Form 276-99 Prepaid Health Plan Cost Report Worksheet

version 2.0
This report is required by law (42 USC 1395mm and 42 USC 1995I).
Failure to report can result in all interim payments made since
the beginning of the cost reporting period being deemed overpayments.

FORM APPROVED
OMB NO. 0938-0165

PREPAID HEALTH PLAN COST REPORT
GENERAL INFORMATION
1

WORKSHEET S

Name and Address of Plan:
XYZ Health Plan, Inc.
1234 Hospital Drive
Anytown, USA 99999

2

Reporting Period:

Plan Number:
From:

01/01/00

To:

12/31/00

H-xxxx

3

a. Type of Report:

b. Bill Processing Option:

[ ] Budget Forecast

c. Reimbursement Under:

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.

PLAN NO.:
INTERIM REPORT
H-xxxx

PERIOD
FROM:
TO:

WORKSHEET C
01/01/00
12/31/00
1

1
2
3
4
5
6
7
8

Hospitals
Skilled Nursing Facilities
Home Health Agencies
Other Providers
Non-Providers
Plan Administration
Special Administrative Costs
Administrative and General

1
2
3
4
5
6
7
8

9 Total Costs (Sum of lines 1 thru 8)

-

9

10 Cost per Member-Month (Line 9 divided by Part II, Line 1)
11 Appropriate ratio from budget forecast (Worksheet A, Part V)
12 Medicare costs (Line 10 times Line 11)

-

10
11
12

13 Payment Rate (Line 12 times Line 5 of Part II)

-

13

14 Current Payment Rate

PART II - MEMBERSHIP
1
2
3
4
5

14

PART B
1

Total Member Months
Total Medicare Member-Months
Medicare Member-Months (Secondary)
Medicare Member-Months (Primary)
Ratio (Line 4 divided by Line 2)
FORM CMS 276-99 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
SECTION 2305 - 2305.3)

0.0000

1
2
3
4
5