Form CMS-10653 Model Notice to HHS

OMB Control No. 0938-NEW
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 54.98152713A, 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 0938-NEW. 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: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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:
__________________________________________________________________________.
(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
[ ]Issuer or [ ]TPA
[ ]Issuer or [ ]TPA
[ ]Issuer or [ ]TPA
[ ]Issuer or [ ]TPA

(e) Plan type (if applicable)
[
[
[
[

]Church plan
]Church plan
]Church plan
]Church 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

]Student plan
]Student plan
]Student plan
]Student plan