CMS-287-21 Home Office Cost Statement

Home Office Cost Statement (CMS-287-22)

r3p248f.xlsx

OMB: 0938-0202

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Overview

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

Sheet 1: S

04-23			FORM CMS-287-22							4895
										FORM APPROVED
										OMB NO. 0938-0202
										EXPIRES 11/30/2024
HOME OFFICE COST STATEMENT STATUS AND CERTIFICATION					HOME OFFICE	PERIOD:			SCHEDULE S
					NUMBER:		FROM:	____________
					_________________		TO:	____________
					_________________		TO:	____________

PART I - COST STATEMENT STATUS
1	Amended cost statement									1
2	Amendment number									2
3	Date received									3
4	First cost statement for this home office number									4
5	Last cost statement for this home office number									5
6	Cost statement status									6
7	Reopening number									7
8	Date of Finalization of Home Office Cost Statement									8
9	Contractor number									9
10	ADR software vendor code									10

PART II - CERTIFICATION














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




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




























FORM CMS-287-22 (04/2023) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4801 THROUGH 4801.12.)
Rev. 2										48-501

Sheet 2: S-1

4895 (CONT.)					FORM CMS-287-22														04-23
IDENTIFICATION DATA										HOME OFFICE		PERIOD:					SCHEDULE S-1
										NUMBER:			FROM:	____________
										_________________			TO:	____________
										_________________			TO:	____________

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

							HOME OFFICE		DATE OPERATIONS		REPORTING PERIOD
		HOME OFFICE NAME					NUMBER		BEGAN		BEGINNING DATE					ENDING DATE
		1					2		3		4					5
2	HO/CO Information																		2

		TYPE OF CONTROL	DESCRIPTION
		1	2
3	HO/CO Control																		3

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

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

PART II - KEY OFFICER DATA
	POSITION / JOB TITLE		KEY OFFICER NAME
	1		2
1	President																		1
2	Vice President																		2
3	Secretary																		3
4	Treasurer																		4
5	Controller																		5
6																			6
7																			7
8																			8
9																			9
10																			10
11																			11
12																			12
13																			13
14																			14
15																			15
16																			16
17																			17
18																			18
19																			19
20																			20



FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4801.20 THROUGH SECTION 4801.22.)
48-502																			Rev. 2

Sheet 3: S-2

03-24						FORM CMS-287-22										4895 (CONT.)
LISTING OF COMPONENTS										HOME OFFICE		PERIOD:			SCHEDULE S-2
										NUMBER:			FROM:	____________
										_________________			TO:	____________
										_________________			TO:	____________

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


50																50

PART II - NON-HEALTHCARE COMPONENTS
					ACCOUNTING PERIOD ENDING			DATE
					DURING HO FISCAL YEAR		DATE	SOLD /
	COMPONENT NAME				BEGINNING	ENDING	ACQUIRED	CLOSED
		1	2	3	4	5	6	7	8		9		10		11
1																1
2																2
3																3
4																4
5																5


50																50

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


50																50







FORM CMS-287-22 (03/2024) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4801.30 THROUGH SECTION 4801.33.)
Rev. 3																48-503

Sheet 4: A

4895 (CONT.)					FORM CMS-287-22										03-24
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES									HOME OFFICE		PERIOD:			SCHEDULE A
									NUMBER:			FROM:	____________
									_________________			TO:	____________


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





99	Subtotal Non-capital Cost														99
100	Total														100




FORM CMS-287-22 (04/2023) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802 THROUGH SECTION 4802.10.)
48-504															Rev. 3

Sheet 5: A-6

04-23		FORM CMS-287-22												4895 (CONT.)
RECLASSIFICATIONS OF EXPENSES						HOME OFFICE		PERIOD:				SCHEDULE A-6
						NUMBER:			FROM:	____________
						_________________			TO:	____________


			INCREASES				DECREASES
			SCHEDULE A COST CENTER				SCHEDULE A COST CENTER
	EXPLANATION OF RECLASSIFICATION	CODE	DESCRIPTION	LINE #	AMOUNT		DESCRIPTION				LINE #		AMOUNT
	1	2	3	4	5		6				7		8
1														1
2														2
3														3
4														4
5														5
6														6
7														7
8														8
9														9
10														10
11														11
12														12
13														13
14														14
15														15
16														16
17														17
18														18
19														19
20														20
21														21
22														22
23														23
24														24
25														25
26														26
27														27
28														28
29														29
30														30










100	Total reclassifications													100




FORM CMS-287-22 (04/2023) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.70.)
Rev. 2														48-505

Sheet 6: A-7

4895 (CONT.)

