CMS-10492 Issuer Submission to Receive the Federally-Facilitated M

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Overview

Information Tab
User Fee Tab
Instructions Tab

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Sheet 1: Information Tab

		DEPARTMENT OF HEALTH AND HUMAN SERVICES
		CENTERS FOR MEDICARE & MEDICAID SERVICES
	Issuer Submission to Receive the Federally-Facilitated Marketplace User Fee Adjustment
	Company Information
	Legal Business Name (LBN):
	Tax Identification Number (TIN) (9 Digits):
	Company Contact Information
	Contact Name:
	Title or Organizational Role of Contact Person:
		Telephone Number:		extension:
		Email Address:
	Alternate Contact Name:
	Title or Organizational Role of Contact Person:
		Telephone Number:		extension:
		Email Address:
	Payment Information
		Total User Fee Adjustment Amount for Contraceptive Claims Incurred through 12/31/14			$0.00
		calculation from User Fee Tab (15% applied)
	Attestation
		On behalf of my organization, for which I am submitting this submission for the Federally-Facilitated User Fee Adjustment, I attest that my organization qualifies for an adjustment in its Federal-facilitated Exchange user fee pursuant to 45 CFR § 156.50. I attest that, to the best of my knowledge and belief, 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). I certify that the information contained in this submission is true, correct and complete to the best of my knowledge and belief. I attest that I have taken reasonable steps to ascertain the truth, correctness and completeness of this information. I attest that my organization will promptly inform CMS if my organization becomes aware that any of the information contained in this submission is untrue, incorrect or incomplete.
		Signature of Attestor:
		Title or Organizational Role of Attestor:
		Date signed:		ex: mm/dd/yyyy
		Email Address:
		Telephone Number:		extension:
	Please Email this form to [email protected]

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Sheet 2: User Fee Tab

			DEPARTMENT OF HEALTH AND HUMAN SERVICES
			CENTERS FOR MEDICARE & MEDICAID SERVICES
	Required Data Elements for Issuers to Receive the Federally - Facilitated Marketplace User Fee Adjustment
	Payment Information
	Self Insured Plan HIOS ID	TPA or PBM Tax Identification Number	Total Amount of Contraceptive Claims Incurred through December 31st Paid to the TPA by the Issuer	User Fee Adjustment Amount (15 %) from Contraceptive Claims Paid to TPA ( do not populate this row )	Is the issuer part of the same entity as the TPA (same parent company?)
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	Please Email this form to [email protected]

