Information Collection Requirements for Compliance with Individual and Group Market Reforms under Title XXVII of the Public Health Service Act

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

Model Notice to Enrollees in a Self-Funded, Non-Federal 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 delivery by cesarean section.

2. Certain requirements to provide benefits for breast reconstruction after a mastectomy.

3. 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.]

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 0938-0702. The time required to complete this information collection is estimated to average 15 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.