Data Submission for the Federally-facilitated Exchange User Fee Adjustment (CMS-10492)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10492 Notice of Availability of Separate Contraception Payments from Fully Insured Issuers	Form and Instruction	New	Available
Form CMS-10492 Issuer Submission to Receive the Federally-Facilitated Marketplace User Fee Adjustment	Form and Instruction	New	Available
Form CMS-10492 Issuers' Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment	Form and Instruction	New	Available
Form CMS-10492 Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services	Form and Instruction	New	Available
Form CMS-10492 Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment	Form and Instruction	New	Available
CMS-10492 - User Fee Adjustment Supporting Statement - Part A (07-06-14) clean.pdf	Supporting Statement A	Uploaded 2015-07-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217425	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers)	Form and Instruction	New	Notice of Availability of Separate Contraception Payments from Fully Insured Issuers
217424	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer)	Form and Instruction	New	Issuer Submission to Receive the Federally-Facilitated Marketplace User Fee Adjustment
217424	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer)	Form and Instruction	New	Issuers' Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment
217422	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)	Form and Instruction	New	Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services
217422	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)	Form and Instruction	New	Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment

ICR Details

OMB Control No: 0938-1285	ICR Reference No: 201507-0938-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Data Submission for the Federally-facilitated Exchange User Fee Adjustment (CMS-10492)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/07/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/16/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2018	36 Months From Approved
Responses	861	0	0
Time Burden (Hours)	6,546	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CMS will use the data collections from participating issuers and third party administrators to verify the total dollar amount for such payments for contraceptive services provided under this accommodation for the purpose of determining a participating issuer's user fee adjustment. The attestation that the payments for contraceptive services were made in compliance with 26 CFR 54.9815-2713A(b)(2) or 29 CFR 2590.715-2713A(b)(2) will help ensure that the user fee adjustment is being utilized to provide contraceptive services for the self-insured plans in accordance with the previously noted accommodation.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2713 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2713 Name of Law: Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 58354	09/29/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 41042	07/14/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers)	CMS-10492	Notice of Availability of Separate Contraception Payments from Fully Insured Issuers
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer)	CMS-10492, CMS-10492	Issuers' Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment ,   Issuer Submission to Receive the Federally-Facilitated Marketplace User Fee Adjustment
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)	CMS-10492, CMS-10492	Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment ,   Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	861	0	861	0	0	0
Annual Time Burden (Hours)	6,546	0	6,546	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection of information.

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Annual Cost to Federal Government: $144

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/16/2015

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