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picture1_Excel Sample Sheet 32543 | Fin33 017x


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File: Excel Sample Sheet 32543 | Fin33 017x
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 ...

icon picture XLSX Filetype Excel XLSX | Posted on 09 Aug 2022 | 3 years ago
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

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...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 ...

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