Prepaid Health Plan Cost Report (HMO)

CHAPTER 23
INSTRUCTIONS FOR THE PREPAID HEALTH PLAN COST
REPORT
FORM CMS-276-08

FORM CMS 276

Table Of Contents
2300 INTRODUCTION .......................................................................................................................3
2302 WORKSHEET S – CERTIFICATION PAGE ............................................................................5
2303 WORKSHEET A – BUDGET FORECAST ...............................................................................5
2304 WORKSHEET B – PREMIUM DETERMINATIONS ..............................................................10
2305 WORKSHEET C – INTERIM REPORTING .............................................................................11
2306 WORKSHEET D – PLAN STATISTICS ...................................................................................13
2307 WORKSHEET E – SUMMARY TRIAL BALANCE ................................................................17
2308 WORKSHEET F – RECLASSIFICATIONS ..............................................................................21
2309 WORKSHEET G – ADJUSTMENTS TO EXPENSES .............................................................23
2310 WORKSHEET H – STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS ...............................................................................................................................25
2311 WORKSHEET I – ALLOCATION AND STATISTICS FOR A & G ALLOCATION ............26
2312 WORKSHEET J – SUMMARY OF PROVIDER COSTS .........................................................27
2313 WORKSHEET K – SUMMARY APPORTIONMENT OF NONPROVIDER COSTS ............28
2314 WORKSHEET L – SUMMARY OF MISCELLANEOUS ITEMS ...........................................30
2315 WORKSHEET M – SETTLEMENT SHEET .............................................................................31
2316 WORKSHEET N – MEDICARE PREMIUM RECONCILIATION ..........................................31
2317 CERTIFICATION BY INDEPENDENT AUDITOR .................................................................33
APPENDIX A – OPTION 2 INSTRUCTIONS ....................................................................................34

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FORM CMS 276
2300

INTRODUCTION

The reporting requirements of a prepaid health care plan that has contracted with CMS are specifically defined
in 42 C.F.R. §417.572(a) and (c), and 417.576(b)(1). For reimbursement purposes, these plans can be grouped
into two major categories - Health Maintenance Organizations/Competitive Medical Plans (HMOs/CMPs) and
Health Care Prepayment Plans (HCPPs). Briefly, the reporting requirements for each category are:

Cost Report

HMO/CMP Reporting
Requirement

HCPP Reporting
Requirement

Worksheets

1. Budget Forecast

No later than 90 days prior
to the beginning of the
contract period

No later than 60 days prior
to the contract period

S, A and B

2. Interim Report

The Semi-Annual Interim is
due no later than 60 days
after the close of the first 6
months of the contract
period

The Semi-Annual Interim is
due no later than 45 days
after the close of the first 6
months of the contract
Period

S and C

3. 4th Quarter
Interim Report

The Interim Final report
must be filed, using the
worksheets for the Final
Cost Report, no later than
60 days after the close of
the contract period

HCPPs are not required to
file an Interim Final report.

S, D thru N

4. Final Cost
Report

No later than 180 days after
the close of the contract
period. This cost report
must be certified by and
independent certified public
accountant (42 CFR
§417.576 (b))

No later than 120 days after
the close of the contract
period

S, D thru N

If a plan fails to submit the budget and enrollment forecast on time, CMS may (1) establish an interim per capita
rate of payment on the basis of the best available data and adjust the rate accordingly; or (2) if insufficient data
exists on which to base an interim rate, suspend interim payments until the required report is filed and a new
rate is established (42 C.F.R. §417.572(b)).
For failure to submit the final cost report on time, CMS may (1) initiate recovery of amounts previously paid,
or (2) reduce interim payments, or (3) both (42 C.F.R. §417.576(b)(3)). CMS may extend the period for filing
the cost report for good cause shown by the Plan (42 C.F.R. §417.576(b)(1)). However, interest on the amount
owed will still accrue per the regulations (42 C.F.R. 405.378).

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The worksheets cover the prescribed format for the cost reports and are provided in Excel format. Electronic
copies of the worksheets for each category of filing are accessible through CMS’ Health Plan Management
System (HPMS). If the worksheets require modification to accommodate a Plan's unique reporting
requirements, written approval must be obtained from CMS in advance of the contract period to which the
report applies. CMS' approval of an alternative cost report may be granted if the alternative format presents
cost and statistical data in the same detail as the prescribed format. In addition, CMS must be assured that such
an alternative format can be used efficiently to determine the proper amount of reimbursement for covered
services furnished to Medicare enrollees.
Methods of allocation and apportionment of costs set forth in these worksheets are not optional, they are
required for the determination of reimbursement. If the Plan wishes to use an alternative method of allocation or
apportionment or to change the approved method of allocation or apportionment from the prior contract year,
CMS' advance approval is required. The Plan's request for such a change must be received by CMS at least
ninety (90) days prior to the beginning of the first affected reporting period (42 C.F.R. §417.566)).
The cost report worksheets are designed to be of sufficient flexibility to take into account the diversity of
operations, yet provide sufficient cost and statistical information to enable CMS to determine the proper amount
of payment to the Plan. These worksheets accommodate the various bill processing options described in the
Medicare Managed Care Manual (Pub. 100-16, Chapter 17a, §10.2). Therefore, the Plan may not be required to
complete all worksheets. The Plan should confirm the particular reporting requirements applicable to which
lines must be completed by discussing them in detail with the CMS accountant assigned to the Plan. This
discussion should take place prior to the contract period. To avoid any later misunderstanding, the Plan should
submit written confirmation of the conclusions reached to CMS. The Plan must submit all worksheets. Where
appropriate, Plans should enter "NA" on those worksheets that are not used.
The Plan's cost reporting requirements in no way supplant the specific reporting requirements applicable to
providers of services under the Medicare program. Each provider of services, whether owned or operated by the
Plan, must comply with its own cost reporting requirements. (The Provider Reimbursement Manual, HCFA
Pub. 15-II, sets forth these requirements in detail). The costs and statistics submitted for provider services
furnished to enrollees are summaries of the information set forth in the provider cost reports and/or Bill
Summary Report using the options detailed for Worksheet J.
The following sections explain how to fill out each individual worksheet for each category of reporting.

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2302

WORKSHEET S - CERTIFICATION PAGE

Line 1 - Name and Address of Plan - Enter the name and address including any trade name of the plan, if
applicable.
Line 2 - Reporting Period and Plan Number - Enter the reporting period starting and ending dates. Enter the
Plan identification number.
Line 3a - Type of Report - Identify the type of report you are filing: Budget Forecast, Interim Report, or Final
Cost Report. See Section 2300, for the required worksheets that are filed with the type of report identified.
Line 3b - Bill Processing Option - Indicate the bill processing option selected by the plan. For a description of
the different options available, refer to Chapter 17a, Subchapter A, Section 10.2 of the Medicare Managed Care
Manual (HCFA Pub 100.16).
Line 3c - Reimbursement Under - Indicate by selecting from the drop down list the appropriate section of the
Social Security Act under which the plan is seeking reimbursement. Section 1876 is for Health Maintenance
Organizations and Competitive Medical Plans (HMOs/CMPs). Section 1833 is for Health Care Prepayment
Plans (HCPPs).
Certification Statement - The certification must be prepared, signed and uploaded to as a PDF into HPMS
after the worksheets have been completed in their entirety. The individual signing the certification must be an
officer or responsible person authorized to act as an agent of the organization.
2303

WORKSHEET A - BUDGET FORECAST

This worksheet is provided to forecast the allowable Medicare costs per member per month that will be paid on
an interim basis during the period covered by the report. The worksheet uses a prior year's final cost report, as
revised by CMS if applicable, as a basis for establishing forecasted Medicare costs. If the Plan finds that this
worksheet produces results that are not reflective of the forecasted period, use Column 4 of Part II to make the
necessary adjustments to correlate the financial data to the forecasted period. Adjustments in Column 4 of Part
II must be supported by the worksheet attached. For cost Plans that are new to the Medicare program and have
no historical cost and statistical data as the basis for the current year budget, these Plans must instead use the
final cost report form to project the current year budgeted figures. The period's budgeted cost and statistical data
are entered into the final cost report form to generate the Medicare interim PMPM amount from Worksheet M.
All applicable worksheets must be filed as required by the instructions for that final cost report form, if used for
budget purposes.
Since this form is used by HCPPs, HMOs, and CMPs, not all lines and columns will apply to all plans. This
worksheet is only prepared in the submission of the Budget Forecast. If the prior year's final cost report
submission is delinquent at the due date of the budget, the budget will be automatically rejected until the final
cost report is submitted.
2303.1

Part I - Prior Year Cost & Statistical Data

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In the Part I heading, enter the fiscal year-end date from which all of the cost and statistical data reported in this
part are taken. The prior year cost and statistical data must be taken from the period ending two (2) years prior
to the budget period. For example, if the budget forecast is for the period January 1 through December 31, 2014,
the final cost report for the period January 1 through December 31, 2012 will be used. Since the costs entered in
columns 1 through 6 are taken from the final cost report covering the period January 1 through December 31,
2012, the plan should enter this period in the Part I heading. This final cost report should be used for all data
requested in Part I.
Column and Line Descriptions
Column 1 - Trial Balance Per Books - Enter in this column the Trial Balance Per Books taken from
Worksheet E, Column 1 of the prior year final cost report approved by CMS, plus or minus Reclassifications
from Column 2. Cost data should be grouped using the same method of groupings used for Medicare costs on
that prior year final cost report submitted to CMS. The amount for Part B Deductible and Coinsurance on
Services Paid by CMS' Carriers reported on Line 16 of the prior year final cost report must be included with the
amount reported for Nonprovider costs on the Budget Forecast Line 5. The elements of the Special
Administrative Costs reported on Line 26 of the prior year final cost report must be broken out on Lines 7a thru
7c of the Budget Forecast.
Line 1 – 6 – Various Centers – Enter the cost incurred during the previous period, and reported on
Worksheet E of the prior year final cost report.
Line 7A – Accretion/Deletion – Enter the cost incurred for the accretion/deletion of Medicare members
into the plan.
Line 7b - Cost Report Certification - Enter the cost incurred for the independent certified public
accountant to certify the final cost report submitted to CMS according to 42 C.F.R. §417.576(b)(1). This
applies only to 1876 contracts (HMOs and CMPs).
Line 7c – Other – Enter the cost incurred for those services/items that are reimbursed 100% by
Medicare. Supporting documentation for ‘Other’ costs should be provided at the time of submission.

Line 8 – Part B Costs Not Subject to Coinsurance – Enter the total Part B Costs Not Subject to
Coinsurance reported on Worksheet M, Line 16a of the prior year final cost report.

Line 10 - Total Cost - The total cost on this line must equal Column 1, Line 29 on the Worksheet E of
the prior year final cost report.
Column 2 - PMPM Cost - Enter on Line 0 the Total Member Months shown on the prior year final cost report
Worksheet L, Column 5, Line 1. The worksheet formulas divide the cost on each line in Column 1 by the Total
Member Months on Line 0 and the results are entered in this column, lines as appropriate.
Column_3 - Total Medicare PMPM Cost - The worksheet calculates the sum of Columns 4 plus 5 on the lines
as appropriate.

