Form CMS-10430 Model Notice to Enrollees

OMB Control No. 0938-0702
Expiration Date: XX/XX/XXXX

Model Notice to Enrollees in a Self-Funded Nonfederal Governmental Group Health Plan
For Plan Years Beginning On or After September 23, 2010
[This notice is appropriate in the case of a collectively bargained plan ratified on or after
March 23, 2010.]
Group health plans sponsored by State and local governmental employers must generally comply
with Federal law requirements in title XXVII of the Public Health Service Act. However, these
employers are permitted to elect to exempt a plan from the requirements listed below for any part
of the plan that is "self-funded" by the employer, rather than provided through a health insurance
policy. (Name of plan sponsor) has elected to exempt (name of plan) from (all) (or specify which
ones) of the following requirements:
1. Protection against limiting hospital stays in connection with the birth of a child to less than 48
hours for a vaginal delivery, and 96 hours for a cesarean section.
2. Protections against having benefits for mental health and substance use disorders be subject to
more restrictions than apply to medical and surgical benefits covered by the plan.
3. Certain requirements to provide benefits for breast reconstruction after a mastectomy.
4. Continued coverage for up to one year for a dependent child who is covered as a dependent
under the plan solely based on student status, who takes a medically necessary leave of absence
from a postsecondary educational institution.
The exemption from these Federal requirements will be in effect for the (plan year) (period of
plan coverage) beginning (specify date) and ending (specify date). The election may be renewed
for subsequent plan years.
[If the Plan provides protections similar to any of the exempted requirements, either
voluntarily or in accordance with State law, those protections may be identified.]

OMB Control No. 0938-0702
Expiration Date: 08/31/2019

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
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information collection is 0938-0702. The time required to complete this information collection is
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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 C426-05, Baltimore, Maryland 21244-1850.