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Contact information for the individual providing certification |
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Early Market Reforms (list the document that demonstrates that the coverage complies with each provision of Title I of the Affordable Care Act listed below) |
Health Insurance Market Reforms (list the document that demonstrates that the coverage complies with each provision of Title I of the Affordable Care Act listed below) |
Does the coverage provided the essential health benefits listed below? (yes/no) |
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Office Visit Copays/Coinsurance |
Hospital Inpatient Copay/Coinsurance |
Emergency Room Copay/Coinsurance |
Rx Copay/Coninsurance |
| Name of Plan Sponsor or Government Agency |
Name of Plan/Policy (Use new row for each plan/policy application) |
Applicant (Plan/Policy Situs) City |
Applicant (Plan/ Policy Situs) State |
Plan/ Policy Effective Date (mm/dd/yyyy) |
Name of Person Providing Certification |
Title of Individual Providing Certification |
Street Address |
City |
State |
Zip Code |
Phone Number (including area code) (xxx-xxx-xxx) |
Total Number of Individuals Covered by Plan/Policy (include all dependents covered) |
Eligibility criteria (describe briefly) |
Lifetime limits (2711) |
Prohibition on recissions (2712) |
Coverage of preventive health services (2713) |
Extenstion of dependent coverage (2714) |
Development and utilization of coverage documents and standardized definitions (2715) |
Ensuring the quality of care (2717) |
Bringing down the cost of health care coverage (2718) |
Appeals process (2719) |
Patient protections (2719A) |
Fair Health Insurance Premiums (2701) |
Guaranteed availablility of coverage (2702) |
Guaranteed renewability of coverage (2703) |
Prohibition of preexisting condition exclusions or other discrimination based on health status (2704) |
Prohibiting discrimination against indvidual participants and beneficiaries based on health status (2705) |
Non-discrimination in health care (2706) |
Coverage for individuals participaing in approved clinical trials (2709) |
Ambulatory |
Emergency |
Hospitalization |
Laboratory |
Pediatric |
Maternity/ Newborn |
Mental Health/ Substance Abuse |
Rehabilitative/ Devices |
Preventive/ Wellness |
Prescription |
Plan Deductible |
Out-of-pocket maximum limit |
Copay (if applicable) |
Coinsurance (if applicable) |
Copay (if applicable) |
Coinsurance (if applicable) |
Copay (if applicable) |
Coinsurance (if applicable) |
Copay (if applicable) |
Coinsurance (if applicable) |