Crosswalk: Instructions

C. Cost Report Instruction Crosswalk 508.pdf

Prepaid Health Plan Cost Report (CMS-276)

Crosswalk: Instructions

OMB: 0938-0165

Document [pdf]
Download: pdf | pdf
Revisions Crosswalk (Form 276-25)
Cost Report Instructions
Note: In Changes to the Application column, the quoted words are what are to be entered. Example in issue #1 is “276-25”; do not enter the words that
explain the change and that are outside of the quotations.
Issue
#
1.

Page #

2.

6

Action to be
performed
Change form
number
2303.1 Part 1 Change date

3.

6

2303.1 Part 1 Change date

4.

6

2303.1 Part 1 Change date

5.

11

Line 2

Change date

6.

11

Line 2

Change date

7.

11

Line 2

Change date

8.

12

Line 2

Change date

9.

12

Line 2

Change date

10. 12

Line 2

Change date

11.
12.
13.
14.

Line 9a.
Line 9a.
Line 9b.
Line 9b.

Change date
Change date
Change date
Change date

1

34
34
34
34

Section

Changes to the Application

Reason for the Change

Changed form number 276-22 to “276-25”.

To reflect the most recent change in the
form number/year.
To update the date for an example date
range.
To update the date for an example date
range.
To update the date for an example date
range.
To update the date for an example date
range.
To update the date for an example date
range
To update the date for an example date
range
To update the date for an example date
range.
To update the date for an example date
range.
To update the date for an example date
range.
To update the date provided in an example.
To update the date provided in an example.
To update the date provided in an example.
To update the date provided in an example.

Changed date December 31, 2023 to
“December 31, 2025”.
Changed date from December 31, 2021 to
“December 31, 2023”.
Changed date from December 31, 2021 to
“December 31, 2023”.
Changed date December 31, 2023 to
“December 31, 2025”.
Changed date from December 31, 2021 to
“December 31, 2023”.
Changed date from December 31, 2021 to
“December 31, 2023”.
Changed date December 31, 2023 to
“December 31, 2025”.
Changed date from December 31, 2021 to
“December 31, 2023”.
Changed date from December 31, 2021 to
“December 31, 2023”.
Changed date 2023 to “2024”.
Changed date from 2021 to “2022”.
Changed date 2023 to “2024”.
Changed date from 2021 to “2022”.

Page 1 of 2

Issue
Page #
#
15. 34

16. 34

17.
18.
19.
20.

35
35
35
35

21. Footnote

Section
Line 9b.
under
Terminating
Plans
Line 9b.
under
Terminating
Plans
Table.
Table.
Line 12
Line 9b.
under
Terminating
Plans
Footnote

Action to be
performed
Change date

Changes to the Application

Reason for the Change

Changed date 2023 to “2024”.

To update the date provided in an example.

Change date

Changed date from 2022 to “2023”.

To update the date provided in an example.

Change date
Change date
Change date
Change date

Changed date 2021 to “2022”.
Changed date from 2022 to “2023”.
Changed date 2022 to “2024”.
Changed date from 2022 to “2024”.

To update the date provided in an example.
To update the date provided in an example.
To update the date provided in an example.
To update the date provided in an example.

Centered

Centered Footnote in document.

To center the footnote in the document.

Page 2 of 2


File Typeapplication/pdf
File TitleIssue #
AuthorCMS
File Modified2025-01-22
File Created2025-01-16

© 2025 OMB.report | Privacy Policy