter the HO/CO trial balance of expenses for each cost center before adjustments or
reclassification.
Column 2.--Transfer the sum, by cost center, of the reclassification amounts from Schedule A-6,
columns 5 and 8, to each cost center. When the sum of the Schedule A-6 reclassifications for a
cost center results in a net decrease, transfer the amount as negative amount. Line 100 must equal
zero.
Column 3.--For each line, sum columns 1 and 2.
Column 4.--Transfer the sum, by cost center, of the adjustment amounts from Schedule A-8,
column 3, to each cost center. When the sum of the Schedule A-8 adjustments for a cost center
results in a net decrease, transfer the amount as a negative amount. Line 100 must equal
Schedule A-8, line 100, column 3.
Column 5.--For each cost center, sum columns 3 and 4.
Column 6.--Complete Schedules B and B-1. Transfer the direct allocations of capital related costs
from Schedule B, Part III, line 52, (see §4803.13); and non-capital related costs from
Schedule B-1, Part III, line 52 (see §4803.23).
Column 7.--Complete the C and D series. Transfer the functional allocations of capital related
costs from Schedule C, Part III, line 52, (see §4804.13); and non-capital related costs from
Schedule D, Part III, line 52, (see §4805.13).

48-26

Rev. 1

DRAFT

FORM CMS-287-21

4802.10 (Cont.)

Column 8.--For each cost center, calculate the pooled costs (see §4800.02) to be allocated on
Schedule E by subtracting the sum of the amounts in columns 6 and 7 from the amount in
column 5. Transfer the pooled costs to Schedule E as follows:
From Schedule A, Column 8
Line 1
Line 2
Line 8
Line 9
Line 99 minus sum of lines 8, 9, and 28
Line 28

To Schedule E,
Line 4
Column 3
Column 4
Column 5
Column 6
Column 7
Column 8

LINE DESCRIPTIONS
Lines 1 and 2.--Enter amounts related to the HO/CO capital related depreciation, amortization and
lease expenses as recorded on the HO/CO books and records before Medicare adjustment or
reclassification. Do not report interest expense on this line (see line 27).
Line 3.--Sum lines 1 and 2.
Lines 4 through 6.--Enter amounts for other capital related costs including, but not limited to,
insurance premiums, taxes and licenses, and royalty fees on depreciable assets.
Line 7.--Sum lines 4 through 6.
Lines 8 through 26.--Enter the amounts for HO/CO non-capital related costs as recorded on the
HO/CO books and records before Medicare adjustment or reclassification.
Line 27.--Enter all interest expense, including capital related interest expense, and reclassify the
capital related portion to lines 1 and 2, as applicable.
Line 28.--Enter interest income offset against interest expense at the provider or component level.
Report the amount as negative (reduction to expenses). (See also §4802.90 instructions for
line 14.) Do not report interest income offset at the HO/CO level; offset those amounts on
Schedule A-8 against the appropriate capital related interest expense reclassified to lines 1 and 2.
Lines 29 through 98.--Enter the amounts of other non-capital related costs (not identified on
lines 8 through 28).
Line 99.--Sum lines 8 through 98.
Line 100.--Sum lines 3, 7 and 99. Column 2, line 100, must equal zero. Column 4, line 100, must
equal Schedule A-8, line 100, column 3.

Rev. 1

48-27

4802.70
4802.70

FORM CMS-287-21

DRAFT

SCHEDULE A-6 - RECLASSIFICATIONS OF EXPENSES

On Schedule A-6, the HO/CO reports reclassifications of expenses to effect proper cost allocation
to components. Examples include reclassifications of other capital related costs determined on
Schedule A-7 (see §4802.80). Submit copies of work papers used to calculate reclassifications on
this schedule.
COLUMN DESCRIPTIONS
Column 1.--Enter a brief description of the reclassified expenses.
Column 2.--Enter a letter (A, B, etc.) to identify each reclassification. If a reclassification increases
more than one Schedule A cost center, or decreases more than one Schedule A cost center, use the
same letter for all increases and decreases of the reclassification to identify all the entries as a
single reclassification. The net adjustment for each individually identified reclassification (the
sum of amounts in column 5 minus the sum of the amounts in column 8) must equal zero.
Column 3.--Enter the description of the Schedule A cost center increased by the reclassification.
Column 4.--Enter the line number of the Schedule A cost center increased by the reclassification.
Column 5.--Enter the amount of the reclassification increase to the Schedule A cost center
identified in column 4.
Column 6.--Enter the description of the Schedule A cost center decreased by the reclassification.
Column 7.--Enter the line number of the Schedule A cost center decreased by the reclassification.
Column 8.--Enter the amount of the reclassification decrease to the Schedule A cost center
identified in column 7.
LINE DESCRIPTIONS
Lines 1 through 99.--Enter the information for each reclassification. Transfer the reclassified
amounts on each line to Schedule A, column 2. Transfer each increase amount in column 5 to the
Schedule A cost center identified in column 4; and transfer each decrease amount in column 8 to
the Schedule A cost center identified in column 7. When multiple increases and/or decreases apply
to the same Schedule A cost center, transfer the net amount for the cost center (the net of the
increases in column 5 and the decreases in column 8) to Schedule A, column 2.
Line 100.--Sum all reclassified increases in column 5. Sum all reclassified decreases in column 8.
Line 100, column 5, must equal line 100, column 8.

48-28

Rev. 1

DRAFT
4802.80

FORM CMS-287-21

4802.81

SCHEDULE A-7 - ANALYSIS OF CAPITAL COST CENTERS

On Schedule A-7, the HO/CO reports information about the capital cost centers. The schedule
consists of the following parts:
Part I - Analysis of Changes in Capital Asset Balances
Part II - Reconciliation of Capital Cost Centers

4802.81

Part I - Analysis of Changes in Capital Asset Balances

Report changes in capital asset balances during the cost statement period. Include only the assets
that relate to the HO/CO; do not include assets directly assigned to components.
COLUMN DESCRIPTIONS
Column 1.--Enter the balance recorded in the HO/CO books at the beginning of the cost statement
period.
Columns 2 through 4.--Enter the cost of capital assets acquired by purchase in column 2. (The
amounts in column 2 represent transfers from obligated capital and/or a transfer of assets on a
change of ownership.) Enter the fair market value at date acquired of donated assets in column 3.
Sum columns 2 and 3 in column 4.
Column 5.--Enter the cost or other approved basis of all capital assets retired, sold, or disposed in
any other manner during the cost statement period.
Column 6.--Sum columns 1 and 4, minus column 5.
Column 7.--Enter the gross book value of fully depreciated assets still in use at the end of the cost
statement period.
LINE DESCRIPTIONS
Lines 1 through 6.--Enter the amounts for each asset category. Include the asset values of leases
that are capital leases under generally accepted accounting principles (GAAP), or recognized by
Medicare as a capital related cost under 42 CFR 413.130, and for which the component pays other
capital related costs such as insurance and taxes.
Line 7.--Sum lines 1 through 6.
Line 8.--Enter amounts to be excluded from lines 1 through 6, such as leases capitalized in
accordance with GAAP and included it in the assets reported on Schedule G; the excess of amounts
paid for the assets acquired at a cost over fair market values; assets directly allocated to
components; and, construction in progress at the end of the cost statement period.
Line 9.--Calculate the total for each column by subtracting line 8 from line 7. Column 6, must
equal the balance recorded in the books of accounts at the end of the cost statement period, and
must equal the sum of the total fixed assets reported on Schedule G, line 26, column 2.