FORM CMS-287-22

04-23

ANALYSIS OF CAPITAL COST CENTERS

HOME OFFICE

PERIOD:

SCHEDULE A-7

NUMBER:

FROM:

____________

_________________

TO:

____________

PART I - ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCES

RETIRE-

FULLY DE-

BEGINNING

ACQUISITIONS

MENTS AND

ENDING

PRECIATED

BALANCE

PURCHASES

DONATIONS

TOTAL

DISPOSALS

BALANCE

ASSETS

DESCRIPTION

Land

Land Improvements

Buildings & Fixtures

Building Improvements

Fixed Equipment

Movable Equipment

Subtotal

Reconciling Items

Total

PART II - RECONCILIATION OF CAPITAL COST CENTERS

COMPUTATION OF RATIOS

ALLOCATION OF OTHER CAPITAL RELATED COSTS

CAPITAL-

GROSS

INSURANCE

TAXES &

ALL OTHER

GROSS

IZED

ASSETS

PREMIUMS-

LICENSES-

CAPITAL

ALLOCATION

ASSETS

LEASES

FOR RATIO

RATIO

OTHER CRC

REL COSTS

TOTAL

DESCRIPTION

CRC-B&F

CRC-ME

Total

SUMMARY OF CAPITAL

INSURANCE

TAXES &

ALL OTHER

DEPRE-

PREMIUMS-

LICENSES-

CAPITAL

CIATION

LEASE

INTEREST

OTHER CRC

REL COSTS

TOTAL

DESCRIPTION

CRC-B&F

CRC-ME

Total

FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4802.80 THROUGH SECTION 4802.82.)

48-506

Rev. 2

Sheet 7: A-8

10-22		FORM CMS-287-22											4895 (CONT.)
ADJUSTMENTS TO EXPENSES						HOME OFFICE		PERIOD:			SCHEDULE A-8
						NUMBER:			FROM:	____________
						_________________			TO:	____________
						_________________			TO:	____________

							SCHEDULE A COST CENTER
	DESCRIPTION OF ADJUSTMENT		BASIS		AMOUNT				DESCRIPTION			LINE #
	1		2		3				4			5
1	Federal, state income tax, franchise tax, and related interest and penalties on late payments (CMS Pub. 15-1, chapter 21, §2122.2)												1
2	Stockholders servicing costs (CMS Pub. 15-1, chapter 21, §2134.9)												2
3	Acquisition expenses (CMS Pub. 15-1, chapter 21, §2134.11)												3
4	Bad debts (CMS Pub. 15-1, chapter 3, §300)												4
5	Life insurance premiums where home office is direct/indirect beneficiary (CMS Pub. 15-1, chapter 21, §2130)												5
6	Annual stockholder meeting expenses (CMS Pub. 15-1, chapter 21, §2134.9)												6
7	Non-healthcare projects (CMS Pub. 15-1, chapter 21, §2102.3)												7
8	Non-competition agreement expenses (CMS Pub. 15-1, chapter 21, §2105.1)												8
9	Fund-raising expenses (CMS Pub. 15-1, chapter 21, §2136.2)												9
10	Rebates/refunds on expenses (CMS Pub. 15-1, chapter 8, §804)												10
11	Cost of ownership of assets leased from related organization in lieu of rent (CMS Pub. 15-1, chapter 10, §1011.5)												11
12	Related organizations (CMS Pub. 15-1, chapter 10, §1000)			Sch. A-8-1									12
13	Value of services of non-paid workers (CMS Pub. 15-1, chapter 7, §700)												13
14	Interest on loans between home office and components (CMS Pub. 15-1, chapter 21, §2150.2C)												14
15	Costs of corporate acquisitions of capital stocks and acquisition & development department (CMS Pub. 15-1, chapter 21, §2150.2B)												15
16	Interest on loans paid to owners/partners (CMS Pub. 15-1, chapter 2, §218)												16
17	Abandoned construction in progress cost (CMS Pub. 15-1, chapter 21, §2155)												17
18													18
19													19
20													20
21													21
22													22
23													23
24													24
25													25
26													26
27													27
28													28
29													29
30													30










