CMS-276 Budget Forecast

version 5.0
This report is required by law (42 USC 1395mm and 42 USC 1995I).
Failure to report can result in all interim payments made since
the beginning of the cost reporting period being deemed overpayments.

FORM APPROVED
OMB NO. 0938-0165

PREPAID HEALTH PLAN COST REPORT
GENERAL INFORMATION
1

Name and Address of Plan:

2

Reporting Period:

WORKSHEET S

Plan Number:
From:
To:

3

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
01/00/1900 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 276-19 (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-annua
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: 12/31/2022

l

BUDGET FORECAST

Name of Plan:
Plan Number:
PART I - PRIOR YEAR
COST & STATISTICAL DATA
Period From:
To:
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

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

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)
1
2
XXXXXXXXXX
-

MEDICARE
PART A
PMPM
COSTS
4
XXXXXXXXX
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000

01/00/1900
01/00/1900

MEDICARE
PART B
PMPM
COSTS
5
XXXXXXXXX

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
0.0000
0.0000
0.0000
0.0000
0.0000

0.0000

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

0.0000
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
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

0

0.0000

0

0.0000

0.0000

0.0000

0.0000

0.0000

12 Est. Deductible & Coinsurance

0.0000

0.0000

0.0000

13 Medicare Costs (Ln 11 - 12)

0.0000

0.0000

0.0000

0.0000

0.0000

0.0000

0.0000

14 Medicare Primary Rate (Ln13*Pt.IV,Ln4)
.
FORM CMS 276-19
(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTION 2303.1-2303.2)

0.0000
0.0000
0.0000
0.0000

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

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................................................................................................................
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)..

TOTAL
1
XXXXXXXXX
XXXXXXXXX
0.0000

01/00/00
01/00/00
MEDICARE
PART A

MEDICARE
PART B

2

3
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

0.0000

10 Part B Costs less Deductibles (Line 7 minus sum of Lines 8 and 9).........................................
11 Part B Coinsurance (Line 10 times 20%).....................................................................................
12 Part B Coinsurance on MAC Paid Bills PMPM (Attach Worksheet)...........................................

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

0.0000
0.0000
0.0000

13 Total Deductible and Coinsurance (Sum of Lines 3, 8, 9, 11 and 12).............................

0.0000

0.0000

7 Net Part B Costs (Line 4 minus Lines 5 and 6).............................................................................
8 Part B Standard Deductible...........................................................................................................
9 Part B Blood Deductible PMPM (Attach Worksheet).....................................................................

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

0.0000

MEDICARE
PART A
1
-

0.0000
0.0000
0.0000
0.0000
0.0000
0.0000

MEDICARE
PART B
2
-

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

-

-

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

0.0000

0.0000

PMPM
1
0.0000
0.0000

Projection
Ratio
2
XXXXXXXXXX
0.0000

PART V - ANNUAL PROJECTIONS
1 Total Medicare Cost Per Capita Rate (Part II, Col 5, Line 13).................................................................................
2 Total Costs Per Member Per Month (Part II, Col 2, Line 11)....................................................................................

FORM CMS 276-19
(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:

01/00/1900
01/00/1900

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

01/00/1900
01/00/1900

Total deductible and coinsurance (Worksheet A, Part III, Col 1, Line 13)............................................................
(Over)/Involuntary Under collection for the period (Worksheet N, Col 3, Line 11/12b, respectively)..............................................
Medicare Member Months for the period (Worksheet L, Column 2, Line 1)….………………..……………………
Ratio of (Wkst B, Col 1, Line 3) to (Worksheet A, Part IV, Col 2, Line 1)..............................................................................................
Adjusted (Over)/Under 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 276-19
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