CMS-1728-20 HHA Cost Report

DRAFT

FORM CMS-1728-20

This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g).
HOME HEALTH AGENCY COST REPORT
CERTIFICATION AND SETTLEMENT SUMMARY

HHA CCN:
____________________

4795 (Cont.)

FORM APPROVED
OMB NO. 0938-0022
EXPIRES: XX/XX/202X
PERIOD:
WORKSHEET S
FROM: ______________ PARTS I, II & III
TO: _________________

PART I - COST REPORT STATUS
Provider use only
DATE: _____________
TIME: __________
1. [ ] Electronically prepared cost report
2. [ ] Manually prepared cost report (limited to low or no utilization)
3. [ ] If this is an amended cost report enter the number of times the provider resubmitted this cost report.
4. [ ] Medicare Utilization. Enter "F" for full, "L" for low, or "N" for no utilization.
Contractor use only
6. Date Received:_________
10. NPR Date:___________
5. [ ] Cost Report Status
(1) As Submitted
7. Contractor No.:________
11. Contractor Vendor Code: ____________
(2) Settled without audit
8. [ ] Initial Report for this HHA CCN
12. [ ] If line 5, column 1 is 4: Enter the number of
(3) Settled with audit
9. [ ] Final Report for this HHA CCN
times reopened = 0-9.
(4) Reopened
(5) Amended
PART II - CERTIFICATION
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL,
CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN
THIS REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT, DIRECTLY OR INDIRECTLY, OF A KICKBACK OR WERE OTHERWISE
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.
CERTIFICATION BY CHIEF FINANCIAL OFFICER OR ADMINISTRATOR OF PROVIDER(S)
I HEREBY CERTIFY that I have read the above certification statement and that I have examined the accompanying electronically filed or manually submitted
cost report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Number(s)}for
the cost reporting period beginning ______________ and ending ______________ and that to the best of my knowledge and belief, this report and statement
are true, correct, complete and prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further certify
that I am familiar with the laws and regulations regarding the provision of health care services, and that the services identified in this cost report were provided
in compliance with such laws and regulations.

1

2
3
4

SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR
1

CHECKBOX
2

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

Printed Name
Title
Signature date

PART III - SETTLEMENT SUMMARY

2
3
4
TITLE XVIII
1

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

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

Rev.

1

1

47-503

4795 (Cont.)

FORM CMS-1728-20

IDENTIFICATION DATA

HHA CCN:
____________________

HOME HEALTH AGENCY COMPLEX ADDRESS
1

Address 1

2

Address 2

STREET
1

P. O. BOX
2

CITY
1

STATE
2

HOME HEALTH AGENCY COMPONENT IDENTIFICATION
3
4

Home Health Agency
HHA-based Hospice

5

Cost Reporting Period:

6
7
8
9
10
11

From:
1

DRAFT

1
2

COMPONENT NAME
1

PROVIDER CCN
2

DATE CERTIFIED
3

To:
2

6
7
8
9
10
11

PREMIUMS
1

List amounts of malpractice premiums, paid losses, and self-insurance in the applicable columns.
Are malpractice premiums and paid losses reported in a cost center other than A&G? If yes, submit supporting schedule listing cost centers and amounts contained therein.

HO/CO Information

NAME
1

PAID LOSSES
2

SELF-INSURANCE
3

NUMBER OF
ORGANIZATIONS
2
CCN
2

CONTRACTOR
NUMBER
3

FORM CMS-1728-20 (10-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4705)

47-504

3
4
5

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

HOME OFFICE/CHAIN ORGANIZATION INFORMATION
RECEIVE
ALLOCATION
1
16 HO/CO cost allocation

17

WORKSHEET S-2,
PART I

ZIP CODE
3

MALPRACTICE INSURANCE INFORMATION
12 Is this HHA legally required to carry malpractice insurance? Enter "Y" for yes or "N" for no.
13 If line 12 is yes, is the malpractice insurance a claims-made or occurrence policy? Enter "1" for claims-made or "2" for occurrence policy.
14
15

PERIOD:
FROM: ______________
TO: ______________

STREET
ADDRESS
4

12
13
14
15

16
CITY
5

STATE
6

ZIP CODE
7

17

Rev.

09-20

FORM CMS-1728-20
HHA CCN:

REIMBURSEMENT DATA

____________________
PROVIDER ORGANIZATION AND OPERATION
1
2
3

Y/N
1

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

5

DATE
2

V/I
3

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

Y/N
1

A/C/R
2

DATE
3

10
11
12
13
14

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

COST REPORT PREPARER CONTACT INFORMATION
FIRST NAME
1
15 Preparer
16

17

Y/N

Y/N
1

9

11
12
13
14

LAST NAME
2

TITLE
3

15
16

TELEPHONE NUMBER
1

EMAIL ADDRESS
2

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4706)

Rev. 1

DATE
2

6
7
8

10

Employer Name

Contact

4

5

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

PS&R REPORT DATA
9

1

3

BAD DEBT
6
7
8

4795 (Cont.)

