CMS-10704 Model Attestation

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

Individual Coverage HRA Model Attestations
Instructions for Individual Coverage HRAs
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 other
requirements, individual coverage HRAs must implement, and comply with, reasonable
procedures to satisfy two substantiation requirements:
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The annual coverage substantiation requirement: The HRA must substantiate that
participants and each dependent covered by the HRA are, or will be, enrolled in individual
health insurance coverage or Medicare Part A and B or Medicare Part C for the plan year
(or for the portion of the plan year the individual is covered by the HRA, if applicable).

•

The ongoing substantiation requirement: The HRA may not reimburse a medical care
expense unless, prior to the reimbursement, the participant substantiates that the individual
on whose behalf the reimbursement is requested is (or was) enrolled in individual health
insurance coverage or Medicare Part A and B or Medicare Part C for the month during
which the medical care expense was incurred.

Each of these substantiation requirements may be satisfied by a participant attestation, among
other permissible methods. Other methods include providing a third party document or, for the
ongoing substantiation requirement, direct payment of insurance premiums, which the
Departments expect will be a method some HRAs prefer. 2 The Departments have developed
the attached model attestations for HRAs that choose to use attestation to satisfy either the
annual coverage substantiation requirement or the ongoing substantiation requirement.
To use the model attestations properly, the HRA must fill in the additional information specific to
the HRA, such as contact information, which is indicated by italicized prompts in brackets. The
Departments consider the use of the model attestations to constitute reasonable procedures
that satisfy the annual coverage substantiation requirement and the ongoing substantiation
requirement, as applicable. Use of the model attestations is not required, and the models may
be combined with other documents, such as the form the HRA otherwise uses to confirm that
expenses sought to be reimbursed under an HRA are for medical care. The model attestations
also may be modified to reflect the terms of the particular HRA, for example, to remove the
attestations that relate to family members, if the HRA does not cover family members.
NOTE: Individual coverage HRAs should not include this instructions page with the individual
coverage HRA attestation forms 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 be minimal 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.

1

See 26 CFR 54.9802-4, 29 CFR 2590.702-2, and 45 CFR 146.123.
See the final regulations (26 CFR 54.9802-4(c)(5), 29 CFR 2590.702-2(c)(5) and 45 CFR 146.123(c)(5))
for additional information.
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Individual Coverage HRA Model Attestation:
Annual Coverage Substantiation Requirement
Instructions: You have been offered an individual coverage health reimbursement arrangement
(HRA) to help you pay for medical care expenses. To enroll in this individual coverage HRA, you
must be enrolled in individual health insurance coverage, Medicare Part A (Hospital Insurance)
and B (Medical Insurance), or Medicare Part C (Medicare Advantage). You should have
received a notice that describes the individual coverage HRA that you are being offered. If you
have not, or if you have questions about the individual coverage HRA, contact [add contact
information].
If you plan to enroll in the individual coverage HRA, you must complete this form to confirm that
you will have individual health insurance coverage, Medicare Part A and B, or Medicare Part C
while you are covered by the HRA. If your family members will also be covered by the individual
coverage HRA, you need to fill out the applicable section of this form on their behalf.
You must sign and date the form. Your family members do not need to sign or date the form.
Please return the completed form to [add instructions for returning the form]. You must return
the form by [add deadline for returning the form.]
I attest to the following:
I, ____________________________, am covered (or will be covered) by the following health
(insert name)

coverage: ___________________________________________.
(insert name of insurance company or indicate “Medicare”)

This health coverage began (or will begin) on ____________________________________.
(insert date coverage began or will begin)

Instructions: Complete the following if you plan to enroll a family member in the individual
coverage HRA. If more than one family member will be covered by the individual coverage
HRA, fill out a form for each family member. [This section may also be copied to allow a
participant to list all family members on a single form.]
The following family member, _________________________, is covered (or will be covered) by
(insert name)

the following health coverage: ______________________________________________.
(insert name of insurance company or indicate “Medicare”)

This health coverage began (or will begin) on ____________________________________.
(insert date coverage began or will begin)

I hereby affirm that the above information is true and accurate.
Signed: ________________________________________
Date: _________________________________________

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Individual Coverage HRA Model Attestation:
Ongoing Substantiation Requirement
Instructions: To receive reimbursement for medical care expenses under your individual
coverage health reimbursement arrangement (HRA), you must complete this form for each
request for reimbursement.
The individual coverage HRA will reimburse you for a medical care expense incurred during a
month only if you have (or had) individual health insurance coverage, Medicare Part A (Hospital
Insurance) and B (Medical Insurance), or Medicare Part C (Medicare Advantage) during that
month. Similarly, the individual coverage HRA will reimburse you for a medical care expense
your family member incurred during a month only if the family member has (or had) individual
health insurance coverage, Medicare Part A and B, or Medicare Part C during that month. In
this form, you are attesting that you (or your family member) meet this requirement. [If this form
is not combined with the form used to seek reimbursement of medical care expenses, add a
statement that the reimbursement form is separate.]
You must sign and date this form. Your family member does not need to sign or date the form.
Please return the completed form to [add instructions for returning the form, including any
applicable deadline].
Complete the following if you’re requesting reimbursement of your medical care expense from
the individual coverage HRA.
I attest to the following:
I, _____________________________, am requesting reimbursement for a medical care
(insert name)

expense incurred during _________________, and for that month I am (or was) covered under
(insert month, year)

the following health coverage:____________________________________________.
(insert name of insurance company or indicate “Medicare”)

Instructions: Complete the following if you’re requesting reimbursement of a family member’s
medical care expense from the individual coverage HRA.
I, ________________________, am requesting reimbursement for a medical care expense
(insert name)

incurred by _________________________________________, during _______________, and
(insert name of family member)

(insert month, year)

for that month this family member is (or was) covered under the following health coverage:
_____________________________________________.
(insert name of insurance company or indicate “Medicare”)

I hereby affirm that the above information is true and accurate.
Signed: ________________________________________
Date: _________________________________________

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