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Column 4 - Medicare Part A PMPM Cost - Enter in this column the Medicare Part A cost PMPM taken from
the appropriate lines of Worksheet M, Column 2 of prior year final cost report. This column is not applicable to
HCPPs.
Line 10 - Total Cost - The total PMPM amount on this line must equal Column 2, Line 7 on the
Worksheet M of the prior year final cost report.
Column_5 - Medicare Part B PMPM Cost - Enter in this column the Medicare Part B cost PMPM taken from
the appropriate lines of Worksheet M, Column 3 of the prior year final cost report. The following cost centers
should be combined on the Budget Forecast:
 Part B Deductible on Services Paid by CMS' Carriers reported on Line 5a of the prior year final cost
report must be included with the amount reported for Nonprovider costs in Column 5 on the Budget
Forecast Line 5.
 Medicare Bad Debts reported on Line 16 of the prior year final cost report must be included with the
amount reported for Plan Administration costs in Column 5 on the Budget Forecast Line 6.
The elements of the Special Administrative Costs reported on Line 15 of the prior year final cost report must be
broken out on Lines 7a thru 7c of the Budget Forecast.
Line 9 - Total Cost - The total PMPM amount on this line must equal Column 3, Line 7 plus Lines 15,
16, and 16a on the Worksheet M of the prior year final cost report.
Column_6 - Medicare Ratio - The worksheet calculates the ratio of the Medicare PMPM amounts to the total
by dividing each line of Column 3 by each line of Column 2. All ratios must be rounded to 4 decimal places.
Column 7 - Medicare Part A Ratio - The worksheet calculates the ratio of the Medicare Part A PMPM Cost in
Column 4 to the Total Medicare PMPM cost in Column 3. All ratios must be rounded to 4 decimal places.
2303.2

Part II – Budget Year Cost & Statistical Data

This part determines the interim payment rate by applying the ratios developed in Part I to the projected costs
for the period covered by the Budget Forecast Report to derive the estimated Medicare costs for the period.
Projected costs shown in Column 1 of this part should be classified in the same manner as Column 1 in Part I
(including reclassifications, and Part B Deductible and Coinsurance on Services Paid by CMS' Carriers included
with the amount reported for Non-provider costs on Line 5) plus expected Third Party Revenue. The
assumption being used in Part II is that the relative ratio of Medicare costs to total costs should remain fairly
constant. Column 4 is provided for those instances where the relative ratio is expected to vary significantly for a
given line item. Adjustments made in Column 4 must be supported by the attached worksheet.
Column and Line Descriptions
Column_1 - Total Projected Cost - Enter the projected trial balance of expenses for the period covered by the
Budget Forecast Report. The cost data should be grouped using the same method of groupings used in Part I,
Column 1. Please note that costs of Prescriptions covered by Part B, but are not reimbursed 100%, should be
placed in Line 5 “Non-Providers”.
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Line 8 – Part B Costs Not Subject to Coinsurance - Enter in column 1 the amount of Part B costs not subject
to coinsurance; such as, clinical diagnostic lab according to §1833(a)(2)(D) of the Social Security Act,
services/drugs covered 100% by Medicare this includes flu and pneumonia shots. A worksheet showing how
this amount was determined must be attached in order to include it in the budget forecast.

Column 2 - Projected PMPM Cost - Enter on Line 0 the Total Member Months projected for the period that
were used in developing the projected trial balance of expenses in Column 1. The worksheet calculates the
projected PMPM cost by dividing the costs in Column 1, lines as appropriate, by the Total Member Months on
Line 0.
Column_3 - Medicare Projected PMPM Cost - The worksheet calculates the Medicare portion of the total
costs PMPM by multiplying the Total Projected PMPM Cost in Column 1 by the prior period ratio of Medicare
cost to total cost from Part I, Column 6, lines as appropriate.
Column 4 - PMPM Adjustment - The plan may adjust the costs calculated in Column 3 for any amount
believed to be necessary to produce a more appropriate Medicare cost per member month for the budget period.
Adjustments can be positive and negative. Due to changing facts and circumstances, a plan may find it
necessary to adjust the Medicare cost for a given period of time. These PMPM adjustment amounts must be
calculated on the supporting worksheet and brought forward to Column 4 in this Part II. All rationale and
backup information that verify the need and amount of the adjustment must be submitted with the Budget
Forecast. Supporting documentation must be submitted, as noted in the Budget Forecast.
Column 5 - Adjusted Medicare PMPM Cost - The adjusted Medicare PMPM is calculated in this column by
adding the amounts in Columns 3 plus 4 on the lines as appropriate.
Line 12 - Estimated Deductibles & Coinsurance - The worksheet enters on Line 11 the amount
computed from Part III, Column 1, Line 15 minus Lines 13 and 14.
Line 14 - Pay% - This is the interim PMPM payment rate calculated on the worksheet by multiplying
the total Medicare PMPM cost net of coinsurance and deductible on Column 5, Line 12 by the ratio of
the Medicare Part B primary member months to the total Part B member months from Part IV, Column
2, Line 4.
Column 6 - Medicare Part A PMPM Cost - The Medicare Part A PMPM amounts are calculated by
multiplying the total Medicare PMPM Cost in Column 5 by the prior period Medicare Part A Ratio determined
in Part I, Column 7, on the lines as appropriate.
Line 9 - Third Party Insurer Revenue - These services pertain to only two categories of services for
which Medicare has a secondary liability: (1) services covered by workers’ compensation; and (2)
services covered by auto medical, no fault, or any liability insurance. The amount to be entered as "Third
Party Insurer Revenue” must be determined by the Plan by multiplying the amount in Column 5 times
the result of dividing the amount on the prior year final cost report Worksheet L, Column 1, Line 16 by
Column 3, Line 16. A worksheet must be attached showing this calculation. The "Third Party Insurer
Revenue" is the amount received for those services that are not paid fully by the insurer.

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Column 7 - Medicare Part B PMPM Cost - The worksheet calculates the Medicare Part B PMPM amounts by
subtracting the PMPM amounts for Medicare Part A in Column 6 from the Total Medicare PMPM in Column 5
for each line in Column 7.
Line 12 - Estimated Deductibles & Coinsurance - The worksheet calculates the Standard Part B
Deductible (Provided by CMS) and Coinsurance amount by subtracting the Standard Medicare Part A
Deductible and Coinsurance in Column 6 from the Total Deductible and Coinsurance in Column 5.
2303.3

Part III - Deductible and Coinsurance

Part III is used to calculate the projected Medicare deductible, coinsurance, and copayment on covered
Medicare benefits incurred by the Plan during the budgeted period.
Line Descriptions
Line 1 - Total Estimated Part A Deductible and Coinsurance - Enter in Column 2 the budgeted amount for
Part A deductible and coinsurance. Attach a worksheet showing how this amount was determined.
Line 8 - Part B Standard Deductible - Enter in Column 3 the Part B Standard Deductible published by CMS
for the budgeted period.
Line 9 - Part B Blood Deductible PMPM - Enter in Column 3 the projected Part B Blood Deductible PMPM
for the budgeted period. Attach a worksheet showing the calculation of this amount.
Line 10 - Mental Health Copayment PMPM - Enter in Column 3 the Mental Health Copayment PMPM for
the budgeted period. This is the professional component of the Mental Health Cost found on Worksheet L, Line
23 of the final cost report. Attach a worksheet showing the calculation of this amount.
Line 13 - Part B Coinsurance on Carrier Paid Bills PMPM - Enter in Column 3 the Part B Coinsurance on
Carrier Paid Bills PMPM for the budgeted period. This is the same type of cost found on Worksheet G, Part I,
Line 23 of the final cost report. Attach a worksheet showing the calculation of this amount.
Line 14 - Part B Coinsurance on Intermediary Paid Bills PMPM - Enter in Column 3 the Part B
Coinsurance on Intermediary Paid Bills PMPM for the budgeted period. This is the same type of cost found on
Worksheet G, Part I, Line 24 of the final cost report. Attach a worksheet showing the calculation of this amount.
2303.4

Part IV - Membership

Part IV is used to report the projected number of Medicare member months for the budgeted period.
Line Descriptions
Line 1 - Total Medicare Member Months - Enter the total projected number of Medicare member months,
used to develop the budget, for Part A in Column 1 and for Part B in Column 2.

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Line 2 - Medicare Secondary Liability Member Months - The Medicare program is usually the primary
payer for covered Medicare services provided to Medicare members of an HMO/CMP or an HCPP. However,
there are four categories of services for which Medicare is secondary payer. These are:
(1)
(2)
(3)
(4)

Services covered by worker's compensation;
Services covered by employer group health plans in the case of end-stage renal disease beneficiaries
during a period of up to 36 months;
Services covered by auto medical, no fault, or any liability insurance;
Services covered by employer group health plans in the case of employed beneficiaries and the
dependents of the employed beneficiary

An HMO/CMP or HCPP need not coordinate benefits in situations where the probability of recovery is highly
unlikely or the amount recoverable does not exceed the cost to pursue the claim. However, no payment will be
made to a cost-based Plan for services to the extent that Medicare is not the primary payer under the provisions
of Section 1862 (b) of the Social Security Act. In addition, no payment can be made for services not covered by
Medicare. Therefore, enter on Line 2 the number of Medicare member months of those beneficiaries the plan
has identified to CMS as a Medicare enrollee that can be classified in categories 2 and 4 above.
2303.5

