EBSA Form 700 Eligible Organization Self-Certification

OMB Control No. 1210-0150

Expiration Date: XX/XX/2018

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 exemptions for group health plans and student health insurance coverage under certain circumstances related to an objection to providing contraception coverage. . An accommodation process is also available for eligible entities, under which the obligation to provide benefits for contraceptive services is shifted to its issuer or third party administrator. The accommodation process is described in 26 CFR 54.9815-2713A, 29 CFR 2590.715-2713A, and 45 CFR 147.131. Different versions of these rules have been in place since July 2015. These instructions and model notice may be used to claim an accommodation (not the exemption) from the contraceptive coverage requirements. These instructions are intended for use in connection with whichever accommodation process is in effect at the time an entity submits this form; either under the July 2015 final rules (80 FR 41318), or the interim final rules published on October 13, 2017 (82 FR 47792, 82 FR 47838). An eligible entity may, but is not required to, use a completed copy of this form to provide notice to its issuer or third party administrator that that the objecting entity has a sincerely held religious or, if applicable under the accommodation process that is in effect, 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. If the October 13, 2017 interim final rules are in effect, 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 Secretary of Health and Human Services. The guidance is available at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Notice-Issuer-Third-Party-Employer-Preventive.pdf. Entities should check current regulations and guidance to determine if revocation is available. If you intend to utilize the 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, as applicable, [  ] 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 5 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, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0150.