Form CMS-10527 Discontinuation Notices

Annual Eligibility Redetermination, Product Discontinuation and Renewal
Notices
(CMS-10527)

ATTACHMENTS:
FEDERAL STANDARD RENEWAL AND DISCONTINUATION NOTICES

Attachment 1: Renewal notice for the individual market where coverage is being renewed
outside the Marketplace.
Important: [Name of issuer1] is continuing to offer your health coverage for next year. Some
plan details may have changed. Unless you take action by [Date2], you will be automatically
enrolled to continue this coverage next year [,but the plan won’t allow you to receive
financial assistance to lower your monthly premiums, copayments, coinsurance, and
deductibles based on income3]. Read this letter to learn more and to review your options.
[Date of Notice4]
[First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]5]

Dear [First Name of Subscriber6]:
Every year, insurance companies can make changes to the plans and coverage options they
offer. This letter summarizes any changes to your coverage so you can decide if you
want to keep your plan or look for a different one. Changes described in this letter will be
effective [Date7].
[For calendar year plans (grandfathered and non-grandfathered): You can choose a new plan
during Open Enrollment from [Beginning date through End date9]. If you choose a new plan
and want coverage to start January 1, you need to enroll by [Date10].
For non-calendar year plans (grandfathered): Briefly describe available open or special
enrollment opportunities so that subscribers are informed when they can choose new plans.8]
Changes we’re making to your coverage
• Premium – Your new premium starts in [Month11]. Your monthly premium will be
$[Dollar amount12].
• [Briefly describe plan changes and/or refer to enclosed materials13]
• You can review more details about your plan at [Issuer website14] and in your Summary
of Benefits and Coverage.
[For renewals for plans outside the Marketplace: This plan doesn’t allow you to receive
financial assistance to lower your monthly premiums or lower your out-of-pockets costs.
If you want to be considered for financial assistance to lower your monthly premiums and lower
your copayments, coinsurance, and deductibles based on your income, you must visit [Name of
Marketplace15] and enroll in a different plan.
[For renewals from a QHP offered through the Marketplace into a plan outside the Marketplace:
Important: This plan doesn’t allow you to receive financial assistance offered through the

2

Attachment 1: Renewal notice for the individual market where coverage is being renewed
outside the Marketplace.
[Name of Marketplace16] to lower your monthly premiums or lower your out-of-pockets
costs
If you choose to keep this plan, you won’t be enrolled through [Name of Marketplace17]. This
means that if you want to be considered for financial assistance offered through the [Name of
Marketplace18] to lower your monthly premiums and lower your copayments, coinsurance, and
deductibles based on your income, you must go back to [Name of Marketplace19] and enroll in a
new plan. [If you don’t enroll through [Name of Marketplace20], any advance payments of
the premium tax credit and lower copayments, coinsurance, and deductibles that you
currently get will stop on [Date23].22]21]
So what are my options if…
• I like the plan changes presented above?
o YOU DON’T HAVE TO DO ANYTHING. You’ll automatically be enrolled and
just have to pay the monthly premium.
•

I don’t like the plan changes presented above?
o YOU HAVE THREE WAYS TO LOOK INTO OTHER PLANS AND ENROLL:
1. Visit [Marketplace website24] and look at other [Name of Marketplace25]
plans.
2. Visit [Marketplace website26] and see if you or your family qualify for
Medicaid or the Children’s Health Insurance Program.
3. Look at other plans outside [Name of Marketplace27].
Just keep in mind that if you qualify for financial assistance to lower your
monthly premiums or out-of-pocket costs, you can only get these savings if
you enroll through [Name of Marketplace28].

Questions?
• Call [Name of issuer29] at [Issuer phone number30], or visit [Issuer website31]. You can
also work with a licensed insurance agent or broker.
•

Visit [Marketplace website32], or call [Marketplace phone number33] to learn more about
[Name of Marketplace34] and to see if you qualify for lower costs.

•

Visit LocalHelp.HealthCare.gov to find personal help in your area.
This notice is also available in alternative formats upon request and at no cost to
persons with disabilities.

[Getting help in other languages
Include the tagline below for the languages spoken by 10% or more of the population in the
county. Taglines in other languages may also be included and are encouraged.
3

Attachment 1: Renewal notice for the individual market where coverage is being renewed
outside the Marketplace.
English: For help in [Language36], call [Phone number37] and an interpreter will assist you with
this notice at no cost.35]

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-XXXX. The time required to complete this information collection is
estimated to average 20 hours 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.

4

Attachment 2: Renewal notice for the individual market where coverage is being renewed under
the same product in a QHP offered through the Marketplace
Important: [Name of issuer1] is continuing to offer your health coverage for next year. Some
plan details may have changed. Unless you take action by [Date2], you will be automatically
enrolled to continue this coverage next year[,but the plan will no longer offer lower
copayments, coinsurance, and deductibles based on income3]. Read this letter to learn
more and to review your options.
[Date of Notice4]
[First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]5]

Dear [First Name of Subscriber6]:
Every year, insurance companies can make changes to the plans and coverage options they
offer. This letter summarizes any changes to your coverage, so you can decide if you
want to keep your plan or enroll in a different one. Changes described in this letter will be
effective [Date7]. You should also update your [Name of Marketplace8] application to make
sure you are getting the right amount of financial assistance.
You can choose a new plan during Open Enrollment from [Beginning date through End date9].
If you choose a new plan and want coverage to start January 1, you need to enroll by
[Date10].
Changes we’re making to your coverage
• Premium – Your new premium starts in January. Your monthly premium will be $[Dollar
amount11]. [This amount assumes you get the same advance payments of the premium
tax credit you received for [Year13], which would lower your monthly premium from
$[Dollar amount14].12]
• [Briefly describe plan changes and/or refer to enclosed materials15]
• You can review more details about your plan at [Issuer website16] and in your Summary
of Benefits and Coverage.
[For renewals into a non-Silver level QHP (except for Indians eligible for cost-sharing
reductions): Important: You can’t get lower deductibles, coinsurance, and copayments
with this plan
If you choose to keep this plan, you won’t be enrolled in a plan at the Silver level. This means
that if you qualify for lower copayments, coinsurance, and deductibles based on your income,
you must go back to the [Name of Marketplace18] and enroll in a Silver plan to get these
savings. [If you don’t enroll in a Silver plan through [Name of Marketplace20], any lower
copayments, coinsurance, and deductibles you currently get will stop on [Date21].19]18]

5

Attachment 2: Renewal notice for the individual market where coverage is being renewed under
the same product in a QHP offered through the Marketplace
Update your [Name of Marketplace22] application by [Date23]
[In [Year25] you saved [Dollar amount26] on your monthly premium because of advance
payments of the premium tax credit. However, you might be able to get more savings or better
plan your budget next year. Visit [Marketplace website27] during Open Enrollment to see if you
qualify.
Estimated Monthly
Savings in [Year28]

Your Potential Savings in [Year30]

$[Dollar amount29]

Visit [Marketplace website31]
24

]
It’s important to review your [Name of Marketplace ] application to make sure the information is
still current and correct. [Name of Marketplace33] uses this information to determine the amount
of any advance credit payments and lower copayments, coinsurance, and deductibles you may
be eligible for.
32

When it’s time to file your federal income tax return, you will compare the amount of advance
credit payments you get for the year with the amount you’re due based on the income you
report on your tax return. You may have to pay back some or all of your advance credit
payments if your income is higher than what you told the [Name of Marketplace34] in your
application.
To help make sure you’re getting all the financial assistance you deserve and don’t owe back
money, contact the [Name of Marketplace35] by [Date36] to update your application and enroll.
[If you didn’t receive advance payments of the premium tax credit in [Year38]
Tax credits and other cost savings are available to many people who have a [Name of
Marketplace39] plan. Even if you didn’t get these savings last year, it’s worth checking to see if
you qualify this year. Visit [Name of Marketplace40] to update your application and find out if you
qualify.37]
So what are my options if…
• I like the plan changes presented above, and there are no changes to my [Name
of Marketplace41] application information?
o YOU DON’T HAVE TO DO ANYTHING. You’ll automatically be enrolled and
just have to pay the monthly premium.
•

I like the plan changes presented above and there are changes to my [Name of
Marketplace42] application information?
o YOU HAVE TO GO BACK TO [NAME OF MARKETPLACE43] TO UPDATE
YOUR INFORMATION AND TELL US YOU WANT TO RE-ENROLL IN [PLAN
NAME and ID44].

6

Attachment 2: Renewal notice for the individual market where coverage is being renewed under
the same product in a QHP offered through the Marketplace
•

I don’t like the plan changes presented above?
o YOU HAVE THREE WAYS TO LOOK INTO OTHER PLANS AND ENROLL:
1. Visit [Marketplace website45] and look at other [Name of Marketplace46]
plans.
2. Visit [Marketplace website47] and see if you or your family qualify for
Medicaid or the Children’s Health Insurance Program.
3. Look at other plans outside [Name of Marketplace48].
Just keep in mind that if you qualify for financial assistance to lower your
monthly premiums or out-of-pocket costs, you can only get these savings if
you enroll through [Name of Marketplace49].

