Excel Sample Sheet 32543

Partial file snippet.

Sheet 1: Instructions

	
	
	
		

		Instructions for Completion of the Template
	
	
		

		

	
	
		Balance Sheet Tab
		

	
	
		1
		Replace the red text in cells A1, A3, and A5 with the name of the current CMO, new CMO, and as of date.
	
	
		

		

	
	
		2
		Replace the red text in cells B9, C9, and D9 with the appropriate date.
	
	
		

		

	
	
		3
		Complete column B of with the most current balance sheet period and identify the period.
	
	
		

		

	
	
		4
		Project the balance sheet as of the last day of business before transition.  This will include a projection of net income through the last day of business.
	
	
		

		

	
	
		5
		Project the working capital position, restricted reserves and solvency fund positions including investment income.
	
	
		

		

	
	
		6
		Complete column C of the template with the projected balance sheet numbers from #s 2 and 3.  This column is as of the last day prior to transition of the balance sheet items to the organization.
	
	
		

		

	
	
		7
		Complete column D of the first day of the new transitioned organization.
	
	
		

		

	
	
		8
		Provide a Description in Column F for every line item that has a change in column E.  Include what is not transitioning and where the item is going through the process (e.g. Furniture is remaining with XXXXX County/District).  Provide supporting documents that outline why the asset and/or laibaility will not be transferred.
	
	
		

		

	
	
		LT Obligations Tab
		

	
	
		

		Provide a listing of all long-term obligatiosn for the currently permitted CMO and for the assuming organization.
	
	
		

		

	
	
		Guarantees Tab
		

	
	
		

		Provide a listing of all financial guarantees for the currently permitted CMO and for the assuming organization.
	



Sheet 2: Balance Sheet

	
	
	
	
		Current CMO:   Name
		

		

		

		

		

	
	
		Transition of Assets and Liabilities
		

		

		

		

		

	
	
		To New CMO:  Name
		

		

		

		

		

	
	
		Projected Balance Sheet
		

		

		

		

		

	
	
		As of MM/DD/CCYY
		

		

		

		

		

	
	
		

		

		

		

		

		

	
	
		

		Most
		Last Day
		First Day
		

		

	
	
		

		Recent Filed
		Old CMO
		New CMO
		Amount of
		

	
	
		

		Enter Date
		Enter Date
		Enter Date
		Transition
		Transition Plan:
	
	
		

		Actual 
		Projected
		Projected
		Change
		Explanation of Change if not to new CMO
	
	
		Current Assets
		

		

		

		

		

	
	
		Cash and cash equivalents, Operating 
		

		

		

		 -   
		

	
	
		Cash and cash equivalents, Other
		

		

		

		 -   
		

	
	
		Short term investments (unrestricted)
		

		

		

		 -   
		

	
	
		Capitation receivable  
		

		

		

		 -   
		

	
	
		Other DHS receivables  
		

		

		

		 -   
		

	
	
		Cost share receivable    
		

		

		

		 -   
		

	
	
		Room & Board receivable 
		

		

		

		 -   
		

	
	
		Spend Down receivable  
		

		

		

		 -   
		

	
	
		Other third party receivable
		

		

		

		 -   
		

	
	
		Other short term receivables 
		

		

		

		 -   
		

	
	
		Parent, subsidiary, affiliate receivable 
		

		

		

		 -   
		

	
	
		Reinsurance receivable 
		

		

		

		 -   
		

	
	
		Prepaid Insurance
		

		

		

		 -   
		

	
	
		Prepaid providers (member service expenses)
		

		

		

		 -   
		

	
	
		Prepaid expenses-Other
		

		

		

		 -   
		

	
	
		Supply Inventory
		

		

		

		 -   
		

	
	
		Other Current assets 
		

		

		

		 -   
		

	
	
		   Total Current Assets
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		

		

		

		

		

		

	
	
		Long Term or Restricted Assets
		

		

		

		

		

	
	