Rev. 1

48-29

4802.82
4802.82

FORM CMS-287-21

DRAFT

Part II - Reconciliation of Capital Cost Centers

Allocate insurance, taxes, and other capital expenditures (not including depreciation, lease, and
interest expense), to the capital related cost centers. A region/division includes assets directly
allocated from the parent HO/CO. In columns 1 through 4, calculate the ratios of gross asset
values (the value of the asset before deducting accumulated depreciation) to total gross asset
values. In columns 5 through 8, allocate other capital related costs (insurance, taxes, and other) to
the capital related cost centers (Schedule A, lines 1 and 2) based on the ratios calculated in
column 4. In columns 9 through 15, summarize the amounts in the capital related cost centers
(Schedule A, lines 1, 2, 4, 5, and 6, sum of columns 6, 7, and 8).
COLUMN DESCRIPTIONS
Column 1.--Enter the gross asset values of assets for which depreciation is reported on Schedule A.
Gross asset value is defined as the value of the asset before deducting accumulated depreciation.
Column 2.--Enter the gross asset amounts reported in column 1 relating to capitalized leases and
any directly allocated assets. The amount in column 2 must equal Part I, line 8, column 1.
Column 3.--Calculate the gross assets amount by subtracting column 2 from column 1.
Column 4.--Calculate the ratio of gross assets for each CRC group to the total by dividing the asset
amount in column 3 by the total gross assets on line 3, column 3.
Column 5.--Allocate line 3, insurance premiums net of amounts directly allocated to components
(Schedule A, line 4, column 1, minus Schedule A, line 4, column 6), based on the ratio calculated
in column 4.
Column 6.--Allocate line 3, taxes net of amounts directly allocated to components (Schedule A,
line 5, column 1, minus Schedule A, line 5, column 6), based on the ratio calculated in column 4
for each line.
Column 7.--Allocate line 3, other capital related costs net of amounts directly allocated to
components (Schedule A, line 6, column 1, minus Schedule A, line 6, column 6), based on the
ratio calculated in column 4 for each line.
Transfer the amounts in columns 5, 6, and 7, to Schedule A-6 to reclassify the amounts from
Schedule A, lines 4, 5, and 6 (Insurance Premiums, Taxes & Licenses, and Other Capital Related,
respectively), to Schedule A, lines 1 and 2 (CRC-B&F and CRC-ME, respectively).
Column 8.--Sum columns 5, 6, and 7.

48-30

Rev. 1

DRAFT

FORM CMS-287-21

4802.82 (Cont.)

Column 9.--Enter the portion of the amount on Schedule A, lines 1 and 2, columns 7 and 8,
relating to depreciation expense.
Column 10.--Enter the portion of the amount on Schedule A, lines 1 and 2, columns 7 and 8,
relating to capital related lease expense (see CMS Pub. 15-1, chapter 28, §2806.1). Do not include
amounts for insurance premiums, taxes and licenses, or other capital related costs, associated with
leased assets; report those amounts in columns 12, 13, and 14, respectively.
Column 11.--Enter the portion of the amount on Schedule A, lines 1 and 2, columns 7 and 8,
relating to capital related interest expense.
Column 12.--Transfer the allocations from column 5. (This represents the portion of the amount
on Schedule A, lines 1 and 2, columns 7, and 8, relating to capital related insurance costs,
including insurance costs related to leased assets.)
Column 13.--Transfer the allocations from column 6. (This represents the portion of the amount
on Schedule A, lines 1 and 2, columns 7, and 8, relating to capital related taxes and licenses costs,
including taxes and licenses costs related to leased assets.)
Column 14.--Transfer the allocations from column 7. (This represents the portion of the amount
on Schedule A, lines 1 and 2, columns 7, and 8, relating to other capital related costs, including
other capital related costs related to leased assets.)
Column 15.--Sum columns 9 through 14. Lines 1 and 2 must equal Schedule A, lines 1 and 2
(respectively), sum of columns 7 and 8.
LINE DESCRIPTIONS
Lines 1 and 2.--Allocate and summarize allowable costs for CRC-B&F on line 1, and for CRC-ME
on line 2. Line 1, column 15, must equal Schedule A, line 1, sum of columns 7 and 8; and line 2,
column 15, must equal Schedule A, line 2, sum of columns 7 and 8.
Line 3.--For columns 1 through 4 and 8, sum lines 1 and 2. Column 4 must equal 1.000000. For
columns 5, 6, and 7, enter the amounts from Schedule A, column 1, lines 4, 5, and 6, respectively,
net of other capital related costs directly allocated to components. Column 8 must equal
Schedule A, line 7, column 1, net of the other capital related costs directly allocated to
components.

Rev. 1

48-31

4802.90
4802.90

FORM CMS-287-21

DRAFT

SCHEDULE A-8 - ADJUSTMENTS TO EXPENSES

On Schedule A-8, the HO/CO adjusts expenses to the actual expenses incurred; offsets expenses
by recoveries through sales, charges, fees, etc.; and adjusts expenses in accordance with the
Medicare principles of reimbursement (see CMS Pub. 15-1). Submit work papers supporting each
adjustment.
COLUMN DESCRIPTIONS
Column 1.--The schedule provides preprinted descriptions on lines 1 through 17 for adjustments
commonly made to HO/CO costs. Enter a brief description for each adjustment for subscripts of
line 14 and for lines 18 through 99.
Column 2.--Enter A, for an adjustment based on cost, or B, for an adjustment based on the amount
received or revenue, to indicate the basis of the adjustment. Base adjustments on cost when the
cost plus applicable overhead can be determined. Adjust costs based on amount received (or
revenue) only when the cost (including direct cost and all applicable overhead) cannot be
determined. Once a cost basis is determined for an adjustment, the HO/CO must base future
adjustments on cost.
Column 3.--Enter the amount of each adjustment.
Column 4 and 5.--Enter the description of the Schedule A cost center to be adjusted in column 4,
and enter the corresponding Schedule A line number in column 5.
LINE DESCRIPTIONS
Lines 1 through 17.--Enter each adjustment amount, as applicable. For line 14, enter the amount
of interest on loans between the HO/CO and components where no exception applies (see
CMS Pub. 15-1, chapter 21, §2150.2C). If the HO/CO offsets interest income against interest
expense at the provider or component level, report each provider or component amount separately
by subscripting line 14, and offset the amounts against Schedule A, line 28. If the HO/CO offsets
interest income at the HO/CO level, offset the amounts against the appropriate capital related costs
on Schedule A, lines 1 and 2.
Lines 18 through 99.--Enter any other adjustments required to HO/CO expenses on Schedule A.
Lines 1 through 99.--Transfer each adjustment amount in column 3 to Schedule A, column 4, for
the cost center identified in column 5. See §4802.101 for instructions to transfer the line 12
adjustment amount. When multiple adjustments on Schedule A-8 and Schedule A-8-1 apply to
the same Schedule A cost center, transfer the net amount for the cost center to Schedule A,
column 4.
Line 100.--Sum lines 1 through 99 in column 3. Line 100, column 3, must equal Schedule A,
line 100, column 4.