Part V - Semi Annual-Fluctuations

Part V is provided to develop ratios that will be used in the Plans' Interim Cost Report. The unit of fluctuation
ratio is the ratio of the total projected Medicare PMPM net of estimated deductible and coinsurance to the total
cumulative PMPM for the first 6 months of the contract period. The ratio calculated by this worksheet in
Column 2, Line 3 derives the Medicare PMPM amount in the Interim Cost Report that is used to establish the
Interim Payment Rate. This part must be completed. Therefore, a submitted Budget Forecast without this part
fully completed will be rejected as unacceptable.
Line Descriptions
Line 3 - Cumulative Estimate of Total Costs PMPM for First Two Quarters - Enter the Plan's estimate of
the total costs (Medicare plus non-Medicare cost) on a per member per month basis that will be incurred by the
plan during the first 6 months of the budget period.
2304
WORKSHEET B – DETERMINATION OF VOLUNTARY UNDER COLLECTIONS AND
PREMIUM DETERMINATIONS
This Worksheet is provided for HMO/CMPs and HCPPs to compute a voluntary under-collection and establish
a premium that will cover all the projected costs in this budget on Worksheet A, all parts, recoup any under
collections from a prior period, and/or adjust the current calculations for any over collections from the
immediate prior period. Line 2 allows the inclusion of any prior under (over) collections.
NOTE: This worksheet is to be completed in conjunction with Worksheet A – Current Budget Forecast and
Worksheet N – Final Cost Report from the most recently completed final cost report.
Line Descriptions
Line 2 - Under(Over) Collection for the Period - Enter the amount of the under/over collection reported on
Worksheet N, Column 3, Line 11 or 12b of the most recent Final Cost Report. For example, in preparing the
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Budget Forecast for contract year 2012, the period January 1 through December 31, 2010 is the most recent
Final Report period. The under/over collection reflected on the Worksheet N, Part I, Column 3, Line 11 or 12b
of the Final Report for the 2010 contract period is entered on this Line 2.
Any over collection from a prior period should be expressed as a negative number and any under collection
should be expressed as a positive number.
Line 3 – Medicare Member Months for the Period – Enter the Medicare Member Months from the period
reported on Worksheet L, Column 2, Line 1 of the Final Cost Report. For example, in preparing the Budget
Forecast for contract year 2012, the period January 1 through December 31, 2010 is the most recent Final
Report period. The Medicare Member Months reflected on Worksheet L, Column 2, Line 1 of the Final Report
for the 2010 contract period is entered on Line 2.
Line 7 - Total Amount to be Charged Including Medicare Enrollee Copayments - Enter the PMPM amount
the Plan intends to charge. A worksheet must be attached to support the determination of the amount. This
worksheet must segregate the total amounts to be charged Medicare enrollees for covered services into two
categories: 1) the monthly premium per Medicare enrollee for covered services, and 2) the average actuarial
value of all deductibles, coinsurance, and co-payments for covered services to be charged each Medicare
enrollee each month. This included Medicare enrollee co-payments collected by someone other than the plan
(e.g. co-payments collected for a doctor office visit by the physician's office).
Note: The Total Amount to be Charged Including Medicare Enrollee Copayments, reported on Line 7, should
not be greater than the Total Allowed to be Collected During the Budget Period, on Line 6. If the number
entered on Line 7 is greater than the amount on Line 6 a warning message will be populated.
2305

WORKSHEET C - INTERIM REPORTING

In accordance with 42 C.F.R. 417.572(c)(1), an HMO or CMP must submit an interim cost report on a quarterly
basis in the form and detail prescribed by CMS. These quarterly interim cost reports must be submitted no later
than 60 days after the close of each quarter of the contract period. Under subsection 42 C.F.R. 417.572 (c)(2)
CMS may reduce the frequency of the reports if CMS determines there is good cause for doing so.
Under 42 C.F.R.417.808(c), an HCPP must submit an interim cost report and enrollment data in the form and
detail prescribed by CMS applicable to the first 6 months of the contract period. The interim cost report must
be submitted no later than 45 days after the close of the first 6-month period.
Each interim cost report must be submitted using this Worksheet C and the Worksheet S indicating in Section 3
this is an interim report. These worksheets must be used by all HMOs, CMPs and HCPPs in order to fulfill their
requirement to submit interim cost reports. The objective for submitting interim reports is to avoid having
excessive balances due to or from the plan at the end of the reporting period. For HMO and CMP, the final
interim cost report for the 12-month period of the contract must be filed on Worksheet S and D through M; the
same worksheets for the final cost report submission.
2305.1

Part I - Costs

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All amounts entered in this part must be YTD cumulative amounts for the period being reported on. If the Plan
is aware of circumstances that will likely occur and will have a material impact on costs after the interim
reporting period, an adjustment should be made to reflect the estimated impact of this change on the interim per
capita rate. Workpapers supporting the estimation of the impact adjustment must be submitted with the interim
cost report; otherwise the adjustment will not be allowed.
Line Descriptions
Lines 1 through 8 - The amounts entered are actual amounts incurred in the interim reporting period. The trial
balance underlying the amounts on these lines and showing the grouping of individual expense items into each
cost center must be submitted with the interim cost report.
Line 9 - This line accumulates the actual total costs reported on Lines 1 through 8.
Line 10 - Cost per Member Month - The worksheet calculates the total per member month amount by
dividing the total cost on Line 9 by the total member months in Part II, Line 1.
Line 11 - Ratio From Budget Forecast - Enter on this line the amount reflected on the Budget Forecast for the
contract period on Worksheet A, Part V, Column 2, Line 3.
Line 12 - Medicare Costs - This is the Medicare PMPM amount calculated on the worksheet by multiplying
the Total Cost PMPM amount on Line 10 by the Medicare ratio on Line 11.
Line 13 - Payment Rate - This is the Medicare primary payment rate calculated on the worksheet by
multiplying the Medicare PMPM amount on Line 12 by the ratio of Medicare primary member month to the
total Medicare member months in Part II, Line 5.
Line 14 - Current Payment Rate - Enter the current Medicare PMPM payment rate on this line.
2305.2

Part II - Membership

Member month amounts reported on these lines should reflect cumulative member months for the period
covered by the report. A member month is defined as each month a person is a member of the plan. For
example, if a Medicare beneficiary was a member of the plan for the six-month period covered by the interim
cost report, the plan would report a total of six Medicare member months.
Line Descriptions
Line 1 - Total Member Months - Enter the total Medicare and non-Medicare member months on this line.
Line 2 - Total Medicare Member Months - Enter on this line the information requested for those Medicare
enrollees that are enrolled in the Supplemental Medicare Insurance (Part B) Program under Medicare. Part B
Member Months should always equal Total Medicare Member Months.

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Line 3 - Medicare Member Months (Secondary) - The Medicare program is usually the primary payer for
covered Medicare services provided to Medicare members of an HMO/CMP or an HCPP. However, there are
four categories of services for which Medicare is secondary payer. These are:
(1)
(2)
(3)
(4)

Services covered by worker's compensation;
Services covered by employer group health plans in the case of end-stage renal disease beneficiaries
during a period of up to 36 months;
Services covered by auto medical, no fault, or any liability insurance;
Services covered by employer group health plans in the case of employed beneficiaries and the
dependents of the employed beneficiary

An HMO/CMP or HCPP need not coordinate benefits in situations where the probability of recovery is highly
unlikely or the amount recoverable does not exceed the cost to pursue the claim. However, no payment will be
made to a cost-based Plan for services to the extent that Medicare is not the primary payer under the provisions
of Section 1862 (b) of the Social Security Act. In addition, no payment can be made for services not covered by
Medicare. Therefore, enter on Line 3 the number of Medicare member months of those beneficiaries the plan
has identified to CMS as a Medicare enrollee that can be classified in categories 2 and 4 above.
Line 4 - Medicare Member Months (Primary) - The worksheet calculates the Medicare primary member
months by subtracting the Medicare secondary member months on Line 3 from the total Medicare member
months on Line 2.
Line 5 - Ratio - The worksheet calculates on this line the ratio of Medicare primary member months to the total
Medicare member months. This ratio is used in Part I to determine the Medicare primary payment rate for the
period being reported.
2306 WORKSHEET D - PLAN STATISTICS
Worksheet D is provided for HMO/CMPs and HCPPs to list the providers and suppliers that are frequently used
by the plan. In addition, the statistics should be grouped appropriately so that they tie to Worksheet K. Statistics
on WS D and K should have a direct relationship to the costs that flow to Column 6 on worksheet K.
Note: Please note that for the completion of this worksheet, all statistics should exclude any claims processed by
MACs, Carriers, and Intermediaries.
2306.1 Part I - Plan Statistics - List Of Providers
This worksheet is provided for only HMOs/CMPs to list the providers that are frequently used by the plan.
HCPPs do not complete this worksheet since their reimbursement is limited to the reasonable cost of
non-provider services covered under Part B of the Social Security Act. Therefore, HCPPs should mark Line 1
with N/A. HMOs/CMPs with bill processing option #1 reported in Worksheet S, Section 3b do not complete
Sections A (Hospitals and SNFs) and B (HHA’s and Other).
Column Descriptions

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For the category descriptions below the "LIST OF PROVIDERS" column for plans with bill processing option
#2 only, list all hospitals and skilled nursing facilities rendering services to the plan's Medicare enrollees under
category "A. HOSPITALS & SNFS”. List all Home Health Agencies under category “B. HHA” and all others
(specifying Name & Type) under category “C OTHER (SPECIFY NAME AND TYPE)" on the continuation page
of Part I - Plan Statistics - "LIST OF PROVIDERS."
Column_1 – Provider Number - Enter the Medicare provider billing number assigned to the provider.
Column 2 – Relationship - Enter the relationship code for that provider. If the provider is owned or controlled
by the plan or if the plan is owned or controlled by the provider, enter the code ”O.” For a full description of
Medicare's rules defining “ownership” or "control", refer to the Provider Reimbursement Manual (HCFA PUB
15-I) Chapter 10. Where the code “O” is entered, the Worksheet H, Section A. must be answered “Yes.” If
there is no relationship between the plan and the provider other than contractual, enter the code “P”.
Column_3 – Bills Processed By - Enter the code (“H” or “P”) representing the bill processing option selected
by the plan. If the plan has elected to process the bills (Option 2) of the provider, enter the code “P”. If the plan
has elected to have CMS process the bills (Option 1) of the provider, enter the code “H”. This coding must be
consistent with that reported In Section 3b on Worksheet S. For a description of the different options available,
refer to Chapter 17a, Subchapter A, Section 10.2 of the Medicare Managed Care Manual (HCFA Pub 100.16).
Column 4 – Total Days - For category A, "Hospitals & SNFs", enter the total number of inpatient days used by
all enrolled plan members. This figure should include all of the days used whether or not the plan has been
billed by the provider due to timing delays. For categories B and C, enter the total statistical unit for all enrolled
plan members used to apportion the costs of that provider type.
Column 5 – Total Medicare - For category A, "Hospitals & SNFs", enter the total number of inpatient days
for all Medicare enrollees. For categories B and C, enter the total applicable statistical units for all Medicare
enrollees.
Column 6 – Covered Medicare Primary - The Medicare program is usually the primary payer for covered
Medicare services provided to Medicare members of an HMO/CMP. However, there are four categories of
services for which Medicare is secondary payer. These are:
(1)
(2)
(3)
(4)

services covered by workers’ compensation;
services covered by employer group health plans in the case of end-stage renal disease beneficiaries
during a period of up to 12 months;
services covered by auto medical, no fault, or any liability insurance; and
services covered by employer group health plans in the case of employed beneficiaries and the
dependents of the employed beneficiary.

An HMO/CMP need not coordinate benefits in situations where the probability of recovery is highly unlikely or
the amount recoverable does not exceed the cost to pursue the claim. However, no payment will be made to a
cost-based HMO/CMP for services to the extent that Medicare is not the primary payer under the provisions of
Section 1862 (b) of the Social Security Act. In addition, no payment can be made for services not covered by
Medicare.