		Restricted Assets:
		

		

		

		

		

	
	
		Risk Reserve Funds-FC Permitted MCO
		

		

		

		 -   
		

	
	
		Reserve guaranty funds on deposit, HMO
		

		

		

		 -   
		

	
	
		Solvency Reserve/guaranty funds on deposit Permitted MCO
		

		

		

		 -   
		

	
	
		LT Assets:
		

		

		

		

		

	
	
		Other LT Investments, unrestricted 
		

		

		

		 -   
		

	
	
		Building/Land (cost)
		

		

		

		 -   
		

	
	
		Accumulated Depreciation- Building/Land 
		

		

		

		 -   
		

	
	
		Leasehold Improvements (cost)
		

		

		

		 -   
		

	
	
		Accumulated Depreciation-Leasehold Improvements 
		

		

		

		 -   
		

	
	
		Furniture, Equipment & Software (cost)
		

		

		

		 -   
		

	
	
		Accumulated Depreciation- Furniture, Equipment & Software 
		

		

		

		 -   
		

	
	
		Other long term assets
		

		

		

		 -   
		

	
	
		   Total Long Term or Restricted Assets
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		Total Assets
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		Liabilities
		

		

		

		

		

	
	
		Short Term Liabilities
		

		

		

		

		

	
	
		Capitation Payable
		

		

		

		 -   
		

	
	
		Unearned Capitation Revenue
		

		

		

		 -   
		

	
	
		Unearned Revenue-Other
		

		

		

		 -   
		

	
	
		Accrued Salaries
		

		

		

		 -   
		

	
	
		Accrued Taxes & Benefits (current)
		

		

		

		 -   
		

	
	
		IBNR Member Services- current Year
		

		

		

		 -   
		

	
	
		IBNR Member Services -prior year
		

		

		

		 -   
		

	
	
		Accounts Payable -Claims Processed, Internal Claims System 
		

		

		

		 -   
		

	
	
		Accounts Payable-Claims Processed, TPA
		

		

		

		 -   
		

	
	
		Accounts Payable -Care Management
		

		

		

		 -   
		

	
	
		Accounts Payable- General
		

		

		

		 -   
		

	
	
		Parent, subsidiary, affiliate payable
		

		

		

		 -   
		

	
	
		Due to Other 
		

		

		

		 -   
		

	
	
		Current Portion of Long Term Debt
		

		

		

		 -   
		

	
	
		Income Taxes Payable 
		

		

		

		 -   
		

	
	
		Other Current Liabilities
		

		

		

		 -   
		

	
	
		   Total Short Term Liabilities
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		Long Term Liabilities
		

		

		

		

		

	
	
		Accrued Employee Benefits (i.e. Vacation, sick leave > 1 year)
		

		

		

		 -   
		

	
	
		Loans Payable 
		

		

		

		 -   
		

	
	
		Due to Other, LT  
		

		

		

		 -   
		

	
	
		Other Long Term Liabilities
		

		

		

		 -   
		

	
	
		   Total Long Term Liabilities
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		Total Liabilities
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		Equity
		

		

		

		

		

	
	
		Beginning Equity
		

		

		

		 -   
		

	
	
		Other Changes to Equity 
		

		

		

		 -   
		

	
	
		Current Year Net Income
		

		

		

		 -   
		

	
	
		Total Equity
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		Total Liabilities and Equity
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		  
		  
		  
		  
		

	
	
		

		

		

		

		

		

	
	
		Solvency Protection
		

		

		

		

		

	
	
		Working Capital, Family Care LTC Programs Only
		

		

		

		

		

	
	
		Current Assets
		 -   
		 -   
		 -   
		 -   
		

	
	
		Current Liabilities
		 -   
		 -   
		 -   
		 -   
		

	
	
		Working Capital
		 -   
		 -   
		 -   
		 -   
		

	
	
		Requirement, Family Care LTC Programs Only
		

		

		

		

		

	
	
