CMS-10704 Model Notice

OMB control number: 0938-1361
Expiration Date: XX/XX/XXXX

Individual Coverage HRA Model Notice
Instructions for the Individual Coverage HRA
The Departments of the Treasury, Labor, and Health and Human Services (the Departments)
have issued final regulations allowing plan sponsors to offer individual coverage health
reimbursement arrangements (HRAs), subject to certain requirements. 1 Among these
requirements, an individual coverage HRA must provide a written notice to all employees
(including former employees) who are eligible for the individual coverage HRA. The final
regulations explain the requirements for the notice. 2
Individual coverage HRAs may use this model notice to satisfy the notice requirement. To use
this model notice properly, the HRA must provide information specific to the HRA (indicated with
italicized prompts in brackets). The HRA may modify the notice based on the terms of the
particular HRA. For example, if the HRA does not cover family members, the notice need not
include references to family members. The use of the model notice is not required, but the
Departments consider use of the model notice, when provided timely, to be good faith
compliance with the notice requirement.
NOTE: Individual coverage HRAs should not include this instructions page with the individual
coverage HRA model notice provided to participants.
Paperwork Reduction Act 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
0938-1361. The time required to complete this information collection is estimated to average 3 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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See 26 CFR 54.9802-4, 29 CFR 2590.702-2, and 45 CFR 146.123.
For information on when the notice must be provided, see 26 CFR 54.9802-4(c)(6)(i), 29 CFR 2590.7022(c)(6)(i) and 45 CFR 147.123(c)(6)(i). For the required contents for the notice, see 26 CFR 54.98024(c)(6)(ii), 29 CFR 2590.702-2(c)(6)(ii) and 45 CFR 147.123(c)(6)(ii). The notice must include a
description of each item listed in the regulations and may include any additional information that does not
conflict with the required information.
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Individual Coverage HRA Model Notice

USE THIS NOTICE WHEN APPLYING FOR
INDIVIDUAL HEALTH INSURANCE
COVERAGE
[Enter date of notice]
You are getting this notice because your employer is offering you an individual coverage health
reimbursement arrangement (HRA). Please read this notice before you decide whether to
accept the HRA. In some circumstances, your decision could affect your eligibility for the
premium tax credit. Accepting the individual coverage HRA and improperly claiming the
premium tax credit could result in tax liability.
This notice also has important information that the Exchange (known in many states as the
“Health Insurance Marketplace”) will need to determine if you are eligible for advance payments
of the premium tax credit. An Exchange operates in each state to help individuals and families
shop for and enroll in individual health insurance coverage.
You may also need this notice to verify that you are eligible for a special enrollment period to
enroll in individual health insurance coverage outside of the annual open enrollment period in
the individual market.

I. The Basics
What should I do with this notice?
Read this notice to help you decide if you want to accept the HRA.
Also, keep this notice for your records. You’ll need to refer to it if you decide to accept the HRA
and enroll in individual health insurance coverage, or if you turn down the HRA and claim the
premium tax credit on your federal income tax return.
What’s an individual coverage HRA?
An individual coverage HRA is an arrangement under which your employer reimburses you for
your medical care expenses (and sometimes your family members’ medical care expenses), up
to a certain dollar amount for the plan year. If you enroll in an individual coverage HRA, you
must also be enrolled in individual health insurance coverage or Medicare Part A (Hospital
Insurance) and B (Medical Insurance) or Medicare Part C (Medicare Advantage) (collectively
referred to in this notice as Medicare) for each month you are covered by the HRA. If your family
members are covered by the HRA, they must also be enrolled in individual health insurance
coverage or Medicare for each month they are covered by the HRA. [Explain where the
participant can find information on which medical care expenses are reimbursed by the HRA.]
The individual coverage HRA you are being offered is employer-sponsored health coverage.
This is important to know if you apply for health insurance coverage on the Exchange.