48-32

Rev. 1

DRAFT

FORM CMS-287-21

4802.101

4802.100 SCHEDULE A-8-1 - COSTS OF SERVICES FROM RELATED ORGANIZATIONS
AND/OR HOME OFFICE/CHAIN ORGANIZATIONS
On Schedule A-8-1, the HO/CO calculates adjustments to costs applicable to services, facilities,
and supplies furnished to the HO/CO by organizations related to the HO/CO. In accordance with
42 CFR 413.17, a HO/CO includes costs applicable to services, facilities, and supplies furnished
by organizations related to the HO/CO by common ownership or control, in the HO/CO allowable
cost at the cost to the related organization, except for the exceptions outlined in 42 CFR 413.17(d);
however, such cost must not exceed the amount a prudent and cost conscious buyer pays for
comparable services, facilities, or supplies purchased elsewhere. The schedule consists of the
following parts:
Part I - Adjustments Required as a Result of Transactions with Related Organizations
and/or Home Office/Chain Organizations
Part II - Interrelationship of Home Office/Chain Organization to Related Organizations

4802.101 Part I - Adjustments Required as a Result of Transactions with Related Organizations
and/or Home Office/Chain Organizations
Calculate adjustments needed to include allowable costs for services, facilities, and supplies from
a related organization at the cost to the related organization.
COLUMN DESCRIPTIONS
Columns 1 and 2.--Enter the Schedule A line number of the cost center to be adjusted and the
corresponding Schedule A cost center description in columns 1 and 2, respectively.
Column 3.--Enter a brief description for the expense associated with the acquisition of services,
facilities, or supplies from a related organization.
Column 4.--Enter the Part II line number on which the related organization is reported. For
example, Brothers Home Office leases an office building from Brothers Property Management, a
related party. Brothers Home Office reports the lease expense on line 1 and identifies Brothers
Property Management as a related organization in Part II, line 1. On Part I, line 1, column 4,
Brothers Home Office enters 1, the line number from Part II, to identify the interrelationship.
Column 5.--Enter the allowable cost from the books and/or records of the related organization.
Allowable cost is the actual cost incurred by the related organization and excludes any markup,
profit or amounts that otherwise exceed the acquisition cost of the services, facilities, and supplies
furnished to the HO/CO.

Rev. 1

48-33

4802.101 (Cont.)

FORM CMS-287-21

DRAFT

Column 6.--Enter the amounts included on Schedule A, column 3, for services, facilities, and
supplies acquired from related organizations.
Column 7.--Calculate the net adjustment for Schedule A by subtracting column 6 from column 5.
LINE DESCRIPTIONS
Lines 1 through 99.--Enter each related party expense item.
Line 100.--Sum lines 1 through 99. Transfer line 100, column 7, to Schedule A-8, line 12,
column 3. Transfer the amount on each line in column 7 to Schedule A, column 4. When multiple
adjustments on Schedule A-8 and Schedule A-8-1 apply to the same Schedule A cost center,
transfer the net amount for the cost center to Schedule A, column 4.

48-34

Rev. 1

DRAFT

FORM CMS-287-21

4802.102

4802.102 Part II - Interrelationship of Home Office/Chain Organization to Related Organizations
Identify the interrelationship between the HO/CO and the individuals, partnerships, corporations,
or other organizations having a related interest to, a common ownership with, or control over the
HO/CO, as defined in CMS Pub. 15-1, chapter 10. Complete the columns pertinent to the type of
relationship that exists.
COLUMN DESCRIPTIONS
Column 1.--Enter the symbol that represents the interrelationship between the HO/CO and the
related organization:
Symbol
A
B
C
D
E
F
G

Relationship
Individual has financial interest (stockholder, partner, etc.) in both the
related organization and in the HO/CO
Corporation, partnership or other organization has financial interest in
the HO/CO
HO/CO has financial interest in corporation, partnership, or other
organization
Director, officer, administrator or key person of the HO/CO or relative
of such person has financial interest in related organization
Individual is director, officer, administrator or key person of the HO/CO
and related organization
Director, officer, administrator or key person of related organization or
relative of such person has financial interest in the HO/CO
Other (financial or non-financial) -- specify

Column 2.--If the symbol entered in column 1 is A, D, E, F, or G, enter the first and last names of
the related individual in column 2.
Column 3.--If the individual reported in column 2, or the organization reported in column 4, has a
financial interest in the HO/CO, enter the percent of ownership.
Column 4.--If the symbol entered in column 1 is B or C, enter the name of each related corporation,
partnership, or other organization.
Column 5.--If the individual reported in column 2, or the HO/CO, has a financial interest in the
organization reported in column 4, enter the percent of ownership.
Column 6.--Enter the type of business of the related organization/individual (e.g., medical drugs
and/or supplies, janitorial services, etc.).
LINE DESCRIPTIONS
Lines 1 through 50.--Enter the pertinent information for each related party relationship.

Rev. 1

48-35

4803

FORM CMS-287-21

4803.

DRAFT

B SERIES

On the B series of schedules, the HO/CO reports the costs that the HO/CO directly allocated to
components. Allowable cost incurred for the benefit of or directly attributable to a component
must be directly allocated to that component. The series consists of the following schedules:
Schedule B - Direct Allocation of Capital Related Costs
Schedule B-1 - Direct Allocation of Non-Capital Related Costs

4803.10

SCHEDULE B - DIRECT ALLOCATION OF CAPITAL RELATED COSTS

On Schedule B, the HO/CO reports the capital related costs that the HO/CO directly allocated to
components. The schedule consists of the following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components
COLUMN DESCRIPTIONS (Parts I, II, and III)
Column 1.--Enter the direct allocation of CRC-B&F to each component.
Column 2.--Enter the direct allocation of CRC-ME to each component.
Column 3.--Intentionally omitted to maintain column number consistency.
Column 4.--Enter the direct allocation of other capital related cost - insurance premiums to each
component.
Column 5.--Enter the direct allocation of other capital related cost - taxes and licenses to each
component.
Column 6.--Enter the direct allocation of other capital related cost - other capital related costs to
each component.
Column 7.--Sum columns 1 through 6.
LINE DESCRIPTIONS (Parts I, II, and III)
Lines 1 through 50.--Enter the amount of each capital related cost directly allocated to each
component.
Line 51.--Sum lines 1 through 50.

48-36

Rev. 1

DRAFT
4803.11

FORM CMS-287-21

4803.13

Part I - Healthcare Provider Components

Report the amount of capital related cost directly allocated to each healthcare provider component.
(Each provider includes the direct allocation in the trial balance on their Medicare cost report.)

4803.12

Part II - Non-Healthcare Components

Report the amount of capital related cost directly allocated to each non-healthcare component.

