Form CMS-10653 Notice of Availability of Separate Payments for Contrace

OMB Control No.
0938-1344 Expiration Date:
XX/XX/2021

Notice of Availability of Separate Payments for Contraceptive Services
Instructions: For each plan year to which an accommodation is to apply, an issuer required to
provide payments for contraceptive services must provide to plan participants and beneficiaries
written notice of the availability of separate payments for contraceptive services
contemporaneous with (to the extent possible), but separate from, any application materials
distributed in connection with enrollment (or re-enrollment) in group health coverage that is
effective beginning on the first day of each applicable plan year. The notice must specify that
the eligible organization does not administer or fund contraceptive benefits, but that the issuer
provides separate payments for contraceptive services, and must provide contact information for
questions and complaints. The following model language, or substantially similar language, may
be used to satisfy the notice requirement:

“Your [employer/institution of higher education] has certified that your [group health
plan/student health insurance coverage] qualifies for an accommodation with respect to the
federal requirement to cover all Food and Drug Administration-approved contraceptive services
for women, as prescribed by a health care provider, without cost sharing. This means that your
[employer/institution of higher education] will not contract, arrange, pay, or refer for
contraceptive coverage. Instead, [name of health insurance issuer] will provide separate
payments for contraceptive services that you use, without cost sharing and at no other cost, for so
long as you are enrolled in your [group health plan/student health insurance coverage]. Your
[employer/institution of higher education] will not administer or fund these payments. If you
have any questions about this notice, contact [contact information for health insurance issuer].”

OMB Control No. 0938-1344
Expiration Date: 04/30/2018

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 0938-1344. The time required to complete this
information collection is estimated to average 1.25 hours per respondent, 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: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.