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pdfOMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
Attachment 1: Renewal notice for the individual market where coverage is being renewed
outside the Exchange.
[1 Date]
[2 [First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]]
Important: It’s time to review your health coverage. Take action by [3 Date], or you’ll be automatically
re-enrolled in the same or similar coverage. This may change some of your costs and coverage, so review
your options carefully.
Important: It’s time to review your health coverage. Take action by [3 Date], or you’ll be
automatically re-enrolled in the same or similar coverage. This may change some of your costs
and coverage, so review your options carefully.
Thank you for choosing [4 Issuer] for your health care needs. [5 We’re here to help you
prepare for Open Enrollment.]
Why am I getting this letter?
Your health coverage is still being offered in [6 Year], but some details may have changed.
Read this letter carefully and decide if you want to keep this plan or choose another one.
Unless you take action by [7 Date], you’ll be automatically enrolled in this plan for [8
Year].
Important: This isn’t a [9 MarketplaceExchange] plan. This means you won’t get any financial
help lowering your monthly premium or out-of-pocket costs (like deductibles, copayments, and
coinsurance) if you remain enrolled in this plan. To see if you qualify for these savings and to
enroll in a [10 MarketplaceExchange] plan, visit [11 MarketplaceExchange website] by [12
Date]. [13 If you don’t, any financial help you currently get will end in [14 Month].] If you
don’t enroll in a [15 MarketplaceExchange] plan by [16 Date], you may not be able to switch
to one for [17 Year], even if your finances change.
Changes you’ll see to your plan in [18 Year]
Your new premium
•
Your [19 Current year] monthly premium is $[20 Dollar amount].
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
•
Starting in [21 Month], your [22 estimated] monthly premium will be $[23
Dollar amount]. Important: This is only an estimate based on current information
we have. It doesn’t reflect any changes to your enrollment, such as adding additional
members to your coverage. You’ll see your new monthly payment amount when you
get your [24 Month] bill.
Other changes
•
[25 Briefly describe plan changes and/or refer to enclosed materials]
•
You can review more details about your plan at [26 Issuer website] and in your [27
Year] Summary of Benefits and Coverage.
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
What you need to do
Decide if you want to enroll in this plan or choose another one.
I want to enroll in this plan.
Pay the new monthly premium [28 by Date] and you’ll be automatically enrolled.
I want to pick a different plan.
[29 You can choose a different plan between [30 Dates]. Enroll by [31 Date] for coverage
to start [32 Date].]
Here are some ways to look at other plans and enroll:
•
•
Check with [33 Issuer] to see what other plans may be available. Remember, you
won’t get financial help unless you qualify and enroll through [34 the
MarketplaceExchange].
Visit [35 MarketplaceExchange website] to see [36 MarketplaceExchange] plans.
Consumers who shop can save hundreds of dollars per year and can find a plan that
best meets their needs and budget.
We’re here to help
•
Call [37 Issuer] at [38 Issuer phone number] or visit [39 Issuer website].
•
Visit [40 MarketplaceExchange website], or call [41 MarketplaceExchange phone
number] to learn more about [42 the MarketplaceExchange] and to see if you
qualify for lower costs.
•
Find in-person help from an assister, agent, or broker in your community at [43 Website]
•
[44 Contact an agent or broker you've worked with before, [ [[45 like Agent/broker
name].], [46 Call Agent/broker phone number]].
• [47 Call [48 Issuer phone number] to requestfor a reasonable accommodation to get
this information in an accessible format, like large print, Braille, or audio, at no cost to
you if you have a disability.].
Getting help in other languages
•
[49 Insert non-discrimination notice and taglines consistent with any applicable
standards, such as under HHS regulations and guidance.]
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
Attachment 2: Renewal notice for the individual market where coverage is being renewed
in a QHP offered under the same product through the Exchange
[1 Date]
[2 First Name][Last Name]
[Address line 1]
[Address line 2]
line2]
[City][State][Zip]
Important: It’s time to review your health coverage. Take action by [3 Date], or you’ll be automatically
re-enrolled in the same or similar coverage. This may change some of your costs and coverage, so review
your options carefully.
Important: It’s time to review your health coverage. Take action by [3 Date], or you’ll be
automatically re-enrolled in the same or similar coverage. This may change some of your costs
and coverage, so review your options carefully.
Thank you for choosing [4 Issuer] for your health care needs. We’re here to help you prepare
for Open Enrollment.
Why am I getting this letter?
Your health coverage is still being offered in [5 Year], but some details may have changed. Read
this letter carefully and decide if you want to keep this plan or choose another one. Also make
sure to update your information with [6 the MarketplaceExchange].
Changes you’ll see to your plan in [7 Year]]:
Your new premium
Your [8 Current year] monthly payment is $[9 Dollar amount].
This reflects a monthly premium of $[10 Dollar amount] minus $[11 Dollar amount] of financial
help per month.
Starting in [12 Month], your [13 estimated] monthly payment will be $[14 Dollar amount].
This reflects an [15 estimated] monthly premium of $[16 Dollar amount] minus the same amount
of financial help you’re getting now. You’ll see your new monthly payment when you receive
your [17 Month] bill.
Important: This is only an estimate based on current information we have, including the amount
of financial help you got in [18 Year]. It also doesn’t reflect any changes to your enrollment,
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
such as adding additional members to your coverage. To find out how much financial help you
qualify for in [19 Year] and your new premium amount, update your [20 MarketplaceExchange]
application. See below for more information.
Other changes
•
•
[21 Briefly describe plan changes and/or refer to enclosed materials]
You can review more details about your plan at [22 Issuer website] and in your [23
Year] Summary of Benefits and Coverage.
What you need to do
•
Update your [24 MarketplaceExchange] application by [25 Date].
Review your [26 MarketplaceExchange] application to make sure the information is still
current and correct, and to see if you qualify for more or less financial help than in [27
Year]. This may result in a lower monthly premium payment or lower out-of-pocket
costs (like deductibles, copayments, and coinsurance). Plus, you can help avoid paying
money back when you file your taxes.
•
Decide if you want to enroll in this plan or choose another one.
I want to enroll in this plan.
Update your Exchange application information in step #1, and then select
[28 Plan name and ID] to enroll. [29 For renewals from a silver level QHP
into a non-silver level QHP (except for Indian enrollees): )]
Important: This isn’t a Silver plan in [30 Year]. This means you can’t get financial
help to lower your out-of-pocket costs if you enroll in this plan. To get these savings if
you qualify, you must go back to [31 the MarketplaceExchange] and enroll in a Silver
plan. If you don’t, any financial help you currently get to lower your out-of-pocket costs
will stop on December 31.]
I want to pick a different plan.
You can choose a different plan between [32 Dates]. Enroll by [33 Date] for
coverage to start January 1.
Here are some ways to look at other plans and enroll:
•
Visit [34 MarketplaceExchange website] to see other [35
MarketplaceExchange] plans. Consumers who shop can save hundreds
of dollars per year and can find a plan that best meets their needs and
budget.
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
•
Check with [36 Issuer] to see what other plans may be available.
Remember, you won’t get financial help unless you qualify and enroll
through [37 the MarketplaceExchange].
Note: If you got financial help in [38 Year] to lower your monthly premium, you’ll have
to “reconcile” using IRS Form 8962 when you file your federal taxes. This means you’ll
compare the amount of premium tax credit you received in advance during [39 Year] with
the amount you actually qualify for based on your final [40 Year] household income and
eligibility information. If the amounts are different, this will affect the amount of your
refund or taxes owed.
We’re here to help
•
Visit [41 MarketplaceExchange website], or call [42 MarketplaceExchange phone
number] to learn more about [43 the MarketplaceExchange] and to see if you
qualify for lower costs.
• Call [44 Issuer] at [45 Issuer phone number] or visit [46 Issuer website].
• Find in-person help from an assister, agent, or broker in your community at [47
Website].
• [48 Contact an agent or broker you've worked with before, [ [[49 like Agent/broker
name].], [50 Call Agent/broker phone number]].
• Call [51 MarketplaceExchange phone number] to requestfor a reasonable
accommodation to get this information in an accessible format, like large print,
Braille, or audio, at no cost to you if you have a disability.
Getting help in other languages
[52 Insert non-discrimination notice and taglines consistent with any applicable standards,
such as under HHS regulations and guidance.]
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
Attachment 3: Discontinuation notice for the individual market outside the Exchange and
the issuer is automatically enrolling the enrollee in a different plan
[1 Date]
[2 [First Name][Last Name]
[Address line 1]
[Address line 2] [City]
[State] [Zip]]
Important: Your plan will no longer be offered. Take action by [3 Date], or you’ll be automatically
enrolled in a different plan. This may change some of your costs and coverage, so review your options
carefully.
Important: Your plan will no longer be offered. Take action by [3 Date], or you’ll be
automatically enrolled in a different plan. This may change some of your costs and coverage, so
review your options carefully.
Thank you for choosing [4 Issuer] for your health care needs. [5 We’re here to help you
prepare for Open Enrollment.]
Why am I getting this letter?
Beginning [6 Date], we won’t offer your current health coverage [7 in your area]. The
last day of your current coverage is [8 Date]. Read this letter carefully and review your
options.
Your new plan for [9 Year]
We found another plan that may meet your needs. Starting in [10 Month], you’ll be
automatically enrolled in [11 Plan name].