WORKSHEET S-2,
PART II

2

FINANCIAL DATA AND REPORTS
4

PERIOD:
FROM: _____________
TO: _______________

17

47-505

4795 (Cont.)

FORM CMS-1728-20

STATISTICAL DATA

HHA CCN:

____________________

PERIOD:
FROM: ______________
TO: _________________

WORKSHEET S-3
PARTS I, II, & III

09-20

PART I - VISITS DATA

DESCRIPTION
1
2
3
4
5
6
7
8
9
10
11
12
13

Skilled Nursing Care - RN
Skilled Nursing Care - LPN
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech-Language Pathology
Medical Social Service
Home Health Aide
All Other Services
Total Visits
Home Health Aide Hours
Unduplicated Census Count

TITLE XVIII - MEDICARE TITLE XIX - MEDICAID
PATIENT
PATIENT
VISITS
CENSUS
VISITS
CENSUS
1
2
3
4

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

STAFF
1

OTHER
PATIENT
VISITS
CENSUS
5
6

CONTRACT
2

PART III - CORE BASED STATISTICAL AREA DATA
34

Enter the total number of CBSAs where Medicare covered services were provided during the cost reporting period.

35

List all CBSA codes for areas where Medicare covered home health services were provided. (see instructions)

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4707 - 4707.3)

47-506

TOTAL
PATIENT
VISITS
CENSUS
7
8

TOTAL
3

1
CBSA Codes

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33

34
35

Rev. 1

09-20

STATISTICAL DATA

FORM CMS-1728-20

HHA CCN:
____________________

PART IV - PPS ACTIVITY DATA
DESCRIPTION
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Skilled Nursing Care Visits
Skilled Nursing Care Charges
Physical Therapy Visits
Physical Therapy Charges
Occupational Therapy Visits
Occupational Therapy Charges
Speech-Language Pathology Visits
Speech-Language Pathology Charges
Medical Social Service Visits
Medical Social Service Charges
Home Health Aide Visits
Home Health Aide Charges
Total Visits (sum of lines 1, 3, 5, 7, 9, and 11)
Other Charges
Total Charges (sum of lines 2, 4, 6, 8, 10, 12, and 14)
Total Number of Episodes/Periods
Total Number of Outlier Episodes/Periods
Total Non-Routine Medical Supply Charges

FULL EPISODES/
PERIODS
WITHOUT OUTLIERS
1

FULL EPISODES/
PERIODS
WITH OUTLIERS
2

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4707.4)

Rev. 1

LUPA
EPISODES/
PERIODS
3

4795 (Cont.)

WORKSHEET S-3
PERIOD:
FROM: ______________ PART IV
TO: _________________
PEP
EPISODES/
PERIODS
4

TOTAL
EPISODES/
PERIODS
5

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

47-507

4795 (Cont.)

STATISTICAL DATA
DIRECT CARE EXPENDITURES

OCCUPATIONAL CATEGORY
Direct Salaries
Nursing Occupations
1 Nursing Supervisor
2 Registered Nurses
3 Licensed Practical Nurses
4 Total Nursing (sum of lines 1 through 3)
5 Physical Therapy Supervisor
6 Physical Therapists
7 Physical Therapy Assistants
8 Occupational Therapy Supervisor
9 Occupational Therapists
10 Occupational Therapy Assistants
11 Speech-Language Pathology Supervisor
12 Speech-Language Pathologists
13 Other Medical Staff

FORM CMS-1728-20

____________________
AMOUNT
REPORTED
1

FRINGE
BENEFITS
2

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4707.5)

47-508

HHA CCN:

ADJUSTED
SALARIES
3

PERIOD:
FROM: ______________
TO: _________________
PAID HOURS
RELATED TO SALARY
4

WORKSHEET S-3
PART V

09-20

AVERAGE
HOURLY WAGE
5
1
2
3
4
5
6
7
8
9
10
11
12
13

14
15
16
17
18
19
20
21
22
23
24
25
26

Rev. 1

FORM CMS-1728-20

09-20

HHA CCN:
_________________
HOSPICE CCN:
_________________

HHA-BASED HOSPICE STATISTICAL DATA

PART I - ENROLLMENT DAYS

1
2
3
4
5

Hospice Continuous Home Care
Hospice Routine Home Care
Hospice Inpatient Respite Care
Hospice General Inpatient Care
Total Hospice Days

PART II - CONTRACTED STATISTICAL DATA

6
7

Hospice Inpatient Respite Care
Hospice General Inpatient Care

PERIOD:
FROM: ___________
TO: ______________

TITLE XVIII
MEDICARE
1

UNDUPLICATED DAYS
TITLE XIX
MEDICAID
OTHER
2
3

TOTAL
4

TITLE XVIII
MEDICARE
1

TITLE XIX
MEDICAID
2

TOTAL
4

OTHER
3

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-2, SECTION 4708 - 4708.2)

Rev. 1

4795 (Cont.)

WORKSHEET S-4
PARTS I & II

1
2
3
4
5

6
7

47-509

4795 (Cont.)

