Minimum Essential Coverage Certification

Minimum Essential Coverage

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1189 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10465 Minimum Essential Coverage Certification Form and Instruction
CMS-10465 Minimum Essential Coverage Certification (WORD) CMS-10465 MEC Certification_final rev clean.docx Form and Instruction
CMS-10465 Minimum Essential Coverage Certification (optional Excel MEC Application - Applicant and plan information.xlsx Form

Information Collection (IC) Details

IC Title:	Minimum Essential Coverage Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 156.304(a)(3) 45 CFR 156.604(d)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10465	Minimum Essential Coverage Certification (WORD)	CMS-10465 MEC Certification_final rev clean.docx		Yes	Yes	Fillable Printable
Form	CMS-10465	Minimum Essential Coverage Certification (optional Excel file)	MEC Application - Applicant and plan information.xlsx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	53	53
Annual IC Cost Burden (Dollars)	2,200	2,200

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.