Important: This isn’t a [12 MarketplaceExchange] plan. This means you won’t get any financial
help lowering your monthly premium or out-of-pocket costs (like deductibles, copayments, and
coinsurance) if you enroll in this plan. To see if you qualify for these savings and to enroll in a
[13 MarketplaceExchange] plan, visit [14 MarketplaceExchange website] by [15 Date]. If you
don’t enroll in a [16 MarketplaceExchange] plan by [17 Date], you may not be able to switch to
one for [18 Year], even if your finances change.
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
Your new premium
Your current monthly premium is $[19 Dollar amount].
Starting in [20 Month], your [21 estimated] monthly premium will be $[22 Dollar amount].
Important: This is only an estimate based on current information we have. It doesn’t reflect any
changes to your enrollment, such as adding additional members to your coverage. You’ll see
your new monthly payment amount when you get your [23 Month] bill.
Other changes
•
[24 Briefly describe plan changes and/or refer to enclosed materials]
•
You can review more details about this plan at [25 Issuer website] and in your [26
Year] Summary of Benefits and Coverage.
If you want to pick another plan, enroll by [27 Date] to make sure you have the coverage
you want. See below for more information.
What you need to do
Decide if you want to enroll in this plan or choose another one.
I want to enroll in this plan.
Pay the monthly premium [28 by Date] and you’ll be automatically enrolled.
I want to pick a different plan
You can choose a different plan between [29 Dates]. Enroll by [30 Date]
for coverage to start [31 Date].
Here are some ways to look at other plans and enroll:
• Check with [32 Issuer] to see what other plans may be available.
• Visit [33 MarketplaceExchange website] to see [34
MarketplaceExchange] plans. Consumers who shop can save hundreds
of dollars per year and can find a plan that best meets their needs and
budget.
We’re here to help
•
Call [35 Issuer] at [36 Issuer phone number] or visit [37 Issuer website].
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
•
•
•
•
Visit [38 MarketplaceExchange website], or call [39 MarketplaceExchange phone
number] to learn more about [40 the MarketplaceExchange] and to see if you
qualify for lower costs.
Find in-person help from an assister, agent, or broker in your community at [41
Website].
[42 Contact an agent or broker you've worked with before, [ [[43 like Agent/broker
name].], [44 Call [Agent/broker phone number]].
[45 Call [46 Issuer phone number] to requestfor a reasonable accommodation to get
this information in an accessible format, like large print, Braille, or audio, at no cost to
you if you have a disability.].
Getting help in other languages
[47 Insert non-discrimination notice and taglines consistent with any applicable standards,
such as under HHS regulations and guidance.]
Attachment 4: Notice for the individual market where coverage was in a QHP offered
through the Exchange and the issuer is automatically enrolling the enrollee
in a plan under a different product offered through the Exchange
[1 Date]
[2 [First Name][Last Name]
[Address line 1]
[Address line 2]
[City] [State] [Zip]]
Important: Your plan will no longer be offered through the Marketplace. Take action by [3 Date] or
you’ll be automatically enrolled in a different [4 Marketplace] plan. This may change some of your costs
and coverage, so review your options carefully.
Important: Your plan will no longer be offered through the Marketplace. Take action by [3
Date] or you’ll be automatically enrolled in a different [4 Marketplace] plan. This may change
some of your costs and coverage, so review your options carefully.
Thank you for choosing [5 Issuer] for your health care needs. [6 We’re here to help you
prepare for Open Enrollment].
Why am I getting this letter?
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
Beginning [7 Date], we won’t offer [8 in your area] your current health coverage [9 in the
MarketplaceExchange]. The last day of your current [10 MarketplaceExchange] coverage is
[11 Date]. Read this letter carefully and review your options. Also make sure to update your
information with [12 the MarketplaceExchange].
Your new plan for [13 Year]
We found another [14 MarketplaceExchange] plan that may meet your needs. Starting in [15
Month], you’ll automatically be enrolled in [16 Plan name].
Your new premium
•
Your [17 Current Year] monthly payment is $[18 Dollar amount].
This reflects a monthly premium of $[19 Dollar amount] minus $[20 Dollar amount] of
financial help per month.
•
Starting in [21 Month], your [22 estimated] monthly payment will be $[23 Dollar
amount].
This reflects an [24 estimated] monthly premium of $[25 Dollar amount] minus the same
amount of financial help you’re getting now. You’ll see your new monthly payment when
you receive your [26 Month] bill.
Important: This is only an estimate based on current information we have, including the
amount of financial help you got in [27 Year]. It also doesn’t reflect any changes to your
enrollment, such as adding additional members to your coverage. To find out how much
financial help you qualify for in [28 Year] and your new premium amount, update your [29
MarketplaceExchange] application. See below for more information.
Other changes
•
[30 Briefly describe plan changes and/or refer to enclosed materials]
•
You can review more details about this plan at [31 Issuer website] and in your [32 Year]
Summary of Benefits and Coverage.
If you want to pick another plan, enroll by [33 Date] to make sure you have the coverage
you want. See below for more information.
What you need to do
1. Update your [34 MarketplaceExchange] application by [35 Date].
Review your [36 MarketplaceExchange] application to make sure the information is still
current and correct, and to see if you may qualify for more or less financial help [37 in
Year] than you’re getting now. This may result in a lower monthly premium payment
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
or lower out-of- pocket costs (like deductibles, copayments, and coinsurance). Plus,
you can help avoid paying money back when you file your taxes.
2. Decide if you want to enroll in this plan or choose another one.
I want to enroll in this plan. Update your Exchange application information in step #1, and
then select [38 Plan name and ID] to enroll.
[39 For re-enrollment from a silver level QHP into a non-silver level QHP (except for Indian
enrollees): Important: This isn’t a Silver plan in [40 Year]. This means you can’t get
financial help to lower your out-of-pocket costs if you enroll in this plan. To get these
savings if you qualify, you must go back to [41 the MarketplaceExchange] and enroll in a
Silver plan. If you don’t, any financial help you currently get to lower your out-of-pocket
costs will stop on [42 Date].]
I want to pick a different plan.
You can choose a different plan between [43 Dates]. Enroll by [44 Date] for coverage
to start [45 Date].
Here are some ways to look at other plans and enroll:
•
Visit [46 MarketplaceExchange website] to see other [47 MarketplaceExchange]
plans. Consumers who shop can save hundreds of dollars per year and can find a
plan that best meets their needs and budget.
•
•
Check with [48 Issuer] to see what other plans may be available.
[ [[49 Important: You may be able to keep your current coverage, but in [50 in Year]
it won’t be offered [51 as a Silver plan] through [52 the MarketplaceExchange.]]
Remember, you won’t get financial help [53 to lower your out-of-pocket costs] unless
you qualify and enroll [54 in a Silver plan] through [55 the MarketplaceExchange].
Note: If you got financial help in [56 Year] to lower your monthly premium, you’ll have to
“reconcile” using IRS Form 8962 when you file your federal taxes. This means you’ll
compare the amount of premium tax credit you received in advance during [57 Year] with
the amount you actually qualify for based on your final [58 Year] household income and
eligibility information. If the amounts are different, this will affect the amount of your
refund or taxes owed.
We’re here to help
•
Visit [59 MarketplaceExchange website], or call [60 MarketplaceExchange phone
number] to learn more about [61 the MarketplaceExchange] and to see if you
qualify for lower costs.
•
Call [62 Issuer] at [63 Issuer phone number] or visit [64 Issuer website].
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
•
Find in-person help from an assister, agent, or broker in your community at [65
Website].
•
[66 Contact an agent or broker you've worked with before, [ [[67 like Agent/broker
name].], [68 Call Agent/broker phone number]].
•
Call [69 MarketplaceExchange phone number] to requestfor a reasonable
accommodation to get this information in an accessible format, like large print,
Braille, or audio, at no cost to you if you have a disability.
Getting help in other languages
[70 Insert non-discrimination notice and taglines consistent with any applicable standards, such
as under HHS regulations and guidance.]
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
Attachment 5: Discontinuation notice for the individual market outside the Exchange and
the issuer is not automatically enrolling the enrollee in a different plan
[1 Date]
[2 [First Name][Last
Name] [Address line 1]
[Address line 2]
[City] [State]
[Zip]
Urgent: Your health coverage is at risk. Take action by [3 Date], or you won’t have health coverage in
[4 Year]. Without health coverage or an exemption, you may have to pay a penalty of [5 $695] or more
when you file your taxes.
Urgent: Your health coverage is at risk. Take action by [3 Date], or you won’t have health
coverage in [4 Year].
Thank you for choosing [65 Issuer] for your health care needs. [76 We’re here to help you
prepare for Open Enrollment.]
Why am I getting this letter?
Beginning [87 Date], we won’t offer your current health coverage [98 in your area]. This
means you may lose your health coverage. You must enroll in a new plan to have health
coverage. The last day of your current coverage is [10 Date]. Read this letter carefully and
review your options.
You can choose a different plan between [1110 Dates]. To make sure there isn’t a gap in your
coverage, and avoid paying a penalty, enroll in a different plan by [11 Date].
What you need to do
Review your coverage options and pick a different plan. If you don’t have health coverage,
you’ll have to pay for all of your health care.
Here are some ways to look at other plans and enroll:
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
•
•
Check with [12 Issuer] to see what other plans may be available. You won’t get financial
help unless you qualify and enroll through [13 the Exchange].
Visit [14 Exchange website] to see [15 Exchange] plans. Consumers who shop can save
hundreds of dollars per year and can find a plan that best meets their needs and budget.