FORM CMS-1728-20

RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

HHA CCN:
____________________

1
2
3
4
5
6
7
8
9

0100
0200
0300
0400
0500
0600
0700
0800
0900

16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

1600
1700
1800
1900
2000
2100
2200
2300
2400
2500
2600
2700
2800
2900
3000

39
40
41
42
43
44
45
46
47
48
49
50

3900
4000
4100
4200
4300
4400
4500
4600
4700
4800
4900
5000

57
58
100

5700
5800

GENERAL SERVICE COST CENTERS
Capital Related - Buildings & Fixtures
Capital Related - Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Telecommunications Technology
Administrative and General
Nursing Administration
Medical Records

SALARIES
1

EMPLOYEE
BENEFITS
2

TRANSPORTATION
3

CONTRACTED
PURCHASED
SERVICES
4

HHA REIMBURSABLE SERVICES
Skilled Nursing Care - RN
Skilled Nursing Care - LPN
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech-Language Pathology
Medical Social Services
Home Health Aide
Medical Supplies Charged to Patients
Drugs
Cost of Administering Vaccines
Durable Medical Equipment/Oxygen
Disposable Devices
HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Services
Telehealth
Advertising
Fundraising
SPECIAL PURPOSE COST CENTERS
Hospice
Total

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4709)

47-510

OTHER
COSTS
5

TOTAL
6

RECLASSIFICATION
7

PERIOD:
FROM: ______________
TO: _________________
RECLASSIFIED
TRIAL
ADJUSTBALANCE
MENTS
9
8

09-20

WORKSHEET A
EXPENSES
FOR
COST
ALLOCATION
10

1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100

Rev. 1

09-20

FORM CMS-1728-20

RECLASSIFICATIONS

HHA CCN:
____________________

1

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

100

EXPLANATION OF RECLASSIFICATION(S)

CODE
1

COST CENTER
2

INCREASE
WS A
LINE
2
NO.
SALARY
3
4

TOTAL RECLASSIFICATIONS
1
2

2

COST CENTER
6

DECREASE
WS A
LINE
2
NO.
SALARY
7
8

4795 (Cont.)

WORKSHEET A-6

OTHER
9

2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

100

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4710)

Rev. 1

OTHER
5

PERIOD:
FROM: ______________
TO: _________________

47-511

4795 (Cont.)

ADJUSTMENTS TO EXPENSES

FORM CMS-1728-20

HHA CCN:
__________________

1

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

DESCRIPTION
Excess funds generated from operations, other than net income
Trade, quantity, time and other discounts on purchases (chapter 8)
Rebates and refunds of expenses (chapter 8)
Related organization transactions (chapter 10)
Sale of medical records and abstracts
Income from imposition of interest, finance or penalty charges
Sale of medical and surgical supplies to other than patients
Sale of drugs to other than patients
Interest expense on Medicare overpayments and borrowings
to repay Medicare overpayments
Lobbying activities (chapter 21)
Advertising costs (chapter 21)

BASIS /
2
CODE
1

AMOUNT
2

PERIOD:
FROM: __________
TO: _____________

EXPENSE CLASSIFICATION ON
WORKSHEET A TO/FROM WHICH
THE AMOUNT IS TO BE ADJUSTED
COST CENTER
LINE NO.
3
4

WKST A-8-1

TOTAL (sum of lines 1 through 49)
1
2

WORKSHEET A-8

09-20

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4711)

47-512

Rev. 1

09-20

COSTS OF SERVICES FROM RELATED ORGANIZATIONS
AND/OR HOME OFFICE/CHAIN ORGANIZATIONS

FORM CMS-1728-20

HHA CCN:
____________________

PART I - ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS AND/OR HOME OFFICE/CHAIN ORGANIZATIONS
W/S S-2,
AMOUNT OF
WKST A
PART II
PART I
ALLOWABLE
LINE NO.
COST CENTER
EXPENSE ITEM
LINE NO. LINE NO.
COST
1
2
3
4
5
6
1
2
3
4
5

50

PERIOD:
FROM: ______________
TO: _________________
AMOUNT INCLUDED
IN WKST. A,
COL. 8
7

4795 (Cont.)

WORKSHEET A-8-1

NET
ADJUSTMENTS
8*

1
2
3
4
5

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

50

* The amounts on lines 1 through 49 (and subscripts as appropriate) are transferred in detail to Worksheet A, column 9, lines as appropriate.
Positive amounts increase cost and negative amounts decrease cost. For related organization or home office cost which have not
been posted to Worksheet A, columns 1 through 5, the amount allowable should be indicated in column 6 of this section.
PART II - INTERRELATIONSHIP BETWEEN RELATED ORGANIZATIONS AND/OR HOME OFFICE/CHAIN ORGANIZATIONS
THE SECRECTARY, BY VIRTUE OF THE AUTHORITY GRANTED UNDER SECTION 1814(b)(1) OF THE SOCIAL SECURITY ACT, REQUIRES THE HHA TO FURNISH THE INFORMATION REQUESTED ON PART II OF
THIS WORKSHEET.
THIS INFORMATION IS USED BY THE CENTERS FOR MEDICARE & MEDICAID SERVICES AND ITS CONTRACTORS IN DETERMINING THE COSTS APPLICABLE TO SERVICES, FACILITIES, AND SUPPLIES FURNISHED
BY ORGANIZATIONS RELATED TO YOU BY COMMON OWNERSHIP OR CONTROL REPRESENT REASONABLE COSTS AS DETERMINED UNDER SECTION 1861 OF THE SOCIAL SECURITY ACT. IF YOU DO NOT PROVIDE
ALL OR ANY PART OF THE REQUESTED INFORMATION, THE COST REPORT IS CONSIDERED INCOMPLETE AND NOT ACCEPTABLE FOR PURPOSES OF CLAIMING REIMBURSEMENT UNDER TITLE XVIII.