Questions?
• Call [Issuer name50] at [Issuer phone number51], or visit [Issuer website52]. You can also
work with a licensed insurance agent or broker.
•

Visit [Marketplace website53], or call [Marketplace phone number54] to learn more about
[Name of Marketplace55] and to see if you qualify for lower costs.

•

Visit LocalHelp.HealthCare.gov to find personal help in your area.
This notice is also available in alternative formats upon request and at no cost to
persons with disabilities.

[Getting help in other languages
Include the tagline below for the languages spoken by 10% or more of the population in the
county. Taglines in other languages may also be included and are encouraged.
English: For help in [Language57], call [Phone number58] and an interpreter will assist you with
this notice at no cost.56]

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-XXXX. The time required to complete this information collection is
estimated to average 24 hours 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.

7

Attachment 3: Discontinuation notice for the individual market outside the Marketplace and the
issuer is automatically enrolling the enrollee in a new plan outside the Marketplace
Important: [Name of issuer1] isn’t offering your current health coverage next year in
your area. Unless you take action by [Date2], you will be automatically enrolled in a
new plan. Read this letter to learn more and to review your options.
[Date of Notice3]

[First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]4]

Dear [First Name of Subscriber5]:
Every year, insurance companies can make changes to the plans and coverage options they
offer. [Name of issuer6] won’t offer the coverage you currently have in [Current year7]
again in your area in [Following year8]. We have suggested a new plan for you, but you
can review your options and decide what to do. The last day of your current coverage is
[Date9].
Your suggested new plan
Even though your current coverage isn’t being offered in your area next year, we have found
another plan you may like. You will automatically be enrolled in [Plan name10] to make
sure there isn’t a gap in your coverage. You can enroll in a different plan anytime
between [Beginning date and End date11]. If you want coverage to start January 1, make
sure you enroll by [Date12].
Please review your new premium and benefits below to see if this plan meets your needs. If it
doesn’t, keep reading to learn about your other options.
•
•
•

Premium – Your new premium starts in [Month13]. Your monthly premium will be
$[Dollar amount14].
[Briefly describe plan changes and/or refer to enclosed materials15]
You can review more details about this plan at [Issuer website16] and in your Summary
of Benefits and Coverage.

So what are my options if…
• I like the suggested plan?
o YOU DON’T HAVE TO DO ANYTHING. You’ll automatically be enrolled and
just have to pay the monthly premium.
•

I don’t like the suggested plan?
o YOU HAVE THREE WAYS TO LOOK INTO OTHER PLANS AND ENROLL:
8

Attachment 3: Discontinuation notice for the individual market outside the Marketplace and the
issuer is automatically enrolling the enrollee in a new plan outside the Marketplace
1. Visit [Marketplace website17] and look at other [Name of Marketplace18]
plans.
2. Visit [Marketplace website19] and see if you or your family qualify for
Medicaid or the Children’s Health Insurance Program.
3. Look at other plans outside [Name of Marketplace20].
Just keep in mind that if you qualify for financial assistance to lower your
monthly premiums or lower your out-of-pocket costs, you can only get these
savings if you enroll through [Name of Marketplace21].
•

I can’t afford a [Name of Marketplace22] plan?
o YOU CAN CONTACT [NAME OF MARKETPLACE23] AND APPLY FOR A
HARDSHIP EXEMPTION. This exemption will allow you to buy a
catastrophic plan that usually has lower monthly premiums and will mainly
protect you from very high medical costs.

When do I need to make a decision?
The [Year24] Open Enrollment period is from [Beginning date through End date25]. But since
your coverage is ending, you qualify to enroll in a new plan from [Beginning date to End date26].
If you want a plan other than the suggested plan, enroll in the new plan by [Date27] to
make sure there isn’t a gap in your coverage.
Questions?
• Call [Issuer name28] at [Issuer phone number29], or visit [Issuer website30]. You can also
work with a licensed insurance agent or broker.
•

Visit [Marketplace website31], or call [Marketplace phone number32] to learn more about
[Name of Marketplace33] and to see if you qualify for lower costs.

•

Visit LocalHelp.HealthCare.gov to find personal help in your area.
This notice is also available in alternative formats upon request and at no cost to
persons with disabilities.

[Getting help in other languages
Include the tagline below for the languages spoken by 10% or more of the population in the
county. Taglines in other languages may also be included and are encouraged.
English: For help in [Language35], call [Phone number36] and an interpreter will assist you with
this notice at no cost.34]

9

Attachment 3: Discontinuation notice for the individual market outside the Marketplace and the
issuer is automatically enrolling the enrollee in a new plan outside the Marketplace
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-XXXX. The time required to complete this information collection is
estimated to average 8 hours 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.

10

Attachment 4: Notice for the individual market where coverage was in a QHP offered through
the Marketplace and the issuer is automatically enrolling the enrollee in a new product
Important: [Name of issuer1] isn’t offering your current health coverage next year in your area
[through [Name of Marketplace]2]. Unless you take action by [Date3], you will be automatically
enrolled in a new plan[, but the plan won’t offer lower copayments, coinsurance, and deductibles
based on income4]. Read this letter to learn more and to review your options.
[Date of Notice5]
[First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]6]

Dear [First Name of Subscriber7]:
Every year, insurance companies can make changes to the plans and coverage options they
offer. [Name of issuer8] won’t offer the coverage you currently have in [Current year9]
again in your area [through [Name of Marketplace]10] in [Following year11]. We have
suggested a new plan for you, but you can review your options and decide what to do.
The last day of your current coverage is [Date12]. You should also update your [Name of
Marketplace13] application to make sure you are getting the right amount of
financial assistance.
Your suggested new plan
Even though your current coverage isn’t being offered next year in your area [through [Name of
Marketplace]14], we have found another plan you may like. You will automatically be enrolled
in [Plan name15] to make sure there isn’t a gap in your coverage. You can enroll in a
different plan anytime between [Beginning date and End date16]. If you want coverage to
start January 1, make sure you enroll by [Date17].
Please review your new premium and benefits below to see if this plan meets your needs. If it
doesn’t, keep reading to learn about your other options.
•

•
•

Premium – Your new premium starts in January. Your monthly premium will be $[Dollar
amount18]. [This amount assumes you get the same advance payments of the premium
tax credit you received for [Year20], which would lower your monthly premium from
$[Dollar amount21].19]
[Briefly describe plan changes and/or refer to enclosed materials22]
You can review more details about this plan at [Issuer website23] and in your Summary
of Benefits and Coverage.

11

Attachment 4: Notice for the individual market where coverage was in a QHP offered through
the Marketplace and the issuer is automatically enrolling the enrollee in a new product
[For auto-enrollment into a non-Silver level QHP (except for Indians eligible for cost-sharing
reductions): Important: You can’t get lower deductibles, coinsurance, and copayments
with this plan
If you choose to keep this plan, you won’t be enrolled in a plan at the Silver level. This means
that if you qualify for lower copayments, coinsurance, and deductibles based on your income,
you must go back to the [Name of Marketplace31] and enroll in a Silver plan to get these
savings. [If you don’t enroll in a Silver plan through [Name of Marketplace33], any lower
copayments, coinsurance, and deductibles you currently get will stop on [Date34].32]30]
Update your [Name of Marketplace35] application by [Date36]
[In [Year38] you saved [Dollar amount39] on your monthly premium because of advance
payments of the premium tax credit. However, you might be able to get more savings or better
plan your budget next year. Visit [Marketplace website40] during Open Enrollment to see if you
qualify.
Estimated Monthly
Savings in [Year41]

Your Potential Savings in [Year43]

$[Dollar amount42]

Visit [Marketplace website44]
37

]
It’s important to review your [Name of Marketplace ] application to make sure the information is
still current and correct. [Name of Marketplace46] uses this information to determine the amount
of any advance credit payments and lower copayments, coinsurance, and deductibles you may
be eligible for.
45

When it’s time to file your federal income tax return, you will compare the amount of advance
credit payments you get for the year with the amount you’re due based on the income you
report on your tax return. You may have to pay back some or all of your advance credit
payments if your income is higher than what you told the [Name of Marketplace47] in your
application.
To help make sure you’re getting all the financial assistance you deserve and don’t owe back
money, contact the [Name of Marketplace48] by [Date49] to update your application and enroll.
[If you didn’t receive advance payments of the premium tax credit in [Year51]
Tax credits and other cost savings are available to most people who have a [Name of
Marketplace52] plan. Even if you didn’t get these savings last year, it’s worth checking to see if
you qualify this year.50]
So what are my options if…
• I like the suggested plan, and there are no changes to my [Name of
Marketplace53] application information?

12

Attachment 4: Notice for the individual market where coverage was in a QHP offered through
the Marketplace and the issuer is automatically enrolling the enrollee in a new product
o

YOU DON’T HAVE TO DO ANYTHING. You’ll automatically be enrolled and
just have to pay the monthly premium.

