Collection of User Fee Adjustment Information from FFE (or SBE-FP) Participating Issuers

Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment (CMS-10492)

Documents and Forms

Document Name Document Type
CMS-10492 - Issuer data elements for FFE Adjustment rev.pdf Instruction
CMS-10492 - Issuer data elements for FFE Adjustment rev.pdf Instruction

Information Collection (IC) Details

IC Title:	Collection of User Fee Adjustment Information from FFE (or SBE-FP) Participating Issuers	Agency IC Tracking Number:	CCIIO -10492

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.50(d)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			CMS-10492 - Issuer data elements for FFE Adjustment rev.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.