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

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.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-10492 Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers) Form and Instruction
Form CMS-10492 Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer) Form and Instruction
Form CMS-10492 Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs) Form and Instruction
CMS-10492 - User Fee Adjustment Supporting Statement - 2223.docx Supporting Statement A
Data Submission and Maintenance of Records for Individual Contraceptive Arrangement
Collection of User Fee Adjustment Information from FFE (or SBE-FP) Participating Issuers Instruction
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 (TPAs) Form and Instruction

All Historical Document Collections

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

OMB Details

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

Federal Enterprise Architecture: Health - Health Care Services

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.