•

I like the suggested plan, and there are changes to my [Name of Marketplace54]
application information?
o YOU HAVE TO GO BACK TO [NAME OF MARKETPLACE55] TO UPDATE
YOUR INFORMATION AND TELL US YOU WANT TO RE-ENROLL IN [PLAN
NAME and ID56]

•

I don’t like the suggested plan?
o YOU HAVE THREE WAYS TO LOOK INTO OTHER PLANS AND ENROLL:
1. Visit [Marketplace website57] and look at other [Name of Marketplace58]
plans.
2. Visit [Marketplace website59] and see if you or your family qualify for
Medicaid or the Children’s Health Insurance Program.
3. Look at other plans outside [Name of Marketplace60].
Just keep in mind that if you qualify for financial assistance to lower your
monthly premiums or out-of-pocket costs, you can only get these savings if
you enroll through [Name of Marketplace61].
•

I can’t afford a [Name of Marketplace62] plan?
o YOU CAN CONTACT [NAME OF MARKETPLACE63] AND APPLY FOR A
HARDSHIP EXEMPTION. This exemption will allow you to buy a
catastrophic plan that usually has lower monthly premiums and will mainly
protect you from very high medical costs.

•

[I like my current coverage and want to enroll outside [Name of Marketplace65]?
o YOU SHOULD CONTACT US AT THE NUMBER BELOW.64]

When do I need to make a decision?
The [Year66] Open Enrollment period is from [Beginning date through End date67]. But since
your coverage is ending, you qualify to enroll in a new plan from [Beginning date to End date68].
If you want a plan other than the suggested plan, enroll in the new plan by [Date69] to
make sure there isn’t a gap in your coverage.
Questions?
• Call [Issuer name70] at [Issuer phone number71], or visit [Issuer website72]. You can also
work with a licensed insurance agent or broker.
•

Visit [Marketplace website73], or call [Marketplace phone number74] to learn more about
[Name of Marketplace75] and to see if you qualify for lower costs.
13

Attachment 4: Notice for the individual market where coverage was in a QHP offered through
the Marketplace and the issuer is automatically enrolling the enrollee in a new product
•

Visit LocalHelp.HealthCare.gov to find personal help in your area.
This notice is also available in alternative formats upon request and at no cost to
persons with disabilities.

[Getting help in other languages
Include the tagline below for the languages spoken by 10% or more of the population in the
county. Taglines in other languages may also be included and are encouraged.
English: For help in [Language77], call [Phone number78] and an interpreter will assist you with
this notice at no cost.76]

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-XXXX. The time required to complete this information collection is
estimated to average 9 hours 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.

14

Attachment 5: Discontinuation notice for the individual market outside the Marketplace and the
issuer is not automatically enrolling the enrollee in a new plan
Important: [Name of issuer1] isn’t offering your current health coverage in your area
next year. Unless you take action by [Date2], you won’t have health coverage next year.
Read this letter to learn more and to review your options.

[Date of Notice3]
[First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]4]

Dear [First Name of Subscriber5]:
Every year, insurance companies can make changes to the plans and coverage options they
offer. [Name of issuer6] won’t offer the coverage you currently have in [Current year7]
again in your area in [Following year8]. This means you must enroll in a new plan to have
health insurance coverage. The last day of your current coverage is [Date9].
What are my options for getting coverage?
• YOU HAVE THREE WAYS TO LOOK INTO OTHER PLANS AND ENROLL:
1. Visit [Marketplace website10] and look at other [Name of Marketplace11]
plans.
2. Visit [Marketplace website12] and see if you or your family qualify for
Medicaid or the Children’s Health Insurance Program.
3. Look at other plans outside [Name of Marketplace13].
Just keep in mind that if you qualify for financial assistance that lowers your
monthly premiums and out-of-pocket costs, you can only get these savings if
you enroll through [Name of Marketplace14].
What if I can’t afford a [Name of Marketplace15] plan?
• YOU CAN CONTACT [NAME OF MARKETPLACE16] AND APPLY FOR A
HARDSHIP EXEMPTION. This exemption will allow you to buy a catastrophic plan
that usually has lower monthly premiums and will mainly protect you from very high
medical costs.
When do I need to make a decision?
The [Year17] Open Enrollment period is from [Beginning date through End date18]. But since
your plan is ending, you qualify to enroll in a new plan from [Beginning date to End date19]. To
make sure there isn’t a gap in your coverage, enroll in the new plan by [Date20].

15

Attachment 5: Discontinuation notice for the individual market outside the Marketplace and the
issuer is not automatically enrolling the enrollee in a new plan

Questions?
• Call [Issuer name21] at [Issuer phone number22], or visit [Issuer website23]. You can also
work with a licensed insurance agent or broker.
•

Visit [Marketplace website24], or call [Marketplace phone number25] to learn more about
[Name of Marketplace26] and to see if you qualify for lower costs.

•

Visit LocalHelp.HealthCare.gov to find personal help in your area.
This notice is also available in alternative formats upon request and at no cost to
persons with disabilities.

[Getting help in other languages
Include the tagline below for the languages spoken by 10% or more of the population in the
county. Taglines in other languages may also be included and are encouraged.
English: For help in [Language28], call [Phone number29] and an interpreter will assist you with
this notice at no cost.27]
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-XXXX. The time required to complete this information collection is
estimated to average 4.5 hours 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.

16

Attachment 6: Discontinuation notice for the individual market where coverage being
discontinued was in a QHP offered through the Marketplace and the issuer is not automatically
enrolling the enrollee in a new plan
Important: [Name of issuer1] isn’t offering your current health coverage next year in
your area. Unless you take action by [Date2], you won’t have health coverage next year.
Read this letter to learn more and to review your options.

[Date of Notice3]
[First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]4]

Dear [First Name of Subscriber5]:
Every year, insurance companies can make changes to the plans and coverage options they
offer. [Name of issuer6] won’t offer the coverage you currently have in [Current year7]
again in your area in [Following year8]. This means you must enroll in a new plan to have
health insurance coverage. The last day of your current coverage is [Date9]. You should
also update your [Name of Marketplace10] application to make sure you are getting the
right amount of financial assistance if you choose a new plan.
Update your [Name of Marketplace11] application by [Date12]
[In [Year14] you saved [Dollar amount15] because of advance payments of the premium tax
credit. However, you might be able to get more savings or better plan your budget next year.
Visit [Marketplace website16] during Open Enrollment to see if you qualify.
Estimated Monthly
Savings in [Year17]

Your Potential Savings in [Year19]

$[Dollar amount18]

Visit [Marketplace website20]
13

]

When you go to the Marketplace to enroll in a new plan, you’ll be asked to update your
application. It’s important to review your [Name of Marketplace21] application to make sure the
information is still current and correct. [Name of Marketplace22] uses this information to
determine the amount of any advance credit payments and lower copayments, coinsurance,
and deductibles you may be eligible for.
When it’s time to file your federal income tax return, you will compare the amount of advance
credit payments you get for the year with the amount you’re due based on the income you
report on your tax return. You may have to pay back some or all of your advance credit

17

Attachment 6: Discontinuation notice for the individual market where coverage being
discontinued was in a QHP offered through the Marketplace and the issuer is not automatically
enrolling the enrollee in a new plan
payments if your income is higher than what you told the [Name of Marketplace23] in your
application.
To help make sure you’re getting all the financial assistance you deserve and don’t owe back
money, contact the [Name of Marketplace24] by [Date25] to update your application and enroll.
[If you didn’t receive advance payments of the premium tax credit in [Year27]
Tax credits and other cost savings are available to most people who have a [Name of
Marketplace28] plan. Even if you didn’t get these savings last year, it’s worth checking to see if
you qualify this year.26]
What are my options for getting coverage?
• YOU HAVE THREE WAYS TO LOOK INTO OTHER PLANS AND ENROLL:
1. Visit [Marketplace website28] and look at other [Name of Marketplace29]
plans.
2. Visit [Marketplace website30] and see if you or your family qualify for
Medicaid or the Children’s Health Insurance Program.
3. Look at other plans outside [Name of Marketplace31].
Just keep in mind that if you qualify for financial assistance to lower your
monthly premiums or out-of-pocket costs, you can only get these savings if
you enroll through [Name of Marketplace32].
What if I can’t afford a [Name of Marketplace33] plan?
YOU CAN CONTACT [NAME OF MARKETPLACE34] AND APPLY FOR A HARDSHIP
EXEMPTION. This exemption will allow you to buy a catastrophic plan that usually has lower
monthly premiums and will mainly protect you from very high medical costs. You should also
look to see if any changes have been made to copayments, coinsurance, and deductibles.
When do I need to make a decision?
The [Year36] Open Enrollment period is from [Beginning date through End date37]. But since
your plan is ending, you qualify to enroll in a new plan from [Beginning date to End date38]. To
make sure there isn’t a gap in your coverage, enroll in the new plan by [Date39].
Questions?
• Call [Issuer name40] at [Issuer phone number41], or visit [Issuer website42]. You can also
work with a licensed insurance agent or broker.
•

Visit [Marketplace website43], or call [Marketplace phone number44] to learn more about
[Name of Marketplace45] and to see if you qualify for lower costs.

