CMS-10465 Minimum Essential Coverage Certification (optional Excel

Minimum Essential Coverage (CMS-10465)

MEC Application - Applicant and plan information Optional Excel2022.xlsx

OMB: 0938-1189

Document [xlsx]
Download: xlsx | pdf







Contact information for the individual providing certification

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) 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) Does the coverage provided the essential health benefits listed below? (yes/no)

Office Visit Copays/Coinsurance Hospital Inpatient Copay/Coinsurance Emergency Room Copay/Coinsurance Rx Copay/Coninsurance
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 Street Address City State Zip Code Phone Number (including area code) (xxx-xxx-xxx) Total Number of Individuals Covered by Plan/Policy (include all dependents covered) Eligibility criteria (describe briefly) Lifetime limits (2711) Prohibition on recissions (2712) Coverage of preventive health services (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 coverage (2718) Appeals process (2719) Patient protections (2719A) Fair Health Insurance Premiums (2701) Guaranteed availablility of coverage (2702) Guaranteed renewability of coverage (2703) Prohibition of preexisting condition exclusions or other discrimination based on health status (2704) Prohibiting discrimination against indvidual participants and beneficiaries based on health status (2705) Non-discrimination in health care (2706) Coverage for individuals participaing in approved clinical trials (2709) Ambulatory Emergency Hospitalization Laboratory Pediatric Maternity/ Newborn Mental Health/ Substance Abuse Rehabilitative/ Devices Preventive/ Wellness Prescription Plan Deductible Out-of-pocket maximum limit Copay (if applicable) Coinsurance (if applicable) Copay (if applicable) Coinsurance (if applicable) Copay (if applicable) Coinsurance (if applicable) Copay (if applicable) Coinsurance (if applicable)
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