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

Forms and Documents

Document Name	Status
Form CMS-10492 Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers) Form and Instruction	Modified
Form CMS-10492 Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer) Form and Instruction	Modified
Form CMS-10492 Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs) Form and Instruction	Modified
CMS-10492 - User Fee Adjustment Supporting Statement - 30-day.docx Supporting Statement A	2019-02-28

IC Document Collections

IC ID	Document Title	Status
217425	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers) Form and Instruction	Modified
217424	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer) Form and Instruction	Modified
217422	Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1285	ICR Reference No: 201902-0938-013
Status: Active	Previous ICR Reference No: 201507-0938-006
Agency/Subagency: HHS/CMS	Agency Tracking No: 10492
Title: Data Submission for the Federally-facilitated Exchange User Fee Adjustment (CMS-10492)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/28/2019
	Date Received in OIRA: 03/18/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	36 Months From Approved
Responses	861	0	0
Time Burden (Hours)	6,546	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 2713 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 2713 Name of Law: Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 54352	10/29/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 6789	02/28/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Fully Insured Issuers)	CMS-10492	Notice of Availability of Separate Contraception Payments from Fully Insured Issuers
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (TPAs)	CMS-10492, CMS-10492	Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment ,   Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services
Data Submission for the Federally-facilitated Exchange User Fee Adjustment (Issuer)	CMS-10492, CMS-10492	Issuers' Data Submission Requirements to Receive the Federally-facilitated Exchange User Fee Adjustment ,   Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	861	0	0	0	0	861
Annual Time Burden (Hours)	6,546	0	0	0	0	6,546
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $9,187

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/18/2019

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