Home Office Cost Statement (CMS-287-22)

Forms and Documents

Document Name	Status
Form CMS-287-21 Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21) Form	Modified
Supporting Statement-CMS-287-22.docx Supporting Statement A	2024-08-29
Crosswalk-287-22.pdf Supplementary Document	2024-08-29

IC Document Collections

IC ID	Document Title	Status
7881	Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21) Form	Modified

ICR Details

OMB Control No: 0938-0202	ICR Reference No: 202408-0938-039
Status: Received in OIRA	Previous ICR Reference No: 202012-0938-018
Agency/Subagency: HHS/CMS	Agency Tracking No: CM
Title: Home Office Cost Statement (CMS-287-22)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 08/29/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2024
Responses	1,646	1,626
Time Burden (Hours)	767,036	757,716
Cost Burden (Dollars)	0	0

---

Abstract: Home Office Cost Statement Form CMS-287-22 is filed annually by home office/chain organizations (HO/CO) to report the information necessary for the determination of Medicare reimbursement of components of the HO/CO. To the extent 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.

---

Authorizing Statute(s): Statute at Large: 18 Stat. 1833
   Statute at Large: 18 Stat. 1815
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 50338	06/13/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 70191	08/29/2024
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-21)	CMS-287-21	Home Office Cost Statement

---

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,646	1,626	0	0	20	0
Annual Time Burden (Hours)	767,036	757,716	0	0	9,320	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The changes in burden and cost for the Form CMS-287-22 result from an increase in the number of respondents by 20 (from 1,626 in 2020 to 1,646 in 2024).

---

Annual Cost to Federal Government: $7,184,790

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/29/2024

---