Exchange
We’re here to help
• Call [16 Issuer] at [17 Issuer phone number] or visit [18 Issuer website].
• Visit [19 Exchange website], or call [20 Exchange phone number] to learn more about
[21 the Exchange] and to see if you qualify for lower costs.
• Find in-person help from an assister, agent, or broker in your community at [22 Website].
• [23 Contact an agent or broker you’ve worked with before [[24 like Agent/broker name],
[25 Call Agent/broker phone number]].
• 26 Call [27 Issuer phone number] for a reasonable accommodation to get this information
in an accessible format, like large print, Braille, or audio, at no cost to you.
Getting help in other languages
[28 Insert non-discrimination notice and taglines consistent with any applicable standards, such
as under HHS regulations and guidance.]
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
Attachment 6: Discontinuation notice for the individual market where coverage being
discontinued was in a QHP offered through the Exchange and the issuer is
not automatically enrolling the enrollee in a different plan
[1 Date]
[2 [First Name][Last Name]
[Address line 1]
[Address line
2] [City]
[State] [Zip]]
Urgent: Your health coverage is at risk. Take action by [3 Date], or you may not have health
coverage in [4 Year].
Thank you for choosing [5 Issuer] for your health care needs. [6 We’re here to help you
prepare for Open Enrollment.]
Why am I getting this letter?
Beginning [7 Date], we won’t offer [8 in your area] your current health coverage [9 in
the Exchange]. The last day of your current [10 Exchange] coverage is [11 Date]. Read this
letter carefully and review your options.
You can choose a different plan between [12 Dates]. To make sure there isn’t a gap in
your coverage enroll in a different plan by [13 Date].
What you need to do
Review your coverage options and pick a different plan. If you don’t have health coverage,
you’ll have to pay for all of your health care.
If you don’t have coverage or an exemption, you may also have to pay a penalty of [13 $695] or more
when you file your taxes.
Here are some ways to look at other plans and enroll:
•
Check with [14 Issuer] to see what other plans may be available. You
won’t get financial help unless you qualify and enroll through [15 the
Marketplace].
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 1: Renewal5: Discontinuation notice for the individual market where coverage is
being renewed outside the Marketplace. and the issuer is not automatically enrolling the
enrollee in a different plan
•
Visit [16 Marketplace website] to see [17 Marketplace] plans. Consumers
who shop can save hundreds of dollars per year and can find a plan that
best meets their needs and budget.
We’re here to help
•
•
•
•
•
Call [18 Issuer] at [19 Issuer phone number] or visit [20 Issuer website].
Visit [21 Marketplace website], or call [22 Marketplace phone number] to learn more
about [23 the Marketplace] and to see if you qualify for lower costs.
Find in-person help from an assister, agent, or broker in your community at [24 Website].
[25 Contact an agent or broker you’ve worked with before, [26 like Agent/broker name].
[27 Call Agent/broker phone number]].
[28 Call [29 Issuer phone number] to request a reasonable accommodation at no cost to
you if you have a disability.]
Getting help in other languages
[30 Insert non-discrimination notice and taglines consistent with any applicable standards, such
as under HHS regulations and guidance.]
OMB Control No.: 0938-1254
Expiration Date: 10/2019
[1 Date]
[2 [First Name][Last Name]
[Address line 1]
[Address line 2]
[City] [State] [Zip]]
Urgent: Your health coverage is at risk. Take action by [3 Date], or you may not have health coverage
in [4 Year]. Without health coverage or an exemption, you may have to pay a penalty of [5 $695] or more
when you file your taxes.
Thank you for choosing [6 Issuer] for your health care needs. [7 We’re here to help you prepare for
Open Enrollment.]
Why am I getting this letter?
Beginning [8 Date], we won’t offer [9 in your area] your current health coverage [10 in the
Marketplace]. The last day of your current [11 Marketplace] coverage is [12 Date]. Read this letter
carefully and review your options.
You can choose a different plan between [13 Dates]. To make sure there isn’t a gap in your
coverage, and avoid paying a penalty, enroll in a different plan by [14 Date].
What you need to doReview your coverage options and pick a different plan. If you don’t have
health coverage, you’ll have to pay for all of your health care.
If you don’t have coverage or an exemption, you may also have to pay a penalty of [15 $695] or more
when you file your taxes.
39.1.
Update your [16 Marketplace14 Exchange] application by [1715 Date].
Review your [18 Marketplace16 Exchange] application to make sure the information is still
current and correct, and to see if you may qualify for more or less financial help [1917 in
Year] than you’re getting now. This may result in a lower monthly premium payment or
lower out-of- pocket costs (like deductibles, copayments, and coinsurance). Plus, you can
help avoid paying money back when you file your taxes.
40.2.
Choose a different plan.
Here are some ways to look at other plans and enroll:
• After you’ve updated your [20 Marketplace18 Exchange] application, you’ll be able to
compare [21 Marketplace19 Exchange] plans in your area. You may even see that [22
20]
[the MarketplaceExchange] has picked a plan for you. Consumers who shop can
save hundreds of dollars per year. Compare your options and enroll in a plan that
best meets your needs and budget. If you don’t enroll in a plan on your own, you
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
may be automatically enrolled in the plan [2321 the MarketplaceExchange]
picked for you.
•
•
Check with [2422 Issuer] to see what other plans may be available.
[25[23 Important: You may be able to keep your current coverage, but [2624 in Year] it
won’t be offered [2725 as a Silver plan][2826 through the MarketplaceExchange]].
Remember, you won’t get financial help [2927 to lower your out-of-pockets costs] unless
you qualify and enroll [3028 in a Sliver plan] through [3129 the MarketplaceExchange].
Note: If you received financial help in [3230 Year] to lower your monthly premium, you’ll have
to “reconcile” using IRS Form 8962 when you file your federal taxes. This means you’ll
compare the amount of premium tax credit you received in advance during [3331 Year] with the
amount you actually qualify for based on your final [3432 Year] household income and
eligibility information. If the amounts are different, this will affect the amount of your refund or
taxes owed.
We’re here to help
•
•
•
•
•
Visit [35 Marketplace33 Exchange website], or call [36 Marketplace34 Exchange phone
number] to learn more about [3735 the MarketplaceExchange] and to see if you qualify
for lower costs.
Call [3836 Issuer] at [3937 Issuer phone number] or visit [4038 Issuer website].
Find in-person help from an assister, agent, or broker in your community at [4139
Website].
[4240 Contact an agent or broker you’ve worked with before, [43 [[41 like Agent/broker
name]. [44], [42 Call [Agent/broker phone number]].
Call [45 Marketplace43 Exchange phone number] to requestfor a reasonable
accommodation to get this information in an accessible format, like large print, Braille, or
audio, at no cost to you if you have a disability.
Getting help in other language
[46[44 Insert non-discrimination notice and taglines consistent with any applicable standards,
such as under HHS regulations and guidance.]
18
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Instructions for Attachment 1 – Renewal notice for the individual market where coverage
is being renewed outside the Exchange
General instructions:
This notice must be used when coverage was purchased outside the MarketplaceExchange and
will be renewed outside the Marketplace. Exchange. This notice also must be used when
coverage was purchased through the MarketplaceExchange and will be automatically renewed
outside the MarketplaceExchange -- where permitted -- because the enrollee will not be
automatically enrolled in another product offered through the MarketplaceExchange, in
accordance with 45 CFR 155.335(j).
Item 1. Enter the date of the notice, in format Month DD, YYYY.
Item 2. Enter the full name and address of the primary subscriber. In the individual market, the
primary subscriber means the individual who purchases the policy and who is responsible for the
payment of premiums.
Item 3. Enter the date by which a plan selection must be made to avoid automatic re-enrollment,
in format Month DD, YYYY.
Item 4. Enter the issuer name.
Item 5. Enter the phrase “We’re here to help you prepare for Open Enrollment” only if the
current policy is renewing on a calendar year basis. Otherwise, omit and skip to item 6.
Item 6. For calendar year plans, enter the following year, in format YYYY. For non-calendar
year plans, enter the month and year, in format Month YYYY.
Item 7. Enter the date by which a plan selection must be made to avoid automatic re-enrollment,
in format Month DD.
Item 7. Enter the date by which a plan selection must be made to avoid automatic re-enrollment,
in format Month DD.
Item 8. For calendar year plans, enter the following year, in format YYYY. For non-calendar
year plans, enter the month and year, in format Month YYYY.
Item 9. Enter the MarketplaceExchange name. For a Federally-facilitated MarketplaceExchange,
enter “Marketplace.”Exchange.”
Item 10. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 11. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 12. Enter the date by which a plan selection must be made, in format Month DD.
19
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 13. Include this sentence only if the enrollee (i) is currently enrolled in a QHP through the
MarketplaceExchange; (ii) receives advanced payments of the premium tax credit or cost-sharing
reductions; and (iii) will be renewed into a plan under the same product outside the
MarketplaceExchange, where permitted. Otherwise, omit and skip to item 15.
Item 14. Enter the last day of coverage through the MarketplaceExchange, in format Month DD.
Item 15. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 16. Enter the date by which a plan selection must be made, in format Month DD.
Item 17. For calendar year plans enter the following year, in format YYYY. For non-calendar
year plans, enter the phrase “until Open Enrollment”..”
Item 18. For calendar year plans enter the following year, in format YYYY. For non-calendar
year plans, enter the phrase “the next policy year”..”
Item 19. If a calendar year plan, enter the current year, in format YYYY. If a non-calendar year
plan, enter the word “current”..”