		Excess/(shortage)
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		Other FC LTC Program Capital Requirements
		

		

		

		

		

	
	
		Restricted Reserve, Family Care LTC Programs Only
		

		

		

		

		

	
	
		Current Restricted Reserve
		 -   
		 -   
		 -   
		 -   
		

	
	
		Requirement
		

		

		

		

		

	
	
		Excess/(shortage)
		 -   
		 -   
		 -   
		 -   
		

	
	
		

		

		

		

		

		

	
	
		Solvency Fund, Family Care LTC Programs Only
		

		

		

		

		

	
	
		Current Solvency Fund
		 -   
		 -   
		 -   
		 -   
		

	
	
		Requirement
		 750,000 
		 750,000 
		 750,000 
		 750,000 
		

	
	
		Excess/(shortage)
		 (750,000)
		 (750,000)
		 (750,000)
		 (750,000)
		

	
	
		

		

		

		

		

		

	



Sheet 3: LT Obligations

	
	
	
	
	
	
	
	
	
	
		Current CMO:   Name
		

		

		

		

		

		

		

		

		

		

		

	
	
		To New CMO:  Name
		

		

		

		

		

		

		

		

		

		

		

	
	
		Long-Term Obligations
		

		

		

		

		

		

		

		

		

		

		

	
	
		As of MM/DD/CCYY
		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

	
	
		

		

		

		

		

		

		

		

		

		

		

		

	
	
		Entity that currently holds the obligation
		If it is the current permitted CMO obligation, will the obligation be assigned to the assuming organization (Y/N)
		Lessor/Service Provider/Lendor
		Purpose/Service
		Payment Terms (include annual escalator)
		Contract Length
		Payment Frequency
		Monthly Amount
		Annual Amount
		Termination Date
		Termination Due to Loss of DHS Contract Clause (Y/N)
		Early Termination Provisions

The words contained in this file might help you see if this file matches what you are looking for:

...Sheet instructions for completion of the template balance tab replace red text in cells a and with name current cmo new as date b c d appropriate complete column most period identify project last day business before transition this will include projection net income through working capital position restricted reserves solvency fund positions including investment projected numbers from s is prior to items organization first transitioned provide description f every line item that has change e what not transitioning where going process eg furniture remaining xxxxx countydistrict supporting documents outline why asset andor laibaility be transferred lt obligations listing all longterm obligatiosn currently permitted assuming guarantees financial assets liabilities mmddccyy recent filed old amount enter plan actual explanation if cash equivalents operating other short term investments unrestricted capitation receivable dhs receivables cost share room amp board spend down third party parent ...

Current CMO: Name
To New CMO: Name
Long-Term Obligations
As of MM/DD/CCYY


Entity that currently holds the obligation	If it is the current permitted CMO obligation, will the obligation be assigned to the assuming organization (Y/N)	Lessor/Service Provider/Lendor	Purpose/Service	Payment Terms (include annual escalator)	Contract Length	Payment Frequency	Monthly Amount	Annual Amount	Termination Date	Termination Due to Loss of DHS Contract Clause (Y/N)	Early Termination Provisions

Related files

Share

Help

	Instructions for Completion of the Template

Balance Sheet Tab
1	Replace the red text in cells A1, A3, and A5 with the name of the current CMO, new CMO, and as of date.

2	Replace the red text in cells B9, C9, and D9 with the appropriate date.

3	Complete column B of with the most current balance sheet period and identify the period.

4	Project the balance sheet as of the last day of business before transition. This will include a projection of net income through the last day of business.

5	Project the working capital position, restricted reserves and solvency fund positions including investment income.

6	Complete column C of the template with the projected balance sheet numbers from #s 2 and 3. This column is as of the last day prior to transition of the balance sheet items to the organization.

7	Complete column D of the first day of the new transitioned organization.

8	Provide a Description in Column F for every line item that has a change in column E. Include what is not transitioning and where the item is going through the process (e.g. Furniture is remaining with XXXXX County/District). Provide supporting documents that outline why the asset and/or laibaility will not be transferred.

