Self-Certification or Notiffication

OMB Control No. 1210-0150 Expiration Date: XX/2020

INSTRUCTIONS FOR MODEL NOTICE

Public Health Service Act section 2713 requires, among other things, that certain group health plans and issuers provide benefits for women’s preventive services without cost sharing as provided for in comprehensive guidelines supported by the Health Resources Services Administration (HRSA). The HRSA Guidelines provide an exemption for group health plans and student health insurance coverage established or maintained by entities that object to providing coverage for all or a subset of contraceptive services based on religious beliefs or moral convictions. However, an optional accommodation process is available for objecting entities that are exempt but choose to shift the otherwise applicable obligation to provide benefits for contraceptive services to its issuer or third party administrator. Objecting entities should note that if their issuer has their own religious or moral objection to providing contraception services, an issuer may also avail themselves of the exemption. Separately, third party administrators with an objection may also decline to enter or continue contracts as a third party administrator of the plan.

A completed copy of this model notice may, but is not required to, be used by an objecting entity to provide notice to the Secretary of Health and Human Services (HHS) that the objecting entity has a sincerely held religious or moral objection to coverage of all or a subset of contraceptive services, pursuant to 26 CFR 54.9815- 2713A, 29 CFR 2590.715-2713A, and 45 CFR 147.131, and that it wishes to invoke the accommodation.. The notice may also, but is not required to, be used by an organization to provide updated information to HHS. If the objecting entity establishes or maintains more than one plan, it may submit a separate notice for each plan, or it may modify this form accordingly.

*Alternatively, an objecting entity that intends to invoke the optional accommodation may elect to provide notice to HHS without using this model form; or may elect to self-certify using an EBSA Form 700 and send a copy to each health insurance issuer and third party administrator. EBSA Form 700 is accessible at: http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf.

An organization may revoke its use of the accommodation process at a later date if it chooses to do so provided that written notice of any such revocation is given to participants and beneficiaries consistent with guidance issued by the Secretaries of Labor and Health and Human Services.

After completing this notice or notice in another form for the same purpose, it should be sent by email to HHS at [email protected] or by U.S. mail to:

Centers for Medicare & Medicaid Services

Center for Consumer Information & Insurance Oversight 200 Independence Avenue, SW

Washington, DC 20201 Room 739H

Line-by-line instructions:

Terminology: As used in this form, the term “PHS Act” refers to the Public Health Service Act (42 USC 300gg et seq.). “ERISA” refers to the Employee Retirement Income Security Act (29 USC 1001 et seq.). The “Code” refers to the Internal Revenue Code (26 USA 1, et seq.). The “Affordable Care Act” refers to the Patient Protection and Affordable Care Act (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152).

Introductory paragraph: Indicate whether the objecting entity has a sincerely held religious or moral objection to providing coverage of: (1) all contraceptive services, or (2) a subset of contraceptive services. If the objecting entity objects to providing coverage of a subset of contraceptive services, insert a description of the services sufficient to specifically identify those for which the objecting entity objects to providing coverage.

Line 1: Enter the name of the objecting entity. Insert contact information for the objecting entity, including mailing address, phone, and email (if available).

Line 2: In column (a), enter the name of each plan. In columns (b) and (c) enter the plan’s service provider name and contact information, respectively. In column (d), identify whether the service provider is acting as an issuer (by insuring the benefit) or a third party administrator (“TPA”, by providing administrative services only). In column (e), identify if the plan is a church plan, as defined in ERISA section 3(33), or a student health plan, as defined in 45 CFR 147.145(a). If the plan is neither a church plan nor a student health plan, leave column (e) blank. If the objecting entity establishes or maintains a plan with more than one service provider, enter “same” in column (a) and provide information in columns (b), (c), (d), and (e), as applicable.

Line 3: Enter whether the information submitted is original information, or updated information. If the information is updated, specify the date upon which the updated information was, or will be, effective and what has changed (including if the entity no longer meets the criteria to be an objecting entity).

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 1210-0150. The time required to complete this information collection is estimated to average 50 minutes 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: U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0150.

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MODEL NOTICE

Date:

To the Secretary of Health and Human Services:

The following objecting entity has a religious or moral objection to providing coverage of [ ] all or [ ] a subset of contraceptive services required to be covered under PHS Act section 2713, as added by the Affordable Care Act, and incorporated into ERISA section 715 and Code section 9815. If the objecting entity objects to providing coverage of a subset of contraceptive services, insert a description of the services for which the objecting entity objects to providing coverage:

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1. Name of objecting entity: Contact information:

2. Service provider information:

(a)	Plan name	(b) Service provider name	(c) Service provider contact information	(d) Service provider category	(e) Plan type (if applicable)
				[ ]Issuer or [ ]TPA	[ ]Church plan [ ]Student plan
				[ ]Issuer or [ ]TPA	[ ]Church plan [ ]Student plan
				[ ]Issuer or [ ]TPA	[ ]Church plan [ ]Student plan
				[ ]Issuer or [ ]TPA	[ ]Church plan [ ]Student	plan

3. Information being submitted is (check one):

[ ] Original information; OR [ ] Updated information.

If updated information is being provided, specify the date upon which the updated information was, or will be, effective and what has changed: .

Signature of authorized representative of objecting entity Date

Typed name of authorized representative of objecting entity