J-22_ESRD_BP_Forms_-_ESRD_2016-20.xlsx

XLSX spreadsheet 228 KB Posted Jun 24, 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

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J-22 ESRD Business Proposal Form

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File	Type	Posted
ESRD_NCC_Questions.pdf	PDF	Oct 26, 2015
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
J.24-A_NCC_SIP_Instructions.pdf	PDF	Sep 29, 2015
ESRD_Amendment_000007_SF30.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
ESRd_Amendment_000006_SF-30.pdf	PDF	Sep 22, 2015
J.23-B_KCER_SOW_9.22.2015.pdf	PDF	Sep 22, 2015
J.23-C_KCER_SOD_9.22.2015.pdf	PDF	Sep 22, 2015
J.23-E_KCER_Contract_Evaluation_Tool.xlsx	XLSX spreadsheet	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
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
ESRD_Amendment_000003_Cover_Letter_.pdf	PDF	Jul 10, 2015
J-9__Healthcare-Associated_Infections_and_the_National_Healthcare_Safety_Network_07102015.docx	DOCX document	Jul 10, 2015
J-1_SOD_07102015.docx	DOCX document	Jul 10, 2015
SOW_07102015_REDLINE.docx	DOCX document	Jul 10, 2015
ESRD_Amendment_000002_Cover_Letter_.pdf	PDF	Jul 2, 2015
ESRD_Amendment_000002.pdf	PDF	Jul 2, 2015
J-22_ESRD_BP_Forms_-_ESRD_2016-20_6_30_15.xlsx	XLSX spreadsheet	Jul 2, 2015
ESRD_Amendment_000001.pdf	PDF	Jun 25, 2015
J-22a_ESRD_BP_Instructions.docx	DOCX document	Jun 25, 2015
J-22_ESRD_BP_Forms_-ESRDFY2016-20.xlsx	XLSX spreadsheet	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-6_Learning_and_Action_Networks.docx	DOCX document	Jun 24, 2015
J-1_SOD_06182015.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
J-4_Reporting_Requirements.docx	DOCX document	Jun 24, 2015
J-7_Quality_Improvement_Activities.docx	DOCX document	Jun 24, 2015
J-5_Recommendations_for_Sanctions_and_Alternative_Sanctions.docx	DOCX document	Jun 24, 2015
J-12_CROWNWeb.docx	DOCX document	Jun 24, 2015
J-3_Paperwork_Reduction_Act.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
Preproposal_conference.docx	DOCX document	Jun 23, 2015
Synopsis_ESRD.docx	DOCX document	Apr 23, 2015
UPDATED_2016_ESRD_Networks_SS.docx	DOCX document	Feb 10, 2015
ESRD_Network_Map.docx	DOCX document	Feb 5, 2015

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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	60 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
	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 12-31-16
	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	1-1-17 to 12-31-17
	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	1-1-18 to 12-31-18
	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	1-1-19 to 12-31-19
	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 b 0 $ - 0

	YEAR 5	1-1-20 to 12-31-20
	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

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
		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 12-31-16
			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	1-1-17 to 12-31-17
			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	1-1-18 to 12-31-18
			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	1-1-19 to 12-31-19
			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	1-1-20 to 12-31-20
			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
	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 12-31-16
	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	1-1-17 to 12-31-17
	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	1-1-18 to 12-31-18
	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	1-1-19 to 12-31-19
	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	60 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	60 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	60 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
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 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 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 12-31-16
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	1-1-17 to 12-31-17
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 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 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	1-1-18 to 12-31-18
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 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 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	1-1-19 to 12-31-19
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 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 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	1-1-20 to 12-31-20
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 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 FIVE:													$0

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

ESRD NETWORK # 0

		ANNUAL MANAGEMENT PLAN 1/1/2016 - 12/31/2016								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%
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%
										0%
SUBTOTAL - DIRECT LABOR	0	0	0	0	0	0	0	0	0	0%

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

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 1/1/2017 - 12/31/2017								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%
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%
										0%
SUBTOTAL - DIRECT LABOR	0	0	0	0	0	0	0	0	0	0%

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

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 1/1/2018 - 12/31/2018								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%
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%
										0%
SUBTOTAL - DIRECT LABOR	0	0	0	0	0	0	0	0	0	0%

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

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 1/1/2019 - 12/31/2019								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%
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%
										0%
SUBTOTAL - DIRECT LABOR	0	0								0%

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

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 1/1/2020 - 12/31/2020								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%
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%
										0%
SUBTOTAL - DIRECT LABOR	0	0								0%

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

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.