100	Total												100





FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.90.)
Rev. 1													48-507

Sheet 8: A-8-1

4895 (CONT.)					FORM CMS-287-22													10-22
COSTS OF SERVICES FROM RELATED ORGANIZATIONS AND / OR HOME OFFICE / CHAIN ORGANIZATIONS										HOME OFFICE			PERIOD:				SCHEDULE A-8-1
										NUMBER:				FROM:	____________
										_________________				TO:	____________
										_________________				TO:	____________

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





100	TOTAL																	100

PART II - INTERRELATIONSHIP OF HOME OFFICE / CHAIN ORGANIZATION TO RELATED ORGANIZATIONS
	INTERRELA-	INTERRELATIONSHIP					RELATED
	TIONSHIP	DESCRIPTION		NAME OF		PERCENTAGE	ORGANIZATION				PERCENTAGE		TYPE OF
	SYMBOL	(IF SCH A-8-1, PART II, COL 1 = G)		RELATED INDIVIDUAL		OWNERSHIP	NAME				OWNERSHIP		BUSINESS
	1	2		3		4	5				6		7
1																		1
2																		2
3																		3
4																		4
5																		5
6																		6
7																		7
8																		8
9																		9
10																		10




50																		50







FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4802.100 THROUGH SECTION 4802.102.)
48-508																		Rev. 1

Sheet 9: B Dir Cap

10-22						FORM CMS-287-22												4895 (CONT.)
DIRECT ALLOCATION OF CAPITAL RELATED COSTS										HOME OFFICE			PERIOD:				SCHEDULE B
										NUMBER:				FROM:	____________
										_________________				TO:	____________
										_________________				TO:	____________

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

50																		50
51	Total																	51

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

50																		50
51	Total																	51

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

50																		50
51	Total																	51
52	Grand Total																	52




FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803 THROUGH SECTION 4803.13.)
Rev. 1																		48-509

Sheet 10: B-1 Dir Non-Cap

4895 (CONT.)

FORM CMS-287-22

10-22

DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE B-1,

NUMBER:

FROM:

____________

PART I

_________________

TO:

____________

PART I - HEALTHCARE PROVIDER COMPONENTS

SALARIES

EMP BEN-

PROFIT

AUDIT /

TRAVEL

& WAGES

PAYROLL

NON-PAY

SHAR/PEN-

LEGAL

ACCOUNT-

COMMUNI-

& ENTER-

TRANS-

OFFICERS

OF OTHERS

TAXES

SION PLANS

FEES

ING FEES

UTILITIES

CATIONS

TAINMENT

PORTATON

COMPONENT NAME

CCN

Total

CLEANING,

REPAIRS &

DUES &

INSURANCE

TAXES &

OFFICE &

MINOR

MAINTEN-

SUBSCRIP-

CONTRI-

PREMIUMS-

LICENSES-

INTEREST

ADMIN SUP

EQUIP

ANCE

TIONS

BUTIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

CCN

Total

FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)

48-510

Rev. 1

10-22

FORM CMS-287-22

4895 (CONT.)

DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE B-1,

NUMBER:

FROM:

____________

PART II

_________________

TO:

____________

PART II - NON-HEALTHCARE COMPONENTS

SALARIES

EMP BEN-

PROFIT

AUDIT /

TRAVEL

& WAGES

PAYROLL

NON-PAY

SHAR/PEN-

LEGAL

ACCOUNT-

COMMUNI-

& ENTER-

TRANS-

OFFICERS

OF OTHERS

TAXES

SION PLANS

FEES

ING FEES

UTILITIES

CATIONS

TAINMENT

PORTATON

COMPONENT NAME

Total

CLEANING,

REPAIRS &

DUES &

INSURANCE

TAXES &

OFFICE &

MINOR

MAINTEN-

SUBSCRIP-

CONTRI-

PREMIUMS-

LICENSES-

INTEREST

ADMIN SUP

EQUIP

ANCE

TIONS

BUTIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

Total

FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)

Rev. 1

48-511

4895 (CONT.)