•

Visit LocalHelp.HealthCare.gov to find personal help in your area.
18

Attachment 6: Discontinuation notice for the individual market where coverage being
discontinued was in a QHP offered through the Marketplace and the issuer is not automatically
enrolling the enrollee in a new plan

This notice is also available in alternative formats upon request and at no cost to
persons with disabilities.
[Getting help in other languages
Include the tagline below for the languages spoken by 10% or more of the population in the
county. Taglines in other languages may also be included and are encouraged.
English: For help in [Language47], call [Phone number48] and an interpreter will assist you with
this notice at no cost.46]

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-XXXX. The time required to complete this information collection is
estimated to average 5.5 hours 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.

19

Attachment 7: Renewal notice to employers for the small group market

Issuers in the small group market may use the draft Federal standard small group notices released
in the June 26, 2014 bulletin and provided below, 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 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”. The following is considered to be the essential
content contained in the form of the Federal standard renewal notices:
• Information about premiums and any advance payments of the premium tax credit
(APTC) for the plan in which the enrollee will be renewed in the next plan or policy year;
• Information about significant changes to the enrollee’s coverage;
• Information about other health coverage options; and
• Contact information for the consumer to call with questions.
The following draft standard notice from the June 26, 2014 bulletin may be used:
Important: We’re Continuing to Offer Your Group Health Coverage.

Dear [Plan Sponsor or Name1],
Your group health insurance coverage is coming up for renewal. On [Date2], your group
members will be automatically re-enrolled and can keep your group’s current coverage.
Below are changes we’ll be making to the plan and options to consider to possibly lower your
costs or choose a new plan.
Changes we’re making to your group’s current coverage
• Premium – Your new premium starts in [Month3]. Your monthly premium will be $[Dollar
amount4]. This is an estimate based on current enrollment. This amount may change
depending on the individuals who actually enroll in the plan. Check to see if you have
other options at: [State Marketplace website/HealthCare.gov5]
• [List changes to renewed plan, including:
• Name of new plan and Plan ID
• Benefit changes
• Cost-sharing changes, including whether the plan is a different metal level from the
previous plan6].
[This plan isn’t being offered through [State SHOP Marketplace Name/the Small Business
Health Options (SHOP) Marketplace8]. If you’re eligible for a small business health care tax
credit, you usually can get that credit only if you buy insurance through [State SHOP
Marketplace Name/ the SHOP Marketplace9]7].
What if I want to change plans?
20

Attachment 7: Renewal notice to employers for the small group market
•

You may be able to choose a new health plan, or offer your employees a choice of
plans, through different insurance companies, through [State SHOP Marketplace
Name/the SHOP Marketplace10]. If you have fewer than 25 full-time-equivalent
employees, you might qualify for a small business health care tax credit if you buy
insurance through [State SHOP Marketplace Name/the SHOP Marketplace11].

•

You can choose to buy a new health plan outside [State SHOP Marketplace Name/the
SHOP Marketplace12]—directly from an insurance company or with the help of an agent
or broker. But remember: If you’re eligible for a small business health care tax credit,
you usually can get that credit only if you buy a plan through [State SHOP Marketplace
Name/the SHOP Marketplace13].

•

You generally can buy coverage any time. If group members enroll by the [Day14] of the
month, coverage can begin on the 1st of the following month.

What else should I look at before deciding to keep or change my plan?
Call or visit the plan’s website to check which doctors, other health care providers, and
prescription medications are covered by the plan. This is an important step when choosing a
plan that meets the needs of your group members.
Questions?
• Call [Issuer Name and Contact Information and Hours of Operation15].
•

Visit [State SHOP Marketplace website and Consumer Assistance
Information/HealthCare.gov or call 1-800-706-7893 (TTY: 1-800-706-7915)16] to learn
more about [State SHOP Marketplace Name/the Health Insurance Marketplace17].

Getting Help in Other Languages
[Include the tagline below for the top languages spoken by 10% or more of the population in the
state.
Spanish (Español): Para obtener asistencia en Español, llame al [Issuer contact information].18]

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-XXXX. The time required to complete this information collection is
estimated to average 20 hours 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.

21

Attachment 8: Discontinuation notice to employers for the small group market

Issuers in the small group market may use the draft Federal standard small group notices released
in the June 26, 2014 bulletin and provided below, 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 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”. The following is considered to be the essential
content contained in the form of the Federal standard discontinuation notices:
• A statement that the coverage is being discontinued;
• If the individual is being auto-enrolled into another product, information about changes in
the individual’s benefits arising out of the change from the old product to the new
product;
• Information about other health coverage options; and
• Contact information for the consumer to call with questions.
The following draft standard notice from the June 26, 2014 bulletin may be used:

Important: Your Group Health Coverage Will Not Be Available Next Year.

Dear [Plan Sponsor or Name1],
We have decided not to offer your group’s current health coverage again next year. The current
coverage will end on [Date2]. This means you may need to choose a new plan for your
group members to have health insurance coverage. This letter explains the options available
to you.
Options from [Issuer Name3]
[We have selected a new [Issuer Name5] plan for your group members that’s similar to their
current plan. We’ll automatically enroll your group members in [Plan Name and Plan ID6]
unless you choose another option. Below are key differences between the new coverage
and the current coverage. You can review all the benefits and coverage for this plan at [Issuer
website7]].
•

•
•
•

Premium – Your new premium starts in [Month8]. Your monthly premium will be $[Dollar
amount9]. This is an estimate based on current enrollment. This amount may change
depending on the individuals who actually enroll in the plan. Check to see if you have
other options at: [State SHOP Marketplace website/HealthCare.gov10]
[List changes to new plan, including:
Benefit changes
Cost-sharing changes, including whether the plan is a different metal level from the
previous plan11].
22

Attachment 8: Discontinuation notice to employers for the small group market

You can also choose any of our other small group plans available to you.4]
[You can choose any other small group coverage offered by [Issuer name13]. Call [Issuer phone
number14] or visit [Issuer website15] to learn about plans available to you.12]
What other options do I have?
• You may be able to choose a new health plan, or offer your employees a choice of
plans, through different insurance companies, through [State SHOP Marketplace
Name/the SHOP Marketplace16]. If you have fewer than 25 full-time-equivalent
employees, you might qualify for a small business health care tax credit if you buy
insurance through [State SHOP Marketplace Name/the SHOP Marketplace17].
•

You can choose to buy a new health plan outside [State SHOP Marketplace Name/the
SHOP Marketplace18]—directly from an insurance company or with the help of an agent
or broker. But remember: If you’re eligible for a small business health care tax credit,
you usually can get that credit only if you buy a plan through [State SHOP Marketplace
Name/the SHOP Marketplace19].

What else should I look at before deciding?
Call or visit the plan’s website to check which doctors, other health care providers, and
prescription medications are covered by the plan. This is an important step when choosing a
plan that meets the needs of your group members.
When do I need to make a decision?
You generally can buy coverage any time. If group members enroll by the [Day20] of the month,
coverage can begin on the 1st of the following month.
We are notifying your employees
Federal law requires that we notify all group members with this coverage that it is no longer
being offered. Because we might not know about other coverage decisions you have made,
we’ll tell your employees to check with the plan sponsor or administrator about coverage options
that might be available through your organization.
Questions?
• Call [Issuer Name and Contact Information and Hours of Operation21].
•

Visit [State SHOP Marketplace website and Consumer Assistance
Information/HealthCare.gov or call 1-800-706-7893 (TTY: 1-800-706-7915)22] to learn
more about [State SHOP Marketplace Name/the Health Insurance Marketplace23].

Getting Help in Other Languages
[Include the tagline below for the top languages spoken by 10% or more of the population in the
state.
23

Attachment 8: Discontinuation notice to employers for the small group market

Spanish (Español): Para obtener asistencia en Español, llame al [Issuer contact information].24]

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-XXXX. The time required to complete this information collection is
estimated to average 12 hours 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.

24

Attachment 9: Instructions for completing Federal standard notices
Instructions for Attachment 1: Renewal notice for the individual market where coverage is being renewed outside the Marketplace
This notice should be used when coverage was purchased outside the Marketplace and will be renewed outside the Marketplace. This notice
should also be used when coverage was purchased through the Marketplace and will be renewed outside the Marketplace because the enrollee
will not be automatically enrolled in another product offered by the issuer through the Marketplace, in accordance with 45 CFR § 155.335(j).
Section
Field
Number(s)
1
2
3

Fixed or
Variable 1
Fixed
Variable
Variable

Date
Address

4
5

Variable
Variable

Salutation

6

Variable

Headline
box

Field Name

Valid Values

Name of issuer
Date
Paragraph

Text
Month, DD, YYYY
Text

Date of Notice
First Name Last Name
Address line 1
Address line 2
City, State, Zip
First Name of
Subscriber

Month, DD, YYYY
Text and numeric

Text

Special Instructions

Include the additional clause concerning loss of
financial assistance if such assistance would no
longer be available at renewal because the plan will
be offered outside the Marketplace.

In the individual market, subscriber means the
individual who purchases an individual policy and who
is responsible for the payment of premiums.

