J-22_ESRD_BP_Forms_-_ESRD_2016-20_6_30_15.xlsx

XLSX spreadsheet 232 KB Posted Jul 2, 2015

Attached to: 2016 End Stage Renal Disease (ESRD) Networks Federal contract opportunity
Solicitation number: CMS-2016-ESRD-NETWORKS
Issued by: Department of Health and Human Services Centers for Medicare and Medicaid Services

About this file

From the source

Attachment J.22 Business Proposal Form

View the file

Other files for this federal contract opportunity

Other files attached to 2016 End Stage Renal Disease (ESRD) Networks, newest first.
File	Type	Posted
ESRD_Amendment_000009_Cover_Letter_.pdf	PDF	Oct 26, 2015
Amendment_000009_SF30.pdf	PDF	Oct 26, 2015
J.24-C_NCC_SOD.pdf	PDF	Sep 29, 2015
ESRD_Amendment_000007_SF30.pdf	PDF	Sep 29, 2015
J.24-B_NCC_SOW.pdf	PDF	Sep 29, 2015
ESRD_Amendment_000007_Cover_Letter_.pdf	PDF	Sep 29, 2015
J.24-D_NCC_Status_Report.docx	DOCX document	Sep 29, 2015
J.24-A_NCC_SIP_Instructions.pdf	PDF	Sep 29, 2015
J.23-D_KCER_Monthly_Status_Report_Template.docx	DOCX document	Sep 22, 2015
ESRD_Amendment_000006_Cover_Letter_.pdf	PDF	Sep 22, 2015
J.23-E_KCER_Contract_Evaluation_Tool.xlsx	XLSX spreadsheet	Sep 22, 2015
KCER_Questions_ _Answers.pdf	PDF	Sep 22, 2015
ESRD_Amendment_000005_Cover_Letter_.pdf	PDF	Sep 3, 2015
J.23-B_KCER_SOW.pdf	PDF	Sep 3, 2015
J.23-A_KCER_SIP_Instructions.pdf	PDF	Sep 3, 2015
Amendment_000005_SF-30.pdf	PDF	Sep 3, 2015
J.23-C_KCER_SOD.pdf	PDF	Sep 3, 2015
ESRD_Amendment_000004.pdf	PDF	Jul 22, 2015
ESRD_Amendment_000004_Cover_Letter_.pdf	PDF	Jul 22, 2015
J-4_Reporting_Requirements_07102015_REDLINE.docx	DOCX document	Jul 10, 2015
ESRD_Amendment_000003.pdf	PDF	Jul 10, 2015
ESRD_Questions_and_Responses.xlsx	XLSX spreadsheet	Jul 10, 2015
SOW_07102015_REDLINE.docx	DOCX document	Jul 10, 2015
J-22_ESRD_BP_Forms_-_ESRD_2016-20_07102015.xlsx	XLSX spreadsheet	Jul 10, 2015
ESRD_Amendment_000002_Cover_Letter_.pdf	PDF	Jul 2, 2015
ESRD_Amendment_000002.pdf	PDF	Jul 2, 2015
ESRD_Amendment_000001.pdf	PDF	Jun 25, 2015
J-22a_ESRD_BP_Instructions.docx	DOCX document	Jun 25, 2015
ESRD_Amendment_000001_Cover_Letter_.pdf	PDF	Jun 25, 2015
J-19_Compliance_Program_Attestation.docx	DOCX document	Jun 25, 2015
J-2_Style_Guide.docx	DOCX document	Jun 25, 2015
J-22_ESRD_BP_Forms_-ESRDFY2016-20.xlsx	XLSX spreadsheet	Jun 25, 2015
J-6_Learning_and_Action_Networks.docx	DOCX document	Jun 24, 2015
J-1_SOD_06182015.docx	DOCX document	Jun 24, 2015
J-19_Compliance_Program_Attestation.docx	DOCX document	Jun 24, 2015
J-11_Contract_Evaluation.docx	DOCX document	Jun 24, 2015
J-9__Healthcare-Associated_Infections_and_the_National_Healthcare_Safety_Network.docx	DOCX document	Jun 24, 2015
J-17_Small_Business_Subcontracting_Plan_Template.doc	DOC document	Jun 24, 2015
J-20_Information_Security_Attestation.docx	DOCX document	Jun 24, 2015
J-21_Question_Submission_Template.xlsx	XLSX spreadsheet	Jun 24, 2015
J-2_Style_Guide.docx	DOCX document	Jun 24, 2015
J-22_ESRD_BP_Forms_-_ESRD_2016-20.xlsx	XLSX spreadsheet	Jun 24, 2015
J-8_Grievance_Overview.docx	DOCX document	Jun 24, 2015
ESRD_NETWORK_RFP.pdf	PDF	Jun 24, 2015
J-15_HHS_565_Form.pdf	PDF	Jun 24, 2015
J-14_Consent_to_Subcontract.docx	DOCX document	Jun 24, 2015
Preproposal_conference.docx	DOCX document	Jun 23, 2015
UPDATED_2016_ESRD_Networks_SS.docx	DOCX document	Feb 10, 2015
2016_ESRD_Networks_SS.docx	DOCX document	Feb 5, 2015
ESRD_Network_Map.docx	DOCX document	Feb 5, 2015

