Form CMS-10465 Minimum Essential Coverage Certification

OMB Control No. 0938-1189 Expiration Date: xx/xx/xxxx

Minimum Essential Coverage Certification

Instructions:

Organizations requesting that the health coverage they sponsor be recognized as minimum essential coverage must provide the following information to CMS. Detailed instructions are available at http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/minimum-essential-coverage.html.

Provide the following organization and contact information in the attached spreadsheet:

1. Name of the organization sponsoring the plan

2. Name and title of the individual who is authorized to make, and makes, the certification below on behalf of the organization

3. Address of individual named above

4. Phone number of individual named above

Provide the following plan information in the attached spreadsheet:

1. Number of enrollees

2. Eligibility criteria

3. Cost sharing requirements, including deductible and out of pocket maximum limit.

4. Whether the coverage provides all of the essential health benefits (as defined in ACA

§1302(b) and its implementing regulations.

5. List of attached plan documentation or other information that demonstrate that the coverage sponsored by the organization substantially complies with the provisions of Title I of the Affordable Care Act applicable to non-grandfathered individual health insurance coverage.

Sign and submit the certification below. Submit any questions to: [email protected]

CERTIFICATION

I certify that the health coverage sponsored by this organization substantially complies with the provisions of Title I of the Affordable Care Act applicable to non-grandfathered individual health insurance coverage.

I declare that I have made this certification, and that, to the best of my knowledge and belief, it is true and correct. I also declare that this certification is complete.

Signature of the individual who is authorized to make this certification on behalf of the organization

Date

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 0935-1189. This information collection is used by sponsors of types of coverage that have not been designated as minimum essential coverage in statute, seeking the coverage to be recognized as minimum essential coverage. The time required to complete this information collection is estimated to average 5.25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection and submit documents to CMS through HIOS. The obligation to respond to this collection is required to obtain or retain a benefit (45 CFR 156.604). No personal identifiable information is being collected. CMS will protect the privacy of the information provided to the extent provided by law (Privacy Act of 1974 (5 U.S.C. §552(a)) and FOIA Exemption (5 U.S.C. §552(b))). 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, Mail Stop C4-26-05, Baltimore, Maryland

21244-1850 or [email protected], Attention: Information Collections Clearance Officer.

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