4803.13

Part III - Region/Division Components

Report the amount of capital related cost directly allocated to each region/division component.
(Each region/division subsequently allocates the direct allocation of capital related costs to its
components on its regional office cost statement.
LINE DESCRIPTIONS
Line 52.--For each column 1 through 7, sum Part I, line 51; Part II, line 51; and Part III, line 51.
For each column 1 through 6, transfer the grand total on line 52 to Schedule A, column 6, as
follows:
From Schedule B, Part III, line 52
column 1
column 2
column 4
column 5
column 6

Rev. 1

To Schedule A, column 6
line 1
line 2
line 4
line 5
line 6

48-37

4803.20
4803.20

FORM CMS-287-21

DRAFT

SCHEDULE B-1 - DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

On Schedule B-1, the HO/CO reports the non-capital related costs the HO/CO directly allocated
to components. The schedule consists of the following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components
COLUMN DESCRIPTIONS (Parts I, II, and III)
Columns 8 through 28--Column headings correspond (abbreviated as necessary) to the cost center
descriptions on Schedule A, lines 8 through 28. In each column, enter the amount of the noncapital related cost directly allocated to each component.
Columns 29 through 98.--Transfer the cost center descriptions (abbreviated as necessary) from
Schedule A, lines 29 through 98, as column headings for columns 29 through 98, respectively.
(For example, in column 29, transfer the cost center description from Schedule A, line 29; in
column 35.01, transfer the cost center description from Schedule A, line 35.01; and so on.) In each
column, enter the amount of the non-capital related cost directly allocated to each component.
Column 99.--Sum columns 8 through 98.
LINE DESCRIPTIONS (Parts I, II, and III)
Lines 1 through 50.--Enter the amount of each non-capital related cost directly allocated to each
component.
Line 51.--Sum lines 1 through 50.

48-38

Rev. 1

DRAFT
4803.21

FORM CMS-287-21

4803.23

Part I - Healthcare Provider Components

Report the amount of non-capital related cost directly allocated to each healthcare provider
component. (Each provider includes the direct allocation of non-capital related cost in the trial
balance on their Medicare cost report.)

4803.22

Part II - Non-Healthcare Components

Report the amount of non-capital related cost directly allocated to each non-healthcare component.

4803.23

Part III - Region/Division Components

Report the amount of non-capital related cost directly allocated to each region/division component.
(Each region/division subsequently allocates the direct allocation of non-capital related cost to the
regional/divisional components on a separate regional office cost statement.)
LINE DESCRIPTIONS
Line 52.--For each column, sum of Part I, line 51; Part II, line 51; and Part III, line 51. For each
column, transfer the grand total on line 52 to the corresponding line on Schedule A, column 6. For
example:
From Schedule B-1, Part III, line 52
column 8
column 29
column 35.01

Rev. 1

To Schedule A, column 6
line 8
line 29
line 35.01

48-39

4804

FORM CMS-287-21

4804.

DRAFT

C SERIES

On the C series of schedules, the HO/CO reports the allocation of HO/CO capital related costs to
components on a functional basis using a statistical basis that reasonably relates to the cost. The
series consists of the following schedules:
Schedule C - Functional Allocation of Capital Related Costs
Schedule C-1 - Functional Allocation of Capital Related Costs - Statistics

4804.10

SCHEDULE C - FUNCTIONAL ALLOCATION OF CAPITAL RELATED COSTS

On Schedule C, the HO/CO reports the allocation of HO/CO capital related costs to components
on a functional basis using the statistics accumulated on Schedule C-1. Calculate the allocations
after completing Schedule C-1. (See also §§4804.20 - 4804.23.) The schedule consists of the
following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components
COLUMN DESCRIPTIONS (Parts I, II, and III)
Column 1.--Calculate the amount of CRC-B&F functionally allocated to each component.
Column 2.--Calculate the amount of CRC-ME functionally allocated to each component.
Column 3.--Sum columns 1 and 2.

48-40

Rev. 1

DRAFT
4804.11

FORM CMS-287-21

4804.12

Part I - Healthcare Provider Components

Report the amount of capital related cost functionally allocated to each healthcare provider
component.
LINE DESCRIPTIONS
Lines 1 through 50.--After completing Schedule C-1, calculate the amount of each capital related
cost allocated to each provider by multiplying the allocation statistic from the corresponding line
and column on Schedule C-1, Part I, by the UCM on Schedule C-1, Part III, line 54, of the same
column. (See also §§4804.21 - 4804.23.) For example, allocate the portion of the total CRC-B&F
cost allocated to the provider listed on Schedule C, Part I, line 1, by multiplying the CRC-B&F
UCM (Schedule C-1, Part III, line 54, column 1) by the allocation statistic for the provider
(Schedule C-1, Part I, line 1, column 1) and enter the resulting allocation amount on Schedule C,
Part I, line 1, column 1.
Line 51.--Sum lines 1 through 50.

4804.12

Part II - Non-Healthcare Components

Report the amount of capital related cost functionally allocated to each non-healthcare component.
LINE DESCRIPTIONS
Lines 1 through 50.--After completing Schedule C-1, calculate the amount of each capital related
cost allocated to each non-healthcare component by multiplying the allocation statistic from the
corresponding line and column on Schedule C-1, Part II, by the UCM on Schedule C-1, Part III,
line 54, of the same column. (See also §§4804.21 - 4804.23.)
Line 51.--Sum lines 1 through 50.

Rev. 1

48-41

4805.13
4804.13

FORM CMS-287-21

DRAFT

Part III - Region/Division Components

Report the amount of capital related cost functionally allocated to each region/division component.
(Each region/division subsequently allocates the functional allocation of capital related cost to its
components on its regional office cost statement.)
LINE DESCRIPTIONS
Lines 1 through 50.--After completing Schedule C-1, calculate the amount of each capital related
cost allocated to each region/division component by multiplying the allocation statistic from the
corresponding line and column on Schedule C-1, Part III, by the UCM on Schedule C-1, Part III,
line 54, of the same column. (See also §§4804.21 - 4804.23.)
Line 51.--Sum lines 1 through 50.
Line 52.--For each column, sum Part I, line 51; Part II, line 51; and Part III, line 51. For each
column, the sum must equal the corresponding column on Schedule C-1, Part III, line 53. Transfer
the grand total from each column as follows:
From Schedule C, Part III, line 52
column 1
column 2

48-42

To Schedule A, Column 7
line 1
line 2

Rev. 1

DRAFT
4804.20

FORM CMS-287-21

4804.22

SCHEDULE C-1 - FUNCTIONAL ALLOCATION OF CAPITAL RELATED
COSTS - STATISTICS

On Schedule C-1, the HO/CO reports the allocation statistics and calculates the UCM to
functionally allocate capital related costs on Schedule C. (See also §§4804 - 4804.13.) The
schedule consists of the following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components
COLUMN DESCRIPTIONS (Parts I, II, and III)
Columns 1 and 2.--In each column heading, enter the statistical basis used to allocate each capital
related cost to components and, in each column, enter the allocation statistics for each component.
LINE DESCRIPTIONS (Parts I, II, and III)
Lines 1 through 50.--Enter the allocation statistics for each component.
Schedule C-1, see §§4804.11 - 4804.13 for allocation instructions.)

(After completing

Line 51.--Sum lines 1 through 50.

4804.21

Part I - Healthcare Provider Components

Report the allocation statistics used to functionally allocate capital related costs to each healthcare
provider component. (After completing Schedule C-1, see §4804.11 for allocation instructions.)