FORM CMS-287-22

10-22

DIRECT ALLOCATION OF NON-CAPITAL RELATED COSTS

HOME OFFICE

PERIOD:

SCHEDULE B-1,

NUMBER:

FROM:

____________

PART III

_________________

TO:

____________

PART III - REGION / DIVISION COMPONENTS

SALARIES

EMP BEN-

PROFIT

AUDIT /

TRAVEL

REGIONAL

& WAGES

PAYROLL

NON-PAY

SHAR/PEN-

LEGAL

ACCOUNT-

COMMUNI-

& ENTER-

TRANS-

OFFICERS

OF OTHERS

TAXES

SION PLANS

FEES

ING FEES

UTILITIES

CATIONS

TAINMENT

PORTATON

COMPONENT NAME

NUMBER

Total

Grand Total

CLEANING,

REPAIRS &

DUES &

INSURANCE

TAXES &

REGIONAL

OFFICE &

MINOR

MAINTEN-

SUBSCRIP-

CONTRI-

PREMIUMS-

LICENSES-

INTEREST

ADMIN SUP

EQUIP

ANCE

TIONS

BUTIONS

NON-CAP

EXPENSE

INCOME

TOTAL

COMPONENT NAME

NUMBER

Total

Grand Total

FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4803.20 THROUGH SECTION 4803.23.)

48-512

Rev. 1

Sheet 11: C Func Cap

04-23			FORM CMS-287-22												4895 (CONT.)
FUNCTIONAL ALLOCATION OF CAPITAL RELATED COSTS						HOME OFFICE			PERIOD:				SCHEDULE C
						NUMBER:				FROM:	____________
						_________________				TO:	____________
						_________________				TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS

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


50															50
51	Total														51

PART II - NON-HEALTHCARE COMPONENTS

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


50															50
51	Total														51

PART III - REGION / DIVISION COMPONENTS

				REGIONAL			CRC-			0
				HO			B&F			0				TOTAL
		COMPONENT NAME		NUMBER			1			2				3
1															1
2															2
3															3
4															4
5															5


50															50
51	Total														51
52	Grand Total														52























FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4804 THROUGH 4804.13.)
Rev. 2															48-513

Sheet 12: C-1 FC Stats

4895 (CONT.)		FORM CMS-287-22								04-23
FUNCTIONAL ALLOCATION OF CAPITAL RELATED COSTS - STATISTICS				HOME OFFICE		PERIOD:			SCHEDULE C-1
				NUMBER:			FROM:	____________
				_________________			TO:	____________
				_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS

			CRC-		CRC-
			B&F		ME
			(SQUARE		(DOLLAR
			FEET)		VALUE)
			(1)		(2)
	COMPONENT NAME	CCN	1		2
1										1
2										2
3										3
4										4
5										5


50										50
51	Total									51

PART II - NON-HEALTHCARE COMPONENTS

			CRC-		CRC-
			B&F		ME
			(SQUARE		(DOLLAR
			FEET)		VALUE)
			(1)		(2)
	COMPONENT NAME	CCN	1		2
1										1
2										2
3										3
4										4
5										5


50										50
51	Total									51

PART III - REGION / DIVISION COMPONENTS

			CRC-		CRC-
			B&F		ME
			(SQUARE		(DOLLAR
			FEET)		VALUE)
			(1)		(2)
	COMPONENT NAME	CCN	1		2
1										1
2										2
3										3
4										4
5										5


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












FORM CMS-287-22 (04/2023) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4804.20 THROUGH SECTION 4804.23.)
48-514										Rev. 2