Item 20. Enter the most recent monthly amount of premium for the enrollment group for which
data are available, for the current policy year.
Item 21. Enter the beginning month of the following policy year.
Item 22. Include the word “estimated” if the new monthly premium for the following policy year
has not yet been finalized at the time of providing the notice.
Item 23. Enter the monthly amount of premium for the enrollment group for which data are
available, for the following policy year.
Item 24. Enter the month in which the enrollee will receive a bill for the actual monthly
premium for the following policy year.
Item 25. List significant plan changes, including but not limited to changes in deductibles, cost
sharing, metal level, covered services, eligibility, plan formulary and provider network. This
section may refer to enclosed supplemental materials. Do not include the italicized instructions.
Item 26. Enter the issuer website.
Item 27. If a calendar year plan, enter the following year, in format YYYY. If a non-calendar
year plan, enter the word “new”..”
Item 28. Enter due date for first premium for following policy year or omit and skip to item 29.
Item 29. Include this section for calendar year plans. For non-calendar year plans, briefly
describe enrollment opportunities so individuals know when and how they can choose a different
plan and skip to item 34. Under 45 CFR 147.104(b) and 155.420(d), consumers in a noncalendar year plan qualify for a special enrollment period based on a policy year that ends on a
non-calendar year basis.
Item 30. Enter the beginning and end dates of the annual open enrollment period for the
applicable benefit year, in format Month DD, YYYY.
20
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Items 31 and 32. Enter the date by which a plan selection must be made and the corresponding
coverage effective date, in format Month DD. For example, enter December 15 for coverage
effective beginning January 1.
Item 33. Enter the issuer name.
Item 34. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 35. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 36. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 37. Enter the issuer name.
Item 38. Enter issuer phone number.
Item 39. Enter the issuer website.
Item 40. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 41. Enter the MarketplaceExchange phone number. For a Federally-facilitated
MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 42. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 43. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated
MarketplaceExchange. In other States, enter the appropriate website.
Item 44. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 47.
Item 45. Insert “like” followed by the name of the agent or broker the enrollee previously used,
if known. Otherwise, omit and skip to item 47.
Item 46. Insert “Call” followed by the phone number of the agent or broker the enrollee
previously used, if known. Otherwise, omit skip to item 47.
Item 47. This sentence must be included for issuers subject to 1557 of the Affordable Care Act
or other applicable Federal or State law and is otherwise encouraged to be included. If this
sentence is omitted, skip to item 49.
Item 48. Enter issuer phone number and issuer TTY number.
Item 49. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
21
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
If you are covered by Section 1557, 1 then by October 17, 2016, provide the nondiscrimination
notice 2 in English and taglines in at least the top 15 languages spoken by individuals with limited
English proficiency of the relevant state or states, 3 in significant publications and significant
communications, among other locations. 4 Taglines are optional but encouraged for issuers
outside the MarketplaceExchange if they are not covered by Section 1557 5 or otherwise subject
to language access standards under the Exchange rules at 45 CFR 155.205(c) and 156.250, or
other applicable Federal or State law. As a reminder, issuers covered by Section 1557 are
responsible for providing timely and accurate language assistance in non-English languages,
regardless of ifwhether a tagline is provided in the language, if the provision of such language
assistance is a reasonable step to provide meaningful access to an individual with limited English
proficiency in the issuer’s health programs or activities. 6
A non-QHP issuer offering coverage outside the Exchanges is subject to Section 1557 if any
health program or activity of the issuer receives Federal financial assistance. See 45 CFR 92.2,
92.4. A QHP issuer offering plans outside of the Exchange may still have to comply with Section
1557 for its plans offered outside the Exchange if the QHP issuer is principally engaged in the
provision or administration of health-related services, health-related coverage or other healthrelated coverage. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the
Exchanges.
Nondiscrimination: [Issuer] doesn’t exclude, deny benefits to, or otherwise discriminate against
any person on the basis of race, color, national origin, disability, sex, or age. If you think you’ve
been discriminated against or treated unfairly for any of these reasons, you can file a complaint
with the Department of Health and Human Services, Office for Civil Rights by calling 1-800368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the
Office for Civil Rights/ U.S. Department of Health and Human Services/200 Independence
Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.
1
For QHP issuers subject to Section 1557 that are principally engaged in the provision or administration of healthrelated services, health-related coverage or other health-related coverage, all of the issuer’s operations are
considered part of the health program or activity, with limited exceptions. Consequently, a QHP issuer must comply
with the nondiscrimination requirements of Section 1557 for the issuer’s plans offered both inside and outside the
Marketplaces. A non-QHP issuer offering coverage outside the Marketplaces might also be subject to Section 1557
if any health program or activity of the issuer receives Federal financial assistance.
2
45 CFR 92.8(a), (b)(1). The content of the notice must include the seven elements listed in 92.8(a)(1)-(7). An
issuer may combine the content of the Section 1557 nondiscrimination notice with the content of other notices as
long as the combined notice clearly informs individuals of their rights under Section 1557. Id. 92.8(h).
3
45 CFR 92.8(d)(1).
4
45 CFR 92.8(f)(1).
5
A non-QHP issuer offering coverage outside the Marketplaces is subject to Section 1557 if any health program or
activity of the issuer receives Federal financial assistance. See 45 CFR 92.2, 92.4. A QHP issuer offering plans
outside of the Marketplace may still have to comply with Section 1557 for its plans offered outside the Marketplace
if the QHP issuer is principally engaged in the provision or administration of health-related services, health-related
coverage or other health-related coverage. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the Marketplaces. See 45 CFR
92.2, 92.4
6
45 CFR 92.201.
22
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Sample Tagline:
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
23
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Instructions for Attachment 2 – Renewal notice for the individual market where coverage
is being renewed under the same product in a QHP offered
through the Exchange.
General instructions:
This notice must be used when coverage was purchased through the MarketplaceExchange and
will be renewed under the same product through the MarketplaceExchange, in accordance with
45 CFR 155.335(j).
Item 1. Enter the date of the notice, in format Month DD, YYYY.
Item 2. Enter the full name and address of the primary subscriber. In the individual market, the
primary subscriber means the individual who purchases the policy and who is responsible for the
payment of premiums.
Item 3. Enter the date by which a plan selection must be made to avoid automatic re-enrollment,
in format Month DD, YYYY.
Item 4. Enter the issuer name.
Item 5. Enter the following year, in format YYYY.
Item 6. Enter the MarketplaceExchange name. For a Federally-facilitated MarketplaceExchange,
enter “the Marketplace.”Exchange.”
Item 7. Enter the following year, in format YYYY.
Item 8. Enter the current year, in format YYYY.
Item 9. Enter the most recent monthly amount of premium for the enrollment group for which
data are available for the current benefit year, minus the most recent monthly amount of any
advance payments of the premium tax credit paid on behalf of the enrollment group for which
data are available.
Item 10. Enter the most recent monthly amount of premium for the enrollment group for which
data are available for the current benefit year.
Item 11. Enter the most recent monthly amount of any advance payments of the premium tax
credit paid on behalf of the enrollment group for which data are available. If the most recent
ATPC paid on behalf of the enrollment group is zero, enter 0.
Item 12. Enter the beginning month of the following benefit year.
Item 13. Include the word “estimated” if the new monthly premium for the following benefit
year has not yet been finalized at the time of providing this notice, or the MarketplaceExchange
has not completed the annual eligibility redetermination by the time of providing the notice.
Item 14. Enter the total monthly amount of premium for the enrollment group for which data are
available for the following benefit year, minus the monthly amount of any advance payments of
the premium tax credit paid on behalf of the enrollment group for which data are available.
Item 15. Enter the word “estimated” if the word “estimated” was included in item 13.
24
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 16. Enter the actual or estimated amount of monthly premium for the enrollment group for
which data are available for the following benefit year.
Item 17. Enter the month in which the enrollee will receive a bill for the actual monthly payment
for the following benefit year.
Item 18. Enter the current year, in format YYYY.
Item 19. Enter the following year, in format YYYY.
Item 20. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”
Exchange.”
Item 21. List significant plan changes, including but not limited to changes in deductibles, cost
sharing, metal level, covered services, eligibility, plan formulary and provider network. For the
purpose of describing plan changes, the issuer may use the current CSR eligibility if it has not
received the updated CSR eligibility from CMS. This section may also refer to enclosed
supplemental materials. Do not include the italicized instructions.
Item 22. Enter the issuer website.
Item 23. Enter the following year, in format YYYY.
Item 24. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 25. Enter the date by which a plan selection must be made to avoid automatic reenrollment, in format Month DD.
Item 25. Enter the date by which a plan selection must be made to avoid automatic reenrollment, in format Month DD.
Item 26. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 27. Enter the current benefit year, in format YYYY.
Item 28. Enter plan name and HIOS Plan ID of plan into which the enrollee’s coverage will be
renewed.
Item 29. Include this paragraph if the enrollee (except for Indian enrollees) is currently enrolled
in a silver level QHP and their coverage is being renewed into a non-silver level QHP, consistent
with 45 CFR 155.335(j). Otherwise, omit and skip to item 32.
Item 30. Enter the following benefit year, in format YYYY.
Item 31. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 32. Enter the beginning and end dates of the annual open enrollment period for the
applicable benefit year, in format Month DD, YYYY.
25
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 33. Enter the date by which a plan selection must be made for coverage effective January 1,
in format Month DD, YYYY.