Show all 50

2016 End Stage Renal Disease (ESRD) Networks has more files on GovTribe.

On GovTribe

Work with this file on GovTribe

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

G. BP J-22 Summary

J.22	CMS Form 685-G
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

Appendix G
DIRECT MEDICARE COSTS		Network Transition	Year 1	Year 2	Year 3	Year 4	Year 5	59 MONTHS PLUS TRANSITION TOTAL
a. LABOR	(See Appendix A)
1.0		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
2.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
3.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
4.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
5.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
6.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
7.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
8.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
9.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
10.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
11.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
12.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
13.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
14.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
15.		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0

	SUBTOTAL - DIRECT LABOR		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
b. PROGRAM CONSULTANTS		(See Appendix B)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
c. TRAVEL		(See Appendix H)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
d. SUBCONTRACTORS		(See Appendix C)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
e. OTHER DIRECT COSTS		(See Appendix D)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
f. FRINGE BENEFITS/LEAVE		(See Appendix E)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
g. G&A/ INDIRECT COSTS		(See Appendix F)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0

h. TOTAL COSTS (excluding fee) $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

i. FEE $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

j. TOTAL COSTS WITH FEE $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

Page &P

A. Labor

J.22	CMS Form 685-A
	ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
	NETWORK #

Appendix A	Network Transition	12-1-15 to 12-31-15
	No of	Hourly	Number	Total
DIRECT MEDICARE COSTS	FTEs	Rate	of Hours	Salary
a. LABOR
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! 0 $ - 0

	YEAR 1	1-1-16 to 11-30-16
	No of	Current	Yr. 1	Number	Total
DIRECT MEDICARE COSTS	FTEs	Hourly Rate	Hourly Rate	of Hours	Salary
a. LABOR
1.0					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! ERROR:#DIV/0! 0 $ - 0

J.22	CMS Form 685-A
	ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

Appendix A	YEAR 2	12-1-16 to 11-30-17
	No of	Hourly	Number	Total
DIRECT MEDICARE COSTS	FTEs	Rate	of Hours	Salary
a. LABOR
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! 0 $ - 0

	YEAR 3	12-1-17 to 11-30-18
	No of	Hourly	Number	Total
DIRECT MEDICARE COSTS	FTEs	Rate	of Hours	Salary
a. LABOR
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! 0 $ - 0

J.22	CMS Form 685-A
	ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

Appendix A	YEAR 4	12-1-18 to 11-30-19
	No of	Hourly	Number	Total
DIRECT MEDICARE COSTS	FTEs	Rate	of Hours	Salary
a. LABOR
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! 0.0 $ - 0 Sum formula doesn't include line 134 in column D; missing average formula in column E; Sum formula missing in column F

	YEAR 5	12-1-19 to 11-30-20
	No of	Hourly	Number	Total
DIRECT MEDICARE COSTS	FTEs	Rate	of Hours	Salary
a. LABOR
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

SUBTOTAL - DIRECT LABOR 0.0 ERROR:#DIV/0! 0 $ - 0 Sum formula missing

B. Consultants

J.22	CMS Form 685-B
Appendix B		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

PROGRAM CONSULTANTS	Network Transition	12-1-15 to 12-31-15
		Rate	Number	Total
Name	Position	Per Hour	Of Hours	Costs
1.0				$ - 0
2.				$ - 0
3.				$ - 0
4.				$ - 0
5.				$ - 0
6.				$ - 0
7.				$ - 0
8.				$ - 0
9.				$ - 0
10.				$ - 0
11.				$ - 0
12.				$ - 0
13.				$ - 0
14.				$ - 0
15.				$ - 0

TOTAL ERROR:#DIV/0! 0 $ - 0

PROGRAM CONSULTANTS	YEAR 1	1-1-16 to 11-30-16
			Rate	Number	Total
Name	Position		Per Hour	Of Hours	Costs
1.0					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

TOTAL	ERROR:#DIV/0!	0	$ - 0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).

