Form CMS-10465 Minimum Essential Coverage Certification (optional Excel

Name of Plan
Sponsor or
Government
Agency

Name of
Plan/Policy
(Use new row
for each
plan/policy
application)

Applicant
(Plan/Policy
Situs) City

OMB Control No. 0938-1189
Expiration Date: 08/2019

Applicant
(Plan/ Policy
Situs) State

Plan/ Policy
Effective Date
(mm/dd/yyyy)

Name of
Person
Providing
Certification

Title of
Individual
Providing
Certification

Contact information for the individual providing
certification

Street
Address

City

State

Phone
Number
(including
area code)
(xxx-xxxZip Code xxx)

Total Number of
Individuals
Covered by
Plan/Policy
(include all
dependents
covered)

Eligibility
criteria
(describe
briefly)

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)

Lifetime
limits
(2711)

Coverage of
preventive
Prohibition
health
on recissions services
(2713)
(2712)

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 Appeals
care coverage process
(2718)
(2719)

Patient
protections
(2719A)

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)

Fair Health
Insurance
Premiums
(2701)

Guaranteed
Guaranteed
renewability
availablility of
of coverage
coverage (2702) (2703)

Prohibiting
discrimination
against indvidual
Prohibition of
preexisting condition participants and
beneficiaries based
exclusions or other
discrimination based on health status
on health status (2704) (2705)

Coverage for
individuals
participaing in
Nondiscrimination approved
in health care clinical trials
(2709)
(2706)

Does the coverage provided the essential health benefits listed below? (yes/no)

Ambulatory

Emergency

Hospitalization

Laboratory

Pediatric

Maternity/
Newborn

Mental
Health/
Substance
Abuse

Rehabilitative/
Devices

Preventive/
Wellness

Prescription

Office Visit
Copays/Coinsurance

Plan
Deductible

Out-ofpocket
maximum
limit

Copay (if
applicable)

Hospital Inpatient
Copay/Coinsurance

Coinsurance (if Copay (if
applicable)
applicable)

Coinsurance (if
applicable)

Emergency Room
Copay/Coinsurance

Copay (if
applicable)

Rx Copay/Coninsurance

Coinsurance (if Copay (if
applicable)
applicable)

Coinsurance (if
applicable)