Item 34. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 35. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 36. Enter the issuer name.
Item 37. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Items 38 - 40. Enter the current benefit year, in format YYYY.
Item 41. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 42. Enter the MarketplaceExchange phone number. For a Federally-facilitated
MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 43. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 44. Enter the issuer name.
Item 45. Enter the issuer phone number.
Item 46. Enter the issuer website.
Item 47. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated
MarketplaceExchange. In other States, enter the appropriate website.
Item 48. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 51.
Item 49. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 51.
Item 50. Enter “call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 51.
Item 51. Enter the MarketplaceExchange phone number and MarketplaceExchange TTY
number. For a Federally-facilitated MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855889-4325).”
Item 52. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
Item 52. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
26
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
CFR 155.205(c) and 156.250) and guidance.If you are covered by Section 1557, 7 then by
October 17, 2016, provide the nondiscrimination notice 8 in English and taglines in at least the
top 15 languages spoken by individuals with limited English proficiency of the relevant state or
states, 9 in significant publications and significant communications, among other locations. 10
Taglines are optional but encouraged for issuers outside the MarketplaceExchange if they are not
covered by Section 1557 11 or otherwise subject to language access standards under the Exchange
rules at 45 CFR 155.205(c) and 156.250, or other applicable Federal or State law. As a reminder,
issuers covered by Section 1557 are responsible for providing timely and accurate language
assistance in non-English languages, regardless of ifwhether a tagline is provided in the
language, if the provision of such language assistance is a reasonable step to provide meaningful
access to an individual with limited English proficiency in the issuer’s health programs or
activities. 12
Nondiscrimination: [Issuer] doesn’t exclude, deny benefits to, or otherwise discriminate against
any person on the basis of race, color, national origin, disability, sex, or age. If you think you’ve
been discriminated against or treated unfairly for any of these reasons, you can file a complaint
with the Department of Health and Human Services, Office for Civil Rights by calling 1-800368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the
Office for Civil Rights/ U.S. Department of Health and Human Services/200 Independence
Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.
Sample Tagline:
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
7
For QHP issuers subject to Section 1557 that are principally engaged in the provision or administration of healthrelated services, health-related coverage or other health-related coverage, all of the issuer’s operations are
considered part of the health program or activity, with limited exceptions. Consequently, a QHP issuer must comply
with the nondiscrimination requirements of Section 1557 for the issuer’s plans offered both inside and outside the
Marketplaces. A non-QHP issuer offering coverage outside the Marketplaces might also be subject to Section 1557
if any health program or activity of the issuer receives Federal financial assistance.
8
45 CFR 92.8(a), (b)(1). The content of the notice must include the seven elements listed in 92.8(a)(1)-(7). An
issuer may combine the content of the Section 1557 nondiscrimination notice with the content of other notices as
long as the combined notice clearly informs individuals of their rights under Section 1557. Id. 92.8(h).
9
45 CFR 92.8(d)(1).
10
45 CFR 92.8(f)(1).
11
A non-QHP issuer offering coverage outside the Marketplaces is subject to Section 1557 if any health program or
activity of the issuer receives Federal financial assistance. See 45 CFR 92.2, 92.4. A QHP issuer offering plans
outside of the Marketplace may still have to comply with Section 1557 for its plans offered outside the Marketplace
if the QHP issuer is principally engaged in the provision or administration of health-related services, health-related
coverage or other health-related coverage. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the Marketplaces. See 45 CFR
92.2, 92.4
12
45 CFR 92.201.
27
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
28
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Instructions for Attachment 3 – Discontinuation notice for the individual market outside
the Exchange and the issuer is automatically enrolling the
enrollee in a different plan outside the Exchange
General instructions:
This notice must be used when the issuer is non-renewing coverage purchased outside the
MarketplaceExchange as the result of a product discontinuance, and consistent with applicable
State law, automatically enrolling the enrollee in different coverage outside the Marketplace.
Exchange. This includes non-renewals based on a product discontinuation or there no longer
being any enrollee in the plan who live, resides, or works within the product’s service area.
Item 1. Enter the date of the notice, in format Month DD, YYYY.
Item 2. Enter the full name and address of the primary subscriber. In the individual market, the
primary subscriber means the individual who purchases the policy and who is responsible for the
payment of premiums.
Item 3. Enter the date by which a plan selection must be made to avoid automatic re-enrollment,
in format Month DD, YYYY.
Item 4. Enter the issuer name.
Item 5. Enter the phrase “We’re here to help you prepare for Open Enrollment” only if the
current policy is terminating on a calendar year basis. Otherwise, omit and skip to item 6.
Item 6. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the month and year,
in format Month YYYY.
Item 7. Enter the phrase “in your area” if non-renewing or terminating based on the fact that
there is no longer any enrollee in the plan who live, resides, or works within the product’s
service area. Otherwise, omit and skip to item 8.
Item 8. Enter the last day on which the enrollee’s current coverage will be remain in force, in
format Month DD, YYYY.
Item 9. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the month and year,
in format Month YYYY.
Item 10. Enter the first coverage month under the different plan, in format Month.
Item 11. Enter the plan name for the plan in which the enrollee will be automatically enrolled.
Item 12. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
29
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 13. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 14. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 15. Enter the date by which a plan selection must be made, in format Month DD.
Item 16. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item17. Enter the date by which a plan selection must be made, in format Month DD.
Item 18. For calendar year plans enter the following year, in format YYYY. For non-calendar
year plans, enter the phrase “until Open Enrollment”..”
Item 19. Enter the most recent amount of monthly premium for the enrollment group for which
data are available for the current policy year.
Item 20. Enter the first month for the following policy year.
Item 21. Include the word “estimated” if the new monthly premium for the following policy year
has not yet been finalized at the time of providing the notice.
Item 22. Enter the amount of monthly premium for the enrollment group for which data are
available for the following policy year.
Item 23. Enter the month in which the enrollee will receive their bill with the actual monthly
premium for the following policy year.
Item 24. List significant plan changes, including but not limited to changes in deductibles, cost
sharing, metal level, covered services, eligibility, plan formulary and provider network. This
section may refer to enclosed supplemental materials. Do not include the italicized instructions.
Item 25. Enter the issuer website.
Item 26. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the word “new”..”
Item 27. The consumer qualifies for a special enrollment period based on loss of minimum
essential coverage. Enter the date by which a plan selection must be made in accordance with 45
CFR 155.420(b) or, if such date falls within an open enrollment period, enter the end date of the
open enrollment period, in format Month DD, YYYY.
Item 28. Enter due date for first premium for following policy year or omit and skip to item 29.
Item 29. Enter the beginning and end dates of the special enrollment period for the loss of
minimum essential coverage or, if such date falls within an open enrollment period, enter the end
date of the open enrollment period, in format Month DD, YYYY.
Items 30 and 31. Enter the date by which a plan selection must be made and the corresponding
coverage effective date that would result in no gap in coverage between the terminating coverage
and the newly selected plan, in format Month DD, YYYY.
30
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 32. Enter the issuer name.
Item 33. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 34. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 35. Enter the issuer name.
Item 36. Enter issuer phone number.
Item 37. Enter the issuer website.
Item 38. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 39. Enter the MarketplaceExchange phone number. For a Federally-facilitated
MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 40. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 41. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated
MarketplaceExchange. In other States, enter the appropriate website.
Item 42. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 45.
Item 43. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 45.
Item 44. Enter “call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 45.
Item 45. This sentence must be included for issuers subject to 1557 of the Affordable Care Act
or other applicable Federal or State law and is otherwise encouraged to be included. If this
sentence is omitted, skip to item46.item 46.
Item 46. Enter issuer phone number and issuer TTY number.
Item 47. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
31
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
If you are covered by Section 1557, 13 then by October 17, 2016, provide the nondiscrimination
notice 14 in English and taglines in at least the top 15 languages spoken by individuals with
limited English proficiency of the relevant state or states, 15 in significant publications and
significant communications, among other locations. 16 Taglines are optional but encouraged for
issuers outside the MarketplaceExchange if they are not covered by Section 1557 17 or otherwise
subject to language access standards under the Exchange rules at 45 CFR 155.205(c) and
156.250, or other applicable Federal or State law. As a reminder, issuers covered by Section
1557 are responsible for providing timely and accurate language assistance in non-English
languages, regardless of ifwhether a tagline is provided in the language, if the provision of such
language assistance is a reasonable step to provide meaningful access to an individual with
limited English proficiency in the issuer’s health programs or activities. 18
Nondiscrimination: [Issuer] doesn’t exclude, deny benefits to, or otherwise discriminate against
any person on the basis of race, color, national origin, disability, sex, or age. If you think you’ve
been discriminated against or treated unfairly for any of these reasons, you can file a complaint
with the Department of Health and Human Services, Office for Civil Rights by calling 1-800368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the
Office for Civil Rights/ U.S. Department of Health and Human Services/200 Independence
Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.
Sample Tagline:
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
13
For QHP issuers subject to Section 1557 that are principally engaged in the provision or administration of healthrelated services, health-related coverage or other health-related coverage, all of the issuer’s operations are
considered part of the health program or activity, with limited exceptions. Consequently, a QHP issuer must comply
with the nondiscrimination requirements of Section 1557 for the issuer’s plans offered both inside and outside the
Marketplaces. A non-QHP issuer offering coverage outside the Marketplaces might also be subject to Section 1557
if any health program or activity of the issuer receives Federal financial assistance.
