CMS-10141 Structure Submission Forms

Attachment 2a - Description of Compensation Structure for
Plans Using Contracted Marketing Organizations
The structures to be provided are the initial and renewal
compensation amounts paid by the plan to the contracted
marketing organization(s).
(Optional form - if your organization has the schedule(s)
in a workbook, or some other format, you may submit that
documentation in lieu of Attachment 2a)

Contracted Marketing Organization Compensation Schedule
(Submit one per schedule)

Initial Compensation Structure:

Renewal Compensation Structure:

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
0938-0964 (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to
average 49 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. 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.

Attachment 2b - Description of Compensation Structure for
Writing Agents Paid Directly by the MA or PDP Organization,
and by Contracted Marketing Organizations
The structures to be provided are the initial and renewal
compensation amounts paid directly to the writing agents by
MA and PDP organizations. In addition, provide structures
for the initial and renewal compensations amounts paid
directly to the writing agents by marketing organization(s)
contracted by the plans.
(Optional form - if your organization has the schedule(s)
in a workbook, or some other format, you may submit that
documentation in lieu of Attachment 2b)

Writing Agents Compensation Schedule
(Submit one per schedule)

Initial Compensation Structure:

Renewal Compensation Structure:

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
0938-0964 (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to
average 49 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. 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.