4804.22

Part II - Non-Healthcare Components

Report the allocation statistics used to functionally allocate capital related costs to each nonhealthcare component. (After completing Schedule C-1, see §4804.12 for allocation instructions.)

Rev. 1

48-43

4804.23
4804.23

FORM CMS-287-21

DRAFT

Part III - Region/Division Components

Report the allocation statistics used to functionally allocate capital related costs to each
region/division component and calculate the UCM to allocate the capital related costs. (After
completing Schedule C-1, see §4804.13 for allocation instructions.)
LINE DESCRIPTIONS
Line 52.--For each column, sum Part I, line 51; Part II, line 51; and Part III, line 51.
Line 53.--Enter each capital related cost to be functionally allocated to components.
Line 54.--Calculate each UCM by dividing line 53 by line 52. See §§4804.11 - 4804.13.

48-44

Rev. 1

DRAFT
4805.

FORM CMS-287-21

4805.10

D SERIES

On the D series of schedules, the HO/CO reports the allocation of HO/CO non-capital related costs
to components on a functional basis using a statistical basis that reasonably relates to the cost. The
series consists of the following schedules:
Schedule D - Functional Allocation of Non-Capital Related Costs
Schedule D-1 - Functional Allocation of Non-Capital Related Costs - Statistics

4805.10

SCHEDULE D - FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED
COSTS

On Schedule D, the HO/CO reports the allocation of HO/CO non-capital related costs to
components on a functional basis using the statistics accumulated on Schedule D-1. Calculate the
allocations after completing Schedule D-1. (See also §§4805.20 - 4805.23.) The schedule consists
of the following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components
COLUMN DESCRIPTIONS (Parts I, II, and III)
Columns 8 through 28.--Column headings correspond (abbreviated as necessary) to the cost center
descriptions on Schedule A, lines 8 through 28. In each column, calculate the amount of each noncapital related cost functionally allocated to each component.
Columns 29 through 98.--Transfer each column heading from the corresponding column on
Schedule B-1. In each column, calculate the amount of the non-capital related cost functionally
allocated to each component.
Column 99.--Sum columns 8 through 98.

Rev. 1

48-45

4805.11
4805.11

FORM CMS-287-21

DRAFT

Part I - Healthcare Provider Components

Report the amount of non-capital related cost functionally allocated to each healthcare provider
component.
LINE DESCRIPTIONS
Lines 1 through 50.--After completing Schedule D-1, calculate the amount of each non-capital
related cost allocated to each provider by multiplying the allocation statistic from the
corresponding line and column on Schedule D-1, Part I, by the UCM on Schedule D-1, Part III,
line 54, of the same column. (See also §§4805.21 - 4805.23.)
Line 51.--Sum lines 1 through 50.

4805.12

Part II - Non-Healthcare Components

Report the amount of non-capital related cost functionally allocated to each non-healthcare
component.
LINE DESCRIPTIONS
Lines 1 through 50.--After completing Schedule D-1, calculate the amount of each non-capital
related cost allocated to each non-healthcare component by multiplying the allocation statistic
from the corresponding line and column on Schedule D-1, Part II, by the UCM on Schedule D-1,
Part III, line 54, of the same column. (See also §§4805.21 - 4805.23.)
Line 51.--Sum lines 1 through 50.

48-46

Rev. 1

DRAFT
4805.13

FORM CMS-287-21

4805.13

Part III - Region/Division Components

Report the amount of non-capital related cost functionally allocated to each region/division
component. (Each region/division subsequently allocates the functional allocation of non-capital
related cost to its components on its regional office cost statement.)
LINE DESCRIPTIONS
Lines 1 through 50.--After completing Schedule D-1, calculate the amount of each non-capital
related cost allocated to each region/division component by multiplying the allocation statistic
from the corresponding line and column on Schedule D-1, Part III, by the UCM on Schedule D-1,
Part III, line 54, of the same column. (See also §§4805.21 - 4805.23.)
Line 51.--Sum lines 1 through 50.
Line 52.--For each column, sum Part I, line 51; Part II, line 51; and Part III, line 51. For each
column, the sum must equal the corresponding column on Schedule D-1, Part III, line 53. Transfer
the grand total from each column to the corresponding line on Schedule A, column 7. For
example:
From Schedule D, Part III, line 52
column 8
column 29
column 35.01

Rev. 1

To Schedule A, Column 7
line 8
line 29
line 35.01

48-47

4805.20
4805.20

FORM CMS-287-21

DRAFT

SCHEDULE D-1 - FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED
COSTS - STATISTICS

On Schedule D-1, the HO/CO reports the allocation statistics and calculates the UCM to
functionally allocate non-capital related costs on Schedule D. (See also §§4805 - 4805.13.) The
schedule consists of the following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components
COLUMN DESCRIPTIONS (Parts I, II, and III)
Columns 8 through 28.--In each column heading, enter the statistical basis used to functionally
allocate each non-capital related cost to components and, in each column, enter the allocation
statistics for each component.
Columns 29 through 98.--Transfer each column heading from the corresponding column on
Schedule B-1 and enter the statistical basis used to functionally allocate the non-capital related
costs to components. In each column, enter the allocation statistic for each component.
LINE DESCRIPTIONS
Lines 1 through 50.--Enter the allocation statistics for each provider.
Schedule D-1, see §§4805.11 - 4805.13 for allocation instructions.)

(After completing

Line 51.--Sum lines 1 through 50.

4805.21

Part I - Healthcare Provider Components

Report the allocation statistics used to functionally allocate non-capital related costs to each
healthcare provider component. (After completing Schedule D-1, see 4805.11 for allocation
instructions.)

4805.22

Part II - Non-Healthcare Components

Report the allocation statistics used to functionally allocate non-capital related costs to each nonhealthcare component. (After completing Schedule D-1, see §4805.12 for allocation instructions.)

48-48

Rev. 1

DRAFT
4805.23

FORM CMS-287-21

4805.23

Part III - Region/Division Components

Report the allocation statistics used to functionally allocate non-capital related costs to each
region/division component, calculate the UCM to allocate non-capital related costs, and calculate
the costs functionally allocated to each component on Schedule D, Part III.
LINE DESCRIPTIONS
Line 52.--For each column, sum Part I, line 51; Part II, line 51; and Part III, line 51.
Line 53.--Enter each non-capital related cost to be functionally allocated to components.
Line 54.--Calculate each UCM by dividing line 53 by line 52. See §§4805.11 - 4805.13.

Rev. 1

48-49

4806
4806.

FORM CMS-287-21

DRAFT

E SERIES

On the E series of schedules, the HO/CO reports the allocation of HO/CO pooled costs (capital
related and non-capital related costs that cannot be directly or functionally allocated to the
components). The series consists of the following schedules:
Schedule E - Allocation of Pooled Costs
Schedule E-1 - Allocation of Pooled Costs to Components
The HO/CO allocates pooled costs to the components through a double allocation method when
the organization consists of non-healthcare components and/or region/district components in
addition to providers. Schedules E and E-1 facilitate this double allocation. The HO/CO allocates
pooled costs through a single allocation method when the organization consists solely of providers.
For the single allocation method, the HO/CO completes only Schedule E-1, Part I.

