EBSA Form 700 Eligible Organization Self-Certification

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

EBSA FORM 700-- CERTIFICATION (revised September 2017) 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. This form may, but is not required to, be used by an objecting entity to provide notice to its issuer or third party administrator that 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. Alternatively, an objecting entity may also provide notice to the Secretary of Health and Human Services. A model notice is available at - http://www.cms.gov/cciio/resources/Regulations-and-Guidance/index.html#Prevention. 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. If you intend to utilize the optional accommodation process, please fill out this form completely and provide it to your plan’s health insurance issuers (for insured coverage) or third party administrators (for self-insured coverage). This form should be made available for examination upon request and maintained on file for at least 6 years following the end of the last applicable plan year.
Name of the objecting entity
Name and title of the individual who is authorized to make, and makes, this certification on behalf of the entity
Mailing and email addresses and phone number for the individual listed above

I certify the organization is an objecting entity (as described in 26 CFR 54.9815-2713A(a), 29 CFR 2590.715-2713A(a); 45 CFR 147.131(c)) that has a sincerely held religious or moral objection to providing coverage for some or all of any contraceptive services.

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

Notice to Third Party Administrators of Self-Insured Health Plans

In the case of a group health plan that provides benefits on a self-insured basis, the provision of this certification to a third party administrator for the plan that will process claims for contraceptive coverage required under 26 CFR 54.9815-2713(a)(1)(iv) or 29 CFR 2590.715- 2713(a)(1)(iv) constitutes notice to the third party administrator that the eligible organization:

1. Will not act as the plan administrator or claims administrator with respect to claims for contraceptive services, or contribute to the funding of contraceptive services; and

2. The obligations of the third party administrator are set forth in 26 CFR 54.9815-2713A, 29 CFR 2510.3-16, and 29 CFR 2590.715-2713A.

This form or a notice to the Secretary is an instrument under which the plan is operated.

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.