Form CMS-10465 Minimal Essential Coverage Certification

Minimum Essential Coverage Certification
Instructions:
Organizations requesting that the health insurance coverage they sponsor be recognized as
minimum essential coverage must provide the following information to CMS.
Submit the information electronically to: [email protected]
Submit any questions to: [email protected]

I.

ORGANIZATION AND CONTACT INFORMATION
Name of the organization sponsoring the plan
Name and title of the individual who is
authorized to make, and makes, this
certification on behalf of the organization
Address of individual named above
Phone number of individual named above

II.

PLAN INFORMATION

A. Provide number of enrollees:

B. Provide eligibility criteria:

C. Provide cost sharing requirements, including deductible and out of pocket maximum
limit:
D. Does the coverage provide all of the essential health benefits (as defined in ACA
§1302(b) and its implementing regulations)?
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Yes
No
If no, list the ones that are not provided:

III.

CERTIFICATION

I certify that the health insurance coverage sponsored by this organization substantially complies
with the provisions of Title I of the Affordable Care Act applicable to non-grandfathered
individual health insurance coverage.
I declare that I have made this certification, and that, to the best of my knowledge and belief, it is
true and correct. I also declare that this certification is complete.

______________________________________
Signature of the individual listed above

______________________________________
Date

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PRA Disclosure Statement
According 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-XXXX. The time required to complete
this information collection is estimated to average 4.25 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.

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