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

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1285 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10492 Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer) Form and Instruction
CMS-10492 Issuers' Data Submission Requirements to Receive the Fed CMS-10492 - Issuer and TPA data elements for FFE adjustment.pdf Form and Instruction
CMS-10492 Issuer Submission to Receive the Federally-Facilitated M CMS-10492 - Attachment #1 UF_Issuer_ContraceptUFAdjustForm_v1_draft_092915 FINAL.xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.50(d)(2)(iii)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10492	Issuers' Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment	CMS-10492 - Issuer and TPA data elements for FFE adjustment.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10492	Issuer Submission to Receive the Federally-Facilitated Marketplace User Fee Adjustment	CMS-10492 - Attachment #1 UF_Issuer_ContraceptUFAdjustForm_v1_draft_092915 FINAL.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	528	528
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.