OMB control number

Home Office Cost Statement (CMS-287-22)

OMB 0938-0202 · HHS/CMS.

OMB 0938-0202

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.

The latest form for Home Office Cost Statement (CMS-287-22) expires 2027-10-31 and can be found here.

Latest Forms, Documents, and Supporting Material

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

All Historical Document Collections

202408-0938-039	Extension without change of a currently approved collection	2024-08-29
202012-0938-018	Reinstatement with change of a previously approved collection	2020-12-24
201410-0938-012 Approved without change	Reinstatement without change of a previously approved collection	2014-10-17
201106-0938-005 Approved without change	Extension without change of a currently approved collection	2011-06-08
200804-0938-005 Approved without change	Extension without change of a currently approved collection	2008-04-29
200504-0938-011 Approved without change	Extension without change of a currently approved collection	2005-04-29
200204-0938-001 Approved without change	Extension without change of a currently approved collection	2002-04-05
199903-0938-001 Approved without change	Extension without change of a currently approved collection	1999-03-05
199605-0938-004 Approved without change	Extension without change of a currently approved collection	1996-05-08
199304-0938-001 Approved without change	Reinstatement with change of a previously approved collection	1993-04-05
199206-0938-007 Approved without change	Revision of a currently approved collection	1992-06-17
199107-0938-008 Approved without change	Reinstatement with change of a previously approved collection	1991-07-23
198910-0938-002 Approved without change	Reinstatement with change of a previously approved collection	1989-10-27
198708-0938-011 Approved with change	No material or nonsubstantive change to a currently approved collection	1987-08-07
198606-0938-005 Approved without change	Reinstatement with change of a previously approved collection	1986-06-16
198410-0938-016 Approved with change	No material or nonsubstantive change to a currently approved collection	1984-10-29
198303-0938-002 Approved without change	Revision of a currently approved collection	1983-03-11
198111-0938-005 Approved without change	New collection (Request for a new OMB Control Number)	1981-11-19