14
45 CFR 92.8(a), (b)(1). The content of the notice must include the seven elements listed in 92.8(a)(1)-(7). An
issuer may combine the content of the Section 1557 nondiscrimination notice with the content of other notices as
long as the combined notice clearly informs individuals of their rights under Section 1557. Id. 92.8(h).
15
45 CFR 92.8(d)(1).
16
45 CFR 92.8(f)(1).
17
A non-QHP issuer offering coverage outside the Marketplaces is subject to Section 1557 if any health program or
activity of the issuer receives Federal financial assistance. See 45 CFR 92.2, 92.4. A QHP issuer offering plans
outside of the Marketplace may still have to comply with Section 1557 for its plans offered outside the Marketplace
if the QHP issuer is principally engaged in the provision or administration of health-related services, health-related
coverage or other health-related coverage. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the Marketplaces. See 45 CFR
92.2, 92.4
18
45 CFR 92.201.
32
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Instructions for Attachment 4 – Notice for the individual market where coverage was in a
QHP offered through the Exchange and the issuer is
automatically enrolling the enrollee in a different product
General instructions:
This notice must be used when the QHP enrollee’s current product is not available for renewal
through the MarketplaceExchange (even if it remains available outside the
MarketplaceExchange) and the enrollee will, consistent with State law and, if applicable, 45 CFR
155.335(j), be automatically enrolled in a plan under a different product offered by the same
QHP issuer through the MarketplaceExchange. This notice must also be used when the enrollee’s
current silver level QHP is no longer available for renewal, the enrollee’s current product no
longer includes a silver level QHP available through the MarketplaceExchange, and the enrollee
will, consistent with State law and, if applicable, 45 CFR 155.335(j), be automatically reenrolled in a silver level QHP under a different product offered by the same QHP issuer through
the Marketplace.Exchange.
Item 1. Enter the date of the notice, in format Month DD, YYYY.
Item 2. Enter the full name and address of the primary subscriber. In the individual market, the
primary subscriber means the individual who purchases the policy and who is responsible for the
payment of premiums.
Item 3. Enter the date by which a plan selection must be made to avoid automatic re-enrollment,
in format Month DD, YYYY.
Item 4. Enter the MarketplaceExchange name. For a Federally-facilitated MarketplaceExchange,
enter “Marketplace.”Exchange.”
Item 5. Enter the issuer name.
Item 6. Enter the phrase “We’re here to help you prepare for Open Enrollment” only if the
current policy is terminating on a calendar year basis. Otherwise, omit and skip to item 7.
Item 7. Enter the first day on which the current plan will no longer be available, in format Month
YYYY.
Item 8. Enter the phrase “in your area” if non-renewing or terminating based on the fact that
there is no longer any enrollee in the plan who live, resides, or works within the product’s
service area.
Item 9. If issuer will not offer the enrollee’s current product through the MarketplaceExchange
for the following benefit year, or will offer the current product through the MarketplaceExchange
but will not offer a silver plan under that product and will auto-enroll the enrollee in a silver level
plan under a different product offered through the MarketplaceExchange in accordance with 45
CFR 155.335(j), include the phrase “in [the MarketplaceExchange]” and enter the
MarketplaceExchange name. For a Federally-facilitated MarketplaceExchange, enter “the
MarketplaceExchange.” Otherwise omit and skip to item 11.
33
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 10. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 11. Enter the last day on which the enrollee’s current coverage will remain in force through
the MarketplaceExchange, in format Month DD, YYYY.
Item 12. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”
Exchange.”
Item 13. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following benefit year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the month and year
following the discontinuance, non-renewal, or termination in format Month YYYY.
Item 14. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 15. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the beginning month of the following benefit year, in format Month YYYY. For
discontinuances, non-renewals, or terminations effective at any time other than the end of a
calendar year, enter the month following the discontinuance, non-renewal, or termination, in
format Month YYYY.
Item 16. Enter the plan name in which the enrollee will be automatically re-enrolled.
Item 17. Enter current year, in format YYYY.
Item 18. Enter the most recent amount of monthly premium for the enrollment group for which
data are available for the current benefit year, minus the most recent monthly amount of any
advance payments of the premium tax credit paid on behalf of the enrollment group for which
data are available.
Item 19. Enter the most recent amount of monthly premium for the enrollment group for which
data are available for the current benefit year.
Item 20. Enter the current year monthly amount of any advance payments of the premium tax
credit paid on behalf of the enrollment group for which data are available. If the most recent
APTC paid on behalf of the enrollment group is zero, enter 0.
Item 21. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the beginning month of the following benefit year. For discontinuances, nonrenewals, or terminations effective at any time other than the end of a calendar year, enter the
month following the discontinuance, non-renewal, or termination, in format Month YYYY.
Item 22. Include the word “estimated” if the new monthly premium for the following benefit
year has not yet been finalized at the time of providing this notice, or the MarketplaceExchange
has not completed the annual eligibility redetermination by the time of providing the notice.
34
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 23. Enter the monthly premium for the enrollment group for which data are available for
the following policy year, minus the monthly amount of any advanced payments of the premium
tax credit paid on behalf of the enrollment group for which data are available.
Item 24. Enter the word “estimated” if the word “estimated” was included in item 23.
Item 25. Enter the actual or estimated total monthly premium for the following benefit year.
Item 26. Enter the month in which the enrollee will receive a bill for the actual monthly payment
for the following benefit year.
Item 27. Enter the current benefit year, in format YYYY.
Item 28. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following benefit year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the month
following the discontinuance, non-renewal, or termination, in format Month YYYY.
Item 29. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 30. List significant plan changes, including but not limited to changes in deductibles, cost
sharing, metal level, covered services, eligibility, plan formulary and provider network. For the
purpose of describing plan changes, the issuer may use the current CSR eligibility if it has not
received the updated CSR eligibility from CMS. This section may also refer to enclosed
supplemental materials. Do not include the italicized instructions.
Item 31. Enter the issuer website.
Item 32. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following benefit year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the word “new”..”
Item 33. The consumer qualifies for a special enrollment period based on loss of minimum
essential coverage. Enter the date by which a plan selection must be made in accordance with 45
CFR 155.420(b) or, if such date falls within an open enrollment period, enter the end date of the
open enrollment period, in format Month DD, YYYY.
Item 34. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 35. Enter the date by which a plan selection must be made to avoid automatic reenrollment, in format Month DD.
Item 36. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 37. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following benefit year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, omit.
Item 38. Enter plan name and HIOS Plan ID of plan into which the enrollee will be enrolled.
35
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 39. Include this paragraph if the enrollee (except for Indian enrollees) is currently enrolled
in a silver level QHP and will be re-enrolled into a non-silver level QHP, consistent with 45 CFR
155.335(j). Otherwise, omit and skip to item 43.
Item 40. Enter the applicable benefit year, in format YYYY.
Item 41. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 42. Enter last day of the current policy year, in format Month DD, YYYY.
Item 43. Enter the beginning and end dates of the special enrollment period for the loss of
minimum essential coverage or, if such date falls within an open enrollment period, enter the end
date of the open enrollment period, in format Month DD, YYYY.
Items 44 and 45. Enter the date by which a plan selection must be made and the corresponding
coverage effective date that would result in no gap in coverage between the terminating coverage
and the newly selected plan, in format Month DD, YYYY.
Item 46. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 47. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 48. Enter the issuer name.
Item 49. Include this sentence only if enrollee’s current product remains available for renewal
for the following benefit year, whether through or outside of the MarketplaceExchange.
Otherwise, omit and skip to item 53.
Item 50. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following benefit year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, omit.
Item 51. Include the words “as a Silver plan” if the enrollee’s current product will no longer
include a silver plan offered through the MarketplaceExchange in the applicable benefit year.
Item 52. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 53. Enter the phrase “to lower your out-of-pocket costs” if you entered “as a Silver plan” in
item 51. Otherwise, omit and skip to item 55.
Item 54. Enter the phrase “in a Silver plan” if you entered “as a Silver plan” in item 51.
Otherwise, skip to item 56.
Item 55. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the MarketplaceExchange.”
Item 56. Enter the current benefit year, in format YYYY.
Item 57. Enter the current benefit year, in format YYYY.
36
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 58. Enter the current calendar year, in format YYYY.
Item 59. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 60. Enter the MarketplaceExchange phone number. For a Federally-facilitated
MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 61. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 62. Enter the issuer name.
Item 63. Enter the issuer phone number.
Item 64. Enter the issuer website.
Item 65. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated
MarketplaceExchange. In other States, enter the appropriate website.
Item 66. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 69.
Item 67. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 69.
Item 68. Enter “Call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 69.
Item 69. Enter the MarketplaceExchange phone number and the MarketplaceExchange TTY
number. For a Federally-facilitated MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855889-4325).”
Item 70. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
Item 70. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
37
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
If you are covered by Section 1557, 19 then by October 17, 2016, provide the nondiscrimination
notice 20 in English and taglines in at least the top 15 languages spoken by individuals with
limited English proficiency of the relevant state or states, 21 in significant publications and
significant communications, among other locations. 22 Taglines are optional but encouraged for
issuers outside the MarketplaceExchange if they are not covered by Section 1557 23 or otherwise
subject to language access standards under the Exchange rules at 45 CFR 155.205(c) and
156.250, or other applicable Federal or State law. As a reminder, issuers covered by Section
1557 are responsible for providing timely and accurate language assistance in non-English
languages, regardless of ifwhether a tagline is provided in the language, if the provision of such
language assistance is a reasonable step to provide meaningful access to an individual with
limited English proficiency in the issuer’s health programs or activities. 24
For QHP issuers subject to Section 1557 that are principally engaged in the provision or
administration of health-related services, health-related coverage or other health-related
coverage, all of the issuer’s operations are considered part of the health program or activity, with
limited exceptions. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the
Exchanges. A non-QHP issuer offering coverage outside the Exchanges might also be subject to
Section 1557 if any health program or activity of the issuer receives Federal financial assistance.
