.2016 ACA Transitional Reinsurance Program Annual Enrollment Contributions
Description: Please use this form ONLY to submit your 2016 benefit year annual enrollment count and remit the contribution amount owed for the ACA Transitional Reinsurance Program. ACH Company ID = 7505008016 and Company Name = USDEPTHHSCMS. Please email reinsurancecontributions@cms.hhs.gov if you need to submit your Previous Year's ACA Transitional Reinsurance Program Annual Enrollment Contributions form and contributions.
Form Number: ACA 2016
OMB Number: 0938-1155, 0938-1187
2014 ACA Transitional Reinsurance Program Annual Enrollment Contributions
Description: Please use this form ONLY to submit your 2014 benefit year annual enrollment count and remit the contribution amount owed for the ACA Transitional Reinsurance Program.... ACH Company ID = 7505008015 and Company Name = USDEPTHHSCMS. Please use the Current Year ACA Transitional Reinsurance Program Annual Enrollment Contributions form to submit your Current Year contributions.
Form Number: ACA
OMB Number: 0938-1155, 0938-1187
2015 ACA Transitional Reinsurance Program Annual Enrollment Contributions
Description: Please use this form ONLY to submit your 2015 benefit year annual enrollment count and remit the contribution amount owed for the ACA Transitional Reinsurance Program. ACH Company ID = 7505008015 and Company Name = USDEPTHHSCMS. Please email reinsurancecontributions@cms.hhs.gov if you need to submit your Previous Year's ACA Transitional Reinsurance Program Annual Enrollment Contributions form and contributions.
Form Number: ACA 2015
OMB Number: 0938-1155, 0938-1187
CLIA Laboratory User Fees
Description: Use this form to pay your CLIA fees.
Form Number: 35
CMS Health Insurance Marketplace and Premium Stabilization Programs Payment Form
Description: Please use this form to pay amounts owed related to the Health Insurance Marketplace and Premium Stabilization Programs. Additionally, if necessary, provide the following information to your bank to prevent debit blocking on the payments processed through Pay.gov on your dunning letter/invoice: ACH Company Name: USDEPTHHSCMS...Agency Company ID: 7505008014
Form Number: HHSCIIO
OMB Number: 0938-1187
Help Form
Form Number: Help
Medicare Coverage Gap Discount Program CMPs
Description: Please use this form to pay your Medicare Coverage Gap Discount Program Civil Monetary Penalties
Form Number: Medicare CGDP CMPs

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