Health Care Prepayment Plans (HCPPs) under Section 1833

Prepaid Health Plan Cost Report (CMS-276)

Documents and Forms

Document Name Document Type
C. Cost Report Instructions CLEAN 508.pdf Instruction
CMS-276 4th Quarter Interim Cost Report K. 4th Quarter Interim Cost Report - Revised 508.pdf Form
CMS-276 Budget Forecast E. Budget Forecast- Revised 508.pdf Form
CMS-276 Interim Cost Report H. Interim Cost Report - Revised VJ508.pdf Form
CMS-276 Final Cost Report N. Final Cost Report PDF 508.pdf Form
C. Cost Report Instruction Crosswalk 508.pdf Crosswalk: Instructions IC Document
F. Budget Forecast Crosswalk 508.pdf Crosswalk: Budget Forecast IC Document
I. Interim Cost Report Crosswalk 508.pdf Crosswalk: Interim Cost Report IC Document
L. 4thQtrInterim Revised Cost Rep Crosswalk 508.pdf Crosswalk: 4th Quarter Interim Cost Report IC Document
O. Final Cost Report Crosswalk 508.pdf Crosswalk: Final Cost Report IC Document

Information Collection (IC) Details

IC Title:	Health Care Prepayment Plans (HCPPs) under Section 1833	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 417.808 42 CFR 417.810

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			C. Cost Report Instructions CLEAN 508.pdf	Yes	No	Fillable Fileable
Form	CMS-276	4th Quarter Interim Cost Report	K. 4th Quarter Interim Cost Report - Revised 508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	Budget Forecast	E. Budget Forecast- Revised 508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	Interim Cost Report	H. Interim Cost Report - Revised VJ508.pdf	Yes	Yes	Fillable Fileable
Form	CMS-276	Final Cost Report	N. Final Cost Report PDF 508.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	18	-6	24
Annual IC Time Burden (Hours)	480	-160	640
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk: Instructions	C. Cost Report Instruction Crosswalk 508.pdf	07/29/2025
Crosswalk: Budget Forecast	F. Budget Forecast Crosswalk 508.pdf	07/29/2025
Crosswalk: Interim Cost Report	I. Interim Cost Report Crosswalk 508.pdf	07/29/2025
Crosswalk: 4th Quarter Interim Cost Report	L. 4thQtrInterim Revised Cost Rep Crosswalk 508.pdf	07/29/2025
Crosswalk: Final Cost Report	O. Final Cost Report Crosswalk 508.pdf	07/29/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.