CMS-10653 Notice of Availability of Separate Payments for Contrace

OMB Control No. 0938-1344
Expiration Date: XXXX/XXXX

Notice of Availability of Separate Payments for Contraceptive Services
Instructions: For each plan year to which the optional accommodation is to apply, an issuer
required to provide payments for contraceptive services must provide to plan participants and
beneficiaries written notice of the availability of separate payments for contraceptive services
contemporaneous with (to the extent possible), but separate from, any application materials
distributed in connection with enrollment (or re-enrollment) in group health coverage that is
effective beginning on the first day of each applicable plan year. The notice must specify that the
eligible organization does not administer or fund contraceptive benefits, but that the issuer
provides separate payments for contraceptive services, and must provide contact information for
questions and complaints. The following model language, or substantially similar language, may
be used to satisfy the notice requirement:
“Your [employer/institution of higher education] has certified that your [group health
plan/student health insurance coverage] qualifies for an accommodation with respect to the
Federal requirement to cover contraceptive services for women, including all Food and Drug
Administration-approved, cleared, or granted contraceptives, as prescribed by a health care
provider, without cost sharing. This means that your [employer/institution of higher education]
will not contract, arrange, pay, or refer for contraceptive coverage. Instead, [name of health
insurance issuer] will provide separate payments for contraceptive services that you use, without
cost sharing and at no other cost, for so long as you are enrolled in your [group health
plan/student health insurance coverage]. Your [employer/institution of higher education] will
not administer or fund these payments. If you have any questions about this notice, contact
[contact information for health insurance issuer].”

OMB Control No. 0938-1344
Expiration Date: XXXX/XXXX

PRA Disclosure Statement
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collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1344. The time required to complete this
information collection is estimated to average 1.25 hours per respondent, including the time to
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Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.