Form CMS-10465 Minimum Essential Coverage Certification (optional Excel

OMB Control No. 0938-1189
Expiration Date: 08/31/2019

Name of Plan
Sponsor or
Government
Agency

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

Applicant
(Plan/Policy
Situs) City

Applicant
(Plan/ Policy
Situs) State

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

Name of
Person
Providing
Certification

Title of
Individual
Providing
Certification

OMB Control No. 0938-1189
Expiration Date: 08/31/2019

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)

OMB Control No. 0938-1189
Expiration Date: 08/31/2019

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
(2712)
(2713)

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 care Appeals
coverage
process
(2718)
(2719)

Patient
protections
(2719A)

OMB Control No. 0938-1189
Expiration Date: 08/31/2019

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
availablility of
coverage (2702)

Prohibiting
discrimination
Prohibition of
against indvidual
Guaranteed
preexisting condition
participants and
renewability of exclusions or other
beneficiaries based
coverage
discrimination based
on health status
(2703)
on health status (2704) (2705)

Coverage for
individuals
Nonparticipaing in
discrimination approved
in health care clinical trials
(2706)
(2709)

OMB Control No. 0938-1189
Expiration Date: 08/31/2019

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

OMB Control No. 0938-1189
Expiration Date: 08/31/2019

Office Visit
Copays/Coinsurance

Plan
Deductible

Out-of-pocket
maximum
Copay (if
limit
applicable)

Hospital Inpatient
Copay/Coinsurance

Coinsurance (if Copay (if
applicable)
applicable)

Coinsurance (if
applicable)

OMB Control No. 0938-1189
Expiration Date: 08/31/2019

Emergency Room
Copay/Coinsurance

Copay (if
applicable)

Rx Copay/Coninsurance

Coinsurance (if Copay (if
applicable)
applicable)

Coinsurance (if
applicable)