{"text_format":"1","workbook":"xlsx","n_sheets":3,"sheets":["Information Tab","User Fee Tab","Instructions Tab "],"not_rendered":{"charts":0,"images":1,"macros":1,"external_links":0,"defined_names":3,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"Information Tab","index":0,"n_rows":56,"n_cols":7,"rows_kept":56,"cut":false,"hidden":false,"merged":[[55,1,55,5],[23,1,23,2],[1,2,1,4],[2,2,2,4],[16,1,16,2],[17,1,17,2],[22,1,22,2],[37,2,42,4],[51,1,51,6],[19,3,19,5],[17,3,17,5],[16,3,16,5],[10,2,10,5],[47,3,47,5],[44,3,44,5],[45,3,45,5],[2,5,3,6],[4,1,4,5],[6,1,6,5],[46,4,46,5],[22,3,22,5],[23,3,23,5],[25,3,25,5],[5,1,5,6]]}
["V2"]
[null,null,"DEPARTMENT OF HEALTH AND HUMAN SERVICES"]
[null,null,"CENTERS FOR MEDICARE & MEDICAID SERVICES ",null,null,"Press Validate Information Tab button to verify data in the input fields."]
[]
[]
[null,"Issuer Submission to Receive the Federally-Facilitated Marketplace User Fee Adjustment "]
[]
[]
[null,"Company Information"]
[]
[null,"Legal Business Name (LBN):"]
[null,"Tax Identification Number (TIN) (9 Digits, no hyphen):"]
[null,"HIOS Issuer ID (5 Digits):"]
[]
[null,"Company Contact Information"]
[]
[null,"Primary Contact Name:"]
[null,"Title or Organizational Role of the Primary Contact Person:"]
[null,null,"Primary Contact Telephone Number (Digits only, no hyphens or parentheses):",null,"extension:"]
[null,null,"Primary Contact Email Address:"]
[]
[]
[null,"Alternate Contact Name:"]
[null,"Title or Organizational Role of the Alternate Contact Person:"]
[null,null,"Alternate Contact Telephone Number (Digits only, no hyphens or parentheses):",null,"extension:"]
[null,null,"Alternate Contact Email Address:"]
[]
[]
[null,"Payment Information "]
[]
[null,null,"Total User Fee Adjustment Amount for Contraceptive Claims Incurred through 12/31/14:",null,null,null,{"$f":"SUM('User Fee Tab'!E8:E507)","v":0}]
[null,null,"calculation from User Fee Tab (15% applied) "]
[]
[]
[null,"Attestation"]
[]
[]
[null,null,"On behalf of my organization, for which I am submitting this submission for the Federally-Facilitated User Fee Adjustment, I attest that my organization qualifies for an adjustment in its Federal-facilitated Exchange user fee pursuant to 45 CFR § 156.50. I attest that, to the best of my knowledge and belief, 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). I certify that the information contained in this submission is true, correct and complete to the best of my knowledge and belief. I attest that I have taken reasonable steps to ascertain the truth, correctness and completeness of this information.  I attest that my organization will promptly inform CMS if my organization becomes aware that any of the information contained in this submission is untrue, incorrect or incomplete."]
[]
[]
[]
[]
[]
[]
[null,null,"Signature of Attester: "]
[null,null,"Title or Organizational Role of Attester: "]
[null,null,"Date signed: ",null,"ex: mm/dd/yyyy"]
[null,null,"Attester Email Address:"]
[null,null,"Attester Telephone Number (Digits only, no hyphens or parentheses):",null,"extension: "]
[]
[]
[null,"Please Email this form to FFMuserfeeadjustments@cms.hhs.gov"]
[]
[]
[]
[null,"PRA Disclosure Statement\nAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1285.  The time required to complete this information collection is estimated to average 11 hours per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. "]

{"sheet":"User Fee Tab","index":1,"n_rows":513,"n_cols":6,"rows_kept":513,"cut":false,"hidden":false,"merged":[[512,1,512,5],[6,6,6,7],[4,1,5,5],[508,1,508,5],[1,2,1,4],[2,2,2,4]]}
[]
[null,null,"DEPARTMENT OF HEALTH AND HUMAN SERVICES"]
[null,null,"CENTERS FOR MEDICARE & MEDICAID SERVICES"]
[null,null,null,null,null,"Press Validate User Fee Tab button to verify data in the input fields."]