LT Obligations Tab
	Provide a listing of all long-term obligatiosn for the currently permitted CMO and for the assuming organization.

Guarantees Tab
	Provide a listing of all financial guarantees for the currently permitted CMO and for the assuming organization.

Current CMO: Name
Transition of Assets and Liabilities
To New CMO: Name
Projected Balance Sheet
As of MM/DD/CCYY

	Most	Last Day	First Day
	Recent Filed	Old CMO	New CMO	Amount of
	Enter Date	Enter Date	Enter Date	Transition	Transition Plan:
	Actual	Projected	Projected	Change	Explanation of Change if not to new CMO
Current Assets
Cash and cash equivalents, Operating				-
Cash and cash equivalents, Other				-
Short term investments (unrestricted)				-
Capitation receivable				-
Other DHS receivables				-
Cost share receivable				-
Room & Board receivable				-
Spend Down receivable				-
Other third party receivable				-
Other short term receivables				-
Parent, subsidiary, affiliate receivable				-
Reinsurance receivable				-
Prepaid Insurance				-
Prepaid providers (member service expenses)				-
Prepaid expenses-Other				-
Supply Inventory				-
Other Current assets				-
Total Current Assets	-	-	-	-


Long Term or Restricted Assets
Restricted Assets:
Risk Reserve Funds-FC Permitted MCO				-
Reserve guaranty funds on deposit, HMO				-
Solvency Reserve/guaranty funds on deposit Permitted MCO				-
LT Assets:
Other LT Investments, unrestricted				-
Building/Land (cost)				-
Accumulated Depreciation- Building/Land				-
Leasehold Improvements (cost)				-
Accumulated Depreciation-Leasehold Improvements				-
Furniture, Equipment & Software (cost)				-
Accumulated Depreciation- Furniture, Equipment & Software				-
Other long term assets				-
Total Long Term or Restricted Assets	-	-	-	-

Total Assets	-	-	-	-

Liabilities
Short Term Liabilities
Capitation Payable				-
Unearned Capitation Revenue				-
Unearned Revenue-Other				-
Accrued Salaries				-
Accrued Taxes & Benefits (current)				-
IBNR Member Services- current Year				-
IBNR Member Services -prior year				-
Accounts Payable -Claims Processed, Internal Claims System				-
Accounts Payable-Claims Processed, TPA				-
Accounts Payable -Care Management				-
Accounts Payable- General				-
Parent, subsidiary, affiliate payable				-
Due to Other				-
Current Portion of Long Term Debt				-
Income Taxes Payable				-
Other Current Liabilities				-
Total Short Term Liabilities	-	-	-	-

Long Term Liabilities
Accrued Employee Benefits (i.e. Vacation, sick leave > 1 year)				-
Loans Payable				-
Due to Other, LT				-
Other Long Term Liabilities				-
Total Long Term Liabilities	-	-	-	-

Total Liabilities	-	-	-	-

Equity
Beginning Equity				-
Other Changes to Equity				-
Current Year Net Income				-
Total Equity	-	-	-	-

Total Liabilities and Equity	-	-	-	-


Solvency Protection
Working Capital, Family Care LTC Programs Only
Current Assets	-	-	-	-
Current Liabilities	-	-	-	-
Working Capital	-	-	-	-
Requirement, Family Care LTC Programs Only
Excess/(shortage)	-	-	-	-

Other FC LTC Program Capital Requirements
Restricted Reserve, Family Care LTC Programs Only
Current Restricted Reserve	-	-	-	-
Requirement
Excess/(shortage)	-	-	-	-

Solvency Fund, Family Care LTC Programs Only
Current Solvency Fund	-	-	-	-
Requirement	750,000	750,000	750,000	750,000
Excess/(shortage)	(750,000)	(750,000)	(750,000)	(750,000)

Related files

Share

Share to social media

Help

Login Area