202x Filetype XLSX File size 0.04 MB Source: oci.wi.gov
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. |
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) | |
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 |
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