CMS-276 Budget Forecast

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Overview

Worksheet S
Worksheet A
Worksheet B
A-Part II, Col 4

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Sheet 1: Worksheet S

										version 4.0
This report is required by law (42 USC 1395mm and 42 USC 1995I).										FORM APPROVED
Failure to report can result in all interim payments made since										OMB NO. 0938-0165
the beginning of the cost reporting period being deemed overpayments.
	PREPAID HEALTH PLAN COST REPORT									WORKSHEET S
	GENERAL INFORMATION
1	Name and Address of Plan:
2	Reporting Period:									Plan Number:
		From:
		To:
3	a. Type of Report:		b. Bill Processing Option:				c. Reimbursement Under:
	[X ] Budget Forecast	Budget Forecast		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 01/00/1900 to 01/00/1900
		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.
	SIGNATURE (Officer or Administrator of the Plan)						DATE
	TITLE						PHONE NUMBER
FORM CMS 276-16 (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 4th quarter and final cost reports, 4 hours to complete the semi-annual Interim, and 0 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 4 hours to complete the semi-annual
Interim 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,
Mail Stop C3-14-16, Baltimore, Maryland 21244-1850 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.
Form Expiration Date: 11/30/2019

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Sheet 2: Worksheet A

BUDGET FORECAST								WORKSHEET A
								PARTS I & II
Name of Plan:			0			Budget Period From:		12/30/1899
Plan Number:			0				To:	12/30/1899
PART I - PRIOR YEAR					TOTAL	MEDICARE	MEDICARE	MEDICARE	MEDICARE
COST & STATISTICAL DATA			TRIAL		MEDICARE	PART A	PART B	RATIO	PART A RATIO
			BALANCE	PMPM	PMPM	PMPM	PMPM	(COL 3 /	(COL 4 /
Period From:			PER BOOKS	COSTS	COSTS	COSTS	COSTS	COL 2)	COL 3)
	To:		1	2	3	4	5	6	7
0	Total Member Months		XXXXXXXXXX	-	XXXXXXXXX	XXXXXXXXX	XXXXXXXXX	XXXXXXXXX	XXXXXXXXXX	0
1	Hospital Costs......................		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	1
2	Skilled Nursing Facilities...…		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	2
3	Home Health Agencies.....…		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	3
4	Other Providers....................		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	4
5	Non-Providers......................		0	0.0000	0.0000		0.0000	0.0000		5
6	Plan Administration………..		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	6
7	Special Admin. Costs:.........									7
7a	Accretion/Deletion…………		0	0.0000	0.0000		0.0000	0.0000		7a
7b	Cost Report Certification…..		0	0.0000	0.0000		0.0000	0.0000		7b
7c	Other:		0	0.0000	0.0000		0.0000	0.0000		7c
8	Part B Cost Not Subj to Coins		0	0.0000	0.0000		0.0000	0.0000		8
9	Administrative and General….		0	0.0000						9
10	Total Costs (Sums Ln 1-9)....		0	0.0000	0.0000	0.0000	0.0000			10
			TOTAL	PROJECTED	MEDICARE	PMPM	ADJUSTED	MEDICARE	MEDICARE
PART II - BUDGET YEAR			PROJECTED	PMPM	PROJECTED	ADJUSTMENT	MEDICARE	PART A	PART B
COST & STATISTICAL DATA			COSTS	COSTS	PMPM COSTS	(FROM	PMPM COSTS	PMPM COSTS	PMPM COSTS
				(COL 1 /	(COL 2 *	ATTACHED	(COL3+ COL4)	(COL 5 *	(COL 5 -
				COL 2, LN 0)	COL 6, Pt. I)	WORKSHEET)		COL 7, PT. I)	COL 6)
			1	2	3	4	5	6	7
0	Total Member Months..........		XXXXXXXXXX	-	XXXXXXXXX	XXXXXXXXX	XXXXXXXXX	XXXXXXXXX	XXXXXXXXXX	0
1	Hospital Costs......................		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	1
2	Skilled Nursing Facilities…...		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	2
3	Home Health Agencies........		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	3
4	Other Providers....................		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	4
5	Non-Providers......................		0	0.0000	0.0000	0.0000	0.0000		0.0000	5
6	Plan Administration.............		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	6
7	Special Admin. Costs:.........								0.0000	7
7a	Accretion/Deletion…………		0	0.0000	0.0000	0.0000	0.0000		0.0000	7a
7b	Cost Report Certification…..		0	0.0000	0.0000	0.0000	0.0000		0.0000	7b
7c	Other:		0	0.0000	0.0000	0.0000	0.0000		0.0000	7c
8	Part B Cost Not Subj to Coins		0	0.0000	0.0000	0.0000	0.0000		0.0000	8
9	3rd Party Insurer Revenue....					0.0000	0.0000	0.0000	0.0000	9
10	Administrative and General		0	0.0000
11	Total Costs (Sum Lns 1-10)....		0	0.0000	0.0000	0.0000	0.0000	0.0000	0.0000	10
12	Est. Deductible & Coinsurance						0.0000	0.0000	0.0000	11
13	Medicare Costs (Ln 11 - 12)						0.0000	0.0000	0.0000	12
14	Medicare Primary Rate (Ln13*Pt.IV,Ln4)						0.0000	0.0000	0.0000	13
							.
FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 2303.1-2303.2)
BUDGET FORECAST								WORKSHEET A
								PARTS III, IV & V
Name of Plan:			0			Budget Period From:		12/30/99
Plan Number:			0				To:	12/30/99
								MEDICARE	MEDICARE
PART III - DEDUCTIBLE AND COINSURANCE							TOTAL	PART A	PART B
							1	2	3
1	Total Estimated Part A deductible and coinsurance (Attach Worksheet)....................................						XXXXXXXXX	-	XXXXXXXXXX	1
2	Part A Member Months (Part IV, Col 1, Line 3).............................................................................						XXXXXXXXX	-	XXXXXXXXXX	2
3	Line 1 divided by Line 2................................................................................................................						0.0000	0.0000	XXXXXXXXXX	3
4	Total Part B Costs (Part II, Col 7, Line 11).....................................................................................						0.0000	XXXXXXXXX	0.0000	4
5	Less Special Administrative Costs (Part II, Col 7, Line 7).............................................................						0.0000	XXXXXXXXX	0.0000	5
6	Part B Costs not Subject to Coinsurance (Part II, Col 7, Line 8)..						0.0000	XXXXXXXXX	0.0000	6
								XXXXXXXXX
7	Net Part B Costs (Line 4 minus Lines 5 and 6).............................................................................						0.0000	XXXXXXXXX	0.0000	7
8	Part B Standard Deductible...........................................................................................................						0.0000	XXXXXXXXX	0.0000	8
9	Part B Blood Deductible PMPM (Attach Worksheet).....................................................................						0.0000	XXXXXXXXX	0.0000	9
								XXXXXXXXX
10	Part B Costs less Deductibles (Line 7 minus sum of Lines 8 and 9).........................................						0.0000	XXXXXXXXX	0.0000	10
11	Part B Coinsurance (Line 10 times 20%).....................................................................................						0.0000	XXXXXXXXX	0.0000	11
12	Part B Coinsurance on MAC Paid Bills PMPM (Attach Worksheet)...........................................						0.0000	XXXXXXXXX	0.0000	12
13	Total Deductible and Coinsurance (Sum of Lines 3, 8, 9, 11 and 12).............................						0.0000	0.0000	0.0000	13
								MEDICARE	MEDICARE
PART IV - MEMBERSHIP								PART A	PART B
								1	2
1	Total Medicare Member Months.........................................................................................................................…							-	-	1
2	Medicare Secondary Liable (Employer Groups) Member Months.........................................................................							-	-	2
3	Medicare Primary Member Months (Line 1 less Line 2).........................................................................................							-	-	3
4	Ratio (Line 3 / Line 1).............................................................................................................................................							0.0000	0.0000	4
									Projection
PART V - ANNUAL PROJECTIONS								PMPM	Ratio
								1	2
1	Total Medicare Cost Per Capita Rate (Part II, Col 5, Line 13).................................................................................							0.0000	XXXXXXXXXX	1
2	Total Costs Per Member Per Month (Part II, Col 2, Line 11)....................................................................................							0.0000	0.0000	2
FORM CMS 276-16
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 2303.1-2303.2)

