Self-Certification or Notification

OMB Control No. 0938-1344

Expiration Date: 11/30/2021

INSTRUCTIONS FOR MODEL NOTICE

Public Health Service Act section 2713 requires, among other things, that certain group health plans and issuers provide benefits for women’s preventive services without cost sharing as provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA). The HRSA Guidelines provide exemptions for group health plans and student health insurance coverage under certain circumstances related to an objection to providing contraception coverage. An accommodation process is also available for eligible entities, under which the obligation to provide benefits for contraceptive services is shifted to the entity’s issuer or third party administrator. The accommodation process is described in 26 CFR 54.9815-2713A, 29 CFR 2590.715-2713A, and 45 CFR 147.131. These instructions and model notice may be used to claim an accommodation (not the exemption) from the contraceptive coverage requirements.

An eligible entity may, but is not required to, use a completed copy of this model notice to provide notice to the Secretary of Health and Human Services (HHS) that the eligible entity has a sincerely held objection, consistent with the applicable rules, to coverage of all or a subset of contraceptive services, pursuant to 26 CFR 54.9815-2713A, 29 CFR 2590.715-2713A, and 45 CFR 147.131, and that it wishes to invoke the accommodation. The notice may also, but is not required to, be used by an organization to provide updated information to HHS. If the objecting entity establishes or maintains more than one plan, it may submit a separate notice for each plan, or it may modify this form accordingly

As an alternative to using this model notice to HHS, an objecting entity that intends to invoke the accommodation may elect to provide notice to HHS without using this model form; or may elect to self-certify using EBSA Form 700 and send a copy to each health insurance issuer and third party administrator. EBSA Form 700 is accessible at: http://www.dol.gov/ebsa/pdf/preventiveserviceseligibleorganizationcertificationform.pdf.

An organization may revoke its use of the accommodation process at a later date if it chooses to do so, provided that written notice of any such revocation is given to participants and beneficiaries consistent with guidance issued by the Secretary of HHS. The guidance is available at https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Notice-Issuer-Third-Party-Employer-Preventive.pdf. Entities should check current regulations and guidance to determine if revocation is available.

After completing this model notice or notice in another form for the same purpose, to provide notice to the Secretary of Health and Human Services (HHS) that the eligible entity has a sincerely held objection to coverage of all or a subset of contraceptive services, it should be sent by email to HHS at [email protected] or by U.S. mail to:

Centers for Medicare & Medicaid Services

Center for Consumer Information & Insurance Oversight

200 Independence Avenue, SW

Washington, DC  20201

Room 739H

Line-by-line instructions:

Terminology: As used in this form, the term “PHS Act” refers to the Public Health Service Act (42 USC 300gg et seq.). “ERISA” refers to the Employee Retirement Income Security Act (29 USC 1001 et seq.). The “Code” refers to the Internal Revenue Code (26 USA 1, et seq.). The “Affordable Care Act” refers to the Patient Protection and Affordable Care Act (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152).

Introductory paragraph: Indicate whether the objecting entity has a sincerely held religious ormoral objection to providing coverage of: (1) all contraceptive services, or (2) a subset of contraceptive services. If the objecting entity objects to providing coverage of a subset of contraceptive services, insert a description of the services sufficient to specifically identify those for which the objecting entity objects to providing coverage.

Line 1: Enter the name of the objecting entity. Insert contact information for the objecting entity, including mailing address, phone, and email (if available).

Line 2: In column (a), enter the name of each plan. In columns (b) and (c) enter the plan’s service provider name and contact information, respectively. In column (d), identify whether the service provider is acting as an issuer (by insuring the benefit) or a third party administrator (“TPA”, by providing administrative services only). In column (e), identify if the plan is a church plan, as defined in ERISA section 3(33), or a student health plan, as defined in 45 CFR 147.145(a). If the plan is neither a church plan nor a student health plan, leave column (e) blank. If the objecting entity establishes or maintains a plan with more than one service provider, enter “same” in column (a) and provide information in columns (b), (c), (d), and (e), as applicable.

Line 3: Enter whether the information submitted is original information, or updated information. If the information is updated, specify the date upon which the updated information was, or will be, effective and what has changed (including if the entity no longer meets the criteria to be an eligible entity).

PRA Disclosure 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 0938-1344. The time required to complete this information collection is estimated to average 50 minutes 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.

MODEL NOTICE

Date: ____________________

To the Secretary of Health and Human Services:

The following objecting entity has a [ ] religious or, as applicable, [ ] moral objection to providing coverage of [  ] all or [ ] a subset of contraceptive services required to be covered under PHS Act section 2713, as added by the Affordable Care Act, and incorporated into ERISA section 715 and Code section 9815. If the objecting entity objects to providing coverage of a subset of contraceptive services, insert a description of the services for which the objecting entity objects to providing coverage: __________________________________________________________________________.

(1) Name of objecting entity: _________________________________

Contact information: _________________________________________

(2) Service provider information:

(a) Plan name	(b) Service provider name	(c) Service provider contact information	(d) Service provider category	(e) Plan type (if applicable)
			[ ]Issuer or [ ]TPA	[ ]Church plan [ ]Student plan
			[ ]Issuer or [ ]TPA	[ ]Church plan [ ]Student plan
			[ ]Issuer or [ ]TPA	[ ]Church plan [ ]Student plan
			[ ]Issuer or [ ]TPA	[ ]Church plan [ ]Student plan

(3) Information being submitted is (check one):

[ ] Original information; OR [ ] Updated information.

If updated information is being provided, specify the date upon which the updated information

was, or will be, effective and what has changed: ______________________________________.

_________________________________________________________________________________

Signature of authorized representative of objecting entity Date

___________________________________________________

Typed name of authorized representative of objecting entity