Information Collection

Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers)

IC 217425 under ICR 202606-0938-010 · OMB 0938-1285.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10492 Notice of Availability of Separate Contraception Payments from Fully Insured Issuers Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers)	Form and Instruction
CMS-10492 Notice of Availability of Separate Contraception Payment CMS-10492 - Issuer and TPA data elements for FFE adjustment.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10492				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 205

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	205	205
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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