1

1
2
3
4
5

SYMBOL
1

NAME
2

PERCENT OF
OWNERSHIP
3

RELATED ORGANIZATIONS AND/OR HOME OFFICE/CHAIN ORGANIZATIONS
PERCENT OF
TYPE OF
NAME
OWNERSHIP
BUSINESS
4
5
6

50

50
1

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4712)

Rev. 1

1
2
3
4
5

47-513

4795 (Cont.)

FORM CMS-1728-20

COST ALLOCATION
ALLOCATION OF GENERAL SERVICE COSTS

1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100

GENERAL SERVICE COST CENTERS
Capital Related - Buildings and Fixtures
Capital Related - Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Telecommunications Technology
Administrative and General
Nursing Administration
Medical Records
Other General Service
HHA REIMBURSABLE SERVICES
Skilled Nursing Care - RN
Skilled Nursing Care - LPN
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech-Language Pathology
Medical Social Services
Home Health Aide
Medical Supplies Charged to Patients
Drugs
Cost of Administering Vaccines
Durable Medical Equipment/Oxygen
Disposable Devices

____________________
NET EXPENSES
FOR COST
ALLOCATION
0

CAP REL
BLDGS &
FIXTURES
1

CAP REL
MOVABLE
EQUIPMENT
2

HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Services
Telehealth
Advertising
Fundraising
SPECIAL PURPOSE COST CENTER
Hospice
Total

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4713)

47-514

HHA CCN:

PLANT
OPERATION &
MAINTENANCE
3

TRANSPORTATION
4

PERIOD:
FROM: ______________
TO: _________________

SUBTOTAL
4A

WORKSHEET B

09-20

TELECOMMUN.
TECHNOLOGY
5
1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100

Rev. 1

09-20

FORM CMS-1728-20

COST ALLOCATION
ALLOCATION OF GENERAL SERVICE COSTS

1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100

GENERAL SERVICE COST CENTERS
Capital Related - Buildings and Fixtures
Capital Related - Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Telecommunications Technology
Administrative and General
Nursing Administration
Medical Records
Other General Service
HHA REIMBURSABLE SERVICES
Skilled Nursing Care - RN
Skilled Nursing Care - LPN
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech-Language Pathology
Medical Social Services
Home Health Aide
Medical Supplies Charged to Patients
Drugs
Cost of Administering Vaccines
Durable Medical Equipment/Oxygen
Disposable Devices

____________________

SUBTOTAL
5A

ADMINISTRATIVE
& GENERAL
6

NURSING
ADMINISTRATION
7

HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Services
Telehealth
Advertising
Fundraising
SPECIAL PURPOSE COST CENTER
Hospice
Total

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4713)

Rev. 1

HHA CCN:

SUBTOTAL
7A

MEDICAL
RECORDS
8

PERIOD:
FROM: ______________
TO: _________________
OTHER
GENERAL
SERVICE
9

4795 (Cont.)

WORKSHEET B

TOTAL
10
1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100

47-515

4795 (Cont.)

FORM CMS-1728-20

COST ALLOCATION
STATISTICAL BASES

____________________

COST CENTER

1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100
101

GENERAL SERVICE COST CENTER
Capital Related - Buildings and Fixtures
Capital Related - Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Telecommunications Technology
Administrative and General
Nursing Administration
Medical Records
Other General Service
HHA REIMBURSABLE SERVICES
Skilled Nursing Care - RN
Skilled Nursing Care - LPN
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech-Language Pathology
Medical Social Services
Home Health Aide
Medical Supplies Charged to Patients
Drugs
Cost of Administering Vaccines
Durable Medical Equipment/Oxygen
Disposable Devices

CAP REL
BLDGS &
FIXTURES
(SQUARE
FEET)
1

CAP REL
MOVABLE
EQUIPMENT
(DOLLAR
VALUE)
2

HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Services
Telehealth
Advertising
Fundraising
SPECIAL PURPOSE COST CENTER
Hospice
Cost To Be Allocated (per wkst B)
Unit Cost Multiplier

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4713)

47-516

HHA CCN:

PLANT
OPERATION &
MAINTENANCE
(SQUARE
FEET)
3

TRANSPORTATION
(MILEAGE)
4

09-20

PERIOD:
FROM: ______________
TO: _________________

RECONCILIATION
5A

TELECOMMUN.
TECHNOLOGY
(ACCUM.
COST)
5
1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100
101

