Model Notice of Objection

Entity Mandating Form: Centers for Medicare & Medicaid Services (CMS).

Applicability: The Affordable Care Act (ACA) requires group health plans to cover certain preventive care services, including contraceptives, without cost sharing. An employer with religious objections to covering contraceptives may be eligible for an accommodation. The employer may notify the Department of Health and Human Services of its objections. (Alternatively, the employer may certify to its health insurance issuer or third-party administrator that it qualifies for the accommodation.)

Obtaining This Form: An employer may download this form directly from the CMS website.

Additional Resources

Centers for Medicare & Medicaid Services

Department of Health and Human Services