CMS-10465 Minimum Essential Coverage Certification

OMB Control No. 0938-1189
Expiration Date: xx/xx/xxxx

Minimum Essential Coverage Certification
Instructions:
Organizations requesting that the health coverage they sponsor be recognized as minimum
essential coverage must provide the following information to CMS. Detailed instructions are
available at http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-MarketReforms/minimum-essential-coverage.html.
Provide the following organization and contact information in the attached spreadsheet:
1. Name of the organization sponsoring the plan
2. Name and title of the individual who is authorized to make, and makes, the certification
below on behalf of the organization
3. Address of individual named above
4. Phone number of individual named above
Provide the following plan information in the attached spreadsheet:
1.
2.
3.
4.

Number of enrollees
Eligibility criteria
Cost sharing requirements, including deductible and out of pocket maximum limit.
Whether the coverage provides all of the essential health benefits (as defined in ACA
§1302(b) and its implementing regulations.
5. List of attached plan documentation or other information that demonstrate that the
coverage sponsored by the organization substantially complies with the provisions of
Title I of the Affordable Care Act applicable to non-grandfathered individual health
insurance coverage.
Sign and submit the certification below.
Submit any questions to: [email protected]

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OMB Control No.
0938-1189 Expiration Date:
xx/xx/xxxx

CERTIFICATION
I certify that the health coverage sponsored by this organization substantially complies with the
provisions of Title I of the Affordable Care Act applicable to non-grandfathered individual
health insurance coverage.
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 who is authorized to make this certification on behalf of the
organization

______________________________________
Date

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OMB Control No.
0938-1189 Expiration Date:
xx/xx/xxxx

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 0938-1189. The time required to complete this
information collection is estimated to average 5.25 hours 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.

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