Information Collection Request

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

ICR 202302-0938-001 · OMB 0938-1285 · Received in OIRA

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 - 2223.docx Supporting Statement A	2023-02-02

IC Document Collections

IC ID	Document Title	Status
258236	Data Submission and Maintenance of Records for Individual Contraceptive Arrangement	New
258183	Collection of User Fee Adjustment Information from FFE (or SBE-FP) Participating Issuers Instruction	New
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

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-1285
Type of Information Collection	Revision of a currently approved collection
Previous ICR Reference No	202208-0938-009
Agency Tracking No	CCIIO
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31