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Therefore, enter in Column 6 the number of days or statistical units used by Medicare enrollees for which
Medicare has primary liability and the days or statistical units that are covered by the Medicare program. Make
certain to include in this column services covered by employer groups (categories 2 and 4). The cost of these
services will be removed through the apportionment on Worksheets K, L and M.
Column 7 – Covered Medicare Secondary - Enter only those inpatient days or statistical units for which
Medicare has no liability for categories 1 and 3 mentioned above. Refer to Chapter 17, Subchapter B, Sections
310 through 350, and Subchapter F, Section 70 of the CMS Managed Care Manual Pub #100-16 for a detailed
discussion of the coordination of benefits provisions under Medicare. Non-covered services should not be
included in Column 7. Therefore, the addition of Column 6 plus Column 7 will be less than Column 5 by the
number of non-covered inpatient days or statistical units used by the Medicare enrollee.
There are circumstances where plans are able to isolate the costs and statistical units of non-covered services
and/or those services for which Medicare is secondary payer. The plan may elect to exclude those statistical
units from the total on Worksheet D, Part I, Column 4 and the costs associated with them from total costs on
Worksheet E through adjustments on Worksheet G. If that election is made then it must be disclosed in the
footnotes to the HMO/CMP certified cost report. Where this occurs, Columns 5 and 6 on these Worksheets will
be the same amount and there will be no entry in Column 7.
2306.2 Part II - Plan Statistics – List Of Suppliers
This worksheet is provided for all plans, including HCPPs, to list the suppliers that are frequently used by the
plan's membership (i.e. the most utilized). The column headings for Columns 4 through 7 are the same as those
for the "LIST OF PROVIDERS" (see § 2306.1 above). These suppliers shall be separated by the CMS
APPROVED type of statistic used to apportion your costs on Worksheet K. For example if you are currently
approved to use “FFS” as your allocation statistic for the Physician Group Cost Center, you must use “FFS” as
your apportionment statistic regardless of the arrangement. However, if you have prior approval for the use of
multiple statistics in one cost center, please separate as suggested in the following example. Example: Fee For
Service arrangements should be listed individually or grouped together if the providers use the same statistic for
utilization; however, a Capitated arrangement that has separate statistics for utilization (e.g. Visits, encounters,
claims) should be listed on a different line and shall not be included under the Fee For Service line. Be careful
of Capitated arrangements that may have different statistics (ex. Encounters/visits vs. claims) as this is a
different statistic as well. The utilization statistic between the plan and provider determines which providers
should be grouped together. If there are various statistics that cannot be grouped under either Fee For Service or
Capitation (ex. RVU’s, Claims, Services, etc.) then Option “C-Other-Specify” should be used. The plan should
then specify what type of statistic is used on Worksheet K column 1.
Line Description
For the category descriptions below "LIST OF SUPPLIERS", list all suppliers of health services rendering
services to the plan's Medicare enrollees as follows:
Category A -Physician Services
Category B -Certified Labs
Category C -X-ray units
Category D -Others (Specify Type)

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All related suppliers should be identified by placing an “R” next to its name.
Column Descriptions
Column 1 – Type of Group - Enter the type of supplier that can be grouped by using the following codes:
A=
B=
C=
D=

IPA
Group Practice
Staff *
Individual Practitioners**
* All services rendered by the staff of the plan should be grouped on one line in each category (if
necessary) and identified as either "staff" or "clinic".
** All individual practitioners should be grouped on one line in each category if the plan uses the
same statistic and identified as "Individual Practitioners”.

Column 2 – Payment Mechanism and Column 3 – How Physicians Paid - For each supplier listed, identify
the method the plan is paying the supplier (Column 2) and the method the supplier is paying physicians
(Column 3). Use the following codes:
"A” for fee-for-service payments
"B" for capitation payments
"C" for other methods - specify the type of method being used
Please note that the Letter Codes entered into Columns 1 & 2 are REQUIRED, and will be used to summarize
the data entered at the bottom of each section. If Columns 1 & 2 are not entered, the data will not be included in
the summary. The summary data is transferred to Worksheet K, which will ensure that Worksheets D and K
match as is required. Group/Payment type allows for one statistic to be used. If you have approval and require
additional statistic types within a Cost Center, please contact your CMS servicing auditor for direction.
For Column 3 only, use “D" when the plan is an HCPP, a physician group pays its physicians on a
fee-for-service basis, and an exception to the Subpart E limits has been granted. The exception would be
granted under 42 C.F.R. 417.802 after CMS has determined that the Physician Group has an agreement that
includes acceptance by its members, to effective incentives designed to avoid unnecessary or unduly costly
utilization of health services. A copy of the determination letter must be attached to Worksheet D.
For Column 4 only, The plan should have indicated whether CMS has determined that the physician group has
an agreement, that includes acceptance by its members, to effective incentives designed to avoid unnecessary or
unduly costly utilization of health services. A copy of the determination letter should be attached to this
Worksheet D and Column 4 for that physician group should not be completed.
Category E – Membership
Column Descriptions

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Column_1- Medicare Part A - Enter the information requested for those Medicare enrollees that are eligible to
receive payment for covered services under Part A of the Medicare Program.
Column 2 – Medicare Part B - Enter the information requested for those Medicare enrollees that are enrolled
in the Supplemental Medicare Insurance (Part B) Program under Medicare. Part B Member Months should
always equal Total Medicare Member Months.
Line Descriptions
Line 1 – Total Medicare Member Months - Enter in the appropriate column Medicare enrollee member
months. A member month is defined as each month a person is a member of the plan. For example, if a
Medicare beneficiary was a member of the plan for the twelve month period covered by the report, the plan
would report a total of 12 Medicare member months for that individual.
Line 2 – Medicare Secondary Liable (Employee Groups) Member Months - Enter the number of member
months of Medicare enrollees who are members of an employer group and Medicare is secondarily liable for
their services. These are the Medicare member months associated with Categories (2) and (4) described above
in Section 2306.1 Part I - Plan Statistics - List Of Providers for the Column 6 description.
Line 3 – Medicare Primary Member Month - The worksheet calculates the Medicare primary member
months by subtracting the Medicare secondary liable member months on Line 2 from the total Medicare
member months on Line 1 for each column.
Line 4 - Ratio – The worksheet calculates the ratio of the Medicare primary member months to total Medicare
member months by dividing Line 3 by Line, 1. All Ratios must be reported to four decimal places.

2307 WORKSHEET E - SUMMARY TRIAL BALANCE
This worksheet is provided to:
•
•
•

Record the operating expenses of the Plan according to Generally Accepted Accounting Principles,
Summarize reclassification and adjustments of expenses in accordance with the Medicare Principles of
Reimbursement, and
Establish the ful1 cost of services for Medicare apportionment after reclassification into the appropriate cost
center..

The necessary reclassifications and adjustments needed for certain accounts detailed and summarized on
Worksheets F and G are brought forward to this worksheet. The allocation of Administrative and General (A &
G) costs on Worksheet I are brought forward to this worksheet after the reclassifications and adjustments are
made. Cost allocations are made in this cost report in two steps:
1. Functional allocations to cost centers
2. Pool allocation of remaining A & G costs

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* Direct allocations may also be accomplished but must be made as prescribed in Section 2307 A. of the
Provider Reimbursement Manual (HCFA PUB 15-I).
The cost centers on this worksheet are listed in a manner to facilitate the transfer of costs to subsequent
worksheets. Column 7 displays the worksheet and line number reference to which each entry in Column 6 is
transferred. Not all of the cost centers will apply to all plans.
Column and Line Descriptions
Column 1 – Trial Balance - Enter on the appropriate lines the total costs the plan incurred during the reporting
period. These costs that are entered must agree with the plan's audited accounting records maintained under
Generally Accepted Accounting Principles without any adjustments. The plan must maintain a worksheet that
groups costs from the audited trial balance of expenses to the various cost centers on this worksheet. Any
needed reclassifications, adjustments and allocations must be recorded in Columns 2, 3, and/or 5, as
appropriate.
Column 2 – Reclassifications (Wkst F) - Reclassification made among the cost centers in Column 1 which are
needed to affect proper cost allocations are brought forward from the summary on Worksheet F, Page 5. The
Worksheet F series has been provided to help the plans complete the reclassifications needed which affect the
appropriate cost centers. Reductions to cost centers should be shown in brackets ( ). The net total of the entries
in Column 2 must equal zero on Line 29.
Column 3 – Adjustments (Wkst G) – The adjustments summarized on Worksheet G, Part I are brought
forward to the appropriate lines in Column 3. The amounts of any adjustments are those needed to determine
allowable costs for apportionment under the Medicare Principles of Reimbursement. The Worksheet G series
and Worksheet H (if applicable) are provided to help the plans to complete the proper adjustments to the costs
recorded in Column 1 in accordance with the Medicare Principles of Reimbursement.
Column_4 – Allowable Costs – The cost report calculates adjustments to Column 1 made in Columns 2 and 3
and enters the net balance to Column 4.
Column 5 – A&G Allocation (Wkst I, Part I) – The cost report brings forward the amounts resulting from the
allocation of Administrative and General Costs shown on Line 28 Column 4 from the Worksheet I, Part I.
Worksheet I is provided to allocate A & G costs to those cost centers receiving a benefit from the A&G costs.
Reductions to cost centers must be shown in brackets ( ). The net total of the entries on Column 5 must equal
zero on Line 29.
Column 6 – Totals – The allocated A&G costs in Column 5 are adjusted to the amounts in Column 4 and
extend to Column 6.
Lines 1 and 2 – Inpatient and Outpatient Hospital - Enter on these lines the costs incurred by the plan, and
reflected in the accounting records, for services furnished through a Hospital. Only Plans electing billing option
#1 in section 3(b) on Worksheet S, may use these forms. Those Plans electing Billing Option 2 must use the
CMS alternative Worksheets E through M. Instructions for these Option 2 alternative worksheets are included
as Appendix A.