48-50

Rev. 1

DRAFT
4806.10

FORM CMS-287-21

4806.10

SCHEDULE E - ALLOCATION OF POOLE COSTS FOR DOUBLE ALLOCATION
METHOD

On Schedule E, the HO/CO allocates HO/CO pooled costs among the three component groups
(healthcare provider, non-healthcare, and/or region/division) using the double allocation method.
The HO/CO does not complete Schedule E when the HO/CO consists solely of comparable
inpatient healthcare providers.
COLUMN DESCRIPTIONS
Column 1.--Enter the allocation basis (see CMS Pub. 15-1, chapter 21, §2150.3.D.2.) in the
column heading and, in the column, enter the statistics used to allocate total pooled costs.
Column 2.--Calculate the allocation ratio for each component group (healthcare provider
components, non-healthcare components, and region/division components) by dividing column 1
by line 4, column 1.
Column 3.--Allocate the CRC-B&F pooled costs from Schedule A, line 1, column 8, among the
component groups based on the ratios in column 2.
Column 4.--Allocate the CRC-ME pooled costs from Schedule A, line 2, column 8, among the
component groups based on the ratios in column 2.
Column 5.--Allocate the salaries of officers pooled costs from Schedule A, line 8, column 8,
among the component groups based on the ratios in column 2.
Column 6.--Allocate the salaries and wages of others pooled costs from Schedule A, line 9,
column 8, among the component groups based on the ratios in column 2.
Column 7.--Allocate the remaining non-capital pooled costs (excluding interest income), from
Schedule A, sum of lines 10 through 27, column 8, plus the sum of lines 29 through 98, column 8,
among the component groups based on the ratios in column 2.
Column 8.--Allocate the pooled interest income from Schedule A, line 28, column 8, among the
component groups based on the ratios in column 2. Report the interest income in the pooled
allocation separately to comply with CMS Pub. 15-1, chapter 2, §202.2.C., which states that
interest income is only offset against allowable interest expense.

Rev. 1

48-51

4806.10 (Cont.)

FORM CMS-287-21

DRAFT

LINE DESCRIPTIONS
Line 1.--Calculate the healthcare provider component grouping ratio and allocate pooled costs and
pooled interest income on line 4 to the healthcare provider component grouping based on the ratio.
Calculate the ratio for column 2 by dividing the statistic on line 1, column 1, by the total statistic
on line 4, column 1. For columns 3 through 8, allocate the portion of the pooled costs to the
healthcare provider component grouping by multiplying line 4 by the ratio on line 1, column 2.
Transfer the allocated amount in each column to the corresponding column on Schedule E-1,
Part I, line 51.
Line 2.--Calculate the non-healthcare component grouping ratio and allocate pooled costs and
pooled interest income on line 4 to the non-healthcare component grouping based on the ratio.
Calculate the ratio for column 2 by dividing the statistic on line 2, column 1, by the total statistic
on line 4, column 1. For columns 3 through 8, allocate the portion of the pooled costs to the nonhealthcare component grouping by multiplying line 4 by the ratio on line 2, column 2. Transfer
the allocated amount in each column to the corresponding column on Schedule E-1, Part II, line 51.
Line 3.--Calculate the region/division component grouping ratio and allocate pooled costs and
pooled interest income on line 4 to the region/division component grouping based on the ratio.
Calculate the ratio for column 2 by dividing the statistic on line 3, column 1, by the total statistic
on line 4, column 1. For columns 3 through 8, allocate the portion of the pooled costs to the
region/division component grouping by multiplying line 4 by the ratio on line 3, column 2.
Transfer the allocated amount in each column to the corresponding column on Schedule E-1,
Part III, line 51.
Line 4.--In column 1, sum the statistics on lines 1, 2, and 3. In column 2, sum the ratios calculated
on lines 1, 2, and 3; the sum of the ratios must equal 1.000000. For each column 3 through 8,
transfer the total pooled amounts to be allocated from Schedule A as follows:
From Schedule A, Column 8
Line 1
Line 2
Line 8
Line 9
Sum of lines 10 through 27 plus sum of lines 29 through 98
Line 28

48-52

To Schedule E, Line 4
Column 3
Column 4
Column 5
Column 6
Column 7
Column 8

Rev. 1

DRAFT
4806.20

FORM CMS-287-21

4806.20

SCHEDULE E-1 - ALLOCATION OF POOLED COSTS TO COMPONENTS

On Schedule E-1, the HO/CO allocates HO/CO pooled costs to the components within each
component grouping. The schedule consists of the following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components
COLUMN DESCRIPTIONS (Parts I, II, and III)
Column 1.--Enter the allocation basis (see §4800.12, Step 3) in the column heading and, in the
column, enter the statistics for each component to allocate the pooled costs on line 51, columns 3
through 8.
Column 2.--Calculate the allocation ratio by dividing column 1 for each component by line 51,
column 1.
Column 3.--Allocate the CRC-B&F pooled costs by multiplying the ratio in column 2 for each
component by line 51.
Column 4.--Allocate the CRC-ME pooled costs by multiplying the ratio in column 2 for each
component by line 51.
Column 5.--Allocate the salaries of officers pooled costs by multiplying the ratio in column 2 for
each component by line 51.
Column 6.--Calculate the salaries and wages of others pooled costs by multiplying the ratio in
column 2 for each component by line 51.
Column 7.--Allocate the all other non-capital pooled costs by multiplying the ratio in column 2 for
each component by line 51.
Column 8.--Allocate the pooled interest income by multiplying the ratio in column 2 for each
component by line 51.

Rev. 1

48-53

4806.20 (Cont.)

FORM CMS-287-21

DRAFT

LINE DESCRIPTIONS (Parts I, II, and III)
Lines 1 through 50, columns 3 through 8.--In each column, for each component calculate the
portion of the pooled costs by multiplying the total pooled costs on line 51 by the ratio from
column 2. The sum of the allocated amounts on lines 1 through 50 must equal the total pooled
costs on line 51.
Line 51.--When the HO/CO consists solely of comparable inpatient healthcare providers, transfer
the pooled costs to be allocated as follows:
From Schedule A, Column 8
Line 1
Line 2
Line 8
Line 9
Sum of lines 10 through 27 plus sum of lines 29 through 98
Line 28

To Schedule E-1,
Part I, Line 51
Column 3
Column 4
Column 5
Column 6
Column 7
Column 8

When the HO/CO allocates HO/CO pooled costs among the three component groups (healthcare
provider, non-healthcare, and/or region/division) using the double allocation method, transfer the
total pooled costs as follows:
From Schedule E
Line 1, columns 3 through 8
Line 2, columns 3 through 8
Line 3, columns 3 through 8

To Schedule E-1
Part I, line 51, columns 3 through 8
Part II, line 51, columns 3 through 8
Part III, line 51, columns 3 through 8

Line 52 (Part III only).--For each column, sum Part I, line 51; Part II, line 51; and Part III, line 51.
The grand total on line 52 of each column must equal the amount on Schedule A, column 8, as
follows:
Schedule E-1,
Line 52
Column 3
Column 4
Column 5
Column 6
Column 7
Column 8

48-54

Schedule A, Column 8
Line 1
Line 2
Line 8
Line 9
Sum of lines 10 through 27 plus sum of lines 29 through 98
Line 28

Rev. 1

DRAFT
4807.