[null,"Payment Information "]
[]
[null,"TPA or PBM Legal Business Name ","Federal Employer Identification Number for TPA or PBM (9 digits, no hyphen)","Total Amount Paid to the TPA by the Issuer for Contraceptive Claims Incurred through Dec 31","User Fee Adjustment Amount (this column is locked and auto-calculated for the user )","Is the issuer part of the same entity as the TPA (same parent company?) "]
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[null,"Please Email this form to FFMuserfeeadjustments@cms.hhs.gov"]
[]
[]
[]
[null," PRA Disclosure Statement\nAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1285.  The time required to complete this information collection is estimated to average 11 hours per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. \n"]

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[]
[null,null,"DEPARTMENT OF HEALTH AND HUMAN SERVICES"]
[null,null,"CENTERS FOR MEDICARE & MEDICAID SERVICES "]
[]
[null,"Required Data Elements for Issuers to Receive the Federally-Facilitated Marketplace User Fee Adjustment \nForm Instructions"]
[null,"Form Objective","This form allows issuers to submit information on payments for contraceptive services made under contract with an eligible organization as described in 26 CFR 54.9815-2713A. Eligible organizations receive an accommodation relating to contraceptive coverage.\n\nHHS will use the amounts reported in this form to adjust Federally-Facilitated Marketplace (FFM) user fees, as is described in 26 CFR 54.9815-2713A(b)(3). For the 2014 benefit year, these user fee adjustments to issuers will include a fifteen percent adjustment to compensate for administrative costs and margin.\n\nThis form is designed for issuers that offer a plan through the FFM.  TPAs or PBMs submitting information on payments for contraceptive services should use the version of this form specific to TPAs.",null,null,null,null,null,null,"`"]
[null,"Submission Guidelines","Email this form to FFMuserfeeadjustments@cms.hhs.gov\n\n45 CFR 156.50(d)(2) requires a participating issuer seeking an FFM user fee adjustment to submit payment amounts for contraceptive services to HHS in the year following the calendar year in which the contraceptive services were provided.\n\n45 CFR 156.50(d)(2)(i)(A) through (E) specifies that issuers must submit: \n• Identifying information for each issuer and each TPA that received a self-certification for the organization for which the issuer is seeking an adjustment. Issuers should include this identifying information whether or not the participating issuer was the entity that made the payments for contraceptive services.\n• Identifying information for each self-insured group plan for which a self-certification was received by a TPA, and for which the issuer is seeking an adjustment. \n• For each self-insured group plan, the total dollar amounts of payments made for contraceptive services provided during the applicable calendar year. \n• If a TPA made or arranged for such payments, the total dollar amount should reflect the amount reported to the participating issuer by the TPA."]
[null,"This section lists each data element required for the form and detailed instructions on how to populate each data field in the workbook."]
[null,"Column Name ","Column and Cell #","Instructions"]
[null,"Information Tab"]
[null,"Company Information"]
[null,"Legal Business Name (LBN)","C11","Enter the Legal Business Name (LBN) of the issuer submitting the form."]
[null,"Tax Identification Number (TIN)","C12","Enter the nine-digit Tax Identification Number (TIN) of the issuer submitting the form.  Do not include a hyphen."]
[null,"HIOS Issuer ID","C13","Enter the 5-digit issuer ID assigned to the FFM issuer in the Health Insurance Oversight System (HIOS)"]
[null,"Company Contact Information"]
[null,"Primary Contact Name","D17","Enter the name of the person CMS can contact if CMS identifies a discrepancy or has a question about the issuer's submission."]
[null,"Title or Organizational Role of the Primary Contact Person","D18","Enter the title or organizational role of the user fee adjustment contact identified above."]
[null,"Primary Contact Telephone Number and Extension","D19 and F19","Enter the telephone number of the contact person and include an extension, if applicable."]
[null,"Primary Contact Email Address","D20","Enter the email address of the contact person."]
[null,"Alternate Contact Name","D23","Enter the name of an additional contact available to answer questions about the issuer's submission."]
[null,"Title or Organizational Role of the Alternate Contact Person","D24","Enter the title or organizational role of the alternate user fee adjustment contact identified in D27."]