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Sheet 3: Instructions Tab

		DEPARTMENT OF HEALTH AND HUMAN SERVICES
		CENTERS FOR MEDICARE & MEDICAID SERVICES
	Issuer Submission to Receive the Federally-Facilitated Marketplace User Fee Adjustment
	Form Objective	This form allows issuers to submit information on payments for contraceptive services made under contract with an eligible organization as described in 26 CFR 54.9815-2713A. Eligible organizations receive an accommodation relating to contraceptive coverage. HHS will use the amounts reported in this form to adjust Federally-Facilitated Marketplace (FFM) user fees, as is described in 26 CFR 54.9815-2713A(b)(3). For the 2014 benefit year, these user fee adjustments to issuers will include a fifteen percent adjustment to compensate for administrative costs and margin. This form is designed for issuers that offer a plan through the FFM. TPAs or PBMs submitting information on payments for contraceptive services should use the version of this form specific to TPAs.							`
	Submission Guidelines	Email this form to [email protected] 45 CFR 156.50(d)(2) requires a participating issuer seeking an FFM user fee adjustment to submit payment amounts for contraceptive services to HHS in the year following the calendar year in which the contraceptive services were provided. 45 CFR 156.50(d)(2)(i)(A) through (E) specifies that issuers must submit: • Identifying information for each issuer and each TPA that received a self-certification for the organization for which the issuer is seeking an adjustment. Issuers should include this identifying information whether or not the participating issuer was the entity that made the payments for contraceptive services. • Identifying information for each self-insured group plan for which a self-certification was received by a TPA, and for which the issuer is seeking an adjustment. • For each self-insured group plan, the total dollar amounts of payments made for contraceptive services provided during the applicable calendar year. • If a TPA made or arranged for such payments, the total dollar amount should reflect the amount reported to the participating issuer by the TPA.
	This section lists each data element required for the form and detailed instructions on how to populate each data field in the workbook.
	Column Name	Column and Cell #	Instructions
	Information Tab
	Company Information
	Legal Business Name (LBN)	C11	Enter the Legal Business Name (LBN) of the issuer submitting the form.
	Tax Identification Digit (TIN)	C12	Enter the nine-digit Tax Identification Number (TIN) of the issuer submitting the form. Please exclude hyphens. The form will reject any values that are not nine digits.
	Company Contact Information
	Federally-Facilitated Marketplace (FFM) User Fee Adjustment Contact Person Name	D17	Enter the name of the person CMS can contact if CMS identifies a discrepancy or has a question about the issuer's submission.
	Title or Organizational Role of Contact Person	D18	Enter the title or organizational role of the user fee adjustment contact identified above.
	Telephone Number/Extension	D19 and E19	Enter the telephone number of the contact person and include an extension, if applicable.
	Email Address	D20	Enter the email address of the contact person.
	Alternate FFM User Fee Adjustment Contact Name	D23	Enter the name of an additional contact available to answer questions about the issuer's submission.
	Title or Organizational Role of Contact Person	D24	Enter the title or organizational role of the alternate user fee adjustment contact identified in D23.
	Telephone Number/Extension	D25 and E25	Enter the telephone number of the alternate contact person and include an extension, if applicable.
	Email Address	D26	Enter the email address of the alternate contact person.
	Payment Information
	Total User Fee Adjustment Amount for Contraceptive Claims Incurred through 12/31/14	F31	Do not populate this field; this field auto populates with the sum of all amounts in Column D in the User Fee sheet, plus an additional 15 percent adjustment. This amount reflects the total dollar amount of payments made by a participating issuer during the applicable calendar year.
	Attestation
	Attestation Text	C38 – E43	This attestation certifies that: • The person signing attests on behalf of the organization that the organization qualifies for a user fee adjustment, • To the best of the attester's knowledge and belief, the reported payments for contraceptive services were made in compliance with federal law [26 CFR § 54.9815-2713A(b)(2) or 29 CFR § 2590.715-2713A(b)(2)], • The information contained in the submission is true, correct, and complete to the best of the attester's knowledge and belief, • The attester has taken reasonable steps to ascertain the truth, correctness, and completeness of the reported information, and • The organization will promptly inform CMS if the organization becomes aware that any information submitted on the form is untrue, incorrect, or incomplete. Read the text of the attestation carefully before signing.
	Signature of Attester	D45	Signature of the person responsible for attesting to the stipulations presented in the attestation statement.
	Title or Organizational Role of Attester	D46	Enter the title of the attester.
	Date Signed	D47	Enter the date the attestation was signed in eight-digit, mm/dd/yyyy format.
	Email Address	D48	Enter the email address of the attester.
	Telephone Number/Extension	D49 and E49	Enter the telephone number of the attester and include an extension, if applicable.
	User Fee Tab
	Self Insured Plan HIOS ID	B10 – B51	Enter the five-digit Health Insurance Oversight System (HIOS) ID for each self insured plan for which the issuer intends to seek an adjustment. The form will reject any values that are not five digits.
	Third Party Administrator (TPA) or Pharmacy Benefit Manager (PBM) Tax Identification Number (TIN)	C10 – C51	Enter the nine-digit Tax Identification Number (TIN) of the TPA or PBM through which payments were made for the self insured plan on this line. Please exclude hyphens. The form will reject any values that are not nine digits.
	Amount of Total Contraceptive Claims Incurred Through December 31st Paid to the TPA by The Issuer	D10 – D51	Enter the total dollar amount of contraceptive claims that the issuer paid to the TPA or PBM for the self-insured plan on this line. The amount should reflect the dollar value of contraceptive claims incurred through December 31st of the year preceding the current benefit year. This amount should reflect the total dollar amount paid to the TPA or PBM by the participating FFM issuer. If a TPA made or arranged for such payments, the total dollar amount should reflect the amount reported to the participating issuer by the TPA or PBM.
	User Fee Adjustment Amount (15 %) from Contraceptive Claims Paid to TPA	E10 – E51	Do not populate this column. This amount displays the total amount of the user fee adjustment that HHS will make to the FFM issuer's user fee amount. This amount equals the dollar amount of contraceptive claims paid to a TPA or PBM by the issuer (or the amount the TPA or PBM reported to the issuer) in Column D, plus an additional margin for the administrative costs of the issuer (15 percent for benefit year 2014). If this amount exceeds an issuer's total user fee liability in any given month, HHS will credit the remaining adjustment to the issuer's user fee obligation for the next month. Any adjustment amounts that have not been credited by the end of the calendar year will be rolled over and applied in the next calendar year.
	Is the issuer part of the same entity as the TPA ( same parent company)	F10 – E51	Indicate with a yes or no whether the issuer is part of the same entity as the TPA, or shares the same parent company with the TPA.