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Form CMS-10261 Attachment III - Medicare Advantage Medical Utilization
ICR 200810-0938-009 · OMB 0938-1054 · Object 8956601.
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| Attachment III: Medicare Advantage Medical Utilization and Expenditure Experience | |||||||||||||
| Contract number | |||||||||||||
| PBP | |||||||||||||
| Organization Name | |||||||||||||
| Reporting period | |||||||||||||
| (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | (9) | (10) | (11) | (12) | (13) | |
| Medical Expenses | |||||||||||||
| Utilization | Plan Experience | Allowed cost | Cost sharing | Net | |||||||||
| Total | Total Member | Allowed | Total | Supplemental | Medicare | Supplemental | supplemental | ||||||
| Member Months | Utilizers | Utilization | Total | Plan | cost | cost | Medicare | benefits | actuarial | benefits | benefits | ||
| Service Category | Months Cov. | Type | Utilization | reimb. | sharing | (g + h) | covered | (i - j) | equivalent | (l - h) | (k + m) | ||
| a. | Inpatient Facility | $- | $- | $- | $- | ||||||||
| b. | Skilled Nursing Facility | $- | $- | $- | $- | ||||||||
| c. | Home Health | $- | $- | $- | $- | ||||||||
| d. | Ambulance | $- | $- | $- | $- | ||||||||
| e. | DME/Prosthetics/Supplies | $- | $- | $- | $- | ||||||||
| f. | OP Facility - Emergency | $- | $- | $- | $- | ||||||||
| g. | OP Facility - Surgery | $- | $- | $- | $- | ||||||||
| h. | OP Facility - Other | $- | $- | $- | $- | ||||||||
| i. | Professional | $- | $- | $- | $- | ||||||||
| j. | Part B Rx | $- | $- | $- | $- | ||||||||
| k. | Other Medicare Part B | $- | $- | $- | $- | ||||||||
| l. | Transportation (Non-Covered) | $- | $- | $- | $- | $- | $- | ||||||
| m. | Dental (Non-Covered) | $- | $- | $- | $- | $- | $- | ||||||
| n. | Vision (Non-Covered) | $- | $- | $- | $- | $- | $- | ||||||
| o. | Hearing (Non-Covered) | $- | $- | $- | $- | $- | $- | ||||||
| p. | Health & Education (Non-Covd) | $- | $- | $- | $- | $- | $- | ||||||
| q. | Other Non-Covered | $- | $- | $- | $- | $- | $- | ||||||
| r. | Total Medical Expenses | $- | $- | $- | $- | ||||||||
| Supplemental data | |||||||||||||
| Total Enrollees | |||||||||||||
| Member months | |||||||||||||
| Premiums collected | |||||||||||||
| CMS revenue collected | |||||||||||||
| Reserve for outstanding claims | |||||||||||||
| Notes | |||||||||||||
| 1. Form to be completed at the plan level. | |||||||||||||
| 2. Data to be entered by Plans are shaded in blue. | |||||||||||||
| 3. Data calculated by CMS are shaded in yellow. | |||||||||||||
| 4. Utilization types: A - Admits; D - Days; BP - Benefit period; V - visits; P - procedures; T - Trips; S - Scripts; O - other; U - Data is unavailable | |||||||||||||
| 5. Medicare actuarial equivalent cost sharing to be developed using actuarial equivalent factors contained in MA bid pricing tool. | |||||||||||||
| 6. Premiums collected include payments from plan enrollees, employer/union groups, State Medicaid agencies, and other third parties. | |||||||||||||
| 7. Optional supplemental benefits, revenues, and member months are to be excluded. | |||||||||||||
| File Type | application/vnd.ms-excel |
| File Title | Form CMS-10261 Attachment III - Medicare Advantage Medical Utilization |
| Author | OACT |
| Last Modified By | CMS |
| File Modified | 2008-09-25 |
| File Created | 2008-02-27 |