Sheet 13: D Func Non-Cap

10-22							FORM CMS-287-22														4895 (CONT.)
FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS													HOME OFFICE		PERIOD:				SCHEDULE D,
													NUMBER:			FROM:	____________		PART I
													_________________			TO:	____________
													_________________			TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS
				SALARIES	SALARIES			EMP BEN-	EMP BEN-	PROFIT		AUDIT /						TRAVEL
				OF	& WAGES	PAYROLL		PAYROLL	NON-PAY	SHAR/PEN-	LEGAL	ACCOUNT-			COMMUNI-			& ENTER-		TRANS-
				OFFICERS	OF OTHERS	TAXES		RELATED	RELATED	SION PLANS	FEES	ING FEES		UTILITIES	CATIONS			TAINMENT		PORTATON
	COMPONENT NAME	CCN		8	9	10		11	12	13	14	15		16	17			18		19
1																					1
2																					2
3																					3
4																					4
5																					5


50																					50
51	Total																				51

				CLEANING,		REPAIRS &		DUES &		INSURANCE	TAXES &
				OFFICE &	MINOR	MAINTEN-		SUBSCRIP-	CONTRI-	PREMIUMS-	LICENSES-	INTEREST		INTEREST
				ADMIN SUP	EQUIP	ANCE		TIONS	BUTIONS	NON-CAP	NON-CAP	EXPENSE		INCOME						TOTAL
	COMPONENT NAME	CCN		20	21	22		23	24	25	26	27		28						99
1																					1
2																					2
3																					3
4																					4
5																					5


50																					50
51	Total																				51





















FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)
Rev. 1																					48-515
4895 (CONT.)							FORM CMS-287-22														10-22
FUNCTIONAL ALLOCATION OF NON-CAPITAL COSTS													HOME OFFICE		PERIOD:				SCHEDULE D,
													NUMBER:			FROM:	____________		PART II
													_________________			TO:	____________
													_________________			TO:	____________

PART II - NON-HEALTHCARE COMPONENTS
				SALARIES	SALARIES			EMP BEN-	EMP BEN-	PROFIT		AUDIT /						TRAVEL
				OF	& WAGES	PAYROLL		PAYROLL	NON-PAY	SHAR/PEN-	LEGAL	ACCOUNT-			COMMUNI-			& ENTER-		TRANS-
				OFFICERS	OF OTHERS	TAXES		RELATED	RELATED	SION PLANS	FEES	ING FEES		UTILITIES	CATIONS			TAINMENT		PORTATON
	COMPONENT NAME			8	9	10		11	12	13	14	15		16	17			18		19
1																					1
2																					2
3																					3
4																					4
5																					5


50																					50
51	Total																				51

				CLEANING,		REPAIRS &		DUES &		INSURANCE	TAXES &
				OFFICE &	MINOR	MAINTEN-		SUBSCRIP-	CONTRI-	PREMIUMS-	LICENSES-	INTEREST		INTEREST
				ADMIN SUP	EQUIP	ANCE		TIONS	BUTIONS	NON-CAP	NON-CAP	EXPENSE		INCOME						TOTAL
	COMPONENT NAME			20	21	22		23	24	25	26	27		28						31
1																					1
2																					2
3																					3
4																					4
5																					5


50																					50
51	Total																				51





















FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)
48-516																					Rev. 1
10-22							FORM CMS-287-22														4895 (CONT.)
FUNCTIONAL ALLOCATION OF NON-CAPITAL COSTS													HOME OFFICE		PERIOD:				SCHEDULE D,
													NUMBER:			FROM:	____________		PART III
													_________________			TO:	____________
													_________________			TO:	____________

PART III - REGIONAL OFFICE / DIVISION COMPONENTS	PART III - REGION / DIVISION COMPONENTS
				SALARIES	SALARIES	0		EMP BEN-	EMP BEN-	PROFIT	0	AUDIT /		0	0			TRAVEL		0
		REGIONAL		OF	& WAGES	PAYROLL		PAYROLL	NON-PAY	SHAR/PEN-	LEGAL	ACCOUNT-		0	COMMUNI-			& ENTER-		TRANS-
		HO		OFFICERS	OF OTHERS	TAXES		RELATED	RELATED	SION PLANS	FEES	ING FEES		UTILITIES	CATIONS			TAINMENT		PORTATON
	COMPONENT NAME	NUMBER		8	9	10		11	12	13	14	15		16	17			18		19
1																					1
2																					2
3																					3
4																					4
5																					5


