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Transitional Reinsurance Fee Filing Service Form

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Transitional Reinsurance Fee Filing Service Form

Transitional Reinsurance Fee Filing Service

Step 1: Please fill out and submit the form below, or complete this spreadsheet and email it back to us. We will use the collected information to file your organization’s data with CMS.

Note that employers may choose to pay the entire $27.00 per covered life contribution in a single payment by the first deadline of January 17th, 2017, or can choose to pay the fee in two installments. If two installments are chosen, the first installment of $21.60 per covered life is due by January 17, 2017. The balance of $5.40 per covered life must be paid no later than November 15, 2017. You will need to tell us in the form below if you want to arrange for a single payment or pay in two installments. We need this information to submit the membership totals. You will actually set up your own payment dates (see step 3 below).

Step 2: Enter the billing information for us to invoice you for our services.

Step 3: You will be contacted by one of our consultants prior to the reporting deadline with instructions for entering your organizations banking information and scheduling your payment dates for CMS to complete the payment through an ACH draft from your account. We do this last step in this manner so you do not have to provide us with your detailed banking information.

Step 4: We will transfer the details of the pay.gov account we have set up on your behalf to you for use with reporting and paying the fee for the next two benefit years.

If you have any questions regarding the process please contact info@benefitcomply.com.

Organization Information

Contributing Entity Legal Business Name*:

Federal EIN/TIN*:

Organization Type*:

Street Address*:

State*:

ZIP*:

Domicilary State: (If different from above)

Annual Enrollment Count*:

Payment plan to CMS*:

Contact Information

Please designate a contact person for your organization. Each submission requires at least 1 contact, but CMS suggests 2 in case there are any problems reaching the main contact.

Contact 1 (required)

First Name*:

Last Name*:

Title*:

Email*:

Phone*:

Contact 2 (optional)

First Name:

Last Name:

Title:

Email:

Phone:

Authorizing Official

The Authorizing Official must be someone who has the authority to authorize the payment of the transitional reinsurance program fee. It may be the same as one of the contacts above.

Same as contact 1Same as contact 2New contact (details below)

First Name:

Last Name:

Title:

Email:

Phone:

Billing Address for Service Invoice

Billing Contact

Same as Contact 1Same as Contact 2Same as Authorizing OfficialNew Contact (Details Below)

First Name:

Last Name:

Email:

Phone:

Billing Address

Same as Organization Address AboveNew Address(Details Below)

Street Address:

State:

ZIP:

I understand that submitting the above information constitutes engagement of the Benefit Comply Reinsurance Fee service and that I will required to remit payment of $1250 upon receipt of the invoice.

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