Comment and response document

Appendix A – Comments and Responses for Information Collection Requirements Related
to Annual Eligibility Redetermination, Product Discontinuance and Renewal Notices
(CMS-10527)

Comment: Several commenters raised concerns about providing accurate and complete
information to individuals about their coverage and recommended the notices serve as model
notices (rather than standard notices) that issuers could customize as along as the notices contain
the essential information.
Response: We believe consumers should receive notices provided in a standardized form
and manner that clearly explain in easy to understand language their choices about their coverage
and any changes to that coverage. We believe this will reduce consumer confusion and help
consumers make more informed decisions. Therefore, we are finalizing guidance specifying the
form and manner of the Federal standard notices that issuers will use when discontinuing or
renewing a product in the individual market. These notices cannot be modified in any way
except where fields for customization are identified in brackets. The guidance will specify that
States that are enforcing the Affordable Care Act have flexibility to develop and require their
own standard notices, provided the State-developed notices are at least as protective as the
Federal standard notices. We note that nothing prevents an issuer from providing additional
information (such as a cover letter, summary of benefits and coverage (SBC), or other
description of benefits) in the same mailing as these Federal standard notices, to the extent
permitted by applicable State law.
Comment: In guidance released in June 2014, we solicited comments on whether to
develop separate notices for coverage offered through the Small Business Health Options
Program (SHOP) to address certain unique features of the SHOP such as employee choice. One
commenter recommended the SHOP, not QHP issuers, send employers using employee choice a
consolidated notice describing whether employees’ current coverage will be offered again in the
next benefit year, arguing that it would be difficult for employers to make coverage decisions
when receiving separate renewal and discontinuation notices from multiple issuers. One
commenter stated that, typically, employers in the small group market must agree before group
health insurance is issued or renewed and that issuers need flexibility to modify the notices to
clearly state what action must be taken.
Response: We are not specifying a final form and manner of the Federal standard notices
for the small group market at this time. We recognize there are important differences in the
renewal process in the small group market—particularly where an employer purchases multiple
products for its employees and where employee choice is offered in the SHOP. We will continue
to consider how best to structure the form and manner of the notices that must be used to inform
small employers of product discontinuations and renewals, including in the SHOP, and may
issue future guidance addressing the small group market. Until the issuance of further guidance,
issuers may use the draft Federal standard small group notices released in the June 26, 2014
bulletin, or any forms of the notice otherwise permitted by applicable laws and regulations. We
expect issuers not using the form and manner of the draft Federal standard notices released in the