Rev. 1

09-20

FORM CMS-1728-20

COST ALLOCATION
STATISTICAL BASES

1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100
101

GENERAL SERVICE COST CENTER
Capital Related - Buildings and Fixtures
Capital Related - Movable Equipment
Plant Operation & Maintenance
Transportation (see instructions)
Telecommunications Technology
Administrative and General
Nursing Administration
Medical Records
Other General Service
HHA REIMBURSABLE SERVICES
Skilled Nursing Care - RN
Skilled Nursing Care - LPN
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech-Language Pathology
Medical Social Services
Home Health Aide
Medical Supplies Charged to Patients
Drugs
Cost of Administering Vaccines
Durable Medical Equipment/Oxygen
Disposable Devices

____________________

RECONCILIATION
6A

ADMINISTRATIVE
& GENERAL
(ACCUM.
COST)
6

NURSING
ADMINISTRATION
(DIRECT
NURS HRS)
7

HHA NONREIMBURSABLE SERVICES
Home Dialysis Aide Services
Respiratory Therapy
Private Duty Nursing
Clinic
Health Promotion Activities
Day Care Program
Home Delivered Meals Program
Homemaker Services
Telehealth
Advertising
Fundraising
SPECIAL PURPOSE COST CENTER
Hospice
Cost To Be Allocated (per wkst B)
Unit Cost Multiplier

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4713)

Rev. 1

HHA CCN:

RECONCILIATION
8A

MEDICAL
RECORDS
(ACCUM.
COST)
8

PERIOD:
FROM: ______________
TO: _________________
OTHER
GENERAL
SERVICE
(SPECIFY)
9

4795 (Cont.)

WORKSHEET B-1

TOTAL
10
1
2
3
4
5
6
7
8
9
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
39
40
41
42
43
44
45
46
47
48
49
50
57
58
100
101

47-517

4795 (Cont. )

FORM CMS-1728-20

APPORTIONMENT OF PATIENT SERVICE COSTS

HHA CCN:
____________________

PART I - AGGREGATE HHA COST PER VISIT AND AGGREGATE MEDICARE COST COMPUTATION

FROM
WKST. B,
COL. 10,
LINE:
1
16
17
18
19
20
21
22
23
24

COST PER VISIT COMPUTATION
PATIENT SERVICES
1
2
3
4
5
6
7
8
9
10

Skilled Nursing Care - RN
Skilled Nursing Care - LPN
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech-Language Pathology
Medical Social Services
Home Health Aide Services
Total (sum of lines 1-9)

PART II - SUPPLIES, DRUGS, AND DISPOSABLE DEVICES COST COMPUTATION

OTHER PATIENT SERVICES
11
12
13
14

Cost of Medical Supplies
Cost of Drugs
Cost of Administering Vaccines
Disposable Devices

FROM
WKST. B,
COL. 10
LINE:
25
26
27
29

TOTAL
COST
1

TOTAL
CHARGES
2

RATIO
3

TOTAL

VISITS
3

MEDICARE COVERED CHARGES
HHA SERVICES
OPPS
NOT SUBJECT
SUBJECT
REIMBURSED
TO DED &
TO DED &
SERVICES
COINSUR
COINSUR
4
5
6

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4714 - 4714.2)

47-518

COST
2

PERIOD:
FROM: ____________
TO: _____________

AVERAGE
COST
PER VISIT
4

HHA
MEDICARE
PROGRAM
VISITS
5

WORKSHEET C
PARTS I & II

HHA
MEDICARE
PROGRAM
COSTS
6

COST OF MEDICARE SERVICES
HHA SERVICES
SUBJECT
OPPS
NOT SUBJECT
REIMBURSED
TO DED &
TO DED &
SERVICES
COINSUR
COINSUR
7
8
9

09-20

1
2
3
4
5
6
7
8
9
10

11
12
13
14

Rev. 1

08-22

CALCULATION OF REIMBURSEMENT SETTLEMENT

FORM CMS-1728-20
HHA CCN:

__________________

PERIOD:
WORKSHEET D
FROM: ______________
TO: _________________

4795 (Cont.)

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

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

NOT SUBJECT
TO DEDUCTIBLES
& COINSURANCE
1

SUBJECT
TO DEDUCTIBLES
& COINSURANCE
2

1
2
3
4
5
6
7
8
9

PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
32.75
33
34
35
36
37
38
39