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Lines 3 and 4 – Other Provider Costs - Enter on the appropriate lines the cost of services incurred by the
plan, and reflected in the accounting records, for services furnished through a Skilled Nursing Facility or Home
Health Agency. Adjustments on Worksheet G must be made to Lines 3 and 4 that include those adjustments
necessary to remove the cost of non-covered services and the cost of services to non-Medicare patients. As a
result of these adjustments, only the reimbursable portion of Skilled Nursing Facility or Home Health Agency
services will be reflected in Column 4 and will flow to Worksheet J from Column 6 after cost finding.
Lines 5 thru 13a – Non-Provider Costs - Enter on the appropriate lines the cost of services incurred by the
plan, and reflected in the accounting records, for services furnished by a non-provider. Separate lines are
provided for the different types of suppliers of services. Services may be furnished by the plan through its own
employees, under arrangements with related and/or unrelated parties, or a combination of both. Payment
arrangements with each non-provider type and/or service arrangement may vary. If this occurs and the plan has
approval from CMS to fragment the apportionment for a specific type(s) of payment and/or service arrangement
on Worksheet K, then these lines must be subscripted for each of the specific type of payment and/or service
arrangement consistent with those on Worksheet K.
Line 14 - Emergency-Urgently Needed Services - Enter the costs of services furnished in an emergency or
urgently needed situation that were provided out-of-plan on an infrequent basis. Services of this type that were
furnished by in-plan providers or suppliers would be entered on Lines 1 through 13, as appropriate. The cost of
those services that would be entered on Lines 1 through 13 but were furnished out-of-plan in an emergency or
urgently needed situation will be recorded on this line.
Line 15 – Mental Health Services - Enter on Line 15 the cost of both the professional and non-professional
components of mental health services. The amount in Column 6 will be entered on Worksheet K, Lines 23 and
24 in the amounts for professional and non-professional components respectively. The professional component
amount determined on Worksheet K transfers to Worksheet L where the 37.5% copayment will be calculated.
Please note that effective in 2010, the 37.3% copayment is being phased out over a five year period. In 2014,
this copayment amount will be 20%, and the Mental Health Services will be treated as standard Part B services.
Note: Claims involving outpatient psychiatric services should no longer be processed by the carrier.
Line 16 – Deductible and Coinsurance Paid by MAC/Carrier/Intermediary - From time to time, bills for
Part B services for which the plan has responsibility are processed by the CMS MAC/Carrier/Intermediary. In
addition, certain services must be billed to the MAC/Carrier/Intermediary (see Section 6101.2 of HCFA PUB
75). Line 16 is provided for the plan to enter the deductible and coinsurance amounts paid by the plan for those
services processed through the MAC/Carrier/Intermediary. The Adjustment in Column 3 is made to eliminate
the amount of Part B coinsurance included in these costs. Entries in Column 6 will be brought forward to
Worksheet L.
Line 17 – Medicare Bad Debts - Enter in Column 1 the total bad debt expense recorded in the records. The bad
debt adjustment on Worksheet G should result in the Allowable Medicare Bad Debts (net of bad debt
recoveries) for premiums, dues, and co-payments charged to Medicare enrollees being reflected in Column 4.
The amount of allowable bad debts for a Medicare enrollee may not exceed three times the monthly rate (or its
equivalent if the premium is payable on other than a monthly basis) for the actuarial value of the deductible and
coinsurance amounts. Any bad debt related to a service furnished to a Medicare enrollee of the HMO/CMP or

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HCPP and claimed on a cost report submitted for payment by a provider or other facility paid on a cost basis
may not be claimed as a bad debt by the plan. See the CMS Managed Care Manual Pub #100-16, Chapter 17,
Subchapter B, Section 220.1 for further discussion on Bad Debts.
Line 18 - Blood Deductible - Enter the amount of the beneficiary's share of the cost for the first three pints of
blood, if not replaced.
Line 19 – Part B Costs not Subject to Coinsurance – Enter the Part B Costs not Subject to Coinsurance. The
amount in Column 6 will flow to Worksheet L, Line 25 and then Worksheet M, Line 16a. Costs on this line
typically include those services and drugs that are reimbursed at 100% by Medicare. Reclassifications to this
line and amounts transferred to worksheets L and M should be for Medicare only amounts. An attached
worksheet showing these separate items and amounts needs to be submitted along with any Fourth Quarter and
Final Cost report.
Line 20 – Non-Allowable Costs – Enter any non-allowable costs on this line. Non-reimbursable services must
also be entered on these lines in order to receive their share of Administrative and General Costs. The amount
in Column 6 will not flow to other worksheets, as these costs are not reimbursable. These costs would consist
of the adjustments for non-allowable costs that were previously made on Worksheet G.
Line 21 through 23 - These lines are provided for the reporting of costs of any other provider or supplier of
health services rendering services to the plan's membership that are not reflected in Lines 1 through 18. The
type of organization paid and the kind of services rendered must be entered in the far left column. If additional
lines are needed, a supplemental schedule should be included reflecting the different cost centers summarized
on lines 21 through 23 on worksheet E. Adjustments and reclassifications to any summarized cost centers on
these lines should also be included on the supplemental schedule.
Entries in Column 6 for reimbursable services will be brought to Worksheet J or Worksheet K, as appropriate.
Line 25 – Plan Administration - These costs benefit the total enrolled population of the plan and have no
relationship to medical care or services. Plan administration includes the total costs incurred for enrollment,
marketing, membership, administering the planand the following types of costs:
o
o
o
o
o
o
o
o
o
o
o
o
o
o

Directors’ salaries
Executive and staff administrative salaries
Organizational management costs
Organizational costs
The cost of preparing cost reports and cost report analyses
Management information systems
Research and development to expand the HMO
Feasibility studies
Studies conducted on utilization
Grant and loan applications
Grant and loan administration
Actuarial studies
Any other costs incurred for the benefit of the entire enrolled population
Allowable Premium taxes

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Entries in Column 6 will be brought to Worksheet L, Line 3.
Line 26 – Special Administrative Costs - Enter the special Medicare Program costs which are fully
reimbursable by the program as described in the Medicare Managed Care Manual Pub #100-16, Chapter 17,
Subchapter B, Section 200. These costs include:
1.
2.
3.

The reasonable cost of reporting Medicare beneficiary enrollment accretion and deletion data.
The reasonable cost incurred solely for the purpose of independently certifying the Medicare cost
report of the HMO/CMP.
The reasonable cost of special data required from HMO/CMPs by Medicare solely for program
evaluation and planning purposes specifically requested and approved by CMS.

Prior approval of special administration costs is required through inclusion of such costs in the annual budget
forecast. Entries in Column 6 will be brought to Worksheet L, Line 6.
NOTE: The Special Administration Costs Tab contained in the 4th Quarter and Final Cost Reports must
be completed.
Line 28 – Administrative & General Costs – Enter on this line all other Administrative and General costs not
included on Lines 25 and 26 above. These costs generally bear a significant relationship to the medical services
furnished by the plan. Include only those costs which are necessary and proper to the efficient management of
all services. All costs that do not pertain to the health plan or are non-allowable must be adjusted out in Column
3. As a result of the cost finding that occurs on Worksheet I and is brought forward to this Worksheet in
Column 5, the amount in Column 6 for this line must equal zero.
2308 WORKSHEET F - RECLASSIFICATIONS
This worksheet provides for the reclassification of costs reported on Worksheet E to the appropriate cost
centers. These reclassifications are necessary for subsequent allocations and apportionments. Review Section
2307 for the description of possible A & G allocations for inclusion as items of reclassification. Direct
allocations should be made to those cost centers actually benefiting from the cost.
Worksheet F should be completed to the extent that costs are not included in the proper cost centers.
Submit with the cost report, copies of any workpapers used to compute the reclassifications affected on this
worksheet.
Column Descriptions
Enter the explanation of the reclassification.
Column 1 - Enter a letter (A, B, etc) on each line used in Column 2 to identify each reclassification entry.
Explain the reason for the reclassification entry just to the left of Column 1. If more than one cost item is being
reclassified, the plan should identify each item reclassified.

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Column 2 - All cost centers being adjusted should be identified in this column. The names of these cost centers
should correspond to the names used on Worksheet E.
Column 3 - List the line number from Worksheet E for each cost center identified in Column 2 of this
worksheet.
Columns 4 and 5 - These columns are provided to record the amount of increase (Column 4) or decrease
(Column 5) for each cost center listed in Column 2.
Examples of the six most common reclassification are as follows:
1. Special Administrative costs must be removed from the Administrative and General cost center. A
reclassification should be made to increase Line 26 of Worksheet E and a corresponding reclassification to
decrease Line 28 of Worksheet E. (See Instructions for Worksheet E, Line 26 for definition of Special
Administrative Cost)
2. Certain insurance costs must be removed from the A & G cost center and placed in the cost centers
benefiting from these costs. Malpractice insurance should be allocated to the various service components of
the plan based on quotes from the plan's insurance company. For example, if the plan's insurance company
states that 50 percent of the malpractice insurance premiums is for insuring the plan against claims arising
out of inpatient hospital services, then the plan must allocate 50 percent of the insurance to Inpatient
Hospital (line 1 of Worksheet E).
3. Space cost should be reallocated to the cost centers occupying the space.
4. Reclassify interest expenses to the cost centers benefiting from the loan for which interest is incurred. Some
plans may prefer to have interest in the A & G cost centers due to further needed adjustments on Worksheet
G for investment income.
5. Marketing, Membership, and Enrollment costs should be reclassified to Plan Administration.
6. All other Plan Administration type of costs should be reclassified from Administrative and General to Plan
Administration. These costs would include, but are not limited to, grievance procedures, actuarial costs and
any other A & G costs that benefit the entire population. (See Section 2307 for more detailed descriptions).
Line Descriptions
Lines 1 through 50; 54-109; 111-166 & 168-223 - Enter on these lines the reclassification entries. All
explanations of reclassification entries and related cost center increases and decreases must be completed on the
page the entry began on.
Line 53-Total - Columns 4 and 5 must equal for all entries

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2309 WORKSHEET G - ADJUSTMENTS TO EXPENSES
2309.1

WORKSHEET G, PART I - ADJUSTMENT TO EXPENSES

This worksheet provides for adjustments to the cost centers listed on Worksheet E. These adjustments, which
are required under the Medicare Principles of Reimbursement, are to be made on the basis of "cost" or "amount
received." Enter the total "amount received" (revenue), only if the cost (including direct cost and all applicable
overhead) cannot be determined, otherwise enter the "cost." Once an adjustment to an expense is made on the
basis of "cost," the plan may not in future cost reporting periods determine the required adjustment to the
expense on the basis of "revenue." The following symbols are to be entered in Column 1 to indicate the basis for
adjustment: "A” for cost; and "B" for amount received. Line description indicate the more common activities
which affect allowable costs, or result in costs incurred for reasons other than patient care and thus, require
adjustments.
Types of items to be entered on Worksheet G are: (1) those needed to adjust expenses to reflect actual expenses
incurred; (2) those items which constitute recovery of expenses through sales, charges, fees, grants, gifts, etc.;
(3) those items needed to adjust expenses in accordance with the Medicare Principles of Reimbursement; and
(4) those needed to reduce the plan's costs for medical and other health care services to reasonable amounts.
Where an adjustment to an expense affects more than one cost center, the plan should either (1) record the
adjustment to each cost center on a separate line on Worksheet G, or (2) enter the total adjustment on line as
appropriate and attach a supporting worksheet showing the required adjustments to the various cost centers
affected. In this latter situation, enter on the appropriate line in Column 1, the words "Supporting Worksheet
Attached." With respect to Line 10, Worksheet H is supporting documentation for any required entry.
Column Descriptions
Columns 3 and 4 - Indicate the cost center title and line number of Worksheet E to which the adjustments are
to be made.
Line Descriptions
Line 1 - Investment income on restricted and unrestricted funds which are commingled with other funds must
be applied against, but should not exceed, the total interest included in allowable costs.
The investment income on restricted and unrestricted funds which are commingled with other funds should be
applied against the appropriate cost centers on the basis of the ratio that interest expense charged to each cost
center bears to the total interest expense charged to all of the plan's cost centers.
Lines 2 thru 7, 9. and 11 thru 18 - Enter on these lines any additional adjustments required by the Medicare
Principles of Reimbursement. Explanations of the necessary adjustments can be found in the HCFA Pub. 15-I.
Line 8 - Enter the allowable home office costs which have been allocated to the plan. Additional lines should be
used to the extent that various plan cost centers are affected.

