Federally-Facilitated Marketplace (Ffm) User Fee Adjustment Web Form Quick Startguide - Centers For Medicare And Medicaid Services Page 5

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FFM User Fee Adjustment Web Form Quick Start Guide
Step
Action
4
Enter the FFM Issuer’s Tax Identification Number.
5
Enter the FFM Issuer’s HIOS ID.
Ensure you have entered a valid HIOS ID for the 2016 benefit year.
6
Enter the number of TPAs or PBMs for which the FFM Issuer has agreed to
reimburse for the cost of contraceptive claims.
7
Select the Create Table button.
Note: The number entered in the “Enter the number of TPA(s) or PBM(s) for
which the FFM Issuer has agreed to reimburse for the cost of contraceptive
claims” field will determine how many rows are created in the FFM User Fee
table.
8
In the FFM User Fee table, enter the TPA or PBM Legal Business Name for
which the FFM Issuer has agreed to reimburse for the cost of contraceptive
claims.
9
In the FFM User Fee table, enter the Tax Identification Number for the TPA or
PBM for which the FFM Issuer has agreed to reimburse for the cost of
contraceptive claims.
10
In the FFM User Fee table, select Yes or No from the drop-down menu for the
question, “Is the issuer part of the same entity as the TPA/PBM that incurred
claims for contraceptive services (same parent company)?”
11
In the FFM User Fee table, enter the total amount paid to the TPA/PBM by the
FFM Issuer for contraceptive claims incurred through December 31, 2016.
Repeat steps 9-12 for each row added.
12
Select the Calculate button.
This will populate the following column/row:
Column/Row
Calculation
FFM User Fee
The total amount paid to the TPA/PBM by the
Adjustment Amount
FFM Issuer for contraceptive claims incurred
through December 31 of the selected benefit year
plus an additional 15% for the administrative
costs of the FFM issuer (rounded to the nearest
hundredth).
Totals
Sum of all amount fields for total amount paid to
the TPA/PBM by the FFM Issuer for
contraceptive claims incurred through December
31 of the selected benefit year and user fee
adjustment amount.
13
Select the Continue button.
You will be directed to the Summary page of the web form.
FFM User Fee Adjustment Web Form Quick Start Guide
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