Total PPS payment - full episodes/periods without outliers
Total PPS payment - full episodes/periods with outliers
Total PPS payment - LUPA episodes/periods
Total PPS payment - PEP episodes/periods
Total PPS outlier payment - full episodes/periods with outliers
Total PPS outlier payment - PEP episodes/periods
Total other payments (see instructions)
Payment for services reimbursed under OPPS
DME Payment
Oxygen Payment
Prosthetics and Orthotics Payment
Primary Payer Payments
Part B deductibles billed to Medicare patients (exclude coinsurance)
Subtotal (sum of lines 9 through 15, plus lines 17 through 20, minus lines 16, 21, and 22)
Coinsurance billed to Medicare patients (from your records)
Allowable bad debts (see instructions)
Adjusted reimbursable bad debts (see instructions)
Allowable bad debts for dual eligible beneficiaries (see instructions)
Subtotal (line 23 minus line 24, plus line 26)
Other demonstration payment adjustment amount before sequestration
Amount due HHA prior to sequestration adjustment (line 28 plus or minus line 29, minus line 30)
Sequestration adjustment (see instructions)
Sequestration adjustment for non-claims based amounts (see instructions)
Amount due HHA after sequestration adjustment (line 31 minus lines 32 and 32.75)
Other demonstration payment adjustment amount after sequestration
Amount due HHA (line 33 minus line 34)
Total interim payments (from Worksheet D-1, line 4)
Tentative settlement (For contractor use only)
Balance due HHA/Medicare program (line 35 minus lines 36 and 37) (indicate overpayments in brackets)
Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-2, section 115.2

FORM CMS-1728-20 (08-2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4715 - 4715.2)

Rev. 3

10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
32.75
33
34
35
36
37
38
39

47-519

4795 (Cont.)

ANALYSIS OF PAYMENTS TO HHA FOR SERVICES RENDERED TO
PROGRAM BENEFICIARIES

1
2
3

FORM CMS-1728-20

DESCRIPTION
Total interim payments paid to HHA
Interim pymts payable on individual bills either submitted or to
be submitted to the contractor, for services rendered in the
cost reporting period. If none, write "NONE" or enter a zero.
List separately each retroactive lump sum
adjustment amount based on subsequent revision
of the interim rate for the cost reporting period.
Also show date of each payment. If none, write
1
"NONE" or enter a zero.

HHA CCN:

PERIOD:
FROM: ____________
____________________
TO: _____________
DATE
1

Program
to
Provider
Provider
to
Program

4

5

6

7
8

SUBTOTAL (sum of lines 3.01 through 3.49, minus sum of lines 3.50 through 3.98)
TOTAL INTERIM PAYMENTS (sum of lines 1, 2, and 3.99)
(transfer to Worksheet D, Part II, line 36)
TO BE COMPLETED BY CONTRACTOR
List separately each tentative settlement payment
after desk review. Also show date of each
payment. If none, write "NONE" or enter
a zero. 1
SUBTOTAL (sum of lines 5.01 through 5.49, minus sum of lines 5.50 through 5.98)
Determine net settlement
amount (balance due) based
on the cost report. 1

TOTAL MEDICARE PROGRAM LIABILITY
(see instructions)
NAME OF CONTRACTOR
1

Program
to
Provider
Provider
to
Program
Program
to
Provider
Provider
to
Program

WORKSHEET D-1

AMOUNT
2

08-22

1
2

.01
.02
.03
.04
.05
.50
.51
.52
.53
.54
.99

3.01
3.02
3.03
3.04
3.05
3.50
3.51
3.52
3.53
3.54
3.99
4

.01
.02
.03
.50
.51
.52
.99
.01

5.01
5.02
5.03
5.50
5.51
5.52
5.99
6.01

.02

6.02
7

CONTRACTOR NUMBER

NPR DATE

8

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4716)

47-520

Rev. 3

04-21

BALANCE SHEET

FORM CMS-1728-20

HHA CCN:
____________________

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
26.50
27
28
29
30
30.50
31
32

33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48

PERIOD:
FROM: ______________
TO: _________________

4795 (Cont.)

WORKSHEET F

ASSETS (Omit Cents)
CURRENT ASSETS
Cash on hand and in banks
Temporary investments
Notes receivable
Accounts receivable
Other receivables
Less: allowances for uncollectible notes and accounts receivable
Inventory
Prepaid expenses
Other current assets
TOTAL CURRENT ASSETS (sum of lines 1 through 9)
FIXED ASSETS
Land
Land Improvements
Less: accumulated depreciation
Buildings
Less: accumulated depreciation
Leasehold improvements
Less: accumulated depreciation
Fixed equipment
Less: accumulated depreciation
Automobiles and trucks
Less: accumulated depreciation
Major movable equipment
Less: accumulated depreciation
Minor equipment
Less: accumulated depreciation
Minor equipment nondepreciable
Other fixed assets
TOTAL FIXED ASSETS (sum of lines 11 through 26, and 26.50)
OTHER ASSETS
Investments
Deposits on leases
Due from owners/officers
Other assets
TOTAL OTHER ASSETS (sum of lines 28 through 30, and 30.50)
TOTAL ASSETS (sum of lines 10, 27 and 31)

AMOUNT

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

AMOUNT

FORM CMS-1728-20 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4717)

Rev. 2

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
26.50
27
28
29
30
30.50
31
32

33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48

47-521

4795 (Cont.)