1

Fixed denotes that bracketed fields will be the same for all of an issuer’s notices in a State. Variable denotes that the bracketed fields will differ depending on
each subscriber or according to coverage.

25

Attachment 9: Instructions for completing Federal standard notices

Section

Intro

Changes
we’re
making to
your
coverage

7

Field
Number(s)
Variable

Date

Month, DD, YYYY

8

Variable

Paragraph

Paragraph

9

Fixed

Beginning date through
End date

Month, DD, YYYY

10

Fixed

Date

Month DD

11
12

Variable
Variable

Month
Dollar amount

Text
Numeric

13

Variable

Briefly describe plan
changes and/or refer to
enclosed materials

Text

14

Fixed

Issuer website

Text

Fixed or Variable

Field Name

Valid Values
Include the appropriate paragraph depending on
whether the coverage is on a calendar plan year
(grandfathered and non-grandfathered plans) or a
non-calendar plan year (grandfathered plans). If
coverage is on a non-calendar plan year
(grandfathered plans), describe the next open or
special enrollment period when subscribers can
change plans. Do not include the italicized
instructions.
Enter the beginning and end dates of the annual open
enrollment period for the upcoming policy year. For
example, for the 2015 policy year, enter “November
15, 2014 through February 15, 2015.”
Enter the date by which a plan selection must be
made for coverage effective January 1 of the following
year
Enter the total monthly premium for the coverage for
upcoming policy year. When necessary, a short
statement may be included indicating that the
premium rate is an estimate and indicating where
consumers will find the actual premium for the
coverage.
List significant changes to coverage, including but not
limited to changes in deductibles, cost sharing, metal
level, covered benefits, eligibility and provider
network. This section may also refer to enclosed
supplemental materials. Do not include the italicized
instructions.

26

Attachment 9: Instructions for completing Federal standard notices

Section

This plan
doesn’t
allow you to
receive
financial
assistance…

So what are
my options
if…

Field
Number(s)
Variable

Paragraph

Paragraph

Include this paragraph if the enrollee was previously
enrolled through the Marketplace; and the enrollee will
not be automatically enrolled in another product
offered by the issuer through the Marketplace; and the
coverage will be renewed outside the Marketplace.

15, 16, 17,
18, 19, 20

Fixed

Name of Marketplace

Text

22

Variable

Sentence

Sentence

For States with Federally-facilitated Marketplaces,
enter “the Marketplace.” For States with State-based
Marketplaces, enter the name of the State
Marketplace.
Included the bolded sentence if any enrollee in the
enrollment group received APTC or CSRs in the
current policy year. If not, omit.

23

Fixed

Date

Month, DD, YYYY

Enter last day of current policy year.

24, 26

Fixed

Marketplace website

Text

25, 27, 28

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces,
enter “HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
For States with Federally-facilitated Marketplaces,
enter “the Marketplace.” For States with State-based
Marketplaces, enter the name of the State
Marketplace.

21

Fixed or Variable

Field Name

Valid Values

27

Attachment 9: Instructions for completing Federal standard notices

Section

Questions?

Getting help
in other
languages

29

Field
Number(s)
Fixed

Name of issuer

Text

30

Fixed

Issuer phone number

Numeric

31

Fixed

Issuer website

Text

32

Fixed

Marketplace website

Text

33

Fixed

Marketplace phone
number

Numeric

34

Fixed

Name of Marketplace

Text

35

Fixed

Section

Text

36

Fixed

Language

Text

37

Fixed

Phone number

Numeric

Fixed or Variable

Field Name

Valid Values

For States with Federally-facilitated Marketplaces,
enter “HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
For States with Federally-facilitated Marketplaces,
enter “1-800-318-2596 (TTY: 1-855-889-4325).” For
States with State-based Marketplaces, enter the
phone number of the State Marketplace.
For States with Federally-facilitated Marketplaces,
enter “the Marketplace.” For States with State-based
Marketplaces, enter the name of the State
Marketplace.
Include the tagline translated in the non-English
language(s) spoken by 10% or more of the population
in the county. Taglines in additional languages are
encouraged. Do not include the italicized instructions.
If no language meets this threshold, this section may
be omitted.
Insert appropriate phone number for language
interpretation services.

28

Attachment 9: Instructions for completing Federal standard notices

Instructions for Attachment 2: Renewal notice for the individual market where coverage is being renewed in a QHP offered under the
same product through the Marketplace
This notice should be used when coverage was purchased through the Marketplace and will be renewed through the Marketplace.
Section
Field
Number(s)
1
2

Fixed or
Variable 2
Fixed
Variable

Name of issuer
Date

3

Variable

Paragraph

Date

4

Variable

Date of Notice

Address

5

Variable

Salutation

6

Variable

First Name Last Name
Address line 1
Address line 2
City, State, Zip
First Name of
Subscriber

Headline
box

Field Name

Valid Values
Text
Month, DD,
YYYY
Text

Special Instructions

Include the additional clause concerning loss of financial
assistance if such assistance would no longer be
available at renewal because the renewal plan will not be
at the silver level.

Month, DD,
YYYY
Text and
numeric

Text

In the individual market, subscriber means the individual
who purchases an individual policy and who is
responsible for the payment of premiums.

2

Fixed denotes that bracketed fields will be the same for all of an issuer’s notices in a State. Variable denotes that the bracketed fields will differ depending on
each subscriber or according to coverage.

29

Attachment 9: Instructions for completing Federal standard notices

Section

Intro

Changes
we’re
making to
your
coverage

Field
Number(s)
7

Fixed or
Variable
Fixed

Date

8

Fixed

Name of Marketplace

Month, DD,
YYYY
Text

9

Fixed

Beginning date through
End date

Month, DD,
YYYY

Enter the beginning and end dates of the annual open
enrollment period for the upcoming policy year. For
example, for the 2015 policy year, enter “November 15,
2014 through February 15, 2015.”

10

Fixed

Date

Month DD

Enter the date by which a plan selection must be made
for coverage effective January 1.

11

Variable

Dollar amount

Numeric

Enter the total monthly premium reduced by the most
recent monthly amount of any APTC for the enrollment
group for which data are available.

12

Variable

Sentence

Text

Include this sentence if any enrollee in the enrollment
group received APTC during the current policy year. If
not, omit.

13

Variable

Year

YYYY

14

Variable

Dollar amount

Numeric

Enter the total monthly premium for the coverage for
upcoming policy year. When necessary, a short
statement may be included indicating that the premium
rate is an estimate and indicating where consumers will
find the actual premium for the coverage.

15

Variable

Briefly describe plan
changes and/or refer to
enclosed materials

Text

List significant changes to coverage, including but not
limited to changes in deductibles, cost sharing, metal
level, covered benefits, eligibility and provider network.
This section may also refer to enclosed supplemental
materials. Do not include the italicized instructions.

16

Fixed

Issuer website

Text

Field Name

Valid Values

Special Instructions

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

30

Attachment 9: Instructions for completing Federal standard notices

Section

You can’t
get lower
deductibles,
coinsurance
and
copayments
for this plan

Update your
[Name of
Marketplace]
application
by [Date]

Field
Number(s)
17

Fixed or
Variable
Variable

Paragraph

Paragraph

18, 20

Fixed

Name of Marketplace

Text

19

Variable

Sentence

Sentence

Included the bolded sentence if any enroll in the
enrollment group received cost-sharing reductions in the
current policy year. If not, omit.

21

Fixed

Date

Month, DD,
YYYY

Enter the last day of current policy year.

22, 32, 33,
34, 35, 40

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

23, 36

Fixed

Date

Month, DD

Enter the date by which a plan selection must be made
for coverage effective January 1.

24

Variable

Text and table

Text and table

Include the text and table if any enrollee in the enrollment
group received APTC in the current benefit year.

25, 28

Fixed

Year

YYYY

Enter the current benefit year

26, 29

Variable

Dollar amount

Numeric

Enter the most recent monthly amount of APTC for the
enrollment group for which data are available

27, 31

Fixed

Marketplace website

Text

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.

30

Fixed

Year

YYYY

Enter the following benefit year

Field Name

Valid Values

Special Instructions
Include this paragraph if the enrollee was previously
enrolled in a silver-level QHP and their coverage is being
renewed in a non-silver-level QHP, consistent with 45 CFR
155.335(j)(1). If not, omit. Do not include this paragraph if
you know the enrollee is an Indian eligible for cost-sharing
reductions. Do not include the italicized instructions.
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

31

Attachment 9: Instructions for completing Federal standard notices

Section

If you didn’t
receive
advance
payments of
the premium
tax credit in
[Year]
So what are
my options
if…

Questions?

Field
Number(s)
37

Fixed or
Variable
Variable

Paragraph

Paragraph

38

Fixed

Year

YYYY

39

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

41, 42, 43,
46, 48, 49

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

44

Variable

Plan name and ID

Enter the name of the plan and HIOS Plan ID

45, 47

Fixed

Marketplace website

Text
Numeric
Text

50
51
52
53

Fixed
Fixed
Fixed
Fixed

Name of issuer
Issuer phone number
Issuer website
Marketplace website

Text
Numeric
Text
Text

54

Fixed

Marketplace phone
number

Numeric

For States with Federally-facilitated Marketplaces, enter
“1-800-318-2596 (TTY: 1-855-889-4325).” For States
with State-based Marketplaces, enter the phone number
of the State Marketplace.