50																					50
51	Total																				51
52	Grand Total																				52

				CLEANING,		REPAIRS &		DUES &		INSURANCE	TAXES &
			REGIONAL	OFFICE &	MINOR	MAINTEN-		SUBSCRIP-	CONTRI-	PREMIUMS-	LICENSES-	INTEREST		INTEREST
			HO	ADMIN SUP	EQUIP	ANCE		TIONS	BUTIONS	NON-CAP	NON-CAP	EXPENSE		INCOME						TOTAL
	COMPONENT NAME		NUMBER	20	21	22		23	24	25	26	27		28						99
1																					1
2																					2
3																					3
4																					4
5																					5


50																					50
51	Total																				51
52	Grand Total																				52



















FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805 THROUGH SECTION 4805.13.)
Rev. 1																					48-517

Sheet 14: D-1 FNC Stats

4895 (CONT.)

FORM CMS-287-22

10-22

FUNCTIONAL ALLOCATION OF NON-CAPITAL RELATED COSTS - STATISTICS

HOME OFFICE

PERIOD:

SCHEDULE D-1,

NUMBER:

FROM:

____________

PART I

_________________

TO:

____________

PART I - HEALTHCARE PROVIDER COMPONENTS

SALARIES

EMP BEN-

PROFIT

AUDIT /

TRAVEL

& WAGES

PAYROLL

NON-PAY

SHAR/PEN-

LEGAL

ACCOUNT-

COMMUNI-

& ENTER-

TRANS-

OFFICERS

OF OTHERS

TAXES

SION PLANS

FEES

ING FEES

UTILITIES

CATIONS

TAINMENT

PORTATON

(ENTER

BASIS)

COMPONENT NAME

CCN

Total

CLEANING,

REPAIRS &

DUES &

INSURANCE

TAXES &

OFFICE &

MINOR

MAINTEN-

SUBSCRIP-

CONTRI-

PREMIUMS-

LICENSES-

INTEREST

ADMIN SUP

EQUIP

ANCE

TIONS

BUTIONS

NON-CAP

EXPENSE

INCOME

(ENTER

BASIS)

COMPONENT NAME

CCN

Total

FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)

48-518

Rev. 1

10-22

FORM CMS-287-22

4895 (CONT.)

FUNCTIONAL ALLOCATION OF NON-CAPITAL COSTS - STATISTICS

HOME OFFICE

PERIOD:

SCHEDULE D-1,

NUMBER:

FROM:

____________

PART II

_________________

TO:

____________

PART II - NON-HEALTHCARE COMPONENTS

SALARIES

EMP BEN-

PROFIT

AUDIT /

TRAVEL

& WAGES

PAYROLL

NON-PAY

SHAR/PEN-

LEGAL

ACCOUNT-

COMMUNI-

& ENTER-

TRANS-

OFFICERS

OF OTHERS

TAXES

SION PLANS

FEES

ING FEES

UTILITIES

CATIONS

TAINMENT

PORTATON

(ENTER

BASIS)

COMPONENT NAME

Total

CLEANING,

DUES &

INSURANCE

OFFICE &

MINOR

MAINTEN-

SUBSCRIP-

CONTRI-

PREMIUMS-

LICENSES-

INTEREST

ADMIN SUP

EQUIP

ANCE

TIONS

BUTIONS

NON-CAP

EXPENSE

INCOME

(ENTER

BASIS)

COMPONENT NAME

Total

FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)

Rev. 1

48-519

4895 (CONT.)

FORM CMS-287-22

10-22

FUNCTIONAL ALLOCATION OF NON-CAPITAL COSTS - STATISTICS

HOME OFFICE

PERIOD:

SCHEDULE D-1,

NUMBER:

FROM:

____________

PART III

_________________

TO:

____________

PART III - REGION / DIVISION COMPONENTS

SALARIES

EMP BEN-

PROFIT

AUDIT /

TRAVEL

& WAGES

PAYROLL

NON-PAY

SHAR/PEN-

LEGAL

ACCOUNT-

COMMUNI-

& ENTER-

TRANS-

OFFICERS

OF OTHERS

TAXES

SION PLANS

FEES

ING FEES

UTILITIES

CATIONS

TAINMENT

PORTATON

REGIONAL

(ENTER

BASIS)