STATEMENT OF REVENUES AND EXPENSES

FORM CMS-1728-20
HHA CCN:

____________________

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Gross patient revenues
Less: Allowances and discounts on patients' accounts
Net patient revenues (line 1 minus line 2)

TITLE XVIII
MEDICARE
1

TITLE XIX
MEDICAID
2

PERIOD:
FROM: ______________
TO: _________________
OTHER
3

TOTAL
4

1

2

Operating expenses (from Wkst. A, line 100, col. 6)

Less total operating expenses (sum of lines 4 through 16)
Net income from service to patients (line 3 minus line 17)
Other income:
Contributions, donations, bequests, etc.
Income from investments
Purchase discounts
Rebates and refunds of expenses
Sale of Medical and Nursing Supplies to other than patients
Sale of durable medical equipment to other than patients
Sale of drugs to other than patients
Sale of medical records and abstracts
Government Appropriations

19
20
21
22
23
24
25
26
27
28
29
30
31
31.50 COVID-19 PHE Funding
32 Total Other Income (sum of lines 19 through 31)
33 Net Income or Loss for the period (line 18 plus line 32)

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4718)

47-522

WORKSHEET F-1

04-21

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
31.50
32
33

Rev. 2

09-20

FORM CMS 1728-20

ANALYSIS OF HHA-BASED HOSPICE COSTS

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

SALARIES
1

OTHER
2

SUBTOTAL
3

HHA CCN:
_________________
HOSPICE CCN:
_________________
RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD:
FROM: ___________
TO: ______________

ADJUSTMENTS
6

4795 (Cont.)

WORKSHEET O

TOTAL
7
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4719)

Rev. 1

47-523

4795 (Cont.)

FORM CMS 1728-20

ANALYSIS OF HHA-BASED HOSPICE COSTS

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

SALARIES
1

OTHER
2

SUBTOTAL
3

HHA CCN:
_________________
HOSPICE CCN:
_________________
RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD:
FROM: ___________
TO: ______________

ADJUSTMENTS
6

WORKSHEET O

09-20

TOTAL
7
40
41
42
43
44
45
46
47
60
61
62
63
64
65
66
67
68
69
70
71
100

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4719)

47-524

Rev. 1

09-20

FORM CMS-1728-20

ANALYSIS OF HHA-BASED HOSPICE COSTS
CONTINUOUS HOME CARE

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

SALARIES
1

OTHER
2

SUBTOTAL
3

HHA CCN:
_________________
HOSPICE CCN:
_________________
RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD:
FROM: ___________
TO: ______________

ADJUSTMENTS
6

4795 (Cont.)

WORKSHEET O-1

TOTAL
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
100

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4720)

Rev. 1

47-525

4795 (Cont.)

FORM CMS-1728-20

ANALYSIS OF HHA-BASED HOSPICE COST
ROUTINE HOME CARE

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

SALARIES
1

OTHER
2

SUBTOTAL
3

RECLASSIFICATIONS
4

HHA CCN:
_________________
HOSPICE CCN:
_________________

SUBTOTAL
5

PERIOD:
FROM: ___________
TO: ______________

ADJUSTMENTS
6

WORKSHEET O-2

09-20

TOTAL
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
100

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4720)

47-526

Rev. 1

09-20

FORM CMS 1728-20

ANALYSIS OF HHA-BASED HOSPICE COSTS
INPATIENT RESPITE CARE

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

SALARIES
1

OTHER
2

SUBTOTAL
3

HHA CCN:
_________________
HOSPICE CCN:
_________________
RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD:
FROM: ___________
TO: ______________

ADJUSTMENTS
6

4795 (Cont.)

WORKSHEET O-3

TOTAL
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
100

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4720)

Rev. 1

47-527

4795 (Cont.)

FORM CMS-1728-20

ANALYSIS OF HHA-BASED HOSPICE COSTS
GENERAL INPATIENT CARE

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

SALARIES
1

OTHER
2

SUBTOTAL
3

HHA CCN:
_________________
HOSPICE CCN:
_________________
RECLASSIFICATIONS
4

SUBTOTAL
5

PERIOD:
FROM: ___________
TO: ______________

ADJUSTMENTS
6

WORKSHEET O-4

09-20

TOTAL
7
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
100

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

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4720)

47-528

Rev. 1

09-20

DETERMINATION OF HHA-BASED HOSPICE TOTAL EXPENSES
FOR ALLOCATION

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

FORM CMS 1728-20

HHA CCN:
____________________
HOSPICE CCN:
____________________
HOSPICE
DIRECT
EXPENSES
1

PERIOD:
FROM: ______________
TO: _________________
GENERAL
SERVICE
EXPENSES
FROM WKST B
2

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4721)

Rev. 1

4795 (Cont.)

WORKSHEET O-5

TOTAL
EXPENSES
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100

47-529

4795 (Cont.)

