Home Office Cost Statement and Supporting Regulations in 42 CFR 413.17 and 413.20 (CMS-287-05)

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Overview

F Part I
F Part II
F_1 Part I
F_1 Part II

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Sheet 1: F Part I

08-05				FORM CMS 287-05						3990 (Cont.)
FUNCTIONAL ALLOCATION OF HOME OFFICE		Home Office:				Period
CAPITAL COSTS TO CHAIN COMPONENTS						From:		SCHEDULE F
						To:		Part 1
				Old Capital				New Capital
	Chain Components
		Building				Building
		and	Interest	Movable	Interest	and	Interest	Movable	Interest
	Health Care Facilities:	Fixtures	Expense	Equipment	Expense	Fixtures	Expense	Equipment	Expense
		1	2.01	2	2.01	3	4.01	4	4.01
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	Total (sum of lines 1-17)									18
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3915)
Rev. 1										39-119
3990 (Cont.)				FORM CMS 287-05						08-05
FUNCTIONAL ALLOCATION OF HOME OFFICE		Home Office:				Period
CAPITAL COSTS TO CHAIN COMPONENTS						From:		SCHEDULE F
						To:		Part 1 (Cont'd)
				Old Capital				New Capital
	Chain Components
		Building				Building
		and	Interest	Movable	Interest	and	Interest	Movable	Interest
	Other Components:	Fixtures	Expense	Equipment	Expense	Fixtures	Expense	Equipment	Expense
		1	2.01	2	2.01	3	4.01	4	4.01
19										18.
20										19.
21										20.
22										21.
23										22.
24										23.
25										24.
26										25.
27	Other Managed Facilities									26.
28	Total (sum of lines 19-27)									27.
	Regional Offices:
										28.
29										29.
30										30.
31										31.
32										32.
33	Total (sum of lines 28-32)									33.
34	Grand Total (sum of lines 18, 28 and 33)									34.
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3915)
39-120										Rev. 1

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Sheet 2: F Part II

08-05			FORM CMS 287-05					3990 (Cont.)
FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL			Home Office:		Period
COSTS TO CHAIN COMPONENTS---STATISTICS					From:	SCHEDULE F
					To:	Part II
			Old Capital			New Capital
		Base:
	Chain Components
		Building			Building
		and	Movable	Interest	and	Movable	Interest
	Health Care Facilities:	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense
	-	1	2	2.01	3	4	4.01
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	Total (sum of lines 1-17)							18
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3915)
Rev. 1								39-121
3990 (Cont.)			FORM CMS 287-05					08-05
FUNCTIONAL ALLOCATION OF HOME OFFICE CAPITAL			Home Office:		Period
COSTS TO CHAIN COMPONENTS---STATISTICS					From:	SCHEDULE F
					To:	Part II (Cont'd)
			Old Capital			New Capital
		Base:
	Chain Components	Building			Building
		and	Movable	Interest	and	Movable	Interest
	Other Components:	Fixtures	Equipment	Expense	Fixtures	Equipment	Expense
	-	1	2	2.01	3	4	4.01
19								19
20								20
21								21
22								22
23								23
24								24
25								25
26								26
27	Other Managed Facilities							27
28	Total (sum of lines 19-27)							28
	Regional Offices:
	-
29								29
30								30
31								31
32								32
33	Total (sum of lines 28-31)							33
34	Total statistics (sum of lines 18, 28 and 33) (A)							34
35	Cost to be Allocated (B)							35
36	Unit Cost Multiplier (B/A)							36
FORM CMS-287-05 (8/2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-1, SECTION 3915)
39-122								Rev. 1

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Sheet 3: F_1 Part I

08-05						FORM CMS 287-05							3990 (Cont.)
FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS							From:______________________________				SCHEDULE
							To:________________________________				F-1 Part I
			Specify:
Chain Components		Medicare										Total
		No.										(cols. 1 thru 9)
	Health Care Facilities:		1	2	3	4	5	6	7	8	9	10
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	Total (sum of lines 1-17)												18
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3916)
Rev. 1													31-123
3990 (Cont.)						FORM CMS 287-05							08-05
FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS							From:______________________________				SCHEDULE
							To:________________________________				F-1 Part I (Cont'd)
			Specify:
Chain Components		Medicare										Total
		No.										(cols. 1 thru 9)
			1	2	3	4	5	6	7	8	9	10
	Other Components:
	---------------------------
19													19
20													20
21													21
22													22
23													23
24													24
25													25
26													26
27	Other Managed Facilities												27
28	Total (sum of lines 18-27)												28
	Regional Offices:
	---------------------
29													29
30													30
31													31
32													32
33	Total (sum of lines 29-32)												33
34	Grand Total (sum of lines 18, 28 and 33)												34
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3916)
39-124													Rev. 1

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Sheet 4: F_1 Part II

08-05						FORM CMS 287-05							3990 (Cont.)
FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS -STATISTICS							From:______________________________				SCHEDULE
							To:________________________________				F-1 Part II
			Base:
Chain Components
												Total
												(cols. 1 thru 9)
			1	2	3	4	5	6	7	8	9	10
	Health Care Facilities:
	---------------------------
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	Total (sum of lines 1-17)												18
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3916)
Rev. 1													39-125
3990 (Cont.)						FORM CMS 287-05							08-05
FUNTIONAL ALLOCATION OF HOME OFFICE NON-CAPITAL RELATED					Home Office:		Period
EXPENSES TO CHAIN COMPONENTS -STATISTICS							From:______________________________				SCHEDULE
							To:________________________________				F-1 Part II (Cont'd)
			Base:
Chain Components
												Total
												(cols. 1 thru 9)
			1	2	3	4	5	6	7	8	9	10
	Other Components:
	---------------------------
19													19
20													20
21													21
22													22
23													23
24													24
25													25
26													26
27	Other Managed Facilities												27
28	Total (sum of lines 19-27)												28
	Regional Offices:
	---------------------
29													29
30													30
31													31
32													32
33	Total (sum of lines 29-32)												33
34	Grand Total (sum of lines 18, 28 and 33)												34
FORM CMS-287-05 (8/2005)(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3916)
39-126													Rev. 1