Nondiscrimination: [Issuer] doesn’t exclude, deny benefits to, or otherwise discriminate against
any person on the basis of race, color, national origin, disability, sex, or age. If you think you’ve
been discriminated against or treated unfairly for any of these reasons, you can file a complaint
with the Department of Health and Human Services, Office for Civil Rights by calling 1-800368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the
Office for Civil Rights/ U.S. Department of Health and Human Services/200 Independence
Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.
19
For QHP issuers subject to Section 1557 that are principally engaged in the provision or administration of healthrelated services, health-related coverage or other health-related coverage, all of the issuer’s operations are
considered part of the health program or activity, with limited exceptions. Consequently, a QHP issuer must comply
with the nondiscrimination requirements of Section 1557 for the issuer’s plans offered both inside and outside the
Marketplaces. A non-QHP issuer offering coverage outside the Marketplaces might also be subject to Section 1557
if any health program or activity of the issuer receives Federal financial assistance.
20
45 CFR 92.8(a), (b)(1). The content of the notice must include the seven elements listed in 92.8(a)(1)-(7). An
issuer may combine the content of the Section 1557 nondiscrimination notice with the content of other notices as
long as the combined notice clearly informs individuals of their rights under Section 1557. Id. 92.8(h).
21
45 CFR 92.8(d)(1).
22
45 CFR 92.8(f)(1).
23
A non-QHP issuer offering coverage outside the Marketplaces is subject to Section 1557 if any health program or
activity of the issuer receives Federal financial assistance. See 45 CFR 92.2, 92.4. A QHP issuer offering plans
outside of the Marketplace may still have to comply with Section 1557 for its plans offered outside the Marketplace
if the QHP issuer is principally engaged in the provision or administration of health-related services, health-related
coverage or other health-related coverage. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the Marketplaces. See 45 CFR
92.2, 92.4
24
45 CFR 92.201.
38
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Sample Tagline:
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
39
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Instructions for Attachment 5 – Discontinuation notice for the individual market outside
the Exchange and the issuer is not automatically enrolling
the enrollee in a different plan
General instructions:
This notice must be used when the issuer is non-renewing coverage purchased outside the
MarketplaceExchange based on a product discontinuation or there no longer being any enrollee
in the plan who live, resides, or works within the product’s service area, and not automatically
enrolling the enrollee in a different plan.
Item 1. Enter the date of the notice, in format Month DD, YYYY.
Item 2. Enter the full name and address of the primary subscriber. In the individual market, the
primary subscriber means the individual who purchases the policy and who is responsible for the
payment of premiums.
Item 3. The consumer qualifies for a special enrollment period based on loss of minimum
essential coverage. Enter the date by which a plan selection must be made in accordance with 45
CFR 155.420(b) to avoid a gap in coverage, in format Month DD, YYYY.
Item 4. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the month and year,
in format Month YYYY.
Item 5. Enter the issuer name.
Item 6.Item 5. Enter the minimum individual shared responsibility payment for the entire
applicable tax year. For more information on the individual shared responsibility payment, see
https://www.irs.gov/affordable-care-act/individuals-and-families/individual-sharedresponsibility-provision.
Item 6. Enter the issuer name.
Item 7. Enter the phrase “We’re here to help you prepare for Open Enrollment” only if the
current policy is terminating on a calendar year basis. Otherwise, omit and skip to item 8.7.
Item 8. 7. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the month and year,
in format Month YYYY.
Item 98. Enter the phrase “in your area” if non-renewing or terminating based on the fact that
there is no longer being any enrollee in the plan who live, resides, or works within the product’s
service area. Otherwise, omit and skip to item 109.
Item 10. 9. Enter the last day on which the enrollee’s current coverage will remain in force, in
format Month DD, YYYY.
40
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 11. 10. Enter the beginning and end dates of the special enrollment period for the loss of
minimum essential coverage or, if such date falls within an annual open enrollment period, enter
the end date of the open enrollment period, in format Month DD, YYYY.
Item 1211. The consumer qualifies for a special enrollment period based on loss of minimum
essential coverage. Enter the date by which a plan selection must be made in accordance with 45
CFR 155.420(b) to avoid a gap in coverage.
Item 12.Item 13. Enter the minimum individual shared responsibility payment for the entire
applicable tax year. For more information on the individual shared responsibility payment, see
https://www.irs.gov/affordable-care-act/individuals-and-families/individual-sharedresponsibility-provision.
Item 14. Enter the issuer name.
Item 13. Item 15. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 14. Item 16. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 15. Item 17. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 16. Item 18. Enter the issuer name.
Item 17. Item 19. Enter issuer phone number.
Item 18. Item 20. Enter issuer website.
Item 19. Item 21. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
Item 20. Item 22. Enter the MarketplaceExchange phone number. For a Federally-facilitated
MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 21. Item 23.Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 24. Item 22. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated
MarketplaceExchange. In other States, enter the appropriate website.
Item 23.Item 25. Include this phrase if the enrollee has previously used an agent or broker to
enroll. Otherwise, omit and skip to item 28.26.
Item 2624. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 2826.
Item 27.Item 25. Enter “call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit skip to item 2826.
41
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 28. 26. This sentence must be included for issuers subject to 1557 of the Affordable Care
Act or other applicable Federal or State law and is otherwise encouraged to be included. If this
sentence is omitted, skip to item 30.28.
Item 29. 27. Enter issuer phone number and issuer TTY number.
Item 30. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
Item 28. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
If you are covered by Section 1557, 25 then by October 17, 2016, provide the nondiscrimination
notice 26 in English and taglines in at least the top 15 languages spoken by individuals with
limited English proficiency of the relevant state or states, 27 in significant publications and
significant communications, among other locations. 28 Taglines are optional but encouraged for
issuers outside the MarketplaceExchange if they are not covered by Section 1557 29 or otherwise
subject to language access standards under the Exchange rules at 45 CFR 155.205(c) and
156.250, or other applicable Federal or State law. As a reminder, issuers covered by Section
1557 are responsible for providing timely and accurate language assistance in non-English
languages, regardless of ifwhether a tagline is provided in the language, if the provision of such
language assistance is a reasonable step to provide meaningful access to an individual with
limited English proficiency in the issuer’s health programs or activities. 30
Nondiscrimination: [Issuer] doesn’t exclude, deny benefits to, or otherwise discriminate against
any person on the basis of race, color, national origin, disability, sex, or age. If you think you’ve
been discriminated against or treated unfairly for any of these reasons, you can file a complaint
25
For QHP issuers subject to Section 1557 that are principally engaged in the provision or administration of healthrelated services, health-related coverage or other health-related coverage, all of the issuer’s operations are
considered part of the health program or activity, with limited exceptions. Consequently, a QHP issuer must comply
with the nondiscrimination requirements of Section 1557 for the issuer’s plans offered both inside and outside the
Marketplaces. A non-QHP issuer offering coverage outside the Marketplaces might also be subject to Section 1557
if any health program or activity of the issuer receives Federal financial assistance.
26
45 CFR 92.8(a), (b)(1). The content of the notice must include the seven elements listed in 92.8(a)(1)-(7). An
issuer may combine the content of the Section 1557 nondiscrimination notice with the content of other notices as
long as the combined notice clearly informs individuals of their rights under Section 1557. Id. 92.8(h).
27
45 CFR 92.8(d)(1).
28
45 CFR 92.8(f)(1).
29
A non-QHP issuer offering coverage outside the Marketplaces is subject to Section 1557 if any health program or
activity of the issuer receives Federal financial assistance. See 45 CFR 92.2, 92.4. A QHP issuer offering plans
outside of the Marketplace may still have to comply with Section 1557 for its plans offered outside the Marketplace
if the QHP issuer is principally engaged in the provision or administration of health-related services, health-related
coverage or other health-related coverage. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the Marketplaces. See 45 CFR
92.2, 92.4
30
45 CFR 92.201.
42
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
with the Department of Health and Human Services, Office for Civil Rights by calling 1-800368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the
Office for Civil Rights/ U.S. Department of Health and Human Services/200 Independence
Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.
Sample Tagline:
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
43
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Instructions for Attachment 6 – Discontinuation notice for the individual market where
coverage being discontinued was in a QHP offered
through the Exchange and the issuer is not automatically
enrolling the enrollee in a different plan
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].General
instructions:
This notice must be used when the QHP enrollee’s product is not available for renewal through
or outside the MarketplaceExchange and the issuer is not automatically enrolling the enrollee in
a different plan through the MarketplaceExchange. This includes non-renewals or terminations
based on a product discontinuation or there no longer being any enrollee in the plan who lives,
resides or works within the product’s service area. This notice must also be used when the QHP
enrollee’s current product is not available for renewal through the MarketplaceExchange but
remains available for renewal outside the MarketplaceExchange, the issuer no longer has plans
available for re-enrollment through the MarketplaceExchange, and, in accordance with 45 CFR
155.335(j), the issuer is not automatically enrolling the enrollee in the enrollee’s current product
outside the Marketplace.Exchange.