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Line 19 - Enter the cash received from imposition of interest, finance or penalty charges on overdue
receivables. This income must be used to offset the cost of the cost center to which the charges apply.
Line 20 - Enter the payments received from physicians who assume the operating costs of a hospital
department.
Line 21 - Enter the amount of any contributions to a risk pool that is not going to be distributed one year after
the close of the plan's reporting period.
Line 22 - For those HCPPs that are limited in reimbursement to the carrier screens, enter the amount of
payments made to suppliers of health care that exceed the Medicare charge screens under Subpart E of the
Medicare regulations. These amounts may be entered here with attached detail worksheets or on Worksheet K.
Line 23 - Enter on this line the Part B coinsurance the plan paid for those services processed by CMS' carriers
for those services rendered to the plan's population that are the responsibility of the plan. See instructions to
Line 16, Worksheet E.
Line 24 - Enter on this line the Part B coinsurance the plan paid for those services processed by CMS’
intermediaries for services rendered to the plan's population that are the responsibility of the plan. This entry is
used to adjust coinsurance costs entered in Worksheet E Lines 1, 2, and 3 where the HMO/CMP elected to have
CMS process the bill.
Line 25 - This line is provided for those plans that have paid for physical therapy services. Worksheet A-8-3 of
the Hospital cost report Form HCFA-2552 must be submitted to have any physical therapy costs allowed. For
further instructions on the type of adjustment needed, refer to HCFA PUB 15-1 Chapter 4
Line 26 - The plan should enter all types of reinsurance including stoploss insurance. These costs are not
allowable.
Line 27 - Where depreciation expense computed in accordance with the Medicare Principles of Reimbursement
differs from depreciation expense per the plan's books, enter the difference on line 27; e.g., such difference
could be due to the provider using the optional allowance for depreciation or non-approved accelerated
methods.
Line 28 - Enter the cost incurred for non-covered purchased services. This line should be used if the remaining
purchased services are to be apportioned on a basis that would not eliminate these service costs.
NOTE: Most costs in this category should be reclassified on Worksheet F, to Line 20 of Worksheet E,
rather than be adjusted out on this line.
Line 29 - Use this line to adjust cost claimed to allowable Medicare Bad Debts described in Worksheet L.
(Refer to instructions for Worksheet L, Line 9 for allowability of Medicare Bad Debts.)
Lines 30 thru 49; 53-107; 108-162 & 163- - Enter any other adjustments not listed on Lines 1 through 29 and
attached supporting worksheets where applicable.

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FORM CMS 276
Line 52 - Columns 4 and 5 must equal for all entries.
2309.2

WORKSHEET G. PART II - SUMMARY OF ADJUSTMENTS

This part is provided for the plans to summarize all adjustments included in Part I.
COLUMN DESCRIPTIONS
Cost Center - The cost centers provided are the same cost centers used on Worksheet E.
Column 1 - Enter all line numbers for which you are summarizing an amount in Column 2.
Column 2 - Enter the sum of the amounts from Part I, lines as indicated in Column 1. Both negative and
positive amounts may be added together. If the sum of the amounts is a negative number, enter the amount in
brackets ( ).
Column 3- Enter in this column the cost center to which the amounts in Column 2 are to be transferred to
Worksheet E.
Column 4 - Enter in this column the line numbers to which the amounts in Column 2 are to be transferred to
Worksheet E.
2310

WORKSHEET H - STATEMENT OF COSTS OF SERVICES FROM RELATED
ORGANIZATIONS

This worksheet provides for the computation of any needed adjustments to costs applicable to services,
facilities, and supplies furnished to the plan by organizations related to the plan by common ownership or
control. In addition, certain information concerning the related organizations with which the plan has transacted
business should be shown.
Part A - Must be completed by all plans. If the answer to Part A is "yes", Parts B and C must also be completed
and submitted with the cost report. If the answer to Part A is "no", no other parts need be completed.
Part B - Cost applicable to services, facilities, and supplies furnished to the plan by organizations related to the
plan by common ownership or control are includable in the allowable cost of the plan at the cost to the related
organization. However, such costs must not exceed the amount a prudent and cost-conscious buyer would pay
for comparable services, facilities, or supplies that could be purchased elsewhere. Transfer the amount in
Column 5, Line 10 to Worksheet G, Part I, Column 2, Line 10.
Part C - This part is used to show the interrelationship of the plan to organizations furnishing services, facilities,
or supplies to the plan. The requested data relative to all individual, partnerships, corporations, or other common
ownership having either a related interest to the plan, a common ownership of the plan, or control over the plan,
must be shown in Columns 1 through 6, as appropriate.
HCFA Form-1513 may be substituted for this part.

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FORM CMS 276
Only those columns which are pertinent to the type of relationship which exists should be completed.
Column Descriptions
Column 1 - Enter the appropriate symbol which describes the interrelationship of the plan to the related
organization.
Column 2 - If the symbol A, D, E, F, or G, as appropriate, is entered in Column 1, enter the name of the related
individual in Column 2.
2311 WORKSHEET I - ALLOCATION-AND STATISTICS FOR A & G ALLOCATION
This worksheet is used to allocate those remaining A & G costs on Line 28 Column 4 of Worksheet E.
Allocation statistics will be placed on Part II. Each cost item identified will be allocated to the various cost
centers by using the unit cost multiplier technique.
Part II will be used to accumulate the statistics that will be used to allocate the costs on Part I. A unit cost
multiplier will be developed by dividing the cost to be allocated by the total statistics of those costs. In reality
the unit cost multiplier is nothing more than the amount of cost dollars per unit of statistic. Cost figures for each
line of Worksheet E will be computed by multiplying the unit cost multiplier by the statistics in Part II on a
line-by-line basis.
Please note A & G is not to be allocated to special administration and plan administration.
2311.1

PART I - ADMINISTRATIVE AND GENERAL COST-ALLOCATION

Enter on this part the allocated costs computed using the unit cost multiplier technique described briefly above
and in more detail below. Columns 1 through 4 represent those costs that can be allocated using a functional
allocation. Please note if column 4 is used, you are required to specify the functional allocation. If statistics are
not available, then these cost items should be allocated using the pool allocation in Column 6, and Columns 1
through 4 should be annotated with "Statistics not available."
Sum Columns 1 through 4 and place the result in Column 5. This column will be used on Part II to properly
allocate all remaining A & G using the pool allocation.
The figures developed for Column 7 should be transferred to Worksheet E, Column 5, lines as appropriate.
2311.2

PART II - ADMINISTRATIVE AND GENERAL STATISTICS

The allocation bases indicated in the column headings are accepted and recommended bases for the allocating
of costs to the benefiting cost centers. If other bases are desired, the plan must seek approval from CMS to use
any other bases. Requests for a change in method from the most recent prior year must be submitted to CMS 90
days prior to the beginning of the period for which the change is to apply.
Enter the total statistics on Line 29 and the statistics for each cost center. Assure that the sum of the statistics
on Lines 1 through 23,25, and 26 equals the amount placed on Line 29. Determine the unit cost multiplier for

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FORM CMS 276
each column (1 through 4 and 7) by dividing the total cost to be allocated on Line 30 by the total statistics on
Line 29.
For example, if the total costs to be allocated are $50,000 (Line 23) and the total statistical units being used to
allocate that cost are 75,000 units (Line 25), then the unit cost multiplier would be .6667 (50,000/75,000.carried
to 4 decimal places). If the number of statistical units that were properly allocated to Inpatient Hospital are 30,000 units (Line 1), the entry for Part I, Line 1, would be $20,001 (30,000 x . 6667).
2312 WORKSHEET J - SUMMARY OF PROVIDER COSTS
The worksheet is specifically designed for HMOs/CMPs to report provider costs paid by the HMO/CMP.
HCPPs should not complete this worksheet. An HMO/CMP may elect under option 1 for CMS to process
the bills for services rendered by hospitals, SNFs and HHAs. This election is made prior to the beginning of a
contract year in writing. All other In-plan and Emergency and Urgently Needed Provider Services must be paid
by the HMO/CMP. Billing Option 1 HMO/CMPs and HCPPs will not complete the entire worksheet. Since an
Billing Option 1 HMO/CMPs and HCPPs may pay for the Medicare deductible and coinsurance for services
rendered in a provider setting, the worksheet should only be completed to the extent of the deductible amounts.
When an HMO/CMP elects option 2, it will process bills from Hospitals, SNFs and HHAs it has elected to pay
directly. The HMO/CMP must use the alternative cost report forms for Billing Option 2 Plans for filing with
CMS. These alternative forms will enable Billing Option 2 Plans to report the providers’ separate
apportionment and settlement worksheets identifying the plan’s costs of services according to Medicare
Principles of Reimbursement. Instructions for the Option 2 alternative worksheets are included in Appendix A.
Column Descriptions
Providers - List the name of the provider on the lines under the appropriate provider type heading.
Column 1 – Provider Number – Enter the Medicare provider billing number.
Column 2 – Reimbursable Part A – Not used for Option 1 Plans.
Column_3 – Part A Deductible and Coinsurance - Enter the Part A deductible and coinsurance incurred by
the plan for services rendered in the provider setting.
Column 4 – Reimbursable Part B – Not used for Option 1 Plans.
Column 5 – Part B Deductible - Enter Part B deductible only. Part B coinsurance should not be included on
this line.
Line Descriptions
Line 1 –Medicare Member Months - The cost report transfers to this line the number of Medicare member
months on Worksheet D, Part II Section E. Membership, Line 3.

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FORM CMS 276
Line 2 – Hospitals - Enter the hospital facilities on lines 3 through 47 and the related information for columns 3
and 5 for the hospital facilities being reimbursed through this cost report. See Appendix A for instructions for
Option 2 Plans using the CMS required alternative worksheets.
Line 48 - Total Hospital Cost – The worksheet adds the hospital Part A deductibles and coinsurance and the
Part B deductibles for those hospitals reported.
Line 49 – Cost PMPM – The worksheet calculates the reimbursable hospital cost PMPM by dividing the total
reimbursable hospital cost on Line 48 by the respective Medicare primary member months on Line 1.
Line 51 – Skilled Nursing Facilities - Enter the skilled nursing facilities on lines 52 through 61 and the related
information for columns 3 and 5 for the skilled nursing facilities being reimbursed through this cost report.
Line 63 – Cost PMPM – The worksheet calculates the reimbursable skilled nursing facilities cost PMPM by
dividing the total reimbursable skilled nursing facilities cost on Line 62 by the respective Medicare primary
member months on Line 1.
Line 65 – Home Health Agencies – Option 1 Plans do not need to complete this section. Option 2 Plans please
see Appendix A for instructions on the CMS required alternative worksheets for the home health agencies being
reimbursed through this cost report.
Line 78 – Other Providers - Enter the name and type on lines 79 through 89 and the related information for
columns 1 through 5 for each provider being reimbursed through this cost report. Examples of the types of
providers reported in this section are Comprehensive Outpatient Rehabilitation Facilities (CORF), Outpatient
Rehabilitation Provider, etc.
2313 WORKSHEET K - SUMMARY APPORTIONMENT OF NONPROVIDER COSTS
This worksheet apportions non-provider medical and other health service costs reimbursed under Part B of the
Social Security Act to the Medicare program. These apportioned costs are then summarized, and the PMPM
amount is calculated and transferred to the settlement sheet on Worksheet M.
Cost and statistical information used in the apportionments transfer to this worksheet from other worksheets on
which they are developed. The worksheet transfers statistical information from Worksheet D, Part II. There
should be no differences between Worksheet D, Part II and Worksheet K statistics. The worksheet transfers cost
information from Worksheet E, Column 6. There should be no variances between these amounts.
Column and Line Descriptions.
Column 1 – Statistic Used - Enter on the spaces provided the type of statistic being used to apportion the
particular cost item in the far left column. For example, a plan may elect to apportion clinic services furnished
directly on a physician-visit basis. The plan should enter in Column 1, Line 1 "visits."
The appropriate code, as explained in footnote (1) of Worksheet D, Part II, should be entered just left of
Column 1.

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FORM CMS 276
Column 2 – Total Statistics - Enter the total statistics for each supplier from Worksheet D, Part II, Column 4.
Column 3 – Covered Medicare Enrollee Statistics - Enter the covered Medicare enrollee statistics for each
supplier from Worksheet D, Part II Column 6.
Column 4 – Subpart E Limits - This column should be completed (1) by only those HCPPs that do not have a
written exception to these limits from CMS and pay for supplier services on a fee-for-service basis or (2) those
that pay for supplier services on a basis other than on a fee-for-service basis and that supplier pays its members
on a fee-for-service basis. In these cases, reimbursement to the plan cannot exceed what a
MAC/Carrier/Intermediary would have paid for these services. For each supplier, the HCPP should enter the
sum of what the MAC/Carrier/Intermediary would have paid for each service rendered. If the HCPP cannot
provide the requested information, a zero should be placed in Column 4 and Column 7.
If the HCPP has been granted an exception to this limitation, the document granting the exception for each
supplier should be attached to the report form and Column 4 should not be completed for that specific group of
costs to which the exception applies.
In addition, HMOs/CMPs must complete Line 18 for Emergency-Urgently Needed Services rendered after
April 1, 1990. Payment for these services is limited to the reasonable cost for such services or the Medicare
prospective payment as provided for in 42 C.F.R. Parts 405, 412, and 413. There is an exception to this
limitation on the basis of advantages gained by the HMO/CMP according to 42 C.F.R.417.558. Refer to
Managed Care Manual Pub# 100-16, Chapter 17, Subchapter 17C, §80 and §90 for further discussion on this
exception.
Column 5 – Ratio – The worksheet calculates the Medicare percentage as follows for each cost center:
Lesser of Column 3 or Column 4
Column 2
All ratios are carried out 4 decimal places.
Column 6 – Total Costs – The Total Costs for apportionment are brought forward to this column for each
supplier cost center from Worksheet E Column 6.
Column 7 – Medicare Costs – The worksheet calculates the Medicare portion of the total cost for each supplier
cost center by multiplying (Column 5 times Column 6) and enters the result in this column.

Line 19 – Professional Component Mental Health - Enter the cost portion for the professional compensation
paid that is in the total Mental Health cost on Worksheet E, Column 6, Line 15. The professional component of
the cost of mental health services must be isolated since there is a 37.5% (and decreasing) coinsurance amount
to be calculated on Worksheet L and carries to Worksheet M for deduction.
Line 20 – Mental Health Services Non-Professional Component – Enter the amount of the remaining cost of
mental health services after the Professional Component on Line 19 is deducted from the total on Worksheet E,
Column 6, Line 15.

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FORM CMS 276

Line 36 – Member Months Part B – The worksheet transfers the total Part B member months from Worksheet
D, Part II, Section E, Column 2, Line 1.The total Medicare member months are used instead of the primary
Medicare member months in order to reflect the effect of the MSP Employer Group member months on the
determination of the PMPM cost.
2314 WORKSHEET L - SUMMARY OF MISCELLANEOUS ITEMS
This worksheet is provided for the recording of certain miscellaneous items. The worksheet is fairly
self-explanatory. However, certain items do need further clarification.
Line 1 - Enter on this line for Columns 1 and 2 the amount of Medicare member months shown on Worksheet
D, Part II E. Membership, Line 1.
Line 4 - Line 4 should be completed by entering in Column 5 the result of the division of Line 3 Column 5 by
Line 1 Column 5. The entries for Columns 1 and 2 of Line 4 should be in the same ratio as Column 1 Line 1
bears to the sum of Column 1 Line 1 plus Column 2 Line 1 and the ratio of Column 2 Line 1 bears to the sum of
Column 1 Line 1 plus Column 2 Line 1. Use the following formulas:
For Col 1 Line 4 use (Line 1 Col 1/(Line 1 Col 1 + Line 1 Col 2)) times Col 5 Line 4;
For Col 2 Line 4 use (Line 1 Col 2/(Line 1 Col 1 + Line 1 Col 2)) times Col 5 Line 4.
Line 9 - Enter the Allowable Medicare Bad Debts (net of bad debt recoveries) for premiums, dues, and copayments charged to Medicare enrollees. The amount of allowable bad debts for a Medicare enrollee may not
exceed three times the monthly rate (or its equivalent if the premium is payable on other than a monthly basis)
for the actuarial value of the deductible and coinsurance amounts. Any allowable bad debts claimed on a cost
report submitted by a provider or other facility reimbursed on a cost-based may not be claimed as a bad debt by
the plan.
Line 15 - Enter the amount of third party insurer revenue received for those services that are not paid fully by
the insurer. These services pertain to only two categories of services for which Medicare has a secondary
liability (see sections 2306.1 (Column 6) and 2306.2 (Column 6) for further details) and were counted in
Column 6 of Worksheet D.

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FORM CMS 276
Line 22 – The coinsurance payment on mental health services is being gradually reduced over the period of
2010 to 2014, per the October 30, 2009 Transmittal 114 issued to change Section 102 of the Medicare
Improvements for Patients and Providers Act (MIPPA). Effective 1/1/2014, the limitation will no longer exist
and Medicare will pay outpatient mental health services at the same level as other Part B services. Beginning
with the final cost reporting for 2010, the Mental Health Services coinsurance on WS L, line 22 will be as
follows:
REPORTING PERIOD
2010
2011
2012
2013
2014

COINSURANCE PERCENTAGE
31.25%
31.25%
25.00%
18.75%
0%

2315 WORKSHEET M - SETTLEMENT SHEET
This worksheet provides for the final computations necessary to determine the balance due the plan or CMS.
Column Descriptions
Column 1 - This column identifies the worksheet from which the information for Columns 2-4 are taken.
Column 2 - Enter the total Medicare Part A per member per month costs requested.
Column 3 - Enter the total Medicare Part B per member per month costs requested.
Column 4 - Sum of Columns 2 and 3, where appropriate.
Line Descriptions
Most of the lines are self-explanatory and are taken from other parts of the report.
Line 13 - The Part B coinsurance is computed. Certain Part B services do not have a coinsurance provision. If a
plan feels that additional Part B services should be excluded from this computation, an additional worksheet
should be added showing how the Part B coinsurance was computed.
Line 22 - Line 22 reflects net payments from CMS (interim payments less amounts returned to CMS by the
plan). If your plan returned money to CMS, attach a schedule listing the amount, date of transaction, reason for
return, and method of payment (wire or check).
2316 WORKSHEET N - MEDICARE PREMIUM RECONCILIATION
The purpose of this form is to perform an annual premium reconciliation to determine net over or under
collection of premiums for the reporting period.

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FORM CMS 276
All over collections of premiums must be returned to the Medicare enrollee. The Plan may select, with prior
approval, one of three methods to refund over collections. The three methods are:
1. By a lump sum payment to the enrollee;
2. By a premium adjustment to the individual enrollee's or all enrollees future years’ premiums; or
3. By a combination of premium adjustment and lump sum payment.
Unintentional under collections of premiums will be collected from the Plan’s Medicare enrollees by an
adjustment to its Medicare enrollee’s future premiums. However, the Plan must collect the under collections
through premium adjustments no later than 24 months following the end of the contract period in which they
were due. Intentional under collections of premiums cannot be recouped by the HMO/CMP or HCPP from the
Medicare enrollee.
Please note that amounts related to Part D premiums/dues should never be reported on Worksheet N. The
premiums/dues reported on Worksheet N (Lines 1-6) shall only reflect those amounts deemed reimbursable by
regulation for the individual MCO filling out this Worksheet. So, HMO/CMPs shall only report those
premiums/dues that reflect the amounts related to Part A (if provided) and Part B. HCPPs shall only report the
amounts related to Part B premiums/dues. These premiums/dues amounts must be separated to calculate any
over or under collection of Medicare premiums.
Line Descriptions
Lines 1 and 2 - Enter on the appropriate lines the actual collections made on premiums, dues, and co-payments
charged to Medicare enrollees or someone on behalf of the Medicare enrollee for all covered Medicare items
and services.
Line 4 - Enter the charges for premiums, dues, and co-payments related to Medicare enrollees for months prior
to the HMO's current reporting period, but not collected by the HMO before the current reporting period.
Line 6 - Enter the charges for premiums, dues and co-payments related to Medicare enrollees for months in the
current reporting period, but not collected by the HMO as of the last day of the current reporting period.

Line 9a - This amount comes from Worksheet N, Line 11 or 12b of the Final Cost Report for the period ending
2 years before the ending date of the current cost report. For example, if the final cost report is for 2012, then
Line 9a should be from Worksheet N of 2010.
Line 9b – This amount comes from Worksheet N, Line 0 of the Final Cost Report for the period ending 2 years
being the ending date of the current cost report. For example, if completing the final cost report for 2012, then
the member months entered on Line 9b should be from Worksheet N of 2010.
Terminating Plans – Terminating plans shall include the involuntary under/ (over) collection from two
years prior, and also add to this the under/(over) collection from the immediate prior year (WS N, Line
11 or 12b). For example, if completing the terminating final cost report in 2014, under/(over)collections
should reflect amounts for 2012, as well as 2013. In order to correctly calculate the gross collections
from the prior periods, the following calculation must be followed. The sum of gross under/ (over)

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FORM CMS 276
collections shall manually be entered on Line 9c only for terminating plans (do not complete lines 9a
and 9b, your CMS servicing auditor will assist with updating line 9c). Terminating plans must also
submit supporting documentation for the amount entered on line 9c.
Prior
Periods

2012
2013

Under/
(Over)
Collection
PMPM (A)
$
$

Prior
Period
MM (B)

Gross Under/ (Over) Collection

MM
MM

A*B
A*B
Sum of above

Line 12 - Enter on Line 12 the amount of voluntary under collections reported on Line 8 of Worksheet B of the
budget forecast covering the current year. (For example, if you are preparing the 2012 4th quarter or final cost
report, then the 2012 budget should be used on this line). Lines 12a and 12b will automatically calculate the
actual voluntary under collection and the involuntary under collection to be recouped during the subsequent
period, respectively.

2317 CERTIFICATION BY INDEPENDENT AUDITOR
One-hundred-eighty days after the close of the contract period, an HMO/CMP must submit a final cost report
that has been certified by an independent auditor.
NOTE: The Certification must be performed by and Independent Auditor. Therefore, the Certification
must be performed by someone other than the person / audit firm that prepared / assisted with the
preparation of the Final Cost Report.

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FORM CMS 276

APPENDIX A – OPTION 2 INSTRUCTIONS
The instructions below for Option 2 plans only include items that differ from the preceding instructions for
Option 1 plans. All instructions besides these below apply to both Option 1 and Option 2 plans. The
alternative cost report forms required for Option 2 plans must be obtained directly from CMS personnel as they
are not available via HPMS.

2307 WORKSHEET E - SUMMARY TRIAL BALANCE
Lines 1 and 2 – Inpatient and Outpatient Hospital - Enter on these lines the costs incurred by the plan, and
reflected in the accounting records, for services furnished through a Hospital. The plan must isolate and record
those costs for inpatient on Line 1 and outpatient services on Line 2 that are subject to rate of increase ceiling
pursuant to §1886(b) and PPS pursuant to §1886(d) from those that are not subject to those statutory payment
methods. The purpose for isolating these amounts is to properly apply the lesser of cost or changes (Section 233
of the Medicare statutes) to those costs of services incurred by Hospitals that are not subjected to those
provisions.
Adjustments on Worksheet G must be made to Lines 1 and 2 that include those necessary to remove the cost of
non-covered services and the cost of services to non-Medicare patients. As a result of these adjustments, only
the reimbursable portion of Hospital services will be reflected in Column 4 and will flow to Worksheet J from
Column 6 after cost finding.
2312 WORKSHEET J - SUMMARY OF PROVIDER COSTS
When an HMO/CMP elects Option 2, it will process bills from Hospitals, SNFs and HHAs it has elected to pay
directly. The HMO/CMP must acquire from these providers separate apportionment and settlement worksheets
identifying the plans costs of services according to Medicare Principles of Reimbursement. HMOs/CMPs must
enter into agreements with these providers so that the reporting requirements outlined in items 1 through 4, as
follows, can be maintained.
1. Data Collection Requirements. - A provider furnishing services to an HMO/CMP Medicare enrollee
is required to maintain separate statistics for the Medicare enrollees. These statistics will be
maintained in such type, detail and form as required for the provider's other Medicare patients.
Separate statistics must be accumulated for each HMO/CMP with which the provider has an
agreement.
2. Filing Requirements for Provider Using Form HCFA 2552. – Hospitals, Hospital-Based Skilled
Nursing Facility, and Hospital-Based Home Health Agency complexes will continue to use the
Form HCFA-2552. These hospitals will prepare their cost reports and submit them to their
MAC/Carrier/Intermediary just as they do now.
In addition, providers must prepare a separate set of apportionment and settlement worksheets to
determine costs of the HMO/CMP Medicare enrollees. The worksheets will apportion the costs of
each cost center between the HMO/CMP Medicare enrollees and all other provider patients. A

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FORM CMS 276
separate set of worksheets will be needed for each HMO/CMP with whom the provider has an
agreement. Providers should make sure that payment for a covered service rendered to a Medicare
beneficiary is not made more than once.
3. Filing Requirements for Providers Using Other Cost Report Form. - Providers using substitute cost
reports, other than Form HCFA-2552 will utilize the principles outlined for the Form HCFA-2552.
That is, separate apportionment and settlement worksheets will be prepared by the provider for each
HMO/CMP. Each set of worksheets will apportion the costs of the appropriate cost centers between
the applicable group of HMO/CMP Medicare beneficiaries and all of the providers' patients.
In seeking reimbursement for home health services furnished to the HMO/CMP Medicare enrollees,
the HMO should attach the appropriate forms used by the home health agency to obtain
reimbursement from the Specialty MAC for services furnished to Medicare beneficiaries who are
not HMO/CMP enrollees. These forms must reflect the cost of services furnished only to the
Medicare enrollees of the HMO/CMP.
4. MAC/Carrier/Intermediary Final Settlement with the Provider. - In making final settlement with the
provider, the MAC/Carrier/Intermediary will treat services furnished to HMO enrollees as if the
services were furnished to non-Medicare beneficiaries, where the services are paid by the
HMO/CMPs. For services furnished to HMO/CMP enrollees the provider will be reimbursed for
such services under the terms of its arrangement with the HMO/CMP and the payment to the
provider need not be limited to cost. However, CMS payment to the HMO/CMP for such services
will be limited to the amount the MAC/Carrier/Intermediary would have paid the provider for
furnishing the services, except where the HMO can demonstrate to the satisfaction of CMS that
payment in excess of what the MAC/Carrier/Intermediary otherwise would have paid is reasonable
on the basis of advantages gained by the HMO/CMP. These advantages gained must be real and
verifiable.
The HMO/CMP must use the alternative cost report forms for Billing Option 2 Plans for filing with CMS.
These alternative forms will enable Billing Option 2 Plans to report the providers’ separate apportionment
and settlement worksheets identifying the plan’s costs of services according to Medicare Principles of
Reimbursement. The apportionment and settlement sheets from each provider must be attached to
Worksheet J. When the HMO/CMP submits its fourth quarterly cost report, apportionment and settlement
sheets for the provider may not be available. In this case, the HMO/CMP should use the best information
available at the time.
Column Descriptions
Column 2 – Reimbursable Part A – Enter total Part A reimbursable costs obtained from the provider for
which the plan is responsible. If the plan is using the Bill Summary Method for the Provider in Column 1, attach
additional sheets identifying any difference between the entry in this column and the information contained in
the Bill Summary Report.
Line Descriptions

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FORM CMS 276
Line 2 - Hospitals subject to rate of increase ceiling pursuant to 1886(b) or PPS pursuant to §1886(d) – As
explained in Section 2307 the Medicare reimbursable costs for hospital services must be separated between
those subject to the rate of increase ceiling or PPS from those that are not. The lesser of cost or charges
provisions do not apply to those hospital costs that are subject to the rate of increase or PPS provisions. The
hospitals and the related information for columns 1 through 5 for those hospitals subject to the rate of increase
or PPS provisions must be reported under this line heading.
Line 33 - Hospitals not subject to rate of increase ceiling pursuant to 1886(b) or PPS pursuant to §1886(d)
– Enter the hospitals and the related information for columns 1 through 5 for those hospitals that are not subject
to the rate of increase or PPS provisions must be reported under this line heading.
Line 46 - Total Medicare Customary Charges – Enter the customary charges of the hospitals not subject to
rate of increase ceiling pursuant to 1886(b) or PPS pursuant to §1886(d) that are uniformly imposed and
collected from a substantial percentage of patients that are liable for payment on a charge basis. Refer to the
HCFA Pub #15-1, Section 2606 for descriptions and definitions for Customary Charges. The charges are
recorded in the aggregate for all services whose costs are entered on Lines 34 through 44.
Line 47 - Lesser of Medicare Reasonable Cost or Customary Charges – The worksheet calculates the lower
of line 45 or line 46 and enters the result on this line.
Line 48 - Total Hospital PPS and Non-PPS Cost – The worksheet adds the hospital PPS and non-PPS
amounts on Lines 31 and 46 to derive the total reimbursable hospital cost for the period.
Line 49 – Cost PMPM – The worksheet calculates the reimbursable hospital cost PMPM by dividing the total
reimbursable hospital cost on Line 48 by the respective Medicare primary member months on Line 1.
Line 51 – Skilled Nursing Facilities - Enter the skilled nursing facilities on lines 52 through 61 and the related
information for columns 1 through 5 for the skilled nursing facilities being reimbursed through this cost report.
Line 63 - Total Medicare Customary Charges – Enter the customary charges of the skilled nursing facilities
that are uniformly imposed and collected from a substantial percentage of patients that are liable for payment on
a charge basis. Refer to the HCFA Pub #15-1, Section 2606 for descriptions and definitions for Customary
Charges. The charges are recorded in the aggregate for all services whose costs are entered on Lines 52 through
61.
Line 64 - Lesser of Medicare Reasonable Cost or Customary Charges – The worksheet calculates the lower
of line 62 or line 63 and enters the result on this line.
Line 65 – Cost PMPM – The worksheet calculates the reimbursable skilled nursing facilities cost PMPM by
dividing the total reimbursable skilled nursing facilities cost on Line 64 by the respective Medicare primary
member months on Line 1.
Line 67 – Home Health Agencies - Enter the home health agencies on lines 68 through 76 and the related
information for columns 1 through 5 for the home health agencies being reimbursed through this cost report.

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FORM CMS 276
Line 78 - Total Medicare Customary Charges – Enter the customary charges of the home health agencies that
are uniformly imposed and collected from a substantial percentage of patients that are liable for payment on a
charge basis. Refer to the CMS Pub #15-1, Section 2606 for descriptions and definitions for Customary
Charges. The charges are recorded in the aggregate for all services whose costs are entered on Lines 52 through
61.
Line 79 - Lesser of Medicare Reasonable Cost or Customary Charges – The worksheet calculates the lower
of line 77 or line 78 and enters the result on this line.
Line 80 – Cost PMPM – The worksheet calculates the reimbursable home health agencies cost PMPM by
dividing the total reimbursable home health agencies cost on Line 64 by the respective Medicare primary
member months on Line 1.
Line 82 – Other Providers - Enter the name and type on lines 83 through 93 and the related information for
columns 1 through 5 for each provider being reimbursed through this cost report. Examples of the types of
providers reported in this section are Comprehensive Outpatient Rehabilitation Facilities (CORF), Outpatient
Rehabilitation Provider, etc.
2313 WORKSHEET K - SUMMARY APPORTIONMENT OF NONPROVIDER COSTS
Column 8 – Medicare Customary Charges – Enter in this column for each supplier cost center the customary
charges of the supplier that are uniformly imposed and collected from a substantial percentage of patients that
are liable for payment on a charge basis. Refer to the HCFA Pub #15-1, Section 2606 for descriptions and
definitions for Customary Charges. The charges are recorded in the aggregate for all services whose costs are
entered on Lines 1 through 34.
Column 9 – Lesser of Cost or Charges - The worksheet calculates the lesser of the Medicare cost in Column 7
or the customary charges in Column 8 and enters the result in this column for each of the supplier cost centers.

Rev. 4/5/2013

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