J.22	CMS Form 685-B
Appendix B	ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

PROGRAM CONSULTANTS	YEAR 2	12-1-16 to 11-30-17
			Rate	Number	Total
Name	Position		Per Hour	Of Hours	Costs
1.					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

TOTAL ERROR:#DIV/0! 0 $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).

PROGRAM CONSULTANTS	YEAR 3	12-1-17 to 11-30-18
			Rate	Number	Total
Name	Position		Per Hour	Of Hours	Costs
1.					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

TOTAL			ERROR:#DIV/0!	0	$ - 0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.22	CMS Form 685-B
Appendix B		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
Name and Address of ESRD Organization:
0				NETWORK #	0.0
0
0

PROGRAM CONSULTANTS	YEAR 4	12-1-18 to 11-30-19
			Rate	Number	Total
Name	Position		Per Hour	Of Hours	Costs
1.					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

TOTAL			ERROR:#DIV/0!	0	$ - 0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
	CMS Form 685-B
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

PROGRAM CONSULTANTS	YEAR 5	12-1-19 to 11-30-20
			Rate	Number	Total
Name	Position		Per Hour	Of Hours	Costs
1.					$ - 0
2.					$ - 0
3.					$ - 0
4.					$ - 0
5.					$ - 0
6.					$ - 0
7.					$ - 0
8.					$ - 0
9.					$ - 0
10.					$ - 0
11.					$ - 0
12.					$ - 0
13.					$ - 0
14.					$ - 0
15.					$ - 0

TOTAL	ERROR:#DIV/0!	0	$ - 0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).

C. Subcontractors

J.22	CMS Form 685-C
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

Appendix C
SUBCONTRACTOR	Network Transition	12-1-15 to 12-31-15
	SUBCONTRACTOR	TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE	FROM	TO	Of Hours	Costs
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0
					$ - 0

TOTAL 0 $ - 0

SUBCONTRACTOR	YEAR 1	1-1-16 to 11-30-16
	SUBCONTRACTOR		TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0

TOTAL		0	$ - 0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).
J.22	CMS Form 685-C

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

Appendix C
SUBCONTRACTOR	YEAR 2	12-1-16 to 11-30-17
	SUBCONTRACTOR		TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0

TOTAL 0 $ - 0

SUBCONTRACTOR	YEAR 3	12-1-17 to 11-30-18
	SUBCONTRACTOR		TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0

TOTAL 0 $ - 0

NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).

J.22	CMS Form 685-C
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

Appendix C
SUBCONTRACTOR	YEAR 4	12-1-18 to 11-30-19
	SUBCONTRACTOR		TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0

TOTAL 0 $ - 0

SUBCONTRACTOR	YEAR 5	1-1-20 to 12-31-20
	SUBCONTRACTOR		TIME FRAME		Number	Total
Name	ACTIVITIES/PURPOSE		FROM	TO	Of Hours	Costs
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0
						$ - 0

TOTAL	0	$ - 0
NOTE: SUBMIT SUPPORTING JUSTIFICATION (INCLUDING THE NATURE OF THE ASSIGNMENT(s)).

D. ODC

J.22 CMS Form 685-D

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

	Appendix D
	OTHER DIRECT COSTS
			TRANSITION
COSTS	YEAR 1
COSTS	YEAR 2 COSTS	YEAR 3 COSTS	YEAR 4 COSTS	YEAR 5 COSTS	59 MONTHS PLUS TRANSITION TOTAL
	Storage		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Utilities		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Maintenance & Repairs		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Depreciation		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Data Processing		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Office Supplies		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Postage & Express Mail		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Meetings & Conferences		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Garage & Parking Spaces		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Dues & Subscriptions		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Recruiting		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Temporary Help		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Continuing Education		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Legal Fees		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Accounting/Auditing Fees		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Printing & Reproduction		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Training		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Other - Attach Schedule

TOTAL	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
NOTE: SUBMIT SUPPORTING JUSTIFICATION FOR EACH LINE ITEM.