Item 1. Enter the date of the notice, in format Month DD, YYYY.
Item 2. Enter the full name and address of the primary subscriber. In the individual market, the
primary subscriber means the individual who purchases the policy and who is responsible for the
payment of premiums.
Item 3. The consumer qualifies for a special enrollment period based on loss of minimum
essential coverage. Enter the date by which a plan selection must be made in accordance with 45
CFR 155.420(b), in order to avoid a gap in coverage.
Item 4. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the month and year,
in format Month YYYY.
Item 5. Enter the minimum individual shared responsibility payment for the entire applicable
tax year. For more information on the individual shared responsibility payment, see
https://www.irs.gov/affordable-care-act/individuals-and-families/individual-sharedresponsibility-provision
Item 5. Enter the issuer name.
Item 6.Item 6. Enter the issuer name.
44
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 7. Enter the phrase “We’re here to help you prepare for Open Enrollment” only if the
current policy is terminating on a calendar year basis. Otherwise, omit and skip to item 8.7.
Item 8. 7. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the following year, in format YYYY. For discontinuances, non-renewals, or
terminations effective at any time other than the end of a calendar year, enter the month and year,
in format Month YYYY.
Item 9. Item8. Enter the phrase “in your area” if non-renewing or terminating based on the fact
that there is no longer any enrollee under the plan who lives, resides, or works in the product’s
service area.
Item 10. 9. Include this phrase if issuer will not offer the enrollee’s current product through the
MarketplaceExchange for the following benefit year (even if the product remains available for
renewal outside the Marketplace). Exchange). In such cases, for a Federally-facilitated
MarketplaceExchange, enter “the MarketplaceExchange.” Otherwise omit and skip to item
11.10.
Item 11. 10. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item12. Item 11. Enter the last day on which the enrollee’s current coverage will remain in force
through the MarketplaceExchange, in format Month DD, YYYY.
Item 13. 12. Enter the beginning and end dates of the special enrollment period for the loss of
minimum essential coverage or, if such date falls within an annual open enrollment period, enter
the beginning and end date of the open enrollment period, in format Month DD, YYYY.
Item 14. 13. The consumer qualifies for a special enrollment period based on loss of minimum
essential coverage. Enter the date by which a plan selection must be made in accordance with 45
CFR 155.420(b), to avoid a gap in coverage.
Item 15. Enter the minimum individual shared responsibility payment for the entire applicable
tax year. For more information on the individual shared responsibility payment, see
https://www.irs.gov/affordable-care-act/individuals-and-families/individual-sharedresponsibility-provision
Item 16. Enter the Marketplace name. For a Federally-facilitated Marketplace, enter
“Marketplace.”
Item 17. Item 14. Enter the Exchange name. For a Federally-facilitated Exchange, enter
“Exchange.”
Item 15. Enter the date by which a plan selection must be made to avoid automatic reenrollment, in format Month DD.
45
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 18. 16. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “MarketplaceExchange.”
Item 19. 17. For discontinuances, non-renewals, or terminations effective at the end of a
calendar year, enter the following benefit year, in format YYYY. For discontinuances, nonrenewals, or terminations effective at any time other than the end of a calendar year, omit.
Items 18 - 20 - 22. . Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “Marketplace.”Exchange.”
Item 21.Item 23. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 24. 22. Enter the issuer name.
Item 25. Item 23. Include this sentence only if the enrollee’s current product remains available
for renewal for the following benefit year, whether through or outside the Marketplace.
Exchange. Otherwise, omit and skip to item 29.27.
Item 26. 24. For discontinuances, non-renewals, or terminations effective at the end of a
calendar year, enter the following benefit year, in format YYYY. For discontinuances, nonrenewals, or terminations effective at any time other than the end of a calendar year, omit.
Item 27. 25. Include the words “as a Silver plan” if the enrollee’s current product will no longer
include a Silver plan offered through the MarketplaceExchange in the applicable benefit year.
Item 26.Item 28. Enter the word “through” followed by the MarketplaceExchange name if
either the words “as a Silver” plan were entered in item 2725 or the enrollee’s current product
remains available outside the MarketplaceExchange, but no longer remains available for renewal
through the MarketplaceExchange. In this case, enter the MarketplaceExchange name. For a
Federally-facilitated MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 29. 27. Enter the phrase “to lower your out-of-pocket costs” if the words “as a Silver plan”
were entered in item 2725. Otherwise, omit and skip to item 31.29.
Item 28. Item 30. Enter the phrase “in a Silver plan” if you entered “as a Silver plan” in item 27.
25. Otherwise, omit and skip to item 31.29.
Item 31. 29. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the MarketplaceExchange.”
Item 30. Item 32. Enter the current benefit year, in format YYYY.
Item 31.Item 33. Enter the current benefit year, in format YYYY.
Item 34. Item 32. Enter the current calendar year, in format YYYY.
Item 33. Item 35. Enter the MarketplaceExchange website. For a Federally-facilitated
MarketplaceExchange, enter “HealthCare.gov.”
46
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
Item 35. Item 36. Enter the MarketplaceExchange phone number. For a Federally-facilitated
MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 35.Item 37. Enter the MarketplaceExchange name. For a Federally-facilitated
MarketplaceExchange, enter “the Marketplace.”Exchange.”
Item 36. Item 38. Enter issuer name.
Item 37. Item 39. Enter issuer phone number.
Item 38. Item 40. Enter issuer website.
Item 39. Item 41.Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated
MarketplaceExchange. In other States, enter the appropriate website.
Item 40. Item 42.Include this phrase if the enrollee has previously used an agent or broker to
enroll. Otherwise, omit and skip to item 45.
Item 43. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 45.
Item 41. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item Item 44. Enter “Call” followed by the phone
number of agent or broker the enrollee has previously used, if known. Otherwise, omit and skip
to item 45.
43.
Item 42. Enter “Call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 43.
Item 45. 43. Enter the MarketplaceExchange phone number and MarketplaceExchange TTY
number. For a Federally-facilitated MarketplaceExchange, enter “1-800-318-2596 (TTY: 1-855889-4325).”
Item 46. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
Item 44. Insert a nondiscrimination notice and taglines consistent with any applicable standards,
such as HHS regulations (e.g., the Section 1557 rule at 45 CFR 92.8 or Exchange rules at 45
CFR 155.205(c) and 156.250) and guidance.
47
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
If you are covered by Section 1557, 31 then by October 17, 2016, provide the nondiscrimination
notice 32 in English and taglines in at least the top 15 languages spoken by individuals with
limited English proficiency of the relevant state or states, 33 in significant publications and
significant communications, among other locations. 34 Taglines are optional but encouraged for
issuers outside the MarketplaceExchange if they are not covered by Section 1557 35 or otherwise
subject to language access standards under the Exchange rules at 45 CFR 155.205(c) and
156.250, or other applicable Federal or State law. As a reminder, issuers covered by Section
1557 are responsible for providing timely and accurate language assistance in non-English
languages, regardless of ifwhether a tagline is provided in the language, if the provision of such
language assistance is a reasonable step to provide meaningful access to an individual with
limited English proficiency in the issuer’s health programs or activities. 36
Nondiscrimination: [Issuer] doesn’t exclude, deny benefits to, or otherwise discriminate against
any person on the basis of race, color, national origin, disability, sex, or age. If you think you’ve
been discriminated against or treated unfairly for any of these reasons, you can file a complaint
with the Department of Health and Human Services, Office for Civil Rights by calling 1-800368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the
Office for Civil Rights/ U.S. Department of Health and Human Services/200 Independence
Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.
Sample Tagline:
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
English: This notice has important information. This notice has important information about
your application or coverage through [Issuer]. Look for key dates in this notice. You may need to
31
For QHP issuers subject to Section 1557 that are principally engaged in the provision or administration of healthrelated services, health-related coverage or other health-related coverage, all of the issuer’s operations are
considered part of the health program or activity, with limited exceptions. Consequently, a QHP issuer must comply
with the nondiscrimination requirements of Section 1557 for the issuer’s plans offered both inside and outside the
Marketplaces. A non-QHP issuer offering coverage outside the Marketplaces might also be subject to Section 1557
if any health program or activity of the issuer receives Federal financial assistance.
32
45 CFR 92.8(a), (b)(1). The content of the notice must include the seven elements listed in 92.8(a)(1)-(7). An
issuer may combine the content of the Section 1557 nondiscrimination notice with the content of other notices as
long as the combined notice clearly informs individuals of their rights under Section 1557. Id. 92.8(h).
33
45 CFR 92.8(d)(1).
34
45 CFR 92.8(f)(1).
35
A non-QHP issuer offering coverage outside the Marketplaces is subject to Section 1557 if any health program or
activity of the issuer receives Federal financial assistance. See 45 CFR 92.2, 92.4. A QHP issuer offering plans
outside of the Marketplace may still have to comply with Section 1557 for its plans offered outside the Marketplace
if the QHP issuer is principally engaged in the provision or administration of health-related services, health-related
coverage or other health-related coverage. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the Marketplaces. See 45 CFR
92.2, 92.4
36
45 CFR 92.201.
48
OMB Control No.: 0938-1254
Expiration Date: XX/XXXX
Attachment 2: Renewal notice for the individual market where coverage is being renewed in a
QHP offered under the same product through the Marketplace
take action by certain deadlines to keep your health coverage or help with costs. You have the
right to get this information and help in your language at no cost. Call [phone number].
49
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |