CMS-276 Budget Forecast

version 3.1
This report is required by law (42 USC 1395mm and 42 USC 1995I).
Failure to report can result in all interim payments made since
the beginning of the cost reporting period being deemed overpayments.

FORM APPROVED
OMB NO. 0938-0165

PREPAID HEALTH PLAN COST REPORT
GENERAL INFORMATION
1

Name and Address of Plan:

2

Reporting Period:

3

WORKSHEET S

Plan Number:
From:

01/01/2014

To:

12/31/2014

a. Type of Report:

b. Bill Processing Option:

[X ] Budget Forecast

c. Reimbursement Under:

Select Option

Select Section

[ ] Interim Reports
[ ] Final Cost Report

MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST
REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW
CERTIFICATION BY OFFICER OF THE PLAN
I HEREBY CERTIFY that I have examined the accompanying Statement of Reimbursable Cost, the allocation of
expenses and services, and the attached Worksheets for the period from
01/01/2014 to 12/31/2014
and that to the best of my knowledge and belief they are true and correct statements prepared from the books
and records of the Plan in accordance with applicable instructions, except as noted.

SIGNATURE (Officer or Administrator of the Plan)

DATE

TITLE

PHONE NUMBER

FORM CMS 276-08 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2302)
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-0165. The time required to complete this information is estimated to average as follows: (1) for HMOs/CMPs,
24 hours to complete the budget forecast, 80 hours to complete the fourth quarter and final cost reports, and 12 hours to complete the first, second, and third quarterly reports;
and (2)for HCPPs, 16 hours to complete the budget forecast, 60 hours to complete the final cost report, and 8 hours to complete the mid-year report. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland
21244-1850 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

BUDGET FORECAST

Name of Plan:
Plan Number:
PART I - PRIOR YEAR
COST & STATISTICAL DATA
Period From:
01/01/2012
To:
12/31/2012
0 Total Member Months
1
2
3
4
5
6
7
7a
7b
7c
8
9

WORKSHEET A
PARTS I & II
Budget Period From:
To:

0
0

TRIAL
BALANCE
PER BOOKS
1
XXXXXXXXXX

Hospital Costs......................
Skilled Nursing Facilities...…
Home Health Agencies.....…
Other Providers....................
Non-Providers......................
Plan Administration………..
Special Admin. Costs:.........
Accretion/Deletion…………
Cost Report Certification…..
Other:
Part B Cost Not Subj to Coins
Administrative and General….

10 Total Costs (Sums Ln 1-9)....

PART II - BUDGET YEAR
COST & STATISTICAL DATA

0 Total Member Months..........
1
2
3
4
5
6
7
7a
7b
7c
8
9
10

Hospital Costs......................
Skilled Nursing Facilities…...
Home Health Agencies........
Other Providers....................
Non-Providers......................
Plan Administration.............
Special Admin. Costs:.........
Accretion/Deletion…………
Cost Report Certification…..
Other:
Part B Cost Not Subj to Coins
3rd Party Insurer Revenue....
Administrative and General

PMPM
COSTS
2
-

TOTAL
MEDICARE
PMPM
COSTS
3
XXXXXXXXX

0
0
0
0
0
0

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0
0
0
0
0

0.0000
0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000

0

0.0000

0.0000

TOTAL
PROJECTED
COSTS

PROJECTED
PMPM
COSTS
(COL 1 /
COL 2, LN 0)
2
-

1
XXXXXXXXXX

MEDICARE
PART A
PMPM
COSTS
4
XXXXXXXXX

MEDICARE
PART B
PMPM
COSTS
5
XXXXXXXXX

0.0000
0.0000
0.0000
0.0000
0.0000

0.0000

01/01/2014
12/31/2014
MEDICARE
RATIO
(COL 3 /
COL 2)
6
XXXXXXXXX

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000

MEDICARE
PART A RATIO
(COL 4 /
COL 3)
7
XXXXXXXXXX

0

0.0000
0.0000
0.0000
0.0000

1
2
3
4
5
0.0000 6
7
7a
7b
7c
8
9

0.0000

10

MEDICARE
PMPM
ADJUSTED
MEDICARE
PROJECTED ADJUSTMENT MEDICARE
PART A
PMPM COSTS
(FROM
PMPM COSTS PMPM COSTS
(COL 2 *
ATTACHED (COL3+ COL4)
(COL 5 *
COL 6, Pt. I) WORKSHEET)
COL 7, PT. I)
3
4
5
6
XXXXXXXXX XXXXXXXXX XXXXXXXXX XXXXXXXXX

0

0
0
0
0
0
0

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000

0
0
0
0

0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000
0.0000

0.0000
0.0000
0.0000
0.0000
0.0000

0.0000

0.0000 1
0.0000 2
0.0000 3
0.0000 4
0.0000 5
0.0000 6
0.0000 7
0.0000 7a
0.0000 7b
0.0000 7c
0.0000 8
0.0000 9

0

0.0000

0

0.0000

0.0000

0.0000

0.0000

0.0000 11

12 Est. Deductible & Coinsurance

0.0000

0.0000

0.0000 12

13 Medicare Costs (Ln 11 - 12)

0.0000

0.0000

0.0000 13

11 Total Costs (Sum Lns 1-10)....

0.0000

14 Pay% (Ln13*Pt.IV,Col2,Ln4)

0.0000
.

