CMS-10141 Compensation Certification to be Completed by Any Organi

Attachment 1b – To be completed by Organizations using
Option One to determine 2019 renewal commissions

2019 Compensation Certification
Organization Name:________________________________________
Certification Date:_______________________________________
CMS Contract Number(s):___________________________________
I have examined the compensation structure(s) for 2016
described herein and attest that this accurately and
completely represents the initial compensation structure(s)
in place at that time, and that the renewal compensation
rate submitted for 2019 is 50% of the 2016 initial rate
adjusted for inflation factors provided in CMS guidance on
2019 compensation structures. The structure(s) herein meet
the requirements set in CMS 4182-F.
__________________________________
___________
CEO (or other authorized official)

Date

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