55

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

Field Name

Valid Values

Special Instructions
Include this paragraph if no enrollee in the enrollment
group received APTC in the current benefit year. If not,
omit.
Enter current benefit year

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.”

32

Attachment 9: Instructions for completing Federal standard notices

Section
Field
Number(s)
Getting help
in other
languages

58

Fixed or
Variable
Fixed

Field Name
Section

Valid Values
Text

Special Instructions
Include the tagline translated in the non-English
language(s) spoken by 10% or more of the population in
the county. Taglines in additional languages are
encouraged. Do not include the italicized instructions.
If no language meets this threshold, this section may be
omitted.

56
57

Fixed
Fixed

Language
Phone number

Text
Numeric

Insert appropriate phone number for language
interpretation services.

33

Attachment 9: Instructions for completing Federal standard notices

Instructions for Attachment 3: Discontinuation notice for the individual market outside the Marketplace and the issuer is automatically
enrolling the enrollee in a new plan outside the Marketplace
This notice should be used when the issuer is non-renewing coverage purchased outside the Marketplace, and, consistent with State law,
automatically enrolling the enrollee in new coverage outside the Marketplace. This includes non-renewals based on a discontinuance of the
product or unavailability of the product based on the enrollee no longer being located within the product’s service area.
Section
Field
Number(s)
1

Fixed or
Variable 3
Fixed

Name of issuer

Text

2

Variable

Date

Date

3

Variable

Date of Notice

Address

4

Variable

Salutation

5

Variable

First Name Last Name
Address line 1
Address line 2
City, State, Zip
First Name of
Subscriber

Month, DD,
YYYY
Month, DD,
YYYY
Text and
numeric

Intro

6

Fixed

Name of issuer

Text

7

Fixed

Current year

Numeric

8

Fixed

Following Year

Numeric

9

Variable

Date

Month DD,
YYYY

Headline
box
Date

Field Name

Valid Values

Text

Special Instructions

In the individual market, subscriber means the individual
who purchases an individual policy and who is
responsible for the payment of premiums.

3

Fixed denotes that bracketed fields will be the same for all of an issuer’s notices in a State. Variable denotes that the bracketed fields will differ depending on
each subscriber or according to coverage.

34

Attachment 9: Instructions for completing Federal standard notices
Section

Your
suggested
new plan

So what are
my options
if…

Field
Number(s)
10
11

Fixed or
Variable
Variable
Variable

12

Field Name

Valid Values

Special Instructions

Plan name
Beginning date
End date

Text
Month DD,
YYYY

Fixed

Date

Numeric

13

Variable

Month

Text

14

Variable

Dollar amount

Numeric

Enter the total monthly premium for the coverage for
upcoming policy year. When necessary, a short
statement may be included indicating that the premium
rate is an estimate and indicating where consumers will
find the actual premium for the coverage.

15

Variable

Briefly describe plan
changes and/or refer to
enclosed materials

Text

List significant changes to coverage, including but not
limited to changes in deductibles, cost sharing, metal
level, covered benefits, eligibility, product network type
(e.g., PPO or HMO) and provider network. This section
may also refer to enclosed supplemental materials. Do
not include the italicized instructions.

16

Fixed

Issuer website

Text

17, 19

Fixed

Marketplace website

Text

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.

18, 20, 21,
22, 23

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

Enter the beginning and end dates of the special
enrollment period.
Enter the date by which a plan selection must be made
for coverage effective January 1.

35

Attachment 9: Instructions for completing Federal standard notices
Section

When do I
need to
make a
decision?

Field
Number(s)
24

Fixed or
Variable
Fixed

25

26

Getting help
in other
languages

Valid Values

Year

YYYY

Fixed

Beginning date through
End date

DD, Month,
YYYY

Variable

Beginning date to
End date
Date

Month DD,
YYYY
Month DD,
YYYY

28
29
30
31

Fixed
Fixed
Fixed
Fixed

Name of issuer
Issuer phone number
Issuer website
Marketplace website

Text
Numeric
Text
Text

32

Fixed

Marketplace phone
number

Numeric

33

Fixed

Name of Marketplace

34

Fixed

Section

Text

35

Fixed

Language

Text

36

Fixed

Phone number

Numeric

27
Questions?

Field Name

Special Instructions

Enter the beginning and end dates of the annual open
enrollment period for the upcoming policy year. For
example, for the 2015 policy year, enter “November 15,
2014 through February 15, 2015.”
Enter the beginning and end dates of the special
enrollment period.

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
For States with Federally-facilitated Marketplaces, enter
“1-800-318-2596 (TTY: 1-855-889-4325).” For States
with State-based Marketplaces, enter the phone number
of the State Marketplace.
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.
Include the tagline translated in the non-English
language(s) spoken by 10% or more of the population in
the county. Taglines in additional languages are
encouraged. Do not include the italicized instructions.
If no language meets this threshold, this section may be
omitted.
Insert appropriate phone number for language
interpretation services.

36

Attachment 9: Instructions for completing Federal standard notices
Instructions for Attachment 4: Notice for the individual market where coverage was in a QHP offered through the Marketplace and the
issuer is automatically enrolling the enrollee in a new product
This notice should be used when the product under which the QHP in which an enrollee is enrolled is not available through the Marketplace for
renewal (even if it remains available outside the Marketplace) and the enrollee will, consistent with State law and, if applicable, 45 CFR
§155.335(j)(2), be automatically enrolled in a different plan under a different product offered by the same QHP issuer . This includes non-renewals
based on a discontinuance of the product and unavailability of the product based on the enrollee no longer being located within the product’s
service area. This notice should also be used when the product under which the QHP in which an enrollee is enrolled is discontinued, the issuer
only offers other plans outside the Marketplace, and the issuer will automatically enroll the enrollee in one of its other plans outside the
Marketplace.
Section

Headline
box

Field
Number(s)
1
2

Fixed or
Variable 4
Fixed
Variable

Field Name
Name of issuer
through [Name of
Marketplace]

Valid Values
Text
Phrase

Special Instructions
Include this phrase if the product will continue to be
offered in the market outside the Marketplace and enter
the name of the Marketplace. For States with Federallyfacilitated Marketplaces, enter “the Marketplace.” For
States with State-based Marketplaces, enter the name of
the State Marketplace.
If the product will not continue to be offered in the market
outside the Marketplace, omit.

3

Variable

Date

4

Variable

Date

5

Variable

through [Name of
Marketplace]
Date of Notice

Address

6

Variable

First Name Last Name
Address line 1
Address line 2
City, State, Zip

Month, DD,
YYYY
Phrase

Include this phrase if the enrollee with a silver level plan
is being auto-enrolled into a non-silver level plan.

Month, DD,
YYYY
Text
Numeric

4

Fixed denotes that bracketed fields will be the same for all of an issuer’s notices in a State. Variable denotes that the bracketed fields will differ depending on
each subscriber or according to coverage.

37

Attachment 9: Instructions for completing Federal standard notices

Section
Field
Number(s)

Fixed or
Variable

Field Name

Valid Values

Special Instructions

Salutation

7

Variable

First Name of
Subscriber

Text

Intro

8
9
10

Fixed
Fixed
Variable

Text
YYYY
Phrase

11

Fixed

Name of issuer
Current year
through [Name of
Marketplace]
Following Year

12

Fixed

Date

13

Fixed

Name of Marketplace

Month DD,
YYYY
Text

14

Variable

Phrase

15

Variable

through [Name of
Marketplace]
Plan name

16

Fixed

Beginning date
End date

Month DD,
YYYY

Enter the beginning and end dates of the special
enrollment period.

17

Fixed

Date

Month DD

18

Variable

Dollar amount

Numeric

19

Variable

Sentence

Text

Enter the date by which a plan selection must be made
for coverage effective January 1.
Enter total monthly premium reduced by the most recent
monthly amount of any APTC for the enrollment group for
which data are available.
Include this sentence if any enrollee in the enrollment
group received APTC during the current policy year. If
not, omit.

Your
suggested
new plan

In the individual market, subscriber means the individual
who purchases an individual policy and who is
responsible for the payment of premiums.

See instruction for field 2.

YYYY

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.
See instruction for field 2.