COMPONENT NAME

NUMBER

Total

Grand Total

Cost to be allocated

UCM

CLEANING,

REPAIRS &

DUES &

INSURANCE

TAXES &

OFFICE &

MINOR

MAINTEN-

SUBSCRIP-

CONTRI-

PREMIUMS-

LICENSES-

INTEREST

ADMIN SUP

EQUIP

ANCE

TIONS

BUTIONS

NON-CAP

EXPENSE

INCOME

REGIONAL

(ENTER

BASIS)

COMPONENT NAME

NUMBER

Total

Grand Total

Cost to be allocated

UCM

FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4805.20 THROUGH SECTION 4805.23.)

48-520

Rev. 1

Sheet 15: E Pooled

03-24

FORM CMS-287-22

4895 (CONT.)

ALLOCATION OF POOLED COSTS FOR DOUBLE ALLOCATION METHOD

HOME OFFICE

PERIOD:

SCHEDULE E

NUMBER:

FROM:

____________

_________________

TO:

____________

ALLOCATION

STATISTICS

NON-CAPITAL RELATED

(TOTAL

CAPITAL RELATED

SALARIES

ALL

COST)

ALLOCATION

CRC-

& WAGES

OTHER

INTEREST

(1)

RATIO

B&F

OFFICERS

OF OTHERS

NON-CRC

INCOME

DESCRIPTION

Healthcare Provider Components

Non-Healthcare Components

Region / Division Components

Total

FORM CMS-287-22 (04/2023) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4806 THROUGH SECTION 4806.10.)

Rev. 3

48-521

Sheet 16: E-1 Pooled

4895 (CONT.)

FORM CMS-287-22

03-24

ALLOCATION OF POOLED COSTS TO COMPONENTS

HOME OFFICE

PERIOD:

SCHEDULE E-1

NUMBER:

FROM:

____________

_________________

TO:

____________

PART I - HEALTHCARE PROVIDER COMPONENTS

ALLOCATION

STATISTICS

NON-CAPITAL RELATED

(ENTER

CAPITAL RELATED

SALARIES

ALL

BASIS)

ALLOCATION

CRC-

& WAGES

OTHER

INTEREST

(BASIS CODE)

RATIO

B&F

OFFICERS

OF OTHERS

NON-CRC

INCOME

COMPONENT NAME

CCN

Total

PART II - NON-HEALTHCARE COMPONENTS

ALLOCATION

STATISTICS

NON-CAPITAL RELATED

(TOTAL

CAPITAL RELATED

SALARIES

ALL

COSTS)

ALLOCATION

CRC-

& WAGES

OTHER

INTEREST

(1)

RATIO

B&F

OFFICERS

OF OTHERS

NON-CRC

INCOME

COMPONENT NAME

Total

FORM CMS-287-22 (03/2024) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4806.20.)

48-522

Rev. 3

03-24

FORM CMS-287-22

4895 (CONT.)

ALLOCATION OF POOLED COSTS TO COMPONENTS

HOME OFFICE

PERIOD:

SCHEDULE E-1

NUMBER:

FROM:

____________

_________________

TO:

____________

PART III - REGION / DIVISION COMPONENTS

ALLOCATION

STATISTICS

NON-CAPITAL RELATED

(TOTAL

CAPITAL RELATED

SALARIES

ALL

REGIONAL

COSTS)

ALLOCATION

CRC-

& WAGES

OTHER

INTEREST

(1)

RATIO

B&F

OFFICERS

OF OTHERS

NON-CRC

INCOME

COMPONENT NAME

NUMBER

Total

Grand Total

FORM CMS-287-22 (03/2024) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4806.20.)