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Sheet 3: Worksheet B

BUDGET FORECAST								WORKSHEET B
Name of Plan:		0				Budget Period From:		12/30/1899
Plan Number:		0				To:		12/30/1899
DETERMINATION OF BUDGETED VOLUNTARY UNDER COLLECTION OF PREMIUMS FOR THE BUDGET PERIOD
PREMIUM DETERMINATIONS ARE COVERED BY THIS PART
	Period From:	12/30/1899							AMOUNT PER
	To:	12/30/1899						TOTALS	MEMBER MONTH
								1	2
1	Total deductible and coinsurance (Worksheet A, Part III, Col 1, Line 13)............................................................							XXXXXXXXXXX	0.0000	1
2	(Over)/Involuntary Under collection for the period (Worksheet N, Col 3, Line 11/12b, respectively)..............................................								XXXXXXXXXXX	2
3	Medicare Member Months for the period (Worksheet L, Column 2, Line 1)….………………..……………………								XXXXXXXXXXX	3
4	Ratio of (Wkst B, Col 1, Line 3) to (Worksheet A, Part IV, Col 2, Line 1)..............................................................................................							0.0000	XXXXXXXXXXX	4
5	Adjusted (Over)/Under Collection for the period (Line 2 times Line 4)....................................................................................................							XXXXXXXXXXX	0.0000	5
6	Total allowed to be collected during the budget period (Line 1 plus Line 5)...................................................................							XXXXXXXXXXX	0.0000	6
7	Total amounts to be charged in budget year, including Medicare enrollee copayments (Attach Worksheet)..............................							XXXXXXXXXXX		7
								XXXXXXXXXXX
8	Budgeted Voluntary under collection for the budget period (Line 6 minus Line 7) ................................................................................................							XXXXXXXXXXX	0.0000	8
FORM CMS 276-16
INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 2304.1 - 2304.2

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Sheet 4: A-Part II, Col 4

SUPPORTING WORKSHEET FOR
WORKSHEET A, PART II
CURRENT YEAR PMPM ADJUSTMENTS
Wkst A											PMPM Adj to Wkst A, Part II
Line Ref.	DESCRIPTION