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Note: There are different kinds of HRAs. The HRA that’s being referred to throughout this
notice, and that your employer is offering you, is an individual coverage HRA. It is not a
qualified small employer health reimbursement arrangement (QSEHRA) or any other type of
HRA.
What are the basic terms of the individual coverage HRA that my employer is offering?
[Add general description of the HRA, including the following specific information:]
(1) The maximum dollar amount available for each participant in the HRA is [insert dollar
amount(s) and describe applicable terms for any variation based on family size or age].
[NOTE: If the HRA varies amounts based on family size, add the following: Note that the
self-only HRA amount available for the plan year, which is the amount you should tell the
Exchange is available to you, is [insert dollar amount(s) and describe any applicable
variation based on age]. If you apply for individual health insurance coverage through
the Exchange, this is the amount the Exchange will use to figure out if your HRA is
considered affordable. [Add any rules regarding the proration of the maximum dollar
amount that applies to any participant (or dependent, if applicable) who is not eligible to
participate in the HRA for the entire plan year].
(2) Your family members [insert are/aren’t] eligible for the HRA. [Revise as needed if
some, but not all, family members are eligible.]
(3) In general, your HRA coverage will start [insert date plan year begins]. However, if
you become eligible for the HRA less than 90 days before the beginning of the plan year
or during the plan year, your HRA coverage will start [insert explanation of earliest date
coverage could start and the latest date HRA coverage could start and other information
about the enrollment procedures, and applicable timing, for these employees.]
(4) The HRA plan year begins on [insert date] and ends on [insert date].
(5) Amounts newly made available under the HRA will be made available on [insert
date(s)].
Note: You will need this information if you apply for health insurance coverage through the
Exchange.
Can I opt out of the individual coverage HRA?
Yes. You can opt out of the HRA for yourself (and your family members, if applicable). [Insert
information on how and when participants may opt out.]
[Add statement as to whether, upon termination of employment, the participant’s HRA is
forfeited or the participant is given the chance to opt out at that time.]
If I accept the individual coverage HRA do I need to be enrolled in other health coverage
too?
Yes. You (and your family members, if applicable) must be enrolled in individual health
insurance coverage or Medicare for each month you (or your family members) are covered by
the HRA. You may not enroll in short-term, limited-duration insurance or only in excepted
benefits coverage (such as insurance that only provides benefits for dental and vision care) to
meet this requirement.

II. Getting Individual Health Insurance Coverage
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How can I get individual health insurance coverage?
If you already have individual health insurance coverage, you do not need to change that
coverage to meet the HRA’s health coverage requirement.
If you don’t already have individual health insurance coverage, you can enroll in coverage
through the Exchange or outside of the Exchange – for example, directly from an insurance
company.
Note: People in most states use HealthCare.gov to enroll in coverage through the Exchange,
but some states have their own Exchange. To learn more about the Exchange in your state, visit
https://www.healthcare.gov/marketplace-in-your-state/.
If you are enrolled in Medicare Part A and B or Medicare Part C, your enrollment in Medicare
will meet the HRA’s health coverage requirement. For information on how to enroll in Medicare,
visit www.medicare.gov/sign-up-change-plans.
When can I enroll in individual health insurance coverage?
Generally, anyone can enroll in or change their individual health insurance coverage during the
individual market’s annual open enrollment period from November 1 through December 15.
(Some state Exchanges may provide additional time to enroll.) If your individual coverage HRA
starts on January 1, you (and your family members, if applicable), generally should enroll in
individual health insurance coverage during open enrollment.
In certain circumstances, such as when your individual coverage HRA starts on a date other
than January 1 or if you are newly hired during the HRA plan year, you (and your family
members, if applicable) can enroll in individual health insurance coverage outside of open
enrollment using a special enrollment period.
If you qualify for a special enrollment period, make sure you enroll on time:
•
•

If you are newly eligible for HRA coverage that would start at the beginning of the HRA
plan year, you generally need to enroll in individual health insurance coverage within the
60 days before the first day of the HRA plan year.
If the HRA was not required to provide this notice 90 days before the beginning of the
plan year, or you are newly eligible for HRA coverage that would start mid-plan year (for
example, because you are a new employee), you may enroll in individual health
insurance coverage up to 60 days before the first day that your HRA can start or up to
60 days after this date. Enroll in individual health insurance coverage as soon as
possible to get the most out of your individual coverage HRA.

