Student Health Insurance Coverage (CMS-10377)

OMB 0938-1157

Under the Student Health Insurance Final Rule, issuers of student health insurance are required to disclose to the student and any dependents in the insurance policy or certificate and any other written materials that the policy being issued does not meet all of the requirements under the Affordable Care Act.

The latest form for Student Health Insurance Coverage (CMS-10377) expires 2022-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
CMS 10377 - Student Health - 30-Day Supporting Statement 03-08-2022 Clean.docx Supporting Statement A
Student Health Insurance Notice Requirement

All Historical Document Collections

202204-0938-005 Approved without change	Extension without change of a currently approved collection	2022-04-15
201907-0938-009 Approved without change	Extension without change of a currently approved collection	2019-07-30
201903-0938-010 Withdrawn and continue	Revision of a currently approved collection	2019-03-26
201606-0938-006 Approved without change	Revision of a currently approved collection	2016-06-22
201309-0938-027 Approved with change	New collection (Request for a new OMB Control Number)	2013-09-26
201111-0938-004 Comment filed on proposed rule	New collection (Request for a new OMB Control Number)	2011-11-08