Text

38

Attachment 9: Instructions for completing Federal standard notices

Section

Your
suggested
new plan

This plan
doesn’t
allow you to
receive
financial
assistance…

You can’t
get lower
deductibles,
coinsurance
and
copayments
for this plan

Field
Number(s)
20
21

Fixed or
Variable
Fixed
Variable

22

Field Name

Valid Values

Year
Dollar amount

YYYY
Numeric

Variable

Describe plan changes
and/or refer to enclosed
materials

Text

23

Fixed

Issuer website

Text

24

Variable

Paragraph

Paragraph

25, 26, 27

Fixed

Name of Marketplace

Text

28

Variable

Sentence

Sentence

29

Fixed

Date

30

Variable

Paragraph

Month, DD,
YYYY
Paragraph

31, 33

Fixed

Name of Marketplace

Text

Special Instructions
Enter the total monthly premium for the coverage for
upcoming policy year. When necessary, a short
statement may be included indicating that the premium
rate is an estimate and indicating where consumers will
find the actual premium for the coverage.
List significant changes to coverage, including but not
limited to changes in deductibles, cost sharing, metal
level, covered benefits, eligibility, product network type
(e.g., PPO or HMO) and provider network. This section
may also refer to enclosed supplemental materials. Do
not include the italicized instructions.
Include this paragraph if the enrollee was previously
enrolled through the Marketplace and the plan in which
the enrollee will automatically be enrolled is offered
outside the Marketplace.
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.
Included the bolded sentence if any enroll in the
enrollment group received APTC or CSRs in the current
policy year. If not, omit.
Enter last day of current policy year.
Include this paragraph if the enrollee was previously
enrolled in a silver-level QHP and their coverage is being
renewed in a non-silver-level QHP through the
Marketplace, consistent with 45 CFR 155.335(j)(1). If not,
omit. Do not include this paragraph if you know the
enrollee is an Indian eligible for cost-sharing reductions.
Do not include the italicized instructions.
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

39

Attachment 9: Instructions for completing Federal standard notices

Section
You can’t
Field
get lower
Number(s)
deductibles, 32
coinsurance
and
copayments 34
for this plan
Update your 35, 45, 46,
47, 48
[Name of
Marketplace]
application
36, 49
by [Date]

If you didn’t
receive
advance
payments of
the premium
tax credit in
[Year]

Fixed or
Variable
Variable

Sentence

Sentence

Fixed

Date

Fixed

Name of Marketplace

Month, DD,
YYYY
Text

Fixed

Date

Month, DD

37

Variable

Text and table

Text and table

38, 41

Fixed

Year

YYYY

Enter the current policy year

39, 42

Variable

Dollar amount

Numeric

Enter the most recent monthly amount of APTC for the
enrollment group for which data are available

40, 44

Fixed

Marketplace website

Text

43

Fixed

Year

YYYY

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
Enter the following benefit year

50

Variable

Paragraph

Paragraph

Include this paragraph if no enrollee in the enrollment
group received APTC in the current benefit year. If not,
omit.

51

Fixed

Year

YYYY

Enter the current policy year

52

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

Field Name

Valid Values

Special Instructions
Included the bolded sentence if any enroll in the
enrollment group received cost-sharing reductions in the
current policy year. If not, omit.
Enter the last day of current policy year.
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.
Enter the date by which a plan selection must be made
for coverage effective January 1.
Include the text and table if any enrollee in the enrollment
group received APTC in the current benefit year.

40

Attachment 9: Instructions for completing Federal standard notices

Section
Field
Number(s)
So what are
my options
if…

When do I
need to
make a
decision?

Questions?

Fixed or
Variable

Field Name

Valid Values

Special Instructions

53, 54, 55,
58, 60, 61,
62, 63, 65

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

56

Variable

Plan name and ID

Enter the name of the plan and HIOS Plan ID

57, 59

Fixed

Marketplace website

Text
Numeric
Text

64

Variable

I like my current
coverage and want to
renew it outside [Name
of Marketplace]?

66

Fixed

Year

Numeric

67

Fixed

Beginning date
End date

DD, Month,
YYYY

Enter the beginning and end dates of the annual open
enrollment period for the upcoming policy year. For
example, for the 2015 policy year, enter “November 15,
2014 through February 15, 2015.”

68

Variable

Beginning date
End date

Month DD,
YYYY

Enter the beginning and end dates of the special
enrollment period.

69

Fixed

Date

Month DD,
YYYY

70
71
72
73

Fixed
Fixed
Fixed
Fixed

Name of issuer
Issuer phone number
Issuer website
Marketplace website

Text
Numeric
Text
Text

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
Include this text if the product will continue to be offered
outside the Marketplace.

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.

41

Attachment 9: Instructions for completing Federal standard notices

Section

Questions?

Getting help
in other
languages

Field
Number(s)
74

Fixed or
Variable
Fixed

75

Field Name

Valid Values

Marketplace phone
number

Numeric

Fixed

Name of Marketplace

Text

76

Fixed

Section

Text

77
78

Fixed
Fixed

Language
Phone number

Text
Numeric

Special Instructions
For States with Federally-facilitated Marketplaces, enter
“1-800-318-2596 (TTY: 1-855-889-4325).” For States
with State-based Marketplaces, enter the phone number
of the State Marketplace.
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.
Include the tagline translated in the non-English
language(s) spoken by 10% or more of the population in
the county. If no language meets this threshold, this
section may be omitted.
Insert the appropriate phone number for language
interpretation services

42

Attachment 9: Instructions for completing Federal standard notices
Instructions for Attachment 5: Discontinuation notice for the individual market outside the Marketplace and the issuer is not
automatically enrolling the enrollee in a new plan
This notice should be used when the issuer is non-renewing coverage purchased outside the Marketplace based on a discontinuance of the
product or unavailability of the product based on the product’s service area no longer including the enrollee’s location, and not automatically
enrolling an enrollee in a new plan.
Section

Headline
box

Field
Number(s)
1
2

Fixed or
Variable 5
Fixed
Variable

Name of issuer
Date

Date

3

Variable

Date of Notice

Address

4

Variable

Salutation

5

Variable

First Name Last Name
Address line 1
Address line 2
City, State, Zip
First Name of
Subscriber

Intro

6
7
8
9

Fixed
Fixed
Fixed
Fixed

Name of issuer
Current year
Following Year
Date

What are my
options for
getting
coverage?

10, 12

Fixed

Marketplace website

Text
YYYY
YYYY
Month DD,
YYYY
Text

11, 13, 14,
15, 16

Fixed

Name of Marketplace

Text

Field Name

Valid Values

Special Instructions

Text
Month, DD,
YYYY
Month, DD,
YYYY
Text
Numeric

Text

In the individual market, subscriber means the individual
who purchases an individual policy and who is
responsible for the payment of premiums.

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

5

Fixed denotes that bracketed fields will be the same for all of an issuer’s notices in a State. Variable denotes that the bracketed fields will differ depending on
each subscriber or according to coverage.

43

Attachment 9: Instructions for completing Federal standard notices

Section

When do I
need to
make a
decision?

Questions?

Getting help
in other
languages

Field
Number(s)
17
18

Fixed or
Variable
Fixed
Fixed

19

Field Name

Valid Values

Special Instructions

Year
Beginning date through
End date

YYYY
DD, Month,
YYYY

Fixed

Beginning date to
End date

Month DD,
YYYY

20

Fixed

Date

21

Fixed

Name of issuer

Month DD,
YYYY
Text

22

Fixed

Issuer phone number

Numeric

23
24

Fixed
Fixed

Issuer website
Marketplace website

Text
Text

25

Fixed

Marketplace phone
number

Numeric

26

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

27

Fixed

Section

Section

Include the tagline translated in the non-English
language(s) spoken by 10% or more of the population in
the county. Taglines in additional languages are
encouraged. Do not include the italicized instructions.
If no language meets this threshold, this section may be
omitted.

28

Fixed

Language

Text

29

Fixed

Phone number

Numeric

Enter the beginning and end dates of the annual open
enrollment period for the upcoming policy year. For
example, for the 2015 policy year, enter “November 15,
2014 through February 15, 2015.”
Enter the beginning and end dates of the special
enrollment period.

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
For States with Federally-facilitated Marketplaces, enter
“1-800-318-2596 (TTY: 1-855-889-4325).” For States
with State-based Marketplaces, enter the phone number
of the State Marketplace.

Insert appropriate phone number for language
interpretation services.

44

Attachment 9: Instructions for completing Federal standard notices
Instructions for Attachment 6: Discontinuation notice for the individual market where coverage being discontinued was in a QHP offered
through the Marketplace and the issuer is not automatically enrolling the enrollee in a new plan
This notice should be used when the product under which the QHP in which an enrollee is enrolled is not available for renewal through or outside
the Marketplace and the issuer is not automatically enrolling the enrollee in a new plan. This includes non-renewals based on a discontinuance of
the product and unavailability of the product based on the enrollee no longer being located within the product’s service area.
Section

Headline
box

Field
Number(s)
1
2

Fixed or
Variable 6
Fixed
Variable

Name of issuer
Date

Date

3

Variable

Date of Notice

Address

4

Variable

Salutation

5

Variable

First Name Last Name
Address line 1
Address line 2
City, State, Zip
First Name of
Subscriber

Intro

6
7
8
9

Fixed
Fixed
Fixed
Fixed

Name of issuer
Current year
Following Year
Date

10

Fixed

Name of Marketplace

Field Name

Valid Values

Special Instructions

Text
Month, DD,
YYYY
Month, DD,
YYYY
Text
Numeric

Text

Text
YYYY
YYYY
Month DD,
YYYY
Text

In the individual market, subscriber means the individual
who purchases an individual policy and who is
responsible for the payment of premiums.

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

6

Fixed denotes that bracketed fields will be the same for all of an issuer’s notices in a State. Variable denotes that the bracketed fields will differ depending on
each subscriber or according to coverage.

45

Attachment 9: Instructions for completing Federal standard notices
Section
Field
Number(s)
Update your
[Name of
Marketplace]
application
by [Date]

If you didn’t
receive
advance
payments of
the premium
tax credit in
[Year]

Fixed or
Variable 7

Field Name

Valid Values

Special Instructions

11, 21, 22,
23, 24

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

12, 25

Fixed

Date

Month, DD

Enter the date by which a plan selection must be made
for coverage effective January 1.

13

Variable

Text and table

Text and table

Include the text and table if any enrollee in the enrollment
group received APTC in the current benefit year.

14, 17

Fixed

Year

YYYY

Enter the current policy year

15, 18

Variable

Dollar amount

Numeric

Enter the most recent monthly amount of APTC for the
enrollment group for which data are available

16, 20

Fixed

Marketplace website

Text

19

Fixed

Year

YYYY

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
Enter the following policy year

26

Variable

Paragraph

Paragraph

27

Fixed

Year

YYYY

28

Fixed

Name of Marketplace

Text

Include this paragraph if no enrollee in the enrollment
group received APTC in the current benefit year. If not,
omit.
Enter current benefit year
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

7

Fixed denotes that bracketed fields will be the same for all of an issuer’s notices in a State. Variable denotes that the bracketed fields will differ depending on
each subscriber or according to coverage.

46

Attachment 9: Instructions for completing Federal standard notices

Section

What are my
options for
getting
coverage?
When do I
need to
make a
decision?

Questions?

Field
Number(s)
29, 31

Fixed or
Variable 8
Fixed

Marketplace website

Text

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.”

30, 31, 32,
33, 34, 35

Fixed

Name of Marketplace

Text

For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

36
37

Fixed
Fixed

Year
Beginning date through
End date

YYYY
DD, Month,
YYYY

38

Fixed

Beginning date to
End date

Month DD,
YYYY

39

Variable

Date

40
41
42
43

Fixed
Fixed
Fixed
Fixed

Name of issuer
Issuer phone number
Issuer website
Marketplace website

Month DD,
YYYY
Text
Numeric
Text
Text

44

Fixed

Marketplace phone
number

Numeric

45

Fixed

Name of Marketplace

Text

Field Name

Valid Values

Special Instructions

Enter the beginning and end dates of the annual open
enrollment period for the upcoming policy year. For
example, for the 2015 policy year, enter “November 15,
2014 through February 15, 2015.”
Enter the beginning and end dates of the special
enrollment period.

For States with Federally-facilitated Marketplaces, enter
“HealthCare.gov.” For States with State-based
Marketplaces, enter the website of the State
Marketplace.
For States with Federally-facilitated Marketplaces, enter
“1-800-318-2596 (TTY: 1-855-889-4325).” For States
with State-based Marketplaces, enter the phone number
of the State Marketplace.
For States with Federally-facilitated Marketplaces, enter
“the Marketplace.” For States with State-based
Marketplaces, enter the name of the State Marketplace.

8

Fixed denotes that bracketed fields will be the same for all of an issuer’s notices in a State. Variable denotes that the bracketed fields will differ depending on
each subscriber or according to coverage.

47

Attachment 9: Instructions for completing Federal standard notices
Section

Getting help
in other
languages

Field
Number(s)
46

Fixed or
Variable
Fixed

Section

Text

47
48

Fixed
Fixed

Language
Phone number

Text
Numeric

Field Name

Valid Values

Special Instructions
Include the tagline translated in the non-English
language(s) spoken by 10% or more of the population in
the county. Taglines in additional languages are
encouraged. Do not include the italicized instructions.
If no language meets this threshold, this section may be
omitted.
Insert appropriate phone number for language
interpretation services.

48

Attachment 9: Instructions for completing Federal standard notices

Instructions for Attachment 7: Renewal notice to employers for the small group market
1- Enter either “Plan Sponsor” or the name of the plan sponsor.
2- Enter the date (Month DD, YYYY) on which the next plan year begins.
Changes we’re making to your group’s current coverage
3- Enter the month in which the new premium is in effect.
4- Enter the estimated dollar amount of the monthly premium for 2015.
5- Enter the website of the SHOP Marketplace in the State. For States with State-based SHOPs, enter the website of the State SHOP.
For States with Federally-facilitated Marketplaces, enter “HealthCare.gov”.
6- If the renewed plan is different from the current plan, briefly describe the significant changes between the current plan and the new
plan, including but not limited to as the name and Plan ID of the new plan, changes in covered benefits (including changes in
eligibility), and changes in cost sharing, including whether the plan is a different metal level from the current plan.
7- If the renewed plan is not being offered through the SHOP, including this text in its entirety and complete items 8-9. If the renewed
plan is being offered through the SHOP, omit this text and skip to item 10 below.
8-9 Enter the name of the SHOP Marketplace for the State. For States with State-based SHOPs, enter the name of the State SHOP.
For States with Federally-facilitated SHOPs, enter “the Small Business Health Options Program (SHOP) Marketplace” or “the SHOP
Marketplace” as indicated.
What if I want to change plans?
10-13 Enter the name of the SHOP Marketplace for the State. For States with State-based SHOPs, enter the name of the State SHOP.
For States with Federally-facilitated SHOPs, enter “the SHOP Marketplace”.
14- Enter the day of the month (e.g., 15th) on which a plan selection must be made for coverage effective the 1st of the following
month.
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Attachment 9: Instructions for completing Federal standard notices

Questions?
15- Enter the name, contact information, and hours of operation of the issuer.
16- Enter the website and consumer assistance information of the SHOP Marketplace for the State. For States with State-based
SHOPs, enter the website and consumer assistance information for the State SHOP. For States with Federally-facilitated SHOPs,
enter “HealthCare.gov or call 1-800-706-7893 (TTY: 1-800-706-7915)”.
17- Enter the name of the SHOP Marketplace for the State. For States with State-based SHOPs, enter the name of the State SHOP.
For States with Federally-facilitated SHOPs, enter “the Health Insurance Marketplace”.
Getting Help in Other Languages
18- Include the following tagline translated in the top languages spoken by 10% of the population in the State. Enter the appropriate
language and the issuer’s phone number:
“For help in [language], call [Issuer phone number.]”

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Attachment 9: Instructions for completing Federal standard notices

Instructions for Attachment 8: Discontinuation notice to employers for the small group market
1- Enter either “Plan Sponsor” or the name of the plan sponsor.
2- Enter the date (Month DD, YYYY) on which coverage under the current product will end.
Options from [Issuer Name]
3- Enter the name of the issuer.
4- Include this text in its entirety if the issuer is auto-enrolling the plan enrollees into a plan within another product, consistent with
applicable Federal and State law, and complete items 5-10. If not, omit this text and skip to item 11 below.
5- Enter the name of the issuer.
6- Enter the name and plan ID number of the new plan
7- Enter the website of the issuer.
8- Enter the month in which the new premium is in effect.
9- Enter the estimated dollar amount of the monthly premium for 2015.
10- Enter the website of the SHOP Marketplace in the State. For States with State-based SHOPs, enter the website of the State SHOP.
For States with Federally-facilitated Marketplaces, enter “HealthCare.gov”.
11- Briefly describe the significant changes between the current plan and the new plan, including but not limited to changes in covered
benefits (including changes in eligibility) and cost sharing (including whether the new plan is a different metal level from the current
plan).
12- If the issuer is not auto-enrolling the plan enrollee into a plan within another product, include this text in its entirety and complete
item 13-15.
13- Enter the name of the issuer.
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Attachment 9: Instructions for completing Federal standard notices

14- Enter the phone number of the issuer.
15- Enter the website of this issuer.
What other options do I have?
16-19 Enter the name of the SHOP Marketplace for the State. For States with State-based SHOPs, enter the name of the State SHOP.
For States with Federally-facilitated SHOPs, enter “the SHOP Marketplace.”
When do I need to make a decision if I want to change plans?
20- Enter the day of the month (e.g., 15th) on which a plan selection must be made for coverage effective the 1st of the following
month.
Questions?
21- Enter the name, contact information, and hours of operation of the issuer.
22- Enter the website and consumer assistance information of the SHOP Marketplace of the State. For States with State-based
SHOPs, enter the website and consumer assistance information for the State SHOP. For States with Federally-facilitated SHOPs,
enter “HealthCare.gov or call 1-800-706-7893 (TTY: 1-800-706-7915)”.
23- Enter the name of the SHOP Marketplace for the State. For States with State-based SHOPs, enter the name of the State SHOP.
For States with Federally-facilitated SHOPs, enter “the Health Insurance Marketplace.”
Getting Help in Other Languages
24- Include the following tagline translated in the top languages spoken by 10% of the population in the State. Enter the appropriate
language and the issuer’s phone number:
“For help in [language], call [Issuer phone number.]”

52