0.0000
0.0000
0.0000
0.0000

MEDICARE
PART B
PMPM COSTS
(COL 5 COL 6)
7
XXXXXXXXXX

14

FORM CMS 276-08
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 2303.1-2303.2)

BUDGET FORECAST

Name of Plan:
Plan Number:

WORKSHEET A
PARTS III, IV & V
0
0

Budget Period From:
To:

PART III - DEDUCTIBLE AND COINSURANCE

1 Total Estimated Part A deductible and coinsurance (Attach Worksheet)....................................
2 Part A Member Months (Part IV, Col 1, Line 3).............................................................................
3 Line 1 divided by Line 2................................................................................................................

TOTAL
1
XXXXXXXXX
XXXXXXXXX
0.0000

4 Total Part B Costs (Part II, Col 7, Line 11).....................................................................................
5 Less Special Administrative Costs (Part II, Col 7, Line 7).............................................................
6 Part B Costs not Subject to Coinsurance (Part II, Col 7, Line 8)..
7
8
9
10

Net Part B Costs (Line 4 minus Lines 5 and 6).............................................................................
Part B Standard Deductible...........................................................................................................
Part B Blood Deductible PMPM (Attach Worksheet).....................................................................
Mental Health Copayment PMPM (Attach Worksheet)..................................................................

11
12
13
14

Part B Costs less Deductibles (Line 7 minus sum of Lines 8 thru 10).........................................
Part B Coinsurance (Line 11 times 20%).....................................................................................
Part B Coinsurance on Carrier Paid Bills PMPM (Attach Worksheet)...........................................
Part B Coinsurance on Intermediary Paid Bills PMPM (Attach Worksheet)...................................

15 Total Deductible and Coinsurance (Sum of Lines 3, 8, 9, 10, 12, 13 and 14).............................

01/01/14
12/31/14
MEDICARE
PART A

MEDICARE
PART B

2

3
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

0.0000

1
2
3

0.0000 XXXXXXXXX
0.0000 XXXXXXXXX
0.0000 XXXXXXXXX
XXXXXXXXX
0.0000 XXXXXXXXX
0.0000 XXXXXXXXX
0.0000 XXXXXXXXX
0.0000 XXXXXXXXX
XXXXXXXXX
0.0000 XXXXXXXXX
0.0000 XXXXXXXXX
0.0000 XXXXXXXXX
0.0000 XXXXXXXXX

0.0000
0.0000
0.0000

0.0000

0.0000 15

PART IV - MEMBERSHIP
1 Total Medicare Member Months.........................................................................................................................…
2 Medicare Secondary Liable (Employer Groups) Member Months.........................................................................

0.0000

MEDICARE
PART A
1
-

4
5
6

0.0000 7
0.0000 8
0.0000 9
0.0000 10
0.0000
0.0000
0.0000
0.0000

11
12
13
14

MEDICARE
PART B
2
-

1
2

3 Medicare Primary Member Months (Line 1 less Line 2).........................................................................................

-

-

3

4 Ratio (Line 3 / Line 1).............................................................................................................................................

0.0000

0.0000

4

PMPM
1
0.0000
0.0000

Fluctuation
Ratio
2
XXXXXXXXXX
0.0000

1
2

0.0000

0.0000

3

PART V - SEMI ANNUAL FLUCTUATIONS
1 Total Medicare Cost Per Capita Rate (Part II, Col 5, Line 12).................................................................................
2 Total Costs Per Member Per Month (Part II, Col 2, Line 10)....................................................................................

3 Cumulative Estimate of Total Costs PMPM for First Two Quarters........................................................................

FORM CMS 276-08
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 2303.1-2303.2)

BUDGET FORECAST

Name of Plan:
Plan Number:

WORKSHEET B

0
0

Budget Period From:
To:

01/01/2014
12/31/2014

DETERMINATION OF BUDGETED VOLUNTARY UNDER COLLECTION OF PREMIUMS FOR THE BUDGET PERIOD
PREMIUM DETERMINATIONS ARE COVERED BY THIS PART
Period From:
To:
1
2
3
4
5
6
7

01/01/2012
12/31/2012

Total deductible and coinsurance (Worksheet A, Part III, Col 1, Line 15)............................................................
Under (over) collection for the period (Worksheet N, Col 3, Line 12b/11, respectively)..............................................
Medicare Member Months for the period (Worksheet L, Column II, Line 1)….………………..……………………
Ratio of (Wkst B, Col 1, Line 3) to (Worksheet A, Part IV, Col 2, Line 1)..............................................................................................
Adjusted Under (Over) Collection for the period (Line 2 times Line 4)....................................................................................................
Total allowed to be collected during the budget period (Line 1 plus Line 5)...................................................................
Total amounts to be charged in budget year, including Medicare enrollee copayments (Attach Worksheet)..............................

TOTALS

AMOUNT PER
MEMBER MONTH

1

2

XXXXXXXXXXX

0.0000
XXXXXXXXXXX
XXXXXXXXXXX
0.0000 XXXXXXXXXXX
XXXXXXXXXXX
0.0000
XXXXXXXXXXX
0.0000
XXXXXXXXXXX

XXXXXXXXXXX
8 Budgeted Voluntary under collection for the budget period (Line 6 minus Line 7) ................................................................................... XXXXXXXXXXX
FORM CMS 276-08
INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 2304.1 - 2304.2

0.0000

1
2
3
4
5
6
7
8

SUPPORTING WORKSHEET FOR
WORKSHEET A, PART II
CURRENT YEAR PMPM ADJUSTMENTS

Wkst A
Line Ref.

DESCRIPTION

PMPM Adj to
Wkst A, Part II