Budget Forecast

F. Budget Forecast Crosswalk VJ508.pdf

Prepaid Health Plan Cost Report

Budget Forecast

OMB: 0938-0165

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Revisions Crosswalk (Form 276-19)
Budget Forecast
Note: In Changes to the Application column, the quoted words are what are to be entered. Example in issue #1 is “276-19”; do not enter the words that
explain the change and that are outside of the quotations.

Issue
#
1.

Page #

Section

Worksheet S

Row 59

2.

Worksheet S

Row 68

3.

Worksheet A

Row 60

4.

Worksheet A

5.

Worksheet B

Column K
(Excel
column K)
Row 22

Action to be
performed
Change form
number
Change Date
Change form
number
Remove

Change form
number

Changes to the Application
Changed form number 276-16 to “276-19”.
Changed Form Expiration Date: 12/31/2019
to “12/31/2022)
Changed form number 276-16 to “276-19”.
Remove this column entirely.

Changed form number 276-16 to “276-19”.

Reason for the Change
To reflect the most recent change in the
form number/year.
Pending until approval of the PRA package
renewal.
To reflect the most recent change in the
form number/year.
Line numbers are already reported in
column A (Excel column A).
To reflect the most recent change in the
form number/year.

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