OMB control number

Data Submission for the Federally-facilitated Exchange User Fee Adjustment (CMS-10492)

OMB 0938-1285 · HHS/CMS.

OMB 0938-1285

CMS will use the data collections from participating issuers and third party administrators to verify the total dollar amount for such payments for contraceptive services provided under this accommodation for the purpose of determining a participating issuer's user fee adjustment. The attestation that the payments for contraceptive services were made in compliance with 26 CFR 54.9815-2713A(b)(2) or 29 CFR 2590.715-2713A(b)(2) will help ensure that the user fee adjustment is being utilized to provide contraceptive services for the self-insured plans in accordance with the previously noted accommodation.

The latest form for Data Submission for the Federally-facilitated Exchange User Fee Adjustment (CMS-10492) expires 2022-06-30 and is listed under ICR 201902-0938-013.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
Document	Type
Form CMS-10492 Notice of Availability of Separate Contraception Payments from Fully Insured Issuers	Form and Instruction
Form CMS-10492 Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services	Form and Instruction
Form CMS-10492 Issuers' Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment	Form and Instruction
Form CMS-10492 Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services	Form and Instruction
Form CMS-10492 Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment	Form and Instruction
CMS-10492 - 60-day comment.docx	Public Comments
CMS-10492 - Response to comments.docx	Supplementary Document
CMS-10492 - Supporting Statement.docx	Supporting Statement A
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers)	Form and Instruction
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer)	Form and Instruction
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer)	Form and Instruction
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)	Form and Instruction
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)	Form and Instruction

All Historical Document Collections

Historical document collections
Reference	Filing	Received	Action
202606-0938-010	Reinstatement with change of a previously approved collection	2026-06-10
202302-0938-001	Revision of a currently approved collection	2023-02-02	Comment filed on proposed rule and continue
202208-0938-009	Reinstatement with change of a previously approved collection	2022-08-05	Approved without change
201902-0938-013	Reinstatement without change of a previously approved collection	2019-03-18	Approved without change
201507-0938-006	New collection (Request for a new OMB Control Number)	2015-07-16	Approved with change

OMB Details

Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
Form	Name	Electronic access	Type
Form CMS-10492	Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services	Fillable Fileable	Form and instruction
Form CMS-10492	Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment	Fillable Fileable	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.