E. Fringe-Leave

J.22	CMS Form 685-E
	ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

	Appendix E
	FRINGE BENEFITS/LEAVE
		TRANSITION
COSTS	YEAR 1
COSTS	YEAR 2 COSTS	YEAR 3 COSTS	YEAR 4 COSTS	YEAR 5 COSTS	59 MONTHS PLUS TRANSITION TOTAL
	1. Employer's FICA Expense							$ - 0
	2. Federal Unemployment Tax							$ - 0
	3. State Unemployment Insurance							$ - 0
	4. Disability Insurance							$ - 0
	5. Pension Expense							$ - 0
	6. Workers Compensation							$ - 0
	7. Group Health Insurance							$ - 0
	8. Group Life Insurance							$ - 0
	9. Employee Relations & Welfare							$ - 0
	10. Leave							$ - 0
	11. Other - Attach Schedule							$ - 0
	TOTAL	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0

12. FRINGE BENEFIT RATE/COSTS:

13. LEAVE RATE/COSTS:

F. G & A

J.22	CMS Form 685-F
		ESRD NETWORK BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

Name and Address of ESRD Organization:
0	NETWORK #	0.0
0
0

	Appendix F
	GENERAL & ADMINISTRATION (G&A) / OVERHEAD
				TRANSITION
COSTS	YEAR 1
COSTS	YEAR 2 COSTS	YEAR 3 COSTS	YEAR 4 COSTS	YEAR 5 COSTS	59 MONTHS PLUS TRANSITION TOTAL
	1. RENT					$ - 0
	2. LEASED EQUIPMENT					$ - 0
	3. TELEPHONE EXPENSES					$ - 0
	4. INSURANCE					$ - 0
	5. OTHER					$ - 0

TOTAL $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

6. INDIRECT RATE/COSTS:

NOTE: SUBMIT SUPPORTING JUSTIFICATION(s) FOR EACH LINE ITEM.

H. Travel - Transition

	TRAVEL DETAIL										J-22	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:			0
0
0									Transition	12-1-15 to 12-31-15
0
Transition Period									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Transition	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR TRANSITION PERIOD:													$0

H. Travel Year 1

	TRAVEL DETAIL										J-22	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:			0
0									YEAR 1:	1-1-16 to 11-30-16
0
0
YEAR 1									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 1	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR ONE:													$0

H. Travel Year 2

	TRAVEL DETAIL										J-22	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:			0
0									YEAR 2	12-1-16 to 11-30-17
0
0
YEAR 2									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 2	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR TWO:													$0

H. Travel Year 3

	TRAVEL DETAIL										J-22	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:			0
0									YEAR 3	12-1-17 to 11-30-18
0
0
YEAR 3									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 3	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR THREE:													$0

H. Travel Year 4

	TRAVEL DETAIL										J-22	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:			0
0									YEAR 4	12-1-18 to 11-30-19
0
0
YEAR 4									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 4	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR FOUR:													$0

H. Travel Year 5

	TRAVEL DETAIL										J-22	CMS Form 685-H
	END STAGE RENAL DISEASE BUSINESS PROPOSAL
	CENTERS FOR MEDICARE & MEDICAID SERVICES
Name and Address of ESRD Organization:				ESRD Network:			0
0									YEAR 5	12-1-19 to 11-30-20
0
0
YEAR 5									Mileage Rate:
Trip Title & Description	# of Days per Trip	# of Nights per Trip	# of Travelers per Trip	Airfare per Person	Departing from:	Arriving to:	FTR Meals & Inc. Daily Rate	FTR Lodging per Night	# of Trips for Year 5	Total # of miles per trip(s)	# of Rental Cars Per Trip	Daily Rental Car Rate	Misc. Cost per Person per Trip (includes parking, gas, taxi, etc.)	TOTAL	Notes
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
														$0
TOTAL FOR YEAR FIVE:													$0

