Form CMS-10492 Notice of Availability of Separate Contraception Payment

Data Elements for Issuer Submission Requirements to Receive the Federally-facilitated
Exchange User Fee Adjustment
Note: HHS intends to collect the required data elements for issuers to receive the FFE user fee
adjustment through a Microsoft Excel spreadsheet. To facilitate submission of the required data elements
in a spreadsheet format, HHS intends to make a spreadsheet of the required data elements available upon
finalization of this PRA.

1. Name and registered HIOS issuer ID of the participating issuer;
2. Name(s) of third party administrator that received a copy of the self-certification with
respect to which the participating issuer seeks an adjustment in the FFE user fee;
3. Name and registered HIOS ID of self-insured plan for which the self-certification was
received by a third party administrator and with respect to which the participating issuer
seeks a Federally-facilitated Exchange user fee adjustment;
4. For each such self-insured plan, the total dollar amount of the payments for contraceptive
services that were provided during the applicable calendar year. (Note: If such payments
were made by the participating issuer, the total dollar amount should reflect the amount
of the payments made by the participating issuer. If the third party administrator made or
arranged for such payments, the total dollar amount should reflect the amount reported to
the participating issuer by the third party administrator.);
5. An attestation that the submitted information is accurate; and
6. Primary and secondary contact information for the participating issuer, including;
a. Name of contact
b. Designation
c. Mailing address
d. Email address
e. Phone number.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is xxx-XXXX. The time required to complete this information collection is
estimated to average 11 hours per response. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Data Elements for Third Party Administrators' Submission Requirements to Receive the
Federally-facilitated Exchange User Fee Adjustment
Note: HHS intends to collect the required data elements for third-party administrators to receive the FFE
user fee adjustment through a Microsoft Excel spreadsheet. To facilitate submission of the required data
elements in a spreadsheet format, HHS intends to make a spreadsheet of the required data elements
available upon finalization of this PRA.

1. Name of the third party administrator;
2. Name and registered HIOS ID of participating issuer seeking the user fee adjustment with
respect to the third party administrator;
3. Name and registered HIOS ID for each self-insured plan for which the self-certification
was received by the third party administrator and with respect to which the participating
issuer seeks an adjustment in the Federally-facilitated Exchange user fee;
4. The total number of participants and beneficiaries for each such self-insured plan during
the applicable calendar year;
5. For each such self-insured plan, the total dollar amount of the payments for contraceptive
services required to be covered provided to such plan participants and beneficiaries
during the applicable calendar year. (Note: If such payments were made by the
participating issuer, the total dollar amount should reflect the amount of the payments
made by the participating issuer. If the third party administrator made or arranged for
such payments, the total dollar amount should reflect the amount reported to the
participating issuer by the third party administrator.);
6. An 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); and
7. Primary and secondary contact information for third party administrator, including: a.
Name of contact
b. Designation
c. Mailing address
d. Email address
e. Phone number.

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this

information collection is 0938-XXXX. The time required to complete this information collection is
estimated to average 11 hours per response. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.