CMS-276 CMS-276.Interim report

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Overview

Worksheet S
Worksheet C

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Sheet 1: Worksheet S

										version 2.0
This report is required by law (42 USC 1395mm and 42 USC 1995I).										FORM APPROVED
Failure to report can result in all interim payments made since										OMB NO. 0938-0165
the beginning of the cost reporting period being deemed overpayments.
	PREPAID HEALTH PLAN COST REPORT									WORKSHEET S
	GENERAL INFORMATION
1	Name and Address of Plan:
		XYZ Health Plan, Inc.
		1234 Hospital Drive
		Anytown, USA 99999
2	Reporting Period:									Plan Number:
		From:		01/01/00
										H-xxxx
		To:		12/31/00
3	a. Type of Report:		b. Bill Processing Option:				c. Reimbursement Under:
	[ ] Budget Forecast	Budget Forecast		Select Option						Select Section
	[X ]	Interim Reports
	[ ]	Final Cost Report
		MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST
		REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW
				CERTIFICATION BY OFFICER OF THE PLAN
		I HEREBY CERTIFY that I have examined the accompanying Statement of Reimbursable Cost, the allocation of
		expenses and services, and the attached Worksheets for the period from 01/01/2000 to 12/31/2000
		and that to the best of my knowledge and belief they are true and correct statements prepared from the books
		and records of the Plan in accordance with applicable instructions, except as noted.
	SIGNATURE (Officer or Administrator of the Plan)						DATE
	TITLE						PHONE NUMBER
FORM CMS 276-99 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2302)
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 0938-0165. The time required to complete this information is estimated to average as follows: (1) for HMOs/CMPs,
24 hours to complete the budget forecast, 80 hours to complete the fourth quarter and final cost reports, and 12 hours to complete the first, second, and third quarterly reports;
and (2)for HCPPs, 16 hours to complete the budget forecast, 60 hours to complete the final cost report, and 8 hours to complete the mid-year report. 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, N2-14-26, Baltimore, Maryland
21244-1850 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

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Sheet 2: Worksheet C

					PLAN NO.:	PERIOD		WORKSHEET C
INTERIM REPORT						FROM:	01/01/00
					H-xxxx	TO:	12/31/00
								1
1	Hospitals								1
2	Skilled Nursing Facilities								2
3	Home Health Agencies								3
4	Other Providers								4
5	Non-Providers								5
6	Plan Administration								6
7	Special Administrative Costs								7
8	Administrative and General								8
9	Total Costs (Sum of lines 1 thru 8)							-	9
10	Cost per Member-Month (Line 9 divided by Part II, Line 1)							-	10
11	Appropriate ratio from budget forecast (Worksheet A, Part V)								11
12	Medicare costs (Line 10 times Line 11)							-	12
13	Payment Rate (Line 12 times Line 5 of Part II)							-	13
14	Current Payment Rate								14
PART II - MEMBERSHIP								PART B
								1
1	Total Member Months								1
2	Total Medicare Member-Months								2
3	Medicare Member-Months (Secondary)								3
4	Medicare Member-Months (Primary)							-	4
5	Ratio (Line 4 divided by Line 2)							0.0000	5
FORM CMS 276-99 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
SECTION 2305 - 2305.3)