Note: If you enroll in individual health insurance coverage through this special enrollment
period, you may need to submit a copy of this notice to the Exchange or the insurance company
to prove that you qualify to enroll outside of the open enrollment period. For more information on
special enrollment periods, visit HealthCare.gov or the website for the Exchange in your state.
Do I need to get new individual health insurance coverage each year if I want to enroll in
my individual coverage HRA each year?
Yes. Individual health insurance coverage is typically sold for a 12-month period that is the
same as the calendar year and ends on December 31. If your HRA starts on January 1, you will
either need to get new individual health insurance coverage or re-enroll in your individual health
insurance coverage. If your HRA has a plan year that starts on a day other than January 1,
because your individual health insurance coverage will stay in effect until December 31, you do
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not need to get new individual health insurance coverage or re-enroll until the next open
enrollment period.
If you are enrolled in Medicare, your Medicare coverage generally will remain in place year to
year.
Do I need to substantiate my (and my family member’s) enrollment in individual health
insurance coverage or Medicare to the individual coverage HRA?
Yes. You must substantiate that you (and your family members, if applicable) will be enrolled in
individual health insurance coverage or Medicare for the period you will be covered by the HRA.
[Add description of when the HRA requires this substantiation to be provided and to whom it
should be provided].
Also, each time you seek reimbursement of a medical care expense from the HRA, you must
substantiate that you had (or have) (or the family member whose medical care expense you are
seeking reimbursement for, if applicable had (or has)) individual health insurance coverage or
Medicare for the month during which the expense was incurred.
[Add description of the reasonable substantiation procedures established or provide information
on where to find information about those procedures.]
What happens if I am (or one of my family members is) no longer enrolled in individual
health insurance coverage or Medicare?
If you (or a family member, if applicable) are no longer enrolled in individual health insurance
coverage or Medicare, the HRA won’t reimburse you for medical care expenses that were
incurred during a month when you (or your family member, as applicable) did not have
individual health insurance coverage or Medicare. This means that you may not seek
reimbursement for medical care expenses incurred when you (or your family member, if
applicable) did not have individual health insurance coverage or Medicare.
Note: You must report to the HRA if your (or your family member’s) individual health insurance
coverage or Medicare has been terminated retroactively and the effective date of the
termination.

III. Information About the Premium Tax Credit
What is the premium tax credit?
The premium tax credit is a tax credit that helps eligible individuals and their families pay their
premiums for health insurance coverage purchased through the Exchange. The premium tax
credit is not available for health insurance coverage purchased outside of the Exchange.
Factors that affect premium tax credit eligibility include enrollment in Exchange coverage,
eligibility for other types of coverage, and household income.
When you enroll in health insurance coverage through the Exchange, the Exchange will ask you
about any coverage offered to you by your employer, including through an HRA. Your ability to
claim the premium tax credit may be limited if your employer offers you coverage, including an
HRA.
The Exchange also will determine whether you are eligible for advance payments of the
premium tax credit, which are amounts paid directly to your insurance company to lower the
cost of your premiums. For more information about the premium tax credit, including advance

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payments of the premium tax credit and premium tax credit eligibility requirements, see
irs.gov/aca.
If I accept the individual coverage HRA, can I claim the premium tax credit for my
Exchange coverage?
No. You may not claim the premium tax credit for your Exchange coverage for any month you
are covered by the HRA. Also, you may not claim the premium tax credit for the Exchange
coverage of any family members for any month they are covered by the HRA.
If I opt out of the individual coverage HRA, can I claim the premium tax credit for my
Exchange coverage?
It depends.
•

If you opt out of the HRA and the HRA is considered unaffordable you may claim the
premium tax credit for yourself and any family members enrolled in Exchange coverage
if you are otherwise eligible.

•

If you opt out of the HRA and the HRA is considered affordable, you may not claim the
premium tax credit for yourself or any family members.

If you are a former employee, the offer of an HRA will not prevent you from claiming the
premium tax credit (if you are otherwise eligible for it), regardless of whether the HRA is
considered affordable and as long as you don’t accept the HRA.
How do I know if the individual coverage HRA I’ve been offered is considered affordable?
The Exchange website will provide information on how to determine affordability for your
individual coverage HRA. To find your state’s Exchange, visit:
https://www.healthcare.gov/marketplace-in-your-state/.
Do I need to provide any of the information in this notice to the Exchange?
Yes. Be sure to have this notice with you when you apply for coverage on the Exchange. If
you’re applying for advance payments of the premium tax credit, you’ll need to provide
information from the answer to “What are the basic terms of the individual coverage HRA my
employer is offering?” on page [page number]. You will also need to tell the Exchange whether
you are a current employee or former employee.
If I’m enrolled in Medicare, am I eligible for the premium tax credit?
No. If you have Medicare, you aren’t eligible for the premium tax credit for any Exchange
coverage you may have.

IV. Other Information You Should Know
Who can I contact if I have questions about the individual coverage HRA?
Contact: [Add contact information (including a phone number) for an individual or a group of
individuals who participants may contact in order to receive additional information regarding the
HRA.]
[For use by an HRA subject to ERISA that meets the safe harbor set forth in 29 CFR 2510.31(l): Is the individual health insurance coverage I pay for with my individual coverage
HRA subject to ERISA?]

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The individual health insurance coverage that is paid for with amounts from your individual
coverage HRA, if any, is not subject to the rules and consumer protections of the Employee
Retirement Income Security Act (ERISA). You should contact your state insurance department
for more information regarding your rights and responsibilities if you purchase individual health
insurance coverage.

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