Form CMS-10492 Data Submission Requirements to Receive the Federally-fa

OMB control number: 0938-1285

Expiration Date: XX/XXXX

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-web form. To facilitate submission of the required data elements in a-web form, HHS intends to make a-web form 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;

   1. Name of contact

   2. Designation

   3. Mailing address

   4. Email address

   5. 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 0938-1285. 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.