CMS-10492 - Issuer data elements for FFE Adjustment rev

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 or
name(s) of the provider of contraceptive services that received a representation that
the individual is an eligible individual, as defined in 26 CFR 54.9815-2713A(a)(3),
29 CFR 2590.715-2713A(a)(3), or 45 CFR § 147.131(a)(3), with respect to which
the participating issuer seeks an adjustment in the FFE (or SBE-FP) 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 an FFE or SBE-FP 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. For each provider of contraceptive services, documentation demonstrating the
participating issuer and provider have a signed written agreement providing issuers have
or will reimburse the provider for the cost of furnishing contraceptive services and the
total dollar amount of the costs of furnishing contraceptive services during the
applicable calendar year;
6. An attestation that the submitted information is accurate; and
7. 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 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.