I. Management Plan J.22 CMS Form 685-I

ESRD NETWORK # 0

		ANNUAL MANAGEMENT PLAN 1/1/2016 - 11/30/2016								YEAR 1
DIRECT MEDICARE		TOTAL CONTRACT	Patient Engagement Activities	Pt. Exp. of Care Activities	Vascular Access	HAI Activities	AIM2	AIM3-QIP	AIM3-Data support	TOTAL
	FTE	HOURS	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	PERCENT*
a. LABOR
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
11.										0.00%
12.										0.00%
13.										0.00%
14.										0.00%
15.										0.00%
										0.00%
SUBTOTAL - DIRECT LABOR	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

b. PROGRAM CONSULTANTS
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
SUBTOTAL-PROGRAM CONSULTANTS	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

NOTE: Enter the Percent of "TOTAL HOURS" in each labor category

* 100% of TOTAL CONTRACT HOURS

J.22 CMS Form 685

ESRD NETWORK # 0

		ANNUAL MANAGEMENT PLAN 12/1/2016 - 11/30/2017								YEAR 2
DIRECT MEDICARE		TOTAL CONTRACT	Patient Engagement Activities	Pt. Exp. of Care Activities	Vascular Access	HAI Activities	AIM2	AIM3-QIP	AIM3-Data support	TOTAL
	FTE	HOURS	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	PERCENT*
a. LABOR
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
11.										0.00%
12.										0.00%
13.										0.00%
14.										0.00%
15.										0.00%
										0.00%
SUBTOTAL - DIRECT LABOR	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

b. PROGRAM CONSULTANTS
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
SUBTOTAL-PROGRAM CONSULTANTS	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

NOTE: Enter the Percent of "TOTAL HOURS" in each labor category

* 100% of TOTAL CONTRACT HOURS

J.22 CMS Form 685

ESRD NETWORK # 0

		ANNUAL MANAGEMENT PLAN 12/1/2017 - 11/30/2018								YEAR 3
DIRECT MEDICARE		TOTAL CONTRACT	Patient Engagement Activities	Pt. Exp. of Care Activities	Vascular Access	HAI Activities	AIM2	AIM3-QIP	AIM3-Data support	TOTAL
	FTE	HOURS	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	PERCENT*
a. LABOR
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
11.										0.00%
12.										0.00%
13.										0.00%
14.										0.00%
15.										0.00%
										0.00%
SUBTOTAL - DIRECT LABOR	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

b. PROGRAM CONSULTANTS
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
SUBTOTAL-PROGRAM CONSULTANTS	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

NOTE: Enter the Percent of "TOTAL HOURS" in each labor category

* 100% of TOTAL CONTRACT HOURS

J.22 CMS Form 685

ESRD NETWORK # 0

		ANNUAL MANAGEMENT PLAN 12/1/2018 - 11/30/2019								YEAR 4
DIRECT MEDICARE		TOTAL CONTRACT	Patient Engagement Activities	Pt. Exp. of Care Activities	Vascular Access	HAI Activities	AIM2	AIM3-QIP	AIM3-Data support	TOTAL
	FTE	HOURS	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	PERCENT*
a. LABOR
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
11.										0.00%
12.										0.00%
13.										0.00%
14.										0.00%
15.										0.00%
										0.00%
SUBTOTAL - DIRECT LABOR	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

b. PROGRAM CONSULTANTS
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
SUBTOTAL-PROGRAM CONSULTANTS	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

NOTE: Enter the Percent of "TOTAL HOURS" in each labor category

* 100% of TOTAL CONTRACT HOURS

J.22 CMS Form 685

ESRD NETWORK # 0

		ANNUAL MANAGEMENT PLAN 12/1/2019 - 11/30/2020								YEAR 5
DIRECT MEDICARE		TOTAL CONTRACT	Patient Engagement Activities	Pt. Exp. of Care Activities	Vascular Access	HAI Activities	AIM2	AIM3-QIP	AIM3-Data support	TOTAL
	FTE	HOURS	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	(% of Time)	PERCENT*
a. LABOR
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
11.										0.00%
12.										0.00%
13.										0.00%
14.										0.00%
15.										0.00%
										0.00%
SUBTOTAL - DIRECT LABOR	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

b. PROGRAM CONSULTANTS
1.										0.00%
2.										0.00%
3.										0.00%
4.										0.00%
5.										0.00%
6.										0.00%
7.										0.00%
8.										0.00%
9.										0.00%
10.										0.00%
SUBTOTAL-PROGRAM CONSULTANTS	0	0	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%	0.00%

NOTE: Enter the Percent of "TOTAL HOURS" in each labor category

* 100% of TOTAL CONTRACT HOURS

File details come from the government source that posted it. Updated Nov 14, 2017.