[null,"Alternate Contact Telephone Number and Extension","D25 and F25","Enter the telephone number of the alternate contact person and include an extension, if applicable."]
[null,"Alternate Contact Email Address","D26","Enter the email address of the alternate contact person."]
[null,"Payment Information"]
[null,"Total User Fee Adjustment Amount for Contraceptive Claims Incurred through 12/31/14","G31","Do not populate this field; this field auto populates with the sum of all amounts in Column E in the User Fee sheet, plus an additional 15 percent adjustment.\n\nThis amount should reflect the total dollar amount of payments made or arranged by an issuer for contraceptive claims during the year preceding the current calendar year. "]
[null,"Attestation"]
[null,"Attestation Text","C38 – E43","This attestation certifies that:\n• The person signing attests on behalf of the organization that the organization qualifies for a user fee adjustment,\n• To the best of the attester's knowledge and belief, the reported payments for contraceptive services were made in compliance with federal law [26 CFR § 54.9815-2713A(b)(2) or 29 CFR § 2590.715-2713A(b)(2)],\n• The information contained in the submission is true, correct, and complete to the best of the attester's knowledge and belief,\n• The attester has taken reasonable steps to ascertain the truth, correctness, and completeness of the reported information, and\n• The organization will promptly inform CMS if the organization becomes aware that any information submitted on the form  is untrue, incorrect, or incomplete. \n\nRead the text of the attestation carefully before signing.  The individual can type his or her name in this line to constitute a signature.\n"]
[null,"Signature of Attester","D45","Signature of the person responsible for attesting to the stipulations presented in the attestation statement.  The individual can type his or her name in this line to constitute a signature."]
[null,"Title or Organizational Role of Attester","D46","Enter the title of the attester."]
[null,"Date signed","D47","Enter the date the attestation was signed in eight-digit, mm/dd/yyyy format."]
[null,"Attester Email Address","D48","Enter the email address of the attester."]
[null,"Attester Telephone Number and Extension","D49 and F49","Enter the telephone number of the attester and include an extension, if applicable."]
[null,"User Fee Tab"]
[null,"TPA or PBM Legal Business Name ","B8 – B507","Enter the TPA or PBM legal business name for each self insured plan for which the issuer intends to seek an adjustment."]
[null,"Federal Employer Identification Number for TPA or PBM ","C8 – C507","Enter the nine-digit Federal Employer Indentification Number (FEIN) of the TPA or PBM through which payments were made for the self insured plan on this line.  Please exclude hyphens. The form will reject any values that are not nine digits."]
[null,"Total Amount Paid to the TPA by the Issuer for Contraceptive Claims Incurred through Dec 31","D8 – D507","Enter the total dollar amount of contraceptive claims paid that the issuer paid to the TPA  or PBM for the self-insured plan on this line.  The amount should reflect the dollar value of contraceptive claims incurred through December 31st of the year preceding the current benefit year.\n\nThis amount should reflect the total dollar amount paid to the TPA or PBM by the participating FFM issuer.  If a TPA made or arranged for such payments, the total dollar amount should reflect the amount reported to the participating issuer by the TPA or PBM.\n"]
[null,"User Fee Adjustment Amount ((15 %) from Contraceptive Claims Paid to TPA )","E8 – E507","Do not populate this column. This amount displays the total amount of the user fee adjustment that HHS will make to the FFM issuer's user fee amount.  \n\nThis amount equals the dollar amount of contraceptive claims paid to a TPA or PBM by the issuer (or the amount the TPA or PBM reported to the issuer) in Column D, plus an additional margin for the administrative costs of the issuer  (15 percent).\n\nIf this amount exceeds an issuer's total user fee liability in any given month, HHS will credit the remaining adjustment to the issuer's user fee obligation for the next month.  Any adjustment amounts that have not been credited by the end of the calendar year will be rolled over and applied in the next calendar year."]
[null,"Is the issuer part of the same entity as the TPA ( same parent company?) ","F8 – F507","Indicate with a yes or no whether the issuer is part of the same entity as the TPA, or shares the same parent company with the TPA."]
[]
[]
[null,"PRA Disclosure Statement\nAccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1285.  The time required to complete this information collection is estimated to average 11 hours per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. "]