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June 26, 2014 bulletin to include the content described in the bulletin “Form and Manner of
Notices When Discontinuing or Renewing a Product in the Group or Individual Market”.
Comment: A number of commenters representing colleges and universities and health
insurance issuers suggested the notices were not appropriate for students. Commenters indicated
that a health insurance issuer that offers student health insurance coverage is not required to
renew or continue in force coverage for individuals who are no longer students or dependents of
students, and therefore renewal notices may be confusing to students graduating from college.
They also indicated that, because the agreement is between the institution of higher education
and the issuer, and the institution makes purchase decisions and, in some instances, pays
premiums on behalf of students, notices should be sent to the institution of higher education
rather than to students. Finally, commenters stated that providing notice 60 days prior to renewal
would not provide sufficient time for institutions of higher education and issuers to finalize
student health insurance plans.
Response: In response to comments, we are not requiring student health insurance
issuers to provide renewal and discontinuation notices to students or to use the standardized form
and manner specified by the Secretary. We will consider a student health insurance issuer to
comply with the product discontinuation and renewal notice requirements if it notifies the
institution of higher education regarding product discontinuations and renewals. For this
purpose, student health insurance issuers may use any form and manner of the notices otherwise
permitted by applicable laws and regulations. We encourage States to provide similar flexibility
to issuers.
Comment: We received comments indicating that some notice content, such as
references to open enrollment periods and benefit requirements (e.g., plan metal levels), is not
relevant to grandfathered health plans. These comments requested flexibility for issuers to use
existing forms and processes for communicating information about renewal and discontinuations
of grandfathered health plans.
Response: We have updated the renewal notices to account for situations in which
grandfathered plans in the individual market may come up for renewal outside of the annual
open enrollment period. We note that issuers need not mention metal levels when describing
benefits under a grandfathered health plan.
Comment: Some commenters representing health insurance issuers were concerned
about implementing the notice requirements for non-calendar year renewals and discontinuations
in 2014. These commenters recommended the standardized format be required only in
connection with plan or policy years ending on or after December 31, 2014.
Response: The CMS bulletin “Form and Manner of Notices When Discontinuing or
Renewing a Product in the Group or Individual Market” will provide that the form and manner of
the Federal standard notice specified by the Secretary applies for discontinuation and renewals
notices required to be sent for plan or policy years ending on or after December 31, 2014. For
notices required to be sent prior to that time, issuers may use any form and manner otherwise
permitted by applicable laws and regulations. Furthermore, as stated in the bulletin, CMS will
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consider issuers that, through September 30, 2015, use either the final Federal standard notices in
the bulletin, or the draft Federal standard notices in the June 26, 2014 bulletin, to have met the
Secretary’s specification under §146.152, §147.106 and §148.122 regarding the form and
manner of the required discontinuance and renewal notices. After that time, the draft Federal
standard notices in the June 26, 2014 bulletin may no longer be used to satisfy this requirement.
Comment: We received comments that generally supported the “Getting Help in Other
Languages” section, which would include taglines in languages spoken by 10 percent or more of
the population, indicating where persons with limited English proficiency could receive language
assistance. Some commenters asked that issuers be permitted to omit this section entirely if no
language met the 10-percent threshold. Some commenters recommended that issuers be allowed
or encouraged to include taglines in languages that do not meet the 10-percent threshold, while
one commenter emphasized that issuers notices must comply with accessibility requirements
under State law, in addition to Federal law.
Response: We are finalizing the language accessibility provisions of the notices
generally as they were proposed. To align with the accessibility requirements applicable to the
summary of benefits and coverage (SBC) required under section 2715 of the PHS Act, we are
modifying the notices to clarify that taglines will be included for languages spoken by 10 percent
or more of the population in the “county.” We encourage issuers, however, to include taglines in
additional languages that do not meet this threshold.
Comment: Several commenters requested clarification as to which bracketed language in
the notices is variable versus optional.
Response: We are releasing instructions for completing the Federal standard notices in
the CMS bulletin “Form and Manner of Notices When Discontinuing or Renewing a Product in
the Group or Individual Market”, which delineates when fields are required or optional.
Comment: Multiple commenters representing consumer groups urged that QHP issuer
notices place greater emphasis on enrollees updating their eligibility information with the
Exchange to ensure they receive the most accurate advanced payments of the premium tax credit
and cost-sharing reductions for the upcoming benefit year. To help enrollees more easily
determine whether their income has changed, some commenters recommended the notices
include enrollees’ most recent income information on file with the Exchange that was used to
calculate any advance payments of the premium tax credit they receive in the current benefit
year.
Response: We have revised the notices in response to comments to emphasize the
importance of enrollees returning to the Exchange to update their eligibility information. This
will help ensure enrollees purchasing coverage through the Exchange receive the full credit they
are entitled to and do not owe back amounts paid as advanced payments of the premium tax
credit on their federal income tax return.
Comment: Many commenters made specific recommendations regarding the content and
format of the notices with the goal of providing more consumer-friendly information. For
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example, commenters suggested modifying the headline box to more clearly communicate the
purpose of the notice, providing additional information to educate consumers about the open
enrollment period and other important dates and deadlines, and communicating terminology
relating to tax credits and coverage options in plainer language.
Response: The draft notices contained in the June 26, 2014 bulletin were tested for
readability and comprehension with consumers. We are generally adopting the feedback from
consumer testing.
Comment: Several commenters representing consumer groups recommended the notices
provide detailed and specific information about any changes in benefits to help consumers make
informed choices. Specifically, commenters recommended the notices list changes in coverage
features such as premium, deductibles, cost-sharing, benefits, product network type (for example,
Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO)),
prescription drug formulary, and provider network. Other commenters representing health
insurance issuers recommended the notices outline only the most significant changes to coverage
and that issuers be permitted to enclose additional materials, such as the SBC or other benefit
information, providing a more detailed description of changes.
Response: We recognize that issuers have experience communicating key coverage
information to consumers. We also recognize that some States have existing requirements for
disclosure of changes. While we encourage issuers to highlight in the notices significant changes
made to benefits, we also permit issuers to use other documentation outside of the context of the
letter that serves substantially similar purposes.

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