FORM CMS-287-21

4807.11

F SERIES

On the F series of schedules, the HO/CO summarizes the direct, functional, and pooled allocations
of HO/CO costs. The series consists of the following schedules:
Schedule F - Summary of Capital Costs
Schedule F-1 - Summary of Non-Capital Costs

4807.10

SCHEDULE F - SUMMARY OF CAPITAL RELATED COSTS

On Schedule F, the HO/CO summarizes the direct, functional, and pooled allocations of HO/CO
capital related costs. The schedule consists of the following parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components

4807.11

Part I - Healthcare Provider Components

Summarize the direct, functional, and pooled allocations of HO/CO capital related costs to each
healthcare provider component.
COLUMN DESCRIPTIONS
Column 1.--Transfer the direct allocations of capital related costs to each provider from
Schedule B, Part I, column 7.
Column 2.--Transfer the functional allocations of capital related costs to each provider from
Schedule C, Part I, column 3.
Column 3.--Transfer the allocations of pooled capital related costs to each provider from
Schedule E-1, Part I, sum of columns 3 and 4.
Column 4.--Sum columns 1, 2, and 3.
LINE DESCRIPTIONS
Line 51.--Sum lines 1 through 50.

Rev. 1

48-55

4807.12
4807.12

FORM CMS-287-21

DRAFT

Part II - Non-Healthcare Components

Summarize the direct, functional, and pooled allocations of HO/CO capital related costs to each
non-healthcare component.
COLUMN DESCRIPTIONS
Column 1.--Transfer the direct allocations of capital related costs to each component from
Schedule B, Part II, column 7.
Column 2.--Transfer the functional allocations of capital related costs to each component from
Schedule C, Part II, column 3.
Column 3.--Transfer the allocations of pooled capital related costs to each component from
Schedule E-1, Part II, sum of columns 3 and 4.
Column 4.--Sum columns 1, 2, and 3.
LINE DESCRIPTIONS
Line 51.--Sum lines 1 through 50.

4807.13

Part III - Region/Division Components

Summarize the direct, functional, and pooled allocations of HO/CO capital related costs to each
region/division component.
COLUMN DESCRIPTIONS
Column 1.--Transfer the direct allocations of capital related costs to each component from
Schedule B, Part III, column 7.
Column 2.--Transfer the functional allocations of capital related costs to each component from
Schedule C, Part III, column 3.
Column 3.--Transfer the allocations of pooled capital related costs to each component from
Schedule E-1, Part III, sum of columns 3 and 4.
Column 4.--Sum columns 1, 2, and 3.
LINE DESCRIPTIONS
Line 51.--Sum lines 1 through 50.
Line 52.--For each column, sum Part I, line 51; Part II, line 51; and Part III, line 51.

48-56

Rev. 1

DRAFT

FORM CMS-287-21

4807.20

SCHEDULE F-1 - SUMMARY OF NON-CAPITAL RELATED COSTS

4807.20

On Schedule F-1, the HO/CO summarizes the direct, functional, and pooled allocations of HO/CO
non-capital related costs as either salaries (for wage index purposes) or all other non-capital related
costs. Do not include interest income on this schedule. The schedule consists of the following
parts:
Part I - Healthcare Provider Components
Part II - Non-Healthcare Components
Part III - Region/Division Components
COLUMN DESCRIPTIONS (Parts I, II, and III)
Column 1.--Transfer the direct allocations of salaries to each component on Parts I, II, and III,
from the corresponding component on Schedule B-1, sum of columns 8 and 9.
Column 2.--Transfer the functional allocations of salaries to each component on Parts I, II, and III,
from the corresponding component on Schedule D, sum of columns 8 and 9.
Column 3.--Transfer the allocations of pooled salaries to each component on Parts I, II, and III,
from the corresponding component on Schedule E-1, sum of columns 5 and 6.
Column 4.--Sum columns 1, 2, and 3.
Column 5.--Transfer the direct allocations of all other non-capital related costs to each component
on Parts I, II, and III, from the corresponding Part I, II, or III, of Schedule B-1, sum of columns 10
through 27 and 29 through 98.
Column 6.--Transfer the functional allocations of all other non-capital related costs to each
component on Parts I, II, and III, from the corresponding Part I, II, or III, of Schedule D, sum of
columns 10 through 27 and 29 through 98.
Column 7.--Transfer the allocations of all other non-capital related pooled costs to each
component on Parts I, II, and III, from the corresponding Part I, II, or III, of Schedule E-1, sum of
columns 10 through 27 and 29 through 98.
Column 8.--Sum columns 5, 6, and 7.
Column 9.--Sum columns 4 and 8.
LINE DESCRIPTIONS
Line 51 (Parts I, II, and III).--Sum lines 1 through 50.
Line 52 (Part III only).--For each column, sum Part I, line 51; Part II, line 51; and Part III, line 51.

Rev. 1

48-57

4808

FORM CMS-287-21

4808.

DRAFT

G SERIES

On the G series of schedules, the HO/CO reports information from the HO/CO financial
statements. The series consists of the following schedules:
Schedule G - Balance Sheet
Schedule G-1 - Statement of Revenues and Expenses

4808.10

SCHEDULE G - BALANCE SHEET

On Schedule G, the HO/CO reports asset, capital, and liability amounts for the HO/CO. Enter
each accumulated depreciation as a negative amount.
LINE DESCRIPTION
Line 1.--Enter the amount of cash on deposit in banks and immediately available for use in
financing activities, amounts on hand for minor disbursements, and amounts invested in savings
accounts and certificates of deposit. Typical accounts include cash, general checking accounts,
payroll checking accounts, other checking accounts, petty cash funds, saving accounts, certificates
of deposit, treasury bills and treasury notes, and other cash accounts.
Line 2.--Enter the amount of current securities evidenced by certificates of ownership or
indebtedness. Typical accounts include marketable securities and other current investments.
Line 3.--Enter current unpaid amounts evidenced by certificates of indebtedness.
Line 4.--Enter the amount of unpaid inpatient and outpatient billings (direct billings to patients for
deductibles, coinsurance and other patient chargeable items not included elsewhere on this
schedule).
Line 5.--Enter a description in column 1 for other receivables not defined on lines 1 through 4 and
enter the amount of the other receivables in column 2.
Line 6.--Enter the estimated amount of uncollectible receivables from patients and third-party
payers. Enter this amount as a negative.
Line 7.--Enter the costs of unused supplies. The HO/CO may maintain perpetual inventory records
and adjust periodically to physical count. The extent of inventory control and detailed
recordkeeping depends upon the size and organizational complexity of the HO/CO. The HO/CO
may value inventories by any generally accepted method and must apply the same method
consistently from year to year.
Line 8.--Enter the costs incurred that are properly chargeable to a future accounting period.

48-58

Rev. 1

DRAFT

FORM CMS-287-21

4808.10 (Cont.)