Rev. 3

48-523

Sheet 17: F SumCap

4895 (CONT.)		FORM CMS-287-22											03-24
SUMMARY OF CAPITAL RELATED COSTS						HOME OFFICE		PERIOD:				SCHEDULE F
						NUMBER:			FROM:	____________
						_________________			TO:	____________
						_________________			TO:	____________

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


50													50
51	Total												51

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


50													50
51	Total												51

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


50													50
51	Total												51
52	Grand Total												52




FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4807 THROUGH SECTION 4807.13.)
48-524													Rev. 3

Sheet 18: F-1 SumNon-Cap

03-24					FORM CMS-287-22										4895 (CONT.)
SUMMARY OF NON-CAPITAL RELATED COSTS									HOME OFFICE		PERIOD:			SCHEDULE F-1
									NUMBER:			FROM:	____________
									_________________			TO:	____________


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


50															50
51	Total														51

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


50															50
51	Total														51

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


50															50
51	Total														51
52	Grand Total														52




FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4807.20.)
Rev. 3															48-525

Sheet 19: F-2 SumIntInc

4895 (CONT.)					FORM CMS-287-22							03-24
SUMMARY OF INTEREST INCOME							HOME OFFICE	PERIOD:			SCHEDULE F-2
							NUMBER:		FROM:	____________
							_________________		TO:	____________
							_________________		TO:	____________

PART I - HEALTHCARE PROVIDER COMPONENTS
			INTEREST INCOME
						TOTAL
			DIRECT	FUNCTIONAL	POOLED	INT INCOME
	COMPONENT NAME	CCN	1	2	3	4
1												1
2												2
3												3
4												4
5												5


50												50
51	Total											51

PART II - NON-HEALTHCARE COMPONENTS
			INTEREST INCOME
						TOTAL
			DIRECT	FUNCTIONAL	POOLED	INT INCOME
	COMPONENT NAME		1	2	3	4
1												1
2												2
3												3
4												4
5												5


50												50
51	Total											51

PART III - REGION OFFICE / DIVISION COMPONENTS
			INTEREST INCOME
		REGIONAL				TOTAL
		HO	DIRECT	FUNCTIONAL	POOLED	INT INCOME
	COMPONENT NAME	NUMBER	1	2	3	4
1												1
2												2
3												3
4												4
5												5


50												50
51	Total											51
52	Grand Total											52




FORM CMS-287-22 (03/2024) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4807.30.)
48-526												Rev. 3

Sheet 20: G

04-23				FORM CMS-287-22						4895 (CONT.)
BALANCE SHEET					HOME OFFICE	PERIOD:			SCHEDULE G
					NUMBER:		FROM:	____________
					_________________		TO:	____________
					_________________		TO:	____________

								AMOUNT
	DESCRIPTION							1

			ASSETS
		CURRENT ASSETS
1	Cash on hand and in banks									1
2	Temporary investments									2
3	Notes receivable									3
4	Accounts receivable									4
5	Other receivables									5
6	Less: allowances for uncollectible notes and accounts receivable									6
7	Inventory									7
8	Prepaid expenses									8
9	Other current assets									9
10	Total current assets									10
		FIXED ASSETS
11	Land									11
12	Land improvements									12
13		`								13
14	Buildings									14
15		Less: accumulated depreciation								15
16	Leasehold improvements									16
17		Less: accumulated depreciation								17
18	Fixed Equipment									18
19		Less: accumulated depreciation								19
20	Automobiles and trucks									20
21		Less: accumulated depreciation								21
22	Major movable equipment									22
23		Less: accumulated depreciation								23
24	Minor equipment non-depreciable									24
25	Other fixed assets									25
26	Total fixed assets									26
		OTHER ASSETS
27	Investments									27
28	Deposits on leases									28
29	Due from owners/officers									29
30	Other assets									30
31	Total other assets									31
32	Total assets									32

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








FORM CMS-287-22 (04/2023) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4808 THROUGH SECTION 4808.10.)
Rev. 2										48-527

Sheet 21: G-1

4895 (CONT.)		FORM CMS-287-22						04-23
STATEMENT OF REVENUES AND EXPENSES			HOME OFFICE	PERIOD:			SCHEDULE G-1
			NUMBER:		FROM:	____________
			_________________		TO:	____________
			_________________		TO:	____________

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










































FORM CMS-287-22 (10/2022) (INSTRUCTIONS FOR THIS SCHEDULE ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4808.20.)
48-528								Rev. 2

File Type

application/vnd.openxmlformats-officedocument.spreadsheetml.sheet