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

OMB 0938-1285

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 Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment (CMS-10492) expires 2022-06-30 and can be found here.

OMB Details

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

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-10492Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative ServicesFillable FileableForm and instruction
Form CMS-10492Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee AdjustmentFillable FileableForm and instruction

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