FORM CMS-1728-20

COST ALLOCATION - HHA-BASED HOSPICE
ALLOCATION OF HHA-BASED HOSPICE GENERAL SERVICE COSTS

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

TOTAL
EXPENSES
0

CAP REL
BLDG
& FIX
1

CAP REL
MVBLE
EQUIP
2

EMPLOYEE
BENEFITS
DEPARTMENT
3

SUBTOTAL
3A

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4722)

47-530

HHA CCN:
_________________
HOSPICE CCN:
_________________
ADMINISTRATIVE &
GENERAL
4

PLANT
OP &
MAINT
5

PERIOD:
FROM: ____________
TO: _____________

09-20

WORKSHEET O-6
PART I

LAUNDRY
& LINEN

HOUSEKEEPING

DIETARY

6

7

8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100

Rev. 1

09-20

FORM CMS-1728-20

COST ALLOCATION - HHA-BASED HOSPICE GENERAL SERVICE COSTS

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

NURSING
ADMINISTRATION
9

ROUTINE
MEDICAL
SUPPLIES
10

MEDICAL
RECORDS
11

STAFF
TRANSPORTATION
12

VOLUNTEER
SVC COORDINATION
13

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4722)

Rev. 1

HHA CCN:
____________________
HOSPICE CCN:
____________________
PHARMACY
14

PHYSICIAN
ADMINISTRATIVE SVCS
15

PERIOD:
FROM: ________________
TO: ___________________
OTHER
GENERAL
SERVICE
16

PATIENT /
RESIDENTIAL
CARE SVCS
17

4795 (Cont.)

WORKSHEET O-6
PART I

TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
100

47-531

4795 (Cont.)

FORM CMS-1728-20

COST ALLOCATION - HHA-BASED HOSPICE
STATISTICAL BASES

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

CAP REL
BLDG
& FIX
(SQUARE
FEET)
1

CAP REL
MVBLE
EQUIP
(DOLLAR
VALUE)
2

EMPLOYEE
BENEFITS
DEPARTMENT
(GROSS
SALARIES)
3

RECONCILIATION
4A

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4722)

47-532

HHA CCN:
____________________
HOSPICE CCN:
____________________
ADMINISTRATIVE &
GENERAL
(ACCUM.
COST)
4

PLANT
OP &
MAINT
(SQUARE
FEET)
5

PERIOD:
FROM: _______________
TO: __________________

09-20

WORKSHEET O-6
PART II

LAUNDRY
& LINEN

HOUSEKEEPING

DIETARY

(IN-FACILITY DAYS)
6

(SQUARE
FEET)
7

(IN-FACILITY DAYS)
8
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
101
102

Rev. 1

09-20

FORM CMS-1728-20

COST ALLOCATION - HHA-BASED HOSPICE
STATISTICAL BASES

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

NURSING
ADMINISTRATION
(DIRECT
NURS. HRS.)
9

ROUTINE
MEDICAL
SUPPLIES
(PATIENT
DAYS)
10

MEDICAL
RECORDS
(PATIENT
DAYS)
11

STAFF
TRANSPORTATION
(MILEAGE)
12

VOLUNTEER
SVC COORDINATION
(HOURS OF
SERVICE)
13

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4722)

Rev. 1

HHA CCN:
_________________
HOSPICE CCN:
_________________
PHARMACY

(CHARGES)
14

PHYSICIAN
ADMINISTRATIVE SVCS
(PATIENT
DAYS)
15

PERIOD:
FROM: ____________
TO: _____________
OTHER
GENERAL
SERVICE
(SPECIFY
BASIS)
16

PATIENT /
RESIDENTIAL
CARE SVCS
(IN-FACILITY DAYS)
17

4795 (Cont.)

WORKSHEET O-6
PART II

TOTAL
18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50
51
52
53
60
61
62
63
64
65
66
67
68
69
70
71
99
101
102

47-533

4795 (Cont.)

APPORTIONMENT OF HHA-BASED HOSPICE SHARED SERVICE COSTS BY LEVEL OF CARE

1
2
3
4
5
6
7
8
9
10

Cost Center Descriptions
ANCILLARY SERVICE COST CENTERS
Physical Therapy
Physical Therapy Assistant
Occupational Therapy
Certified Occupational Therapy Assistant
Speech-Language Pathology
Medical Social Services
Medical Supplies (see instructions)
Drugs
Durable Medical Equipment/Oxygen
Totals (sum of lines 1-9)

WKST. B,
COL. 10,
LINE
0

TOTAL
HHA
COSTS
1

TOTAL
HHA
CHARGES
2

FORM CMS-1728-20

COST TO
CHARGE
RATIO
3

CHARGES BY LOC
HCHC
4

18
19
20
21
22
23
25
26
28

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4723)

47-534

HHA CCN:
____________________
HOSPICE CCN:
____________________

HRHC
5

HIRC
6

PERIOD:
FROM: _______________
TO: __________________

WORKSHEET O-7

09-20

SHARED SERVICE COSTS BY LOC
HGIP
7

HCHC
8

HRHC
9

HIRC
10

HGIP
11
1
2
3
4
5
6
7
8
9
10

Rev. 1

04-21

CALCULATION OF HHA-BASED HOSPICE PER DIEM COST

FORM CMS-1728-20

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

HHA CCN:
__________________
HOSPICE CCN:
__________________
TITLE XVIII
MEDICARE
1

PERIOD:
FROM: _____________
TO: ________________
TITLE XIX
MEDICAID
2

FORM CMS-1728-20 (04-2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4724)

Rev. 2

4795 (Cont.)

WORKSHEET O-8

TOTAL
3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23

47-535

4795 (Cont.)

FORM CMS-1728-20

04-21

This page intentionally left blank.

FORM CMS-1728-20 (09-2020) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4724)

47-536

Rev. 2