Prepaid Health Plan Cost Report (CMS-276)

OMB 0938-0165

These forms are needed to establish the reasonable cost of providing covered services to the enrolled Medicare population of an HMO/CMP/HCPP in accordance with Sections 1876 and 1833 of the Social Security Act.

The latest form for Prepaid Health Plan Cost Report (CMS-276) expires 2022-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
CMS-276 - Supporting Statement - Part A.docx Supporting Statement A
O. Final Cost Report Crosswalk VJ508.pdf Supplementary Document
L. 4th Quarter Interim Cost Report Crosswalk VJ508.pdf Supplementary Document
I. Semi-Annual Interim Cost Report Crosswalk VJ508.pdf Supplementary Document
F. Budget Forecast Crosswalk VJ508.pdf Supplementary Document
Prepaid Health Plan Cost Report (HCPPS) Instruction
Prepaid Health Plan Cost Report (HMO) Instruction

All Historical Document Collections

202203-0938-008 Approved without change	Revision of a currently approved collection	2022-03-30
201904-0938-011 Approved with change	Revision of a currently approved collection	2019-04-30
201605-0938-015 Approved with change	Revision of a currently approved collection	2016-05-27
201305-0938-010 Approved without change	Reinstatement with change of a previously approved collection	2013-05-20
200908-0938-012 Approved without change	Extension without change of a currently approved collection	2009-08-31
200605-0938-007 Approved without change	Extension without change of a currently approved collection	2006-05-15
200301-0938-004 Approved without change	Revision of a currently approved collection	2003-01-06
199910-0938-004 Approved without change	Revision of a currently approved collection	1999-10-26
199608-0938-007 Approved without change	Revision of a currently approved collection	1996-08-14
199307-0938-007 Approved without change	Reinstatement with change of a previously approved collection	1993-07-07
199211-0938-001 Approved without change	Reinstatement with change of a previously approved collection	1992-11-04
199105-0938-017 Approved with change	No material or nonsubstantive change to a currently approved collection	1991-05-07
199012-0938-012 Approved without change	Reinstatement with change of a previously approved collection	1990-12-18
198109-0938-006 Approved with change	No material or nonsubstantive change to a currently approved collection	1981-09-01
198104-0938-003 Approved without change	New collection (Request for a new OMB Control Number)	1981-04-14

OMB Details

Prepaid Health Plan Cost Report (HCPPS)

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-276	Final Cost Report	Fillable Fileable	Form
Form CMS-276	Semi Annual Cost Report	Fillable Fileable	Form
Form CMS-276	Budget Forecast	Fillable Fileable	Form
Form CMS-276	4th Quarter Interim Cost Report	Fillable Fileable	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.