Budget Forecast

F. Budget Forecast Crosswalk VJ508.pdf

Prepaid Health Plan Cost Report (CMS-276)

Budget Forecast

OMB: 0938-0165

Document [pdf]
Download: pdf | pdf
Revisions Crosswalk (Form 276-22)
Budget Forecast
Note: In Changes to the Application column, the quoted words are what are to be entered. Example in issue #1 is “276-22”; 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

Parts
I,II,III,V
Row 22

6.
7.

Worksheet B
Worksheet A
Part II – Line
7a 7b 7c

Columns 1,2
N/A

Action to be
performed
Change form
number
Remove

Changes to the Application
Changed form number 276-19 to “276-22”.
Remove Form Expiration Date: 8/31/2022

Change form
number
Formatting

Changed form number 276-19 to “276-22”.

Change form
number
Formatting
Add a tab

Changed form number 276-19 to “276-22”.

Replace cells with “XXXXX” with shading

Replace cells with “XXXXX” with shading
Add an A Part II – Line 7a 7b 7c tab for
special admin costs supporting documentation

Reason for the Change
To reflect the most recent change in the
form number/year.
This date is not determined until approval
of the PRA package renewal.
To reflect the most recent change in the
form number/year.
To be consistent with other cells in the
worksheet.
To reflect the most recent change in the
form number/year.
To be consistent with other worksheets.
CR instructions requests supporting
documentation for these costs.

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File Typeapplication/pdf
File TitleIssue #
AuthorCMS
File Modified2022-01-19
File Created2022-01-10

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