Line 9.--Enter a description in column 1 for other current assets not included on lines 1 through 8
and enter the amount of the other current assets in column 2.
Line 10.--Sum lines 1 through 9.
Line 11.--Enter the cost of land used in HO/CO operations, including the cost of off-site sewer and
water lines, public utility, charges for servicing the land, governmental assessments for street
paving and sewers, cost of permanent roadways and of grading of a non-depreciable nature. The
cost of land includes the cash purchase price, closing costs such as title and attorney’s fees, real
estate broker’s commission, and accrued property taxes and other liens on the land assumed by the
purchaser. Unlike building and equipment, land does not deteriorate with use or with the passage
of time; therefore, the HO/CO accumulates no depreciation for land.
Line 12.--Enter the cost of structural additions made to land, including all expenditures necessary
to make the improvements ready for their intended use, such as driveways, parking lots, and
sidewalks; as well as the cost of fences and walls, landscaping, on-site sewer and water lines, and
underground sprinklers.
Line 13.--Enter the depreciation accumulated on the assets reported on line 12.
Line 14.--Enter the cost of all buildings and subsequent additions used in HO/CO operations,
including purchase price, closing costs, (attorney fees, title insurance, etc.,) and real estate broker
commission, as well as architectural, consulting and legal fees related to the acquisition or
construction of buildings, and interest paid for construction financing.
Line 15.--Enter the depreciation accumulated on the assets reported on line 14.
Line 16.--Enter expenditures for the improvement of a leasehold used in HO/CO operations.
Line 17.--Enter the depreciation accumulated on the assets reported on line 16.
Line 18.--Enter the cost of building equipment affixed to the building (not subject to transfer or
removal); with a life of more than one year, but less than that of the building to which it is affixed;
and used in hospital operations. Fixed equipment includes such items as boilers, generators,
engines, pumps, and refrigeration machinery, wiring, electrical fixtures, plumbing, elevators,
heating system, air conditioning system, etc.
Line 19.--Enter the depreciation accumulated on the assets reported on line 18.
Line 20.--Enter the cost of automobiles and trucks used in HO/CO operations.
Line 21.--Enter the depreciation accumulated on the assets reported on line 20.

Rev. 1

48-59

4808.10 (Cont.)

FORM CMS-287-21

DRAFT

Line 22.--Enter the cost of equipment that can be moved, as distinguished from fixed equipment
(but not automobiles or trucks); is more or less fixed location in the building; is a unit cost large
enough to justify the expense incident to control by means of an equipment ledger and greater than
or equal to $5,000; has sufficient individuality and size to make control feasible by means of
identification tags; has a minimum life of usually three years; and is used in HO/CO operations.
Line 23.--Enter the depreciation accumulated on the assets reported on line 22.
Line 24.--Enter the cost of equipment with a location generally not fixed (subject to requisition or
use by various departments); relatively in small size; subject to storeroom control; fairly large
number in use; with a useful life of usually approximately three years or less; and used in HO/CO
operations.
Line 25.--Enter a description in column 1 for other fixed assets not included on lines 1 through 24
and enter the cost of those other fixed assets in column 2.
Line 26.--Sum lines 11 through 25.
Line 27.--Enter the cost of investments purchased with HO/CO funds and the fair market value, at
date of donation, of securities donated to the HO/CO.
Line 28.--Enter the amount of deposits on leases, including security deposits.
Line 29.--Enter the amount loaned by the HO/CO to owners and/or officers.
Line 30.--Enter a description in column 1 for other assets not included on lines 1 through 29,
including intangible assets such as goodwill, unamortized loan costs, and other organization costs,
and enter the cost of those assets in column 2.
Line 31.--Sum lines 27 through 30.
Line 32.--Sum lines 10, 26, and 31.
Line 33.--Enter the amounts due trade creditors and others for supplies and services purchased.
Line 34.--Enter the actual or estimated liabilities of the HO/CO for salaries and wages/fees
payable.
Line 35.--Enter the amounts payable for payroll taxes withheld from salaries and wages, payroll
taxes to be paid by the HO/CO and other payroll deductions, such as hospitalization insurance
premiums.
Line 36.--Enter the current amounts owed as evidenced by certificates of indebtedness coming due
in the next 12 months.

48-60

Rev. 1

DRAFT

FORM CMS-287-21

4808.10 (Cont.)

Line 37.--Enter the amount of deferred income received or accrued income applicable to services
to be rendered within the next accounting period. (Report deferred income applicable to
accounting periods extending beyond the next accounting period as other current liabilities.) Also
include amounts for the effects of any timing differences between book and tax or third-party
reimbursement accounting.
Line 38.--Enter the amount of accelerated payments owed (payments not yet due to be repaid to
the contractor).
Line 39.--Enter a description in column 1 for other current liabilities not included on lines 33
through 38, and enter the amount of those liabilities in column 2.
Line 40.--Sum lines 33 through 39.
Line 41.--Enter the amount of the long-term financing obligation used to purchase real
estate/property.
Line 42.--Enter the amount of the HO/CO liabilities to vendors, banks and other, evidenced by
promissory notes due and payable longer than one year.
Line 43.--Enter the amounts loaned without a collateral basis.
Line 44.--Enter a description in column 1 for other long-term liabilities not included on lines 41
through 43, and enter the amount of those liabilities in column 2.
Line 45.--Sum lines 41 through 44.
Line 46.--Sum lines 40 and 45.
Line 47.--Enter the HO/CO retained earnings for the year.
Line 48.--Sum lines 46 and 47. Line 48 must equal line 32.

Rev. 1

48-61

4808.20
4808.20

FORM CMS-287-21

DRAFT

SCHEDULE G-1 - STATEMENT OF REVENUES AND EXPENSES

On Schedule G-1, the HO/CO reports total revenue and total operating expenses for the HO/CO.
If total revenue and total expenses differ from the financial statements, submit a reconciliation
with the home office cost statement.
LINE DESCRIPTIONS
Line 1.--Enter the HO/CO total operating revenue.
Line 2.--Enter the HO/CO operating expenses.
Line 3.--Calculate the operating profit or (loss) by subtracting line 2 from line 1.
Lines 4 through 9.--Enter each miscellaneous revenue.
Lines 10 through 14.--For each revenue not reported on lines 1 through 9, enter a description of
the revenue in column 1 and the amount of the revenue in column 2.
Line 15.--Sum lines 4 through 14.
Lines 16 through 20.--For each expense not reported on line 2, enter a description of the expense
in column 1 and the amount of the expense in column 2.
Line 21.--Sum lines 16 through 20.
Line 22.--Sum lines 3 and 15 minus line 21.

48-62

Rev. 1

DRAFT
4895.

FORM CMS-287-21

4895

FORM CMS-287-21 SCHEDULES

Form CMS-287-21 consists of the following schedules:

Rev. 1

Schedules

Page(s)

S, Parts I & II
S-1, Parts I & II
S-2, Parts I, II & III
A
A-6
A-7
A-8
A-8-1
B, Parts I, II & III
B-1, Parts I, II & III
C, Parts I, II & III
C-1, Parts I, II & III
D, Parts I, II & III
D-1, Parts I, II & III
E
E-1, Parts I, II & III
F, Parts I, II & III
F-1, Parts I, II & III
G
G-1

48-503
48-504
48-505
48-506
48-507
48-508
48-509
48-510
48-511
48-512 - 48-514
48-515
48-516
48-517 - 48-519
48-520 - 48-522
48-523
48-524
48-525
48-526
48-527
48-528

48-501

4895 (Cont.)

FORM CMS-287-21